Medical Forum 04/11 Public Edition

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WA’s Female GPs Speak Out: Ceasarean Rates Workplace Quandries Young Health Termination Advice AMA Leadership

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Contents 12

E-Poll: W.A.’s Female GPs

19

Sun, Sea and Surgery – Cosmetic Tourism

News & Opinion

25

Perth Pharmacies Fail Asthmatics At Risk

35 Oral Contraceptive Update

Guest Columns

2 Letters More Workforce Re-entry Woes

Dr Maria Garefalakis

17 Getting Published Made Easier

36 What is New in Proliferative Glomerulonephritis?

44 Clinical Services Directory

Ms Yasmin Gray

Dr Doris Chan

In Praise of Dr Perlen

18 Women in Practice – One Perspective

AHPRA Responds

21 Help With Sexual Assault Cases

Dr Action for Accidental Poisoning

23 Emotional Impact of Birthing Experience

Dr Andrew Stewart

A/Prof Hilary Fine

Ms Heather Taylor

Dr Maire Kelly

Dr Joanna Flynn

Dr Teresa Ballestas & Dr Andrew Robertson

Lifestyle 14 Humour 38 Competitions Competition Winners 39 Wine Review: Old Kent River

Dr Sara Bayes

A Model Doctor

Dr Ron Jewell

8 The Boyatzis-Capolingua Partnership

Clinical Focus

Dr Rob McEvoy

Dr Craig Drummond

40 Dining Out in Perth 41 Eating In - A Simple, Tasty Recipe

10 Education is Key Against Hearing Loss

5 Congenital Thrombocytopenia

13 Cartoon: Female GPs

7 Chest Pain in Childhood: ‘Don’t Worry, It’s Not the Heart’

Dr Rob McEvoy

Mr David Freeman

Dr Paul Cannell

Dr Luigi D’Orsogna

15 Going Digital on Patient Records 19 Sun, Sea and Surgery – Cosmetic Tourism

30 Female Urinary Incontinence

23 Beneath the Drapes 37 Conference Corner

34 Review: Endometriosis

Mr Jake Millar

28

EPOLL: WA Female GPs on Caesarean Rates

Dr Phil Daborn

33 Early Puberty in Girls Prof Tim Jones Dr Atef Saba

PUBLISHERS Ms Jenny Heyden - Director Dr Rob McEvoy - Director

Advertising Mr Paul Morgan (0403 282 510) advertising@mforum.com.au

EDITORIAL TEAM Managing Editor editor@mforum.com.au (0430 322 066) Medical Editor Dr Rob McEvoy (0411 380 937) rob@mforum.com.au Clinical Services Directory Editor Ms Jenny Heyden (0403 350 810) jen@mforum.com.au

Editorial Advisory Panel Dr John Alvarez Dr Scott Blackwell Ms Michele Kosky Dr Joe Kosterich Dr Alistair Vickery Dr Olga Ward EDITORIAL POLICY This publication protects and maintains its editorial independence from all sponsors or advertisers.

SYNDICATION AND REPRODUCTION Contributors should be aware the publishers assert the right to syndicate material appearing in Medical Forum on the MedicalHub.com.au website.

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

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

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

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

Graphic Design Pierre Designs Graphique

Medical Forum Magazine 8 Hawker Ave, Warwick WA 6024 Telephone (08) 9203 5222 Facsimile (08) 9203 5333 Email editor@mforum.com.au www.mforum.com.au

ISSN: 1837–2783

@

Letters to the Editor editor@mforum.com.au

More workforce re-entry woes Dear Editor

I was interested to read (Medical Forum, March edition) your piece on the bureaucratic barriers being erected to deter those who may wish to re-enter the medical workforce following retirement, and also the response on the letters page from AHPRA. It reminds me of a similar experience I had last year.

Over 15 years ago I was requested by a country hospital to provide ophthalmic services to the area to which I agreed, and did so fortnightly thereafter.

Having served the public hospital system in Western Australia for over 30 years as an ophthalmologist, I was surprised to receive on my recent return from an overseas conference a letter from the newly appointed administrator in this particular country hospital informing me that my accreditation to the hospital had expired. However my “re-credentialling” would be reviewed on receipt of “a recent satisfactory Criminal Record Screening, a Working With Children clearance, a Working With the Aged clearance, and a certificate to say that I had completed a course on the mandatory reporting of child sexual abuse”.

My response was that I would not be providing the above documents myself, but that the Department had my permission to research any relevant information (at their expense of course).

While most medical practitioners would welcome National Registration of medical practitioners, I suspect the great majority would be highly critical of the manner in which it has been implemented as part of a hotch-potch of “health providers”. It seems that the bureaucracies of both AHPRA and

WACHS are intent on discouraging the willing pool of retired and experienced practitioners from providing locums for their colleagues, in particular those in the country, and city-based specialists to provide services to the regional areas.

AHPRA responds Dear Editor [Reponse to Medical Workforce Re-entry a Pain, March edition.]

Dr Andrew Stewart, Subiaco

In praise of Dr Perlen Dear Editor What a delight to read the column The Noncompliant Doctor by Dr Nadine Perlen (March 2011) as it highlights the difference between medical theory in the classroom and medical practice in the real world.

It also acknowledges the importance of the therapeutic relationship between patients and doctors, and the challenges that can exist within that relationship.

Dr Perlen’s individualised approach to treating patients as unique individuals entitled to their own opinions and beliefs is commendable. Instead of being insulted by her patient’s comments she engaged with him in a non-judgmental manner.

Dr Perlen provided him with the information about her rights and responsibilities as a physician, and offered him options to consider, but ultimately left the choice up to the patient on which way he wanted to proceed.

In my view, this is an excellent approach to patient centred care.

Ms Heather Taylor, Senior Advocate, Health Consumers’ Council WA Inc.

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The role of the Medical Board of Australia is to protect the public. The National Registration and Accreditation Scheme has patient safety at its heart.

Under the Health Practitioner Regulation National Law Act (the National Law) as in force in each state and territory, the Board has set Registration Standards, signed off by Ministerial Council, that every practitioner must meet. These relate to a range of areas of professional practice and include requirements for continuing professional development (CPD) and recency of practice.

It is the right of individual medical practitioners to choose when to retire or which form of registration to seek (e.g. non-practising registration). It is the responsibility of the Board to make sure that every doctor who is registered, has the current skills, qualifications and experience to provide safe care. The Board does not set any minimum level of practice, but requires doctors who choose to renew their general or specialist registration to have Professional Indemnity Insurance to cover all aspects of their practice and to meet the Board’s Continuing Professional Development and Recency of Practice registration standards.

Limited registration (public interest – occasional practice) was only available under the National Law as a one-off transition to the national scheme. It only applies to practitioners who on 30 June 2010 (or 18 October 2010 for WA practitioners) held a type of registration that allowed them to refer and/or prescribe, but not receive a fee for providing that service. The law does not allow the Board to grant this category of registration to new applicants who did not hold this type of registration previously.

In relation to temporary absences from practice, any period less than 12 months will not require any CPD requirements before return to practice; any periods of absence greater than 12 months but less than three years will require the practitioner to complete a minimum of one year’s pro rata CPD activities relevant to the intended scope of practice before return to practice. The Board does not regard an absence of more than three years as a temporary absence and applicants will be required to provide a plan for professional development and for re-entry to practice to the Board for consideration.

For more information • Visit www.ahpra.gov.au under Contact us to lodge an online enquiry form • For registration enquiries: 1300 419 495 (within Australia) +61 7 3666 4911 (overseas callers) • For media enquiries: (03) 8708 9200

Call or SMS POWER to 1300 1 HONDA for your nearest Honda specialist dealer honda.com.au

Dr Joanna Flynn, Chair, Medical Board of Australia.

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Dr action for accidental poisoning Dear Editor Accidental poisonings are recognised as a significant cause of injury morbidity and mortality. In WA, accidental poisoning ranks sixth and fifth as a cause of injury hospitalisation and deaths, respectively.

From 2000 to 2008, 7,636 people were hospitalised due to poisoning in WA, with the majority being children aged 0-4 years. In addition, 481 deaths due to poisoning occurred during 2000–2007.

Significant progress in the prevention of hospitalisations due to poisoning has been achieved in the last decade. In a recent review of the epidemiology of injury in WA, the age-standardised rate of hospitalisation due to accidental poisoning fell dramatically from 57 to 37 per 100,000 population between 2000 and 2008.

However, when the age-standardised rate of death due to accidental poisoning was examined, it was found that the change was statistically significant but not clinically significant [Age standardised rate (ASR) = 4 cases per 100,000 population in 2000; ASR = 3 cases per 100,000 in 2007].

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Further efforts to prevent accidental poisoning are needed.

Pharmaceuticals have been identified as the most common agents reported in poisoning deaths and hospitalisations in WA. These include analgesics, anti-inflammatory agents, antiepileptic, sedativehypnotic, anti-parkinsonism and psychotropic drugs such as antidepressants and other drugs.

Medicines can harm people if they are out-of date, taken without prescription or left within reach of children. Dumped in the toilet, down the sink, or thrown into the rubbish bin, unwanted medicines can also harm the environment.

Poisoning by pharmaceuticals can be prevented by storing medicines in high and out-of-sight cupboards and cabinets fitted with child restraint locks, buying products with child resistant packaging, clear labelling and administration instructions on the package, reminding children that medicines are not lollies and returning outof-date and unwanted medicines to the local pharmacy. Education for the community on these strategies is also important in prevention.

As doctors, we are in a unique position to discuss with our patients strategies to prevent accidental poisoning when prescribing any medicines.

Patients should be advised to check the contents of their medicine cabinets and take any unwanted or out-of-date medicines to the pharmacy for disposal regularly. Unwanted medicines can be returned to any pharmacy in WA for safe disposal free of charge.

For information on the Returning Unwanted Medicines please refer to www.returnmed.com.au.

Dr Teresa Ballestas & Dr Andrew Robertson, Disaster Management, Public Health Division

A model doctor Dear Editor My sister in her 70s and elderly husband, 80, both have severe chronic health problems. Their GP is Dr Laurie Stanley from Tandera Medical Group in Gosnells. They have both been his patients for many years.

His level of care is incredible, even calling at their home to deliver bad or important news. He reflects the difficulty that doctors face, having to run a bulk billing practice in a less affluent area. The government continually refuses to realistically fund Medicare and it relies on the ethics of the Dr Stanleys of the State to give good patient care.

I think that the system is terrible as the sort of patient my sister and her husband represent are extremely complex and require lots of thought and time. This is unrealistically rewarded even though the sort of care Laurie provides saves lots of government money in ED presentations, unnecessary repetition of investigations, etc.

I would like to bring this to the attention of your readership in some way and also like Laurie to be recognised and respected for his personal ethics in being a caring human being in a system that doesn’t deserve him!

Dr Ron Jewell, Bunbury

3

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Congenital Thrombocytopenia C

ongenital thrombocytopenias are rare but important. More severe variants are usually recognised in childhood. Milder variants are more often diagnosed in adults and often falsely attributed to, and treated as, Idiopathic Thrombocytopenic Purpura (ITP). It is important to avoid inappropriate use of immunosuppression and splenectomy in these disorders.

Autosomal Dominant Thrombocytopenias May Hegglin Anomaly This long recognised entity of thrombocytopenia, large platelets and neutrophil inclusions (Dohle “like” bodies) is associated with mutations of the nonmuscle myosin heavy chain IIA gene, MYH9.

Thrombocytopenia is usually modest and probably due to reduced production. Three variants are recognised, with the Fechtner variant associated with nephritis, deafness and cataracts. The diagnosis is usually made on routine testing and bleeding is usually modest.

Mediterranean Macrothrombocytopenia Seen in southern Europe, this syndrome is associated with modest thrombocytopenias (70-150 X 109/l) and has been linked to an unidentified gene defect on chromosome 17, with reduced surface expression of GP Ib-IX-V. Sequencing has demonstrated a GP1ba mutation in most cases (Ala156Val). Pts do not suffer with bleeding

Other Syndromes

X-Linked Thrombocytopenias

Thrombocytopenia may be a minor clinical feature of a number of other Autosomal Dominant disorders such as DiGeorge Syndrome, Velocardiofacial Syndrome, ParisTrousseau Syndrome and Jacobsen Syndrome, where multiple other abnormalities usually make diagnosis likely.

Wiskott-Aldrich Syndrome (WAS) and X-linked Thrombocytopenia

Autosomal Recessive Thrombocytopenias A variety of acute causes for thrombocytopenia can be seen in the sick newborn e.g. bacterial and viral sepsis. Additionally, maternal ITP or allo-antibody thrombocytopenia may occur due to transfer of maternal antibodies across the placenta – these syndromes are self limited.

Congenital Amegakaryocytic Thrombocytopenic Purpura Rare, this disorder presents with profound thrombocytopenia at birth (<10 X109/l) and markedly reduced megakaryocytes on marrow examination. The cause is a variety of mutations of the thrombopoietin receptor gene, with severity dependent on the amount of residual receptor function. Allogenic bone marrow transplant offers the only cure.

Thrombocytopenia with Absent Radii

n I mage 1: Giant platelet in May Hegglin Anomaly.

Courtesy ASH image bank Braza, J. ASH Image Bank 2007; 2007:7-00004.

Familial Platelet Disorder Associated with Myeloid Malignancy There is mild to moderate thrombocytopenia and an aspirin-like platelet defect on aggregation studies. The syndrome is due to mutations of the AML1 gene (also known as CBFA2) on chromosome 21. There is a high risk of transformation to AML. Grey Platelet Syndrome In this rare condition, platelets appear grey and enlarged with failure to transport and incorporate proteins results in reduced alphagranules. The genetic basis in not known.

Bleeding episodes are usually mild, with no specific treatment needed.

By Dr Paul Cannell

These syndromes are characterised by a variety of upper and lower limb skeletal abnormalities associated with moderately severe thrombocytopenia (15-30 X109/l). One third have associated cardiac anomalies e.g. tetralogy of Fallot and ASD. The thrombocytopenia improves with age, with children surviving more than two years having a normal lifespan.

Bone marrow examination shows reduced megakaryocytes. The pathogenesis is unclear but does not appear to be related to defects in the thrombopoietin receptor. The syndrome is distinguished from Fanconi anaemia by the presence of thumbs and absent chromosomal fragility.

WAS is characterised by immunodeficiency, eczema and thrombocytopenia (with small platelets, typically 5-50 X109/l). The precise pathogenesis of thrombocytopenia is uncertain.

Mutations of an X chromosome gene WAS, which encodes a protein (WASP), are responsible for the syndrome. The WAS protein is thought to link the cells cytoskeleton and signal transduction pathways. Variations in disease phenotype are thought due to variation in WAS gene mutations in different kindreds.

There is an increased risk of malignancy, especially haematologic. Some other variants of this syndrome have been noted, occurring in female patients and with both autosomal dominant and recessive patterns of inheritance.

It is possible that defects of other WASP interacting proteins are responsible.

GATA1 Mutation This recently described entity is associated with thrombocytopenia (10-40 X109/l) and moderate dyserythropoiesis. Platelets are normal to increased in size; platelet function abnormalities are usually present. The bone marrow shows both dyserythropoiesis and dysmegakaryopoiesis. The GATA1 gene encodes a transcription factor required for normal erythroid and megakaryocyte development. The syndrome should be suspected in male children lacking the features of the more common Wiskott Aldrich Syndrome.

References: Clinical Haematology 2006. Editors Neal Young, Stanton Gerson an Katherine High

Bernard-Soulier Syndrome There is mild to moderate thrombocytopenia (with large platelets) and associated platelet dysfunction that leads to more severe bleeding in some affected individuals. Platelets are decreased in size and have reduced or absent expression of von Willebrand receptor. The diagnosis is confirmed with platelet function studies. Severe bleeding may require platelet transfusion.

n Image 2: Grey Platelet Syndrome – note (boxed) faintly staining platelets. Courtesy medicine.virginia.edu

Main Laboratory located at 647 Murray Street, West Perth Contact 9476 5222 for General Enquiries or 9476 5252 for Patient Results.

Information on our extensive network of Collection Centres, as well as other clinical information, can be viewed at www.clinipath.net.

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5

Have You Heard?

Limping toward hip resolution A class action has been launched against Johnson & Johnson subisidiary DePuy Othopaedics over their ASR XL Acetabular and the ASR Hip Resurfacing Systems. Apparently, 93,000 devices have been recalled worldwide and claimants say more than 5000 Australians have the hips (implanted post July 2003) that have a failure rate of 12-13% over five years. Normal lifespan is around 15 years and claimants suggest metal wear and tear is such that removal before failure may be indicated. Orthopaedic surgeons will be doing more hip revisions than they planned, it seems.

Training for primary care WA General Practice Network has formed Primary Care Education Solutions (PCES) to provide primary health education and training within divisions. It has Medicare Locals in mind, so will include population health planning in its fee-paying programs, with a hope of government subsidies later. PCES also sees its training markets as general practice, WA Health and other primary care NGOs. Current courses are limited to population health and practice management. PCES has applied for funding under the Productivity Places Program (PPP) this year. Courses are nationally accredited.

Naomi Green is the Training and Education Co-ordinator.

Complaints…same old The annual report to the Senate into anticompetitive behaviour by private health care providers shows complaints to the health insurance ombudsman more than doubled last year (n=143) when it came to failure to inform on policy changes, while complaints about medical gap payment increased to 130 (from 84 the previous year). Some 632 health care complaints were received by the ACCC: only 75 related to private health insurers; 170 against specialist medical services; 90 against GPs; and 65 against dentists - mainly around cost disclosure and treatment effectiveness.

Bullseye research The State Government has $5.2m in a new Targeted Research Fund (TRF) that it will hand out to medical researchers over the next five years – those who want to find new ways to improve the health of West Australians. Some goes to WA Health, while the remainder will be awarded “through a competitive process.”

Primary care, chronic conditions, public health, emerging risks, health delivery models….all being considered.

JHC upgrade happening The Colin and Kim duo recently opened the new $29m ED and $20.8m ward block at Joondalup Health Campus (JHC) as part of a $229.8m investment in public facilities there over the next two years. The ward block has 55 new public beds - aged care, rehabilitation and surgical ­- as part of the planned 60% inpatient bed increase to 451 beds by 2013. JHC has >150,000 public patients annually and >68,000 ED presentations.

The new ED has 30 adult treatment bays, a 12-bed observation area, an 11-bed paediatric area, and three resus bays. A whiz-bang $350,000 digital radiography machine can x-ray patients with minimal patient movement and produce high quality images in five seconds. Watch out for the new specialist medical centre, 11 new operating theatres, and new CCU, coming soon.

Rural health bits Kim Hames, whilst distributing our taxes to rural health, has mentioned some interesting things. The WA Country Health Service has a $1billion operating budget – more ED presentations than combined metro hospitals and nearly as many births as King Edward.

Builders have been appointed to construct the $170m Albany Health Campus. A $6m upgrade has gone into the Telehealth system so specialist consultations can happen long distance. The St John Ambulance services will be getting an additional 25 new vehicles, more staff and improvements to the communication centre. The RFDS gets $65m over five years for additional aircraft and crews.

6

Resus methods change Around 300 delegates - nurses from critical care, emergency personnel, hospitals, paramedics, and some doctors will be descending on the Sheraton for the Australian Resuscitation Council International Spark of Life Conference (April 7).

The big news is that the resuscitation guidelines have changed - perform compressions (rate just under 2 per sec) before ventilations and give

quality cardio-pulmonary resuscitation. UWA Winthrop Professor Ian Jacobs said getting help immediately was important as it takes two to perform consistent, uninterrupted, quality CPR.

Pneumococcal straining Pneumococcal pneumonia, meningitis and septicaemia were targeted by the vaccination program introduced in 2001 for kids. Aboriginal kids particularly were doing it tough with hospitalisation rates 15 times their nonAboriginal counterparts. The Telethon Institute for Child Health Research examined the efficacy of the vaccination program for Aboriginal children and said hospitalisation for severe pneumonia dropped by a third between 1996 and 2005. Improvements in socioeconomic indicators, including better access to out-ofhospital care, also played a part. How much, we don’t know, and our enquiries didn’t yield absolute figures or a cost-benefit analysis. In January 2005, when Prevenar was added to the Australian Childhood Immunisation invasive pneumococcal disease (IPD) of all sorts inn WA dropped for children under 5 - IPD notifications 49 (25% of total cases) in 2004 to 18 (14%) in 2006. Actual figures are thought to be much higher as antibiotics (which decrease laboratory detection rates and therefore notifications) are often given before patients are transferred to a regional centre.

WAIMR getting closer The Western Australian Institute for Medical Research (WAIMR) announced Doric Contractors will build the institute’s new 10-storey, $100m research complex at QEII Medical Centre (above). WAIMR received $50m federal and $25m state funding, along with $25m from UWA, $5.4m from Lotterywest, and $1.5m from the McCusker Foundation. Completion is in 2013, making it the largest medical research and education facility in Perth.

?

What have you heard Share the

news editor@mforum.com.au or ring the editor on 9203 5222

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14 Cardiologists, together with Ancillary Staff, provide a comprehensive range of private Adult and Paediatric Services.

Chest Pain in Childhood: ‘Don’t Worry, It’s Not the Heart’ C

hest pain in childhood is a common presentation, particularly in school age children and adolescents. In the vast majority of cases, the cause of the chest pain is non-cardiac in origin.

Indeed, most cases are benign and probably musculoskeletal in origin with no specific treatment required other than reassurance. However, chest pain in children, particularly if it is left-sided, generates a good deal of anxiety in both the child and parents as they often interpret this as arising from the heart. Here are some tips for doctors facing this dilemma.

The history is important As always, careful history is most important in evaluating a child with chest pain. The location, duration and type of pain with any associated symptoms are important factors.

It is important to differentiate chest pain from palpitation, particularly if the chest discomfort is left-sided. If chest pain precedes the sensation of increased praecordial activity, then it is likely sinus tachycardia brought on by the anxiety associated with pain. This compares to palpitation from arrhythmia, where the chest discomfort is less prominent but follows the onset of the palpitation.

Chest pain that occurs at rest is almost always benign. One should interpret exercise-induced chest pain more cautiously, even though non-cardiac origin is much more common, including asthma or musculoskeletal chest pain.

Cardiac origins Apart from pericarditis, chest pain of cardiac origin is very rare in childhood.

With pericarditis, there may be a history of intercurrent viral illness and associated fever.

The chest pain may be alleviated by sitting forward and a pericardial friction rub should be audible on examination. ECG changes are usually present and, as most cases are postviral in origin, treatment usually only involves a short course of anti-inflammatory agents.

Mitral valve prolapse tends not to cause chest pain in childhood or adolescence as most cases are asymptomatic.

Myocardial ischaemia from coronary artery disease is extremely rare in childhood.

Congenital anomalous origin of the coronary artery or coronary ostial stenosis/atresia is

rare. The chest pain is almost always exerciseinduced and associated with excessive sweating and pallor.

If a child has a past history of Kawasaki Disease and complains of chest pain, especially exercise-induced, then coronary artery disease including aneurysm formation or stenosis needs to be excluded. However, this is very uncommon in our population with current management of Kawasaki Disease.

Coronary vasospasm from cocaine abuse may need to be excluded in a teenager if there is suspicion of illicit drug usage.

Chest wall pain The most common cause of chest pain in childhood and teenagers is chest wall pain.

This includes praecordial catch syndrome and idiopathic chest pain of childhood in which pain of no definite origin is thought to arise from the chest wall and musculoskeletal system.

Typically, the pain is brief, sharp and “stabbing-like”, mostly left-sided but occasionally both sides. It usually occurs at rest and is not related to exercise. The pain may be worsened by deep inspiration and is sometimes improved by altering posture. There are no other significant associated symptoms apart from perhaps a heart rate increase if pain leads to anxiety. The pain resolves spontaneously, usually over several minutes but may recur randomly with no obvious precipitating factors.

Invariably, when the child presents for evaluation, the pain has resolved and the clinical examination is normal. Although investigations are unnecessary, an ECG can be reassuring for the older child or teenager and

By Dr Luigi D’Orsogna, Paediatric Cardiologist

About the Author Dr Luigi D’Orsogna is a graduate of UWA who trained in Paediatrics at the Children’s Hospital in Vancouver, Canada, and Princess Margaret Hospital. He completed a fellowship in Paediatric Cardiology at the Children’s Hospital in Boston and the Harvard Medical School where he developed a special interest in Fetal Cardiology and interventional cardiac catheterisation procedures for congenital heart disease. Currently, he is a consultant cardiologist at Princess Margaret Hospital and is the Fetal Cardiologist in the Maternal Fetal Medicine Unit at King Edward Memorial Hospital for Women. His private practice includes all aspects of general Paediatric Cardiology.

their parents. Nothing apart from reassurance is needed and a good analogy is “growing pain of the chest” because most children and adults can relate to “growing pains” of the lower limbs.

More definitive musculoskeletal causes of chest pain include chest wall strain from exercise or trauma and costochondritis. In these cases, chest pain is more persistent and tenderness over the chest wall is evident. A short course of analgesia or anti-inflammatory agents may be needed.

Other origins Non-cardiac causes of chest pain include respiratory origin. Asthma may cause chest tightness and discomfort, especially with exercise. Pneumonia and pneumothorax are uncommon but are usually associated with other respiratory symptoms and signs, and clearly a chest x-ray would be helpful in these situations.

Another non-cardiac cause is gastrointestinal.

Gastro-oesophageal reflux with oesophagitis or gastritis may cause central or retrosternal chest pain that is usually “burning” in quality.

The pain may be related to food or after eating and epigastric tenderness may be evident.

Visit www.westerncardiology.com.au to search information on locations, cardiologists and services.

Main Rooms: St John of God Hospital, Suite 324 / 25 McCourt Street, Subiaco 6008 Tel 9346 9300 • Country Free Call: 1800 702 600.

Urban Branches: Applecross, Balcatta, Duncraig, Joondalup & Midland Regional Clinics: Busselton, Geraldton, Kalgoorlie, Mandurah & Northam After Hours on call cardiologist: Ph 08 9382 6111 SJOG Chest pain Service 0411 707 017

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That means, if you’re an HBF hospital member and you get sick or injured, you can rest assured that the bill you get when the treatment is done will be as low it can be.

The State of the Health Funds report also found that HBF hospital members get their choice of more participating hospitals throughout WA and register fewer industry complaints in proportion to our market share than members of any other fund.

Why do HBF hospital members register fewer complaints? The report doesn’t say. But we plan to keep it this way. That’s why we do everything we can to keep your bills as small as HBF Hospital members are covered for possible. more hospital-related charges in WA And it’s why we make sure to do than members of any major fund. the little things too. Like having an HBF Personal Hospital Liaison there in the flesh if you have any questions about your cover or anything else to do with being in a hospital.

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Medical Update Dr Rob McEvoy

Education is Key Against Hearing Loss A new education program hopes to prevent hearing damage in young Australians.

Personal music players and earphones could leave children with serious hearing problems in their late teens or early 20s, according to the Cheers for Ears free education initiative from WA’s Ear Science Institute Australia. The aim is to help children and parents prevent permanent noise-related hearing loss by educating primary school children.

primary schools across the state. She conducts classroom presentations to show what damage can be done, and how to avoid it. She is hoping schools will include the information in their health curriculum and parents will take notice.

“Parents don’t always realise that personal music players can do damage – they often say to the kids to put headphones on so they don’t have to listen to their music. So if the kids have information to take home to their parents, it can help educate the parents as well,” she added.

Program coordinator Ms Natalie Leishman said noise-related hearing loss threatens a generation of young people.

“They could see the problems from noise within 5-10 years if they continue negative behaviours. It’s becoming more common and research shows personal music players that use small headphones are a major cause of this. Longer battery life means you can listen for hours on end, so it’s becoming more of an issue.”

“If they don’t start turning down the volumes we will have a lot of younger people with hearing problems. This will impact on the workforce and a whole lot of other areas in their lives, so it does impact on public health,” she said

Tuart Hill Primary School Principal Mr Stephan Bevan said his school’s involvement in the last two years was valuable, noting that program coordinators return to assess impact after the first session, which covers a range of ear health matters.

n Ms Natalie Leishman

She stressed that the hearing loss was permanent and irreparable and their audiologists were already seeing the effects.

Simple things like the adverse impact of earphones that reach inside our ears, need to be part of the education.

Last year Natalie brought the program to 47 schools to educate some 4000 students and this year plans to see at least 37 more

“From what teachers have told me, students have a high interest in it and there’s been a lot of discussion in class, so I think the students are taking the messages on board and I hope it will have a positive impact. It adds to the health curriculum and will hopefully have a positive impact on student behaviour now and into the future,” Stephan said See www.cheersforears.org.au for more information. l

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E-Poll

W.A.’s Female GPs Female GPs give their views on the issues that matter to them in the medical profession Many of the 126 female GPs who responded to our E-Poll said they are still providing longer consultations and earning less than their male counterparts. They gave us their views on everything from gender inequality in the medical profession, to issues affecting young women, and leadership in the medical profession. The questions regarding a potential Boyatzis-Capolingua conflict of interest are reported in our editorial (page 8, and answers on caesarean rates are part of our feature article (pages 28-9). Thanks to all who took part. Dr Jacqui Frayne, a GP working at Mosman Park Medical Group, was the lucky winner of this month’s wine pack.

Top issues facing young women From your consulting experience, what do you consider the most challenging health matters facing younger women these days?

Please choose up to three answers as your ‘top choices’ [multiple choice]?

Q

Body image – weight control �������������������70.6% Sexually transmitted infections ���������������� 58.7% Contraception ��������������������������������������������36.5% Unplanned pregnancy �������������������������������25.3% Illicit drug use �������������������������������������������24.6% Access to suitable health care ������������������ 11.9%

Sexual harassment ��������������������������������������� 7.9% Cosmetic procedures ������������������������������������7.1% Other ���������������������������������������������������������� 16.6% Ed. Mental health issues featured prominently in the comments received – 15 of the 35 comments mentioned body image and

depression. Obesity is also clearly a major worry for many of the GPs surveyed, as are safe sex, pregnancy and alcohol abuse.

COMMENTS “Mental health issues- anxiety, depression and eating disorders are extremely common, often time consuming, difficult to treat and a source of stress for the treating the GP. Excess alcohol intake is also a big problem.

“I see a lot of mental health, anxiety and depression issues in teenage girls, which have been inappropriately managed by other, often older male practitioners who don’t always communicate well with them.

“It is not about body image – many of these younger women are seriously overweight, and they are unlikely to get thinner. Mental health (or lack thereof) is the next big issue.

“Drug use and its mental health effects are an ongoing disaster.

“The pressure on young women to be sexual and have “perfect” bodies is enormous, and media-driven. We should be embracing diversity not Barbie-clones.

“I would consider that alcohol abuse/overuse would have to be up there among the top health matters for young women.

“Excessive and inappropriate media focus on weight loss and exercise.

“I think younger women are conflicted about their chances of work /life balance. They have seen their mothers attempt to juggle work and family life, often to their own detriment, especially those who have been through divorce.

They are concerned at how they will negotiate the same path.

“Most of the younger ones are wanting to delay pregnancy and feeling guilty about this.

Most of my young female patients are also worrying about their future and their farms as I am in the country.

“I have a large number of overweight, obese and morbidly obese young female patients which may be possible due to my practice in a low socioeconomic area. This is usually a large management problem and one I have had very little success with.

Termination advice bias

Q

Do you think bias in advice - community agency or doctor - is currently a significant problem for women seeking termination of pregnancy? [See 2008 results for comparison]

2011

2008

Yes...........................................43.6% ������������� 41% No............................................35.7% �������������36% Uncertain.................................20.6% �������������23%

Care continuity and part-timers

Q

Do patients have good reason to complain about not getting the continuity of care they prefer, because of the high proportion of part-time female GPs? [See 2008 results for comparison]

2011 2008

No...............................................49.2% �������������45% Yes..............................................34.1% ������������� 41% Unsure........................................6.6% ��������������� 14%

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What irks female GPs most?

Q

From this list, what single issue affecting the role of female GPs in general practice matters most to you?

Better pay for longer consultations ����������44.4% Flexible work hours ������������������������������������8.0% Childcare ������������������������������������������������������ 4.7% Equal status ������������������������������������������������� 3.1% Decision-making ������������������������������������������� .1% Nothing ��������������������������������������������������������2.3% Other ������������������������������������������������������������3.9% Ed. Many of the 33 comments focused on the pay and consultation time differences between male and female GPs and why this is so. Being able to strike a balance between work and family life was also a concern, particularly if there was not a spouse willing to shoulder some of the burden at home. Here is a selection:

COMMENTS “Female GPs (as a generalisation of course) are still expected to take the lions’ (lioness’?) share of childcare, household duties etc. Flexible working hours are essential.

“Possibly higher fatigue rates for female GPs due to longer, often more psychological problems seen by female GPs. Patients often will bring depression/ stress/marital disharmony/life dissatisfaction topics up more with female GPs as they are perceived by patients to listen more and have more empathy. This can be draining.

Sometimes longer consults aren’t billed privately as if someone is depressed/not coping, we feel this will add to their stressors.

“I forgo equal status and decision making and pay in order to be available to my kids these days, but are a bit resentful of it I will admit.

“When children are school aged, working hours matter a lot. It gets easier as they are older.

Sick children are the hardest thing to cope with by a long way - disaster. I always said I’d be fine if I had a wife at home!

“Still ridiculous amount of sexism in the health profession.

“It took two years of homecare for my husband to make the comment, “It sucks that we (he) has to balance family and work”. Until he took on the role, he thought he was balancing everything well. Usually females get this point, men do not.

“It’s very important to me to have the choice to be with my kids out of school hours. Luckily I have this. However, this is not so convenient for the women who want to see me!

Feeling represented or not

Q

In the last 10 years, do you believe the points of view expressed by medical leaders in WA have come to better represent the majority point of view of women working in general practice?

No ���������������������������������������������������������� 47.6% Uncertain ���������������������������������������������� 37.3% Yes ���������������������������������������������������������15.0% Ed. Clearly there is still a lot of work to be done here. Around a third of the 17 comments related to GPs who feel their concerns fall on deaf ears – some said there are too few female leaders for the profession.

COMMENTS “A Catholic AMA female president did NOT represent the majority viewpoint of women in GP. It was a personal stance informed by her religion, not the majority view.

“AMA and ANU no longer have political clout of former times - politicians and Dept of Health bureaucrats ignore all health care professionals’ advice/requests/opinions. The only way to achieve anything medicopolitically is to have a patient approach – sensationalist news media to create community outrage. We have no voice.

“Almost all the leaders are men. Most women are still running the rest of everyone’s lives and don’t have the time or interest for politics.

“More women in medicine is good - but has necessarily had an impact on the available workforce. Its a pay off between wanting women to be Doctors, but allowing them to manage their own families as well.

“Feminisation” is a term from endocrinology that has no place in the discussion of women in medicine - this whole survey reflects the bias of the male who put it together!

Paying the price?

Which of these statements would you choose as best representing a strong point of view you currently hold on women working in general practice? [multiple choice]

Q

You pay a financial and personal price for listening more and being more compassionate than male doctors. ��������62.6% A feminised GP workforce means that things like flexible work hours, childcare and shared care arrangements must be built into the workplace �������������������������������� 41.2% Female GPs are getting burnt out with all the womanly caring that is expected of them. ����������������������������������������������������� 19.8% Female GPs encourage too much dependency in their patients. ������������������ 3.1% More part time female GPs has meant less continuity of care, which is not best practice – we should be working to improve this situation ��������������������������������������������������� 3.1% None of the above ��������������������������������� 11.9%

“The phrase “tears and smears” is one of my pet hates. Mental health issues, family and relationship issues, and contraception, STD screening, gynaecology problems etc. are complex issues that take time and more than a tissue and a speculum to deal with adequately.

“My average consult is 18 minutes. Many are much longer. I get the same pay/ consult as the doctor up the corridor who sees one problem per patient and sees about four patients to my one.

“I am sick of seeing five-minute medicine and having to mop up complex problems which really should have been sorted properly the first time.

“Continuity of care is not a problem, if parttime staff effectively use medical notes and letters as communication tools.

“It did seem to me that a minority of younger ones were interested in general practice as an intellectual pursuit and are happy to dabble as they are financially secure. This is just as unsatisfactory for them and for the community as sacrificing career for their husbands. If all parttime female GPs worked 8 hours extra per week we would not have to steal so many doctors from other countries.

medicalforum

13

n n n n n n Puns for educated minds

Workers’ Comp matters

No matter how much you push the envelope, it’ll still be stationery.

By Michelle Reynolds Chief Executive Officer, WorkCover WA

A hole has been found in the nudist camp wall. The police are looking into it.

An early return to work is the best medicine

I wondered why the football kept getting bigger. Then it hit me.

As I have discussed in previous columns, there is strong evidence to support injured workers staying at work, or returning as early as possible following an injury, if it is safe to do so.

The midget fortune-teller who escaped from prison was a small medium at large.

Treatment decisions from the very first consultation can have a major impact on an injured workers physical, mental and financial health.

What if the injured worker can’t return to their full duties straight away?

Two silk worms had a race. They ended up in a tie.

Atheism is a non-prophet organisation.

A sign on the lawn at a drug rehab center said: “Keep off the Grass.”

The soldier who survived mustard gas and pepper spray is now a seasoned veteran.

A backward poet writes inverse.

n n n n On the green A husband and wife are on the 9th green when suddenly she collapses from a heart attack!

“Help me dear,” she groans to her husband.

The emphasis in conversations with your patient should always be on what he or she can do rather than what they can’t do.

Look at the duties involved in the job and ask:

The husband calls 000 on his phone, talks for a few minutes, picks up his putter and lines up his putt. His wife raises her head off the green and stares at him.

•C an pre-injury duties be carried out if the hours are reduced?

• Can the duties be modified?

• Are alternative duties available?

“Don’t worry dear,” says the husband calmly, “they found a doctor on the second hole and he’s coming to help you.”

If you or the worker are unsure, talk to the employer about what is available in the workplace.

Conferencing with the worker and employer

“I’m dying here and you’re putting?”

“Well, how long will it take for him to get here?” she asks feebly.

“No time at all,” says her husband. “Everybody’s already agreed to let him play through.”

Case conferences can be an integral component of a return to work strategy, with the medical practitioner, the injured worker and their employer coming together to set goals.

Police are called to an apartment and find a woman holding a bloody 5-iron standing over a lifeless man. The detective asks, “Ma’am, is that your husband?”

General Practitioners can organise the conference by phoning the employer to arrange a time for all parties to meet. The conference will usually take place in the practitioner’s room.

While helpful when building a return to work plan, case conferences can be used at any stage of the claim and may also involve the insurance claims officer, rehabilitation providers or allied health practitioners.

The workers’ compensation system provides for the cost of case conferences to be invoiced to the employer’s insurer. The 2010/11 prescribed rate for these conferences is $236.65 an hour.

“Yes,” says the woman.

“Did you hit him with that golf club?”

“Yes, yes, I did.” The woman begins to sob, drops the club, and puts her hands on her face.

“How many times did you hit him?”

“I don’t know -- five, six, maybe seven times… just put me down for a five.”

n n n Hearing clearly now After becoming virtually deaf, a man finally decided to invest in a great new invisible hearing aid.

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“Well, how do you like your new hearing aid?” asked his doctor.

“I like it great. I’ve heard sounds in the last few weeks that I didn’t know existed.”

“Well, how does your family like your hearing aid?”

“Oh, nobody in my family knows I have it yet. Am I having a great time!

I’ve changed my will three times in the last two months.”

medicalforum

Technology Update Dr Rob McEvoy

Going Digital on Patient Records A surprising number of practices are still to convert to electronic medical records.

Medical Forum examines what is involved in making the change to digital.

While the vast majority of general practices have gone digital for some purpose, about one third have not transitioned to digital medical records, according to our recent polling (see inset). With 23% saying they planned to move to digital patient records soon, we spoke to five practice managers about their experiences in this regard.

digital, office space savings are obvious. Our enquiries reveal however, that most practices remain trapped between the two systems for years because they elect to change patient records to digital gradually, as the patients come for consultation. They still devote areas of the clinic to archived files.

For a start, computerising the complete patient records makes searching for them a breeze, compared to pulling them off a shelf, and there is little risk of misplacing files.

Applecross Medical Centre’s Ms Terri Anza said this is definitely a time saver. She found filing patients’ test results is particularly easy – they are now electronically downloaded and automatically sorted into a patient’s file.

“We used to have three people full time retrieving files, results and letters, now we really only have one person who scans in letters so it’s a huge difference,” Terri said.

Ms Kerry Whitehurst of Mirrabooka Medical Centre agreed, adding digital filing of x-rays and referrals to the list.

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East Fremantle Medical Centre’s Dr Hilary Fine said her practice has kept archived paper files for medicolegal reasons, so they have both digital and hard-copy records (off site). She said practices expecting to do away with paper altogether will be disappointed.

“It doesn’t seem to have reduced the paper that comes into the practice, it just means we do a lot more shredding than we used to.” She recommends investing in a quality scanner to keep on top of the paper trail and training staff to make data entry quick and accurate.

Ms Rachael Hadlow from Third Avenue Surgery said scanning past medical records is still on their to-do list. “We’ve got a huge number of archived files and we’re in the process of culling all of those down to a manageable amount. We’ll be scanning them in, but not probably in the near future.

We’ve got a photocopier that scans it into our

computers, but we still have to allocate it to the patient and title it ourselves, so there is a bit of work to actually put it in.”

Ms Lucy Reed from Lindisfarne Medical Group is another in favour of a gradual changeover once everyone in the practice is prepared to take the plunge. “It n Ms Rachael Hadlow is quite an involved process but when you’re done, the benefits outweigh any problems that you have,” she said. l

Move to Digital Medical Records Is your practice considering making the move from paper to digital records in the near future (n=151 GPs): Yes ����������������������������������������������� 23% No �������������������������������������������������11% Already fully changed over �������� 54% Uncertain ������������������������������������ 12% N.B. We are interested to hear of your experiences in changing from paper to digital medical records (editor@mforum.com.au).

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Guest Column

Getting Published Made Easier Ms Yasmin Gray from Self Publish Australia offers some helpful advice to those hoping to publish their own book. quality paper with a user-friendly typeface and You’ve done the hard work, you’ve finished a distinctive bookstore-quality cover, add up to writing your book and you’re looking at a good-looking, high-calibre publication. The your best options to get it published. The saying holds true; people do judge a book by its next step is easier than you think. You self cover. publish. Self-publishing means you leave the Self-publishing is exciting and current technology next stages to be handled by an expert in makes it possible for your book to be easily the business, preferably one demonstrating available for purchase by a worldwide readership a proven track record of professionally through Amazon and other global online sales produced books. Yes, you are taking on all channels. the financial risk, but you can choose the Distribution General Practitioner – Street Doctor doesn’t just mean getting your level of your involvement based on your book into bookshops. By putting it in the path Care Network (PPCN) is a leading not-for-profit knowledge ofPerth the Primary process.

You own the of you target organisation in the primary health care industry that focuses on market (clinics and health centres) copyright and by cutting out intermediaries delivering health outcomes to local communities by supporting General and promoting it through articles and reviews and selling direct your target market, Practice andto the broader primary healthyou care sector. in health and lifestyle magazines, via blogs, get 100% of the proceeds.

PPCN operates a mobile medical Street Doctor service that takes primary relevant online discussion forums and social healthcare to the marginalised populations of Perth. We are currently

online networks, you optimise your book’s Hereseeking are my top self-publishing tips: two Vocationally Registered General Practitioners to join our

exposure. Adding an e-book version is relatively A qualified editor will help you services to produce a committed team who deliver to Indigenous and Refugee groups inexpensive and provides instant global reach properly presented book. Sometimes it isofhard forshifts may arise. on Thursday mornings.

The possibility further as well as eliminating the need for extra storage an author to be objective when so much For more information aboutspending this role please contact Tracey space. timeSnowden, closely involved a manuscript.

Human with Resources Coordinator, on 9376 9200, or to apply please send your resume to hr@ppcn.org.au . Now you know the bare bones of the process, Attract attention with an eye-catching book using keep in mind the following before submitting a talented designer. A professional layout on your manuscript:

Editing Cut out repetitions and cull irrelevant details. If you can say something in one paragraph, don’t use a whole chapter. A short, succinct (self-help/ information) book is much more attractive to readers than one where they have to work hard to extract relevant information.

Correct labeling Find the right title. Like branding, you want to attract buyers and using a descriptive subtitle is another excellent way of ‘hooking’ potential readers.

Packaging

Choose an appropriate format for your book: for a professional look choose between B Format (198mm x 128mm) or C Format (229mm x 152mm).

If design isn’t your strong point but you have some ideas for your book cover, self-publishing allows you to have input, but keep in mind the breadth of experience that in-house designers have and enjoy the process.

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Guest Column

Women in Practice – One Perspective Dr Hilary Fine outlines how women practitioners have shaped the style of her practice and what this might mean for us all.

When I took over my small practice in 1993, the 85% of patients who were seeking drugs of addiction disappeared after we put carpet down in the waiting room, toys in a toybox, and started an appointment system. Six months later I was so busy I needed help. This came from Nicki, the wonderful touchy-feely, listening GP that patients adore – she even insisted on taking bloods herself, believing it connected you to patients. A year later, we had morphed into four part-time female GPs juggling childcare needs around two new babies and seven other children under five. Patients ringing up for an appointment asked, “Is that the female doctor practice?”

Although we now have three male doctors (and six female), the label holds. Urban myth has it that patients prefer female doctors because they listen and are more compassionate.

However, there is an unspoken reality that female GPs may have other pressing priorities, such as picking up kids from day-care and being at the end of the phone for any school issues. Whilst Wonder GP Dads abound, there

18

is something different (not necessarily better) in the female GP style of parenting.

Most male GPs work longer hours and are more available throughout the working week to see their patients. Even with nannies, daycare and family and friend help, the female GP arranges her kids’ needs and then her session times. “I have to choose what day to be sick to see you,” is the common lament of my patients.

I’m a baby boomer; generation X Y and Z may be different.

“Smears and tears” is perhaps a choice thing.

Can it be unlearned? Female GPs seem to encourage the dependency of their patients whilst their male counterparts “poke and joke”, to coin a phrase, and have different relaxed ways to engage their patients and get down to the physical complaint and examination.

Women run late, patients complain and those same patients take more than their allotted time (although heaven forbid you should mention it to explain why you run late). We try all the time-management tips but female doctors traditionally listen and talk. They possibly chat, opening up conversation that might seem irrelevant but which creates the

‘friendly consultation atmosphere’. A medical student sitting in with me commented, “It seems like you’ve seen all your friends today”.

That was a reality check.

Male GPs are more likely to chase the dollars.

They mostly have the responsibility of being providers, so time matters. Doing procedures matter. In our practice we have single-mum GPs, female married-to-doctors GPs and dual professional married GPs. There is the same mix with the men. Yet women do less hours, they earn less per hour and they are incredibly busy.

My comments are hopefully not a sexist reflection on right/wrong or better/worse, just a celebration of difference. I enjoy the mix in my practice and am happy the reality is not ‘that female doctor practice’. There are challenges and joys as a practice owner working alongside many part-time female GPs. We should not lose sight of the positive and negative impact that a feminised workforce can have on a patient’s access to one GP, that they call ‘my doctor’. l

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Feature Article Mr Jake Millar

Cosmetic Tourism – Sun, Sea & Surgery Those in the market for a nip and tuck are finding cosmetic tourism an attractive option. The promise of cheaper rates and recovery in a luxury Southeast Asian resort are drawing a growing number of patients overseas, but not everyone is convinced. There are accusations of poor-quality work and limited patient monitoring, and we could find no strong audit trail behind the surgeons or tour operators’ endorsements.

To date, Rebecca reported they have not had to return anyone to Thailand.

Mark has noticed a “definite increase” in the number of corrective surgeries he is performing on patients who have returned from Asia, including breast augmentation, and he mentioned unconfirmed reports of “knock-off implants coming out of Asia” being used.

What is on offer?

Business at Restored Beauty Getaways is booming. In 2003, brother and sister team Rebecca and Robbie Degenaar established their first branch in WA and have since expanded to ten offices across Australia and New Zealand. Cheaper rates and the promise of recovery in four-star comfort has attracted over 1800 patients since business began, now running at 45-50 customers every month.

They offer the full gamut of cosmetic procedures, including laser eye surgery and cosmetic dentistry. Rebecca said most customers choose packages that include surgery, travel and accommodation. Their agency has exclusivity arrangements with Bangkok Hospital Pattaya and Bangkok Hospital Phuket.

Patients are flown to Thailand for surgery and recover in a hotel close to the hospital where follow-up appointments are made.

How much cheaper?

Cosmetic tourism websites tempt customers with photos of tropical paradises and, as with Restored Beauty Getaways, boast “incredible savings”; bilateral breast enlargement – one of their most popular procedures – costs $3700, plus an extra $1800 for travel, accommodation and taxes.

Even so, this falls far short of the $10-12,000 WA Society of Plastic Surgeons President Dr Mark Duncan-Smith said customers can expect to pay in Perth.

But he suggested [the relative handful of] patients whose abdominoplasties or breast reductions may be covered by Australian Medicare could be more out of pocket if they took the cosmetic tourist option.

How safe is it?

Rebecca said the hospital they use in Thailand is accredited by the Joint Commission International, a private assessment company that certifies much of the US hospital system. They have used the same plastic and reconstructive surgeons in Thailand for eight years, who each have 15-30 years’ experience. All are listed on their website, including their credentials. Post-op care lasts the duration of the patient’s stay in Thailand (typically eight days) and Rebecca said they also monitor patients closely when they return home.

n Ms Rebecca Degenaar

Mark agreed it is likely WA surgeons are losing business to overseas providers, and said it is worrying that patients are turning their backs on WA surgical expertise.

“We have world-class people here. If you’re going somewhere and you’re not willing to drink the water, then why would you go there for surgery?

The most important time you’ll find out how good your surgeon is, is when something goes wrong. With cosmetic tourism, you’ve already buggered off by then.”

If the patient requires corrective surgery, Rebecca said they are returned to Thailand free of charge under the Thai hospital’s insurance. Mark is not convinced.

“I heard one of these companies saying they offer a free return fare is something goes wrong, but they’ve never had to do it. It’s just ridiculous to suggest they’re not having any problems – it’s that patients aren’t going back to them with their problems,” he said.

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“I’ve even had a couple of patients who’ve had surgery in Southeast Asia who had silicon injected into their breast, rather than actual breast implants,” he said. n Tropical scenes tempt patients overseas.

Rebecca is aware of these reports, but said all their breast enlargement patients receive a certificate verifying the authenticity of their implants.

Marketing These stories have done little to reduce the demand for overseas surgery. Rebecca said word of mouth and a strong Facebook following means there is no need for them to advertise. They regularly hold free information seminars, and appearances on Today Tonight and Women’s Day have also helped to get the company’s name heard.

“It’s flat out at the moment, we’re really busy,” Rebecca said. l

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19

Guest Column

Help with Sexual Assault Cases Dr Maire Kelly from SARC says nurses and midwives will be trained to assist with sexual assault cases, supported by new legislation.

Doctors in regional WA who provide services to patients alleging recent sexual assault will be pleased to learn that soon (self-selected) specially-trained nurses and midwives will be able to collect intimate forensic specimens and perform forensic examinations. The existing WA legislation (Criminal Investigation Act, 2006) is currently being amended to permit this because at present only doctors are permitted to collect forensic specimens from intimate, internal orifices.

Sexual assault examinations are timeconsuming; patients frequently have to wait some time before being seen under the current system. In some regional hospital emergency departments, there is often only one after-hours doctor available who is required to respond to emergencies as well as provide in-patient cover.

In other areas, GPs may be asked to see patients who allege recent sexual assault. Medical staff may feel reluctant to collect forensic specimens for a variety of reasons that include lack of training and a fear of future court involvement.

To become qualified to collect these specimens under the proposed amended legislation, nurses and midwives will have to complete a three-

MEDIFIT_MFWA_HP_Ad.indd medicalforum

1

day training program that has been developed by the Sexual Assault Resource Centre (SARC). This training will include theoretical components on the medical, psychological, legal and forensic issues surrounding sexual assault. There will also be an intensive handson component to rehearse practical skills such as injury documentation and forensic specimen collection.

Unit of Princess Margaret Hospital will provide 24/7 telephone support. This training will allow nurses to collect forensically useful specimens and streamline patient care and improve their satisfaction. Where available, local sexual assault counselling services, such as Waratah in Bunbury and Chrysalis in Geraldton, will provide support during the acute phase and also provide on-going counselling if required.

SARC is funded to develop and deliver this training, which is supported by the Chief Nurse and Midwifery Officer, WA Country Health Services and the Commissioner of Police.

A pilot site has been selected and training commences in late March, 2011.

To increase awareness of the medical and forensic needs of a patient alleging recent sexual assault, SARC will deliver three-hour teaching sessions, Responding to Sexual Assault, to doctors outside of Metropolitan Perth over the next 12 months. These will be in areas where up-skilling of regional and remote doctors will help support these qualified nurses and midwives.

Rural and remote doctors will still need to be involved in the care of sexual assault patients to ensure that any serious medical concerns and injuries are addressed as well as providing emergency contraception and prophylaxis for sexually transmitted infections.

Ideally, nurses doing this training will be speculum-trained but where this is not the case, doctors may be requested to perform the speculum examination. Speculum training for the nurses is outside the scope of the course.

Doctors from SARC and the Child Protection

For more information, please contact the Education and Training Department at SARC on 9340 1820.

For advice dealing with alleged recent sexual assault contact the SARC 24 hour crisis number: 9340 1828.

For suspected child sexual abuse, please contact PMH and speak to a senior doctor with the Child Protection Unit. l

3/03/11 1:46 PM

21

Guest Column

Emotional Impact of Birthing Experience Dr Sara Bayes PhD RN says the mother’s expectation should be given precedence in deciding birth satisfaction, not the method of delivery.

To many health professionals, a ‘good’ birth is one from which the mother and the baby emerge alive and largely (physiologically) unscathed. For the vast majority of women, however, a good childbirth experience is much more. Having a baby has been described as a rite of womanhood that is so multi-dimensional it is difficult to explain.

Positive, satisfying birth experiences imbue women with a sense of deeply gratifying accomplishment that lasts forever. In contrast, an unfulfilling experience of childbirth is known to have potentially devastating long-term consequences for the woman and for her family.

expectations of childbirth have been found to include being in control, being supported by their partner, being supported by the staff caring for them, and being active in clinical decision-making.

A number of factors are now recognised to be important for how women evaluate their experience of childbirth. A fundamental driver of women’s childbirth satisfaction, however, seems to be the extent to which their birth experience met their original and often longheld expectations.

Irrespective of their preferred birth mode, it is now clear that for women whose childbirth expectations cannot be fulfilled for some reason, a deep and long-lasting sense of disappointment, regret, loss, grief and sometimes despair can follow.

Internationally and in Australia, women’s

Perhaps most importantly, though, women have a very definite idea about how they want to give birth. In recent years, caesarean section scheduled ahead of time has become the preferred option for a small but consistent number of women, usually in relation to a fear of natural birth. In the main, however, and despite caesarean section rates being at an all-time high globally, most women across the world reportedly still expect and/or want to give birth naturally.

There are two primary concerns that relate to this scenario. The first is that the infants and

children of women whose emotional health is suboptimal are well known to be at increased risk of emotional, behavioural and cognitive developmental difficulties. We already have a postnatal depression rate of at least 15% in this country, and it is likely that in part this is associated with a disappointing, unfulfilling childbirth experience.

The second is that grief, regret and despair are closely correlated to hopelessness which, if it continues, is known to be the primary indicator for suicidal intent and suicide, as we are all too well aware, has been identified as a leading cause of indirect maternal death in Australia in recent years.

So the take-home messages from this piece are simple: ensure the pregnant women you come into contact with are actively involved in making decisions about their care, and give them an opportunity to talk about whether it’s all going as they imagined it would. Ask those who have already borne their baby/ies if the birth was what they expected. If the woman replies in the negative, she may well be a candidate for grief support. l

Medical professionals – insurance issues Medical professionals face unique personal and professional insurance issues that warrant detailed attention from a professional adviser.

With the Atlanta based Centre for Diseases Control estimating that health professionals who receive needle stick injuries have a 1 in 300 chance of being infected with HIV – with up to one in 10 of these injuries resulting in hepatitis C and two in every five resulting in hepatitis B - the need for the right type of comprehensive coverage is paramount.

Financial adviser Murray McKinley says while health care professionals are mindful of how critical insurance coverage for occupationally acquired infectious diseases is, many are unaware of how they may be disadvantaged by the finer details of different insurers’ policies.

Mr McKinley, a director at McKinley Plowman financial planning and accounting firm, says medical professionals need to be aware of the regulations and timeframes surrounding insurance coverage for occupationally acquired infectious diseases.

“Most insurers cover occupationally acquired HIV and hepatitis, however many have exceptionally stringent requirements about proving the time and precise source of the

acquired infection, he says.

“In some cases, it can be impossible for the insured medical professional to identify the exact date and source of the infection they have acquired.”

Mr McKinley says while these stringent requirements are a common scenario with many third party insurers, there are insurers which acknowledge how difficult it is for health professionals to pinpoint the source of the infectious disease.

For example, Comminsure’s Income Care policy acknowledges the strong likelihood of occupationally acquired infectious diseases.

Some features of Comminsure’s policy include provision for 75 per cent of monthly income as well as a lump sum payment in the case of accidental infection with HIV, hepatitis B or hepatitis C. Available to health care workers aged between 17 and 59, the coverage is paid in addition to Work Cover entitlements, and ensures financial security against accidents including sharps, splash back and inhalation of blood or bone dust.

The insured health professional can choose income protection cover between $15000 to $30,000 per month.

Beneaththe Drapes u Prof D’Arcy Holman and Prof Bryant Stokes have received Consumer Excellence Awards from the Health Consumer Council for their work in support of consumer advocacy. u Director of the Lung Institute of WA Prof Philip Thompson received the inaugural Asia Pacific Society of Respirology (APSR) medal for his contribution to the practice of respiratory medicine. u Prof Yvonne Hauck has been appointed WA’s inaugural Professor of Midwifery – a joint partnership between KEMH and Curtin Uni. u The Office of Aboriginal Health has appointed Ms Jenni Collard as its new director. Ms Collard was previously executive director of the Department of Child Protection’s Aboriginal Directorate and worked on the Gordon inquiry into government agency response to complaints of family violence and child abuse in Aboriginal communities. She replaces Ken Wyatt, now Federal Member for Hasluck. u Mr Neil Keen has been appointed to the Chief Pharmacist position within WA’s Public Health Division. Formerly the Director of Pharmacy at Canberra Hospital, Mr Keen trained in Perth. u Silver Chain’s marketing manager Mr Nick Harvey has resigned and the organisation is seeking his replacement.

For more information phone Mr McKinley on 9301 2200 or visit www.mckinleyplowman.com.au

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23

Pharmacy Practice

By Dr Rob McEvoy

Perth Pharmacies Fail Asthmatics At Risk Very poor retail pharmacy assessment of at-risk asthmatics is causing second thoughts on a primary care role for pharmacists.

Pharmacists want more of a role in primary health care. This includes cough management, both symptomatic treatment of acute cough and advising referral to a GP for chronic cough that might indicate asthma, amongst other things. However, research by UWA in 2007, just published, showed that only 38% of simulated patients (‘mystery shoppers’) who presented to 40% of Perth’s retail pharmacies (n=155) with a story compatible with poorly controlled asthma received appropriate advice, that is, referral to see their GP. Since then, attempts have been made to remedy this very poor situation, fuelled by the 400 asthma deaths in Australia annually. Medical Forum discussed the results with researcher Dr Rhonda Clifford PhD FPS, Assoc/Prof of Pharmacy Practice at UWA. Pharmacy behaviour was highlighted this way.

Simulated patients walked into the pharmacy reception and asked to “buy something for their cough”. If asked, they were instructed to describe n WA pharmacists will need to take time to assist asthma patients the cough as being dry, occurring mainly at night and present for “a couple of months or so”, that maybe the asthma card was a wake-up call for these results are “disturbing”, she is quick to point it was untreated, that they had asthma that was the pharmacist as much as the consumer or GP. out that this research was done three years ago getting worse, and they were currently using their Rhonda partly agreed. and much effort has gone into rectifying matters, reliever puffer twice daily. In this scenario, the helped by funding from UWA, the Asthma “Once you know this card will start a researchers concluded it was reasonable to assume Foundation (which funded the original research), conversation with either a pharmacist or GP about the consumer’s cough was due to worsening and the Pharmaceutical Society. your asthma, then that conversation is valuable. asthma that needed to be referred to a medical We would like the asthma card to be seen as so practitioner.

She said one good outcome has been the asthma valuable that they carry it with them. The one pharmacy card (see inset), a collaborative effort What happened instead was that most patients question “how often do you use your reliever” between her staff at UWA (all community were sent on their way with no referral and a can tell the pharmacist, the consumer or the GP pharmacists), WA Health’s Health Networks, cough suppressant. (See separate box for other whether they need to be reviewed by the GP to respiratory physicians and GPs. We suggested that important findings.) While Prof Clifford says change their medication.”

Asthmatic Cough Management by Perth Pharmacies Questioning of consumers. The assessment questions that predicted referral (and the percentage of pharmacies that asked these questions) were: discovery of asthma (28%), discovery of asthma reliever medication (68%), discovery of cough duration (23%), and frequency of asthma reliever use (31%).

However, while two thirds of pharmacy staff elicited answers that indicated asthma, the majority recommended an antitussive.

Overall, the more questions asked, the more likely was referral.

Referral, yes. Only 38% of pharmacies advised the patient to see a GP – the study’s benchmark for an appropriate response – and 13% of pharmacies did this while also providing an antitussive. The researchers suggested that “use of antitussives may delay medical review and treatment of the underlying condition”, and noted that only 47% of pharmacies that appropriately

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referred also suggested a time period for referral (mostly within a week).

Referral, no. Of those the 62% that failed to provide referral advice, virtually all sold the consumer an antitussive. The 17 pharmacies in medical centres were not significantly different to the rest in this regard. (The research did not examine whether the pharmacy sold a salbutamol inhaler, or checked the expiry date on the current inhaler.)

Who knows best? The position of the staff member was a predictor of likely appropriate referral. Pharmacist advice (either directly or at the request of an assistant) was linked to a more appropriate outcome but pharmacist access only happened in 39% of cases. Pharmacy busyness, location or pharmacy type had no impact on access.

However, in their study, referrals to GPs only got past 50% when staff asked five or more key questions (which most did not), and 78% of pharmacies devoted three or less minutes to the patient encounter. We suggested this is not news – spend more time and you do a better job.

“We subsequently visited every community pharmacy to tell them one-on-one this is how you do the right thing and reinforcing the message that it only takes between 3 and 5 minutes to ask those extra questions and get the right outcome and potentially save a life. Spend the time, ask the questions and use the asthma card,” she said.

Of course, pharmacies have high staff turnover, which makes training difficult but should nonpharmacists be involved anyway?

“We do know that where you first get a pharmacy intern or a pharmacist, you are much more likely to get a good outcome for the patient. So you either need to train the assistant much better or put the assistant away from areas where you are selling S3 or pharmacy-only products. Some pharmacists have moved to that model.”

Continued on page 27 25

Pharmacy Practice

By Dr Rob McEvoy

Perth Pharmacies Fail Asthmatics At Risk continued from page 25 Should the S3 asthma puffer come up in questioning by the pharmacy assistant, it is illegal for them to provide advice. “The Poisons Legislation says that it can only be sold by a pharmacist or pharmacy intern under supervision.

This automatically means this product does need the higher level of care.”

Pharmacists are trying to engage consumers so they expect pharmacist advice. But most pharmacies in this study failed to ask simple questions and ultimately didn’t refer (62%)

but virtually all sold an inappropriate cough suppressant to the consumer as part of their retail turnover.

Rhonda agreed this was an issue that needed to be addressed head on. As to a conflict of interest, she does not think this exists anymore, in the light of recent changes – guidelines now say never refuse a salbutamol inhaler request in a pharmacy.

As happens in most interventions, 80% of the effort will go into impacting the 20% of people who are not proactive or caring about their health.

She suggests doctors have a part to play.

“You can help us get this message across.

Consumers have a right to speak to the pharmacist and the old message ‘ask your pharmacist’ is the correct one. We know that practice change takes a long time and engaging consumers in that 20% is even harder, but we are in it for the long haul. Those that don’t take an interest in their health are most at risk. Our next mystery shop survey will be to tell us how the asthma card is used and see if referral rates have improved.”

Ref: Provision of Primary Care to Patients with Chronic Cough in the Community Pharmacy Setting.

Schneider et al. Annals of Pharmacotherapy 2011; 45: online. l

Asthma Action Cards – Prompting Whom?

Over 30,000 Asthma Action Plan cards have been distributed in WA in the last 4 months. Consumers carrying the card are expected to take the initiative, by treating the card as a passport to bypass the pharmacy assistant and access the pharmacist (previously less than half of pharmacy encounters). The card’s contents will also prompt the pharmacist to refer to the GP for an action plan or review.

However, it not only duplicates the National Asthma Council’s Asthma Action Plan (where uptake has slid from 40% to under 20%), it is a marketing failure, with nowhere to list patient benefits (kick the footy with the kids, more sex, better sleep, or whatever). GPs still write out the plan. OTC reliever inhaler tracking will be hindered by “pharmacy shopping” and failure to carry the card, made more likely in men because the card is 5mm too wide to fit the average wallet slot and is as thick as two credit cards.

The HDWA website for ordering Asthma Action Plan cards (Ref HP11656) is currently a dog and does not work with some browsers (www.health.wa.gov.au/ ordering) Fact sheets are at www.healthnetworks.health.wa.gov.au/network/respiratory

CRS AUSTRALIA

n A good idea gone wrong – 5mm wider than will fit in the average wallet?! But there are info panels for the doctor, pharmacist and patient to use to co-manage asthma.

We hope this card improves morbidity and mortality associated with asthma in WA. Surveying the card’s effective use in April this year, as is planned, will be timed to the peak of publicity and uptake, so expect a better result than in a year’s time. l

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CRS Australia can help your patient with a disability, injury or health condition to find a suitable job or keep their current job.

Our team of qualified allied health professionals work with you and your patient to get results in their journey back to work. Our services are free and include: n n n

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coordinating a Job Capacity Assessment tailoring assessment and employment placement programs providing 6 months support once employed.

We welcome your referrals at any of our 18 WA offices. To make a referral or to receive a referral form call 9236 7370 or email WA.Referrals@crsaustralia.gov.au

27

WA female GPs on I

Eye Surgery Foundation Our Vision Is Improved Vision

n WA one in three women are having their babies surgically removed rather by vaginal birth. For enlightenment on the underlying issues, Medical Forum has gone to some grass roots female GPs – those with enough medical knowledge for a well-informed opinion but also a high awareness of overall female attitudes. The results from the 126 survey respondents are enthralling.

In WA, 33.3% of babies are delivered by caesarean section, and a minority (12%) of women who have had a previous caesarean will be delivered vaginally the next time. Which statement best describes your emotional reaction to these figures?

Q

Very upset or alarmed ����������������������������������������������������������������������������3.9% Worried and want a satisfactory explanation ��������������������������������������� 30.1% Not affected in either a positive or negative way ��������������������������������19.0% Content with the figures and know they can be explained �����������������19.0% No emotional reaction �������������������������������������������������������������������������� 21.4% None of the above. �����������������������������������������������������������������������������������6.3%

Thinking of the circumstances surrounding a woman approaching her first birth, which of the following explanations would be your first choice to explain the caesarean rates (above)? [multiple choice]

Q

More women entering labour these days see vaginal birth as potentially dangerous or damaging to their bodies. �����������������������������������������������42.0% Women are not always receiving accurate information for informed choice................... ���������������������������������������������������������������������������������25.3%

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Dr Annette Gebauer Tel: 9386 9922 Dr David Greer Tel: 9481 1916 Dr Boon Ham Tel: 9474 1411 Dr Philip House Tel: 9316 2156 Dr Brad Johnson Tel: 9381 3409 Dr Jane Khan Tel: 9385 6665 Dr Ross Littlewood Tel: 9374 0620 Dr Nigel Morlet Tel: 9385 6665

Dr Robert Patrick Tel: 9300 9600 Dr Jo Richards Tel: 9321 5996 Dr Stuart Ross Tel: 9250 7702 Dr Andrew Stewart Tel: 9381 5955 Dr Michael Wertheim Tel: 9312 6033

The rate reflects the level of current obstetric complications. ������������16.6% Doctors are offering and/or promoting caesarean for non-medical reasons. �������������������������������������������������������������������������������������������������������������� 11.1% None of the above. �������������������������������������������������������������������������������� 17.4% Ed. Female GPs place maternal fears and requests well above obstetric practice in determining whether a woman facing her first birth ends up having a caesarean. However, one third believe doctors are influencing women towards caesarean, through providing inaccurate information, or directly.

Q

Around 60% of all caesareans (CS) occur without any preceding labour. In WA, for the next birth after caesarean, around 85% have an elective repeat caesarean and about 12% will deliver vaginally. Which of the following explanations best explains these figures, in your view? [multiple choice] Obstetricians are reticent to conduct a proper ‘trial of scar’. ��������������46.0% Previous CS generates fear of childbirth and many women thereafter regard vaginal birth as unpredictable, unsafe and potentially unachievable. ��������������������������������������������������������������������������������������������������������������33.3% Women are wrongly convinced that a repeat CS is the best course of action and consent to this. ��������������������������������������������������������������������23.0% Caesarean rates simply reflect the overall high level of interventions in labour. ���������������������������������������������������������������������������������������������������23.0%

Expert day surgery for

Reporting in the media has normalised CS as a method of choice for childbirth. ����������������������������������������������������������������������������������������������18.2%

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The figures reflect best practice in obstetrics. ������������������������������������12.6%

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The rate reflects maternal requests. �����������������������������������������������������19.0%

None of the above ����������������������������������������������������������������������������������� 7.9% Ed. In the conduct of repeat births following initial caesarean, just over three quarters of female GPs say that repeat caesareans are due either to the maternal emotional effects from the first caesarean or inadequate ‘trial of scar’ by the obstetrician. Only one in ten believe the 88% repeat caesarean rate reflects best obstetrical practice.

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caesarean rates PIVET MEDICAL CENTRE COMMENTS

Specialists in Reproductive Medicine & Gynaecological Services

Here is a representative sample from the 40 or so GPs who offered comment. “[Caesarean rates] reflect the doctor’s fear of being sued and of association with an adverse outcome rather than a careful risk-benefit analysis that includes all factors e.g. increasing risk of placenta acreta, which in rural WA especially, can be expected to cause increasing morbidity. Also, the mining boom results in more requests for elective induction or caesarean on social grounds.

“Doctors have allowed this situation to evolve because it is easier to book a caesarean than hang around in the middle of the night waiting for a baby to be delivered. Perhaps women doctors are at fault by subconsciously trying to protect our sisters from the “chaos” of natural delivery, because our own lives are rigidly timetabled to juggle career and motherhood.

“As a young female doctor who has not yet been pregnant but worked in neonatal medicine, I am clear I will be having an elective C-section. I don’t care to put myself, my perineum and my unborn child at unnecessary risk of injury because some people think I am ‘too posh to push’. No one has the right to tell me what I should do with my body and my child when it is completely my decision. I have seen things go horribly wrong on somany occasions (albeit while working in a tertiary hospital with high risk deliveries) for the mother and the infant. I don’t feel a vaginal delivery is some major accomplishment that makes another woman more ‘womanly’ than me or a better mother.

“Most women come to pregnancy with very strong beliefs about what method of delivery they desire. Beliefs appear to be informed by media reporting (accurate?) and firm lifestyle convictions (e.g. everything ‘natural’ is good). No amount of discussion from doctor or midwife will change these beliefs.

FERTILITY NEWS

Medical Director Dr John Yovich

Chocolate Cysts Currently there is a world-wide interest in chocolate – its varieties reflecting different cocoa bean species and different combinations of cocoa solids and cocoa butter with or without milk products and sugar.

Similarly Gynaecologists are facing an intense interest in pelvic endometriosis, an enigmatic condition with a rising prevalence and a range of clinical presentations including ovarian endometriomata (chocolate cysts) and their varied features.

In of

the

world infertility,

endometriosis as a major

underlying

feature has risen from 5% to 20% over the past 2 Chocolate exuding from cyst

decades and can be identified in 50%

of all cases having a laparoscopy as part of infertility investigation or management. Many of these present with endometriomata either

“I don’t think [caesarean rates] are high enough. I spend much of my working day with women whose pelvic floors have been wrecked by labour, especially now that HRT, which can improve pelvic floor tone, is out of favour.

as the major form of endometriosis or as part of a “frozen pelvis”

“When I did a review of this issue over 12 years in WA it was ironic that the high risk public patients had lower rates of CS than the low risk high-earning patients with private cover. Most women who opted for elective CS did so because their obstetrician promoted it as a safer controlled option and they were not aware of the real risks and impact.

of dysmenorrhoea,

“I never hear the incidence of genital herpes (said to be at least 1 in 4) mentioned as a common reason for caesarean, and it is, but for everyone’s privacy it is couched in other ways.

regulatory systems operating within the pelvis and reproductive tract.

scenario.

Other present

cases

will

because

pelvic pain which may associate with irritable

bladder

or irritable bowel symptoms if there

Removing the entire cyst wall

is structural involvement or dyspareunia as a feature when there is nodularity of the uterosacral ligaments or invasion into the rectovaginal septum. Research currently focuses on abnormal immunoThe rise in endometriosis associates with increasing delay in pregnancies and rising infertility – the latter having a complex aetiological basis but the presence of endometriosis limits the prognosis for fertility treatment, even for mild cases. Raised CA125 levels in the range 35-150 kU/L are usual for endometriomata and such cases require advanced laparoscopic surgery to drain the “chocolate”, remove the cyst wall in its entirety and re-suture the ovary for larger lesions.

“The rate really represents maternal requests, including painless labour, no vaginal tears and right to choose gynaecologist, hospital, type of delivery and even the delivery date. These days we can see more written agreements that women request to be followed by gynaecologists. – Continued on page 37...

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For ALL appts/queries: T:9422 5400 f: 9382 4576 E: info@pivet.com.au W: www.pivet.com.au

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Female urinary incontinence

By Dr Phil Daborn, Urogynaecologist, Suite 5/400 Barker Rd, Subiaco. Tel 93822055

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rinary incontinence affects around 30% of women over their lifetime. The most frequent types include: stress incontinence where a rapid rise in intra-abdominal pressure causes a urine leakage; urge incontinence where a uninhibited detrusor contraction leads to the urgent need to void and leakage; and mixed incontinence (stress and urge incontinence). The most significant risk factors for urinary incontinence are age, pregnancy (vaginal delivery is associated with stress incontinence) and hereditary factors (likely related to collagen weakness).

Stress incontinence can be considered as a mechanical defect in the valve mechanism, which may be related to the musculature component of the urethra or the urethral support structures. Urge incontinence is the end point of many potential pathophysiological mechanisms resulting in uninhibited detrusor contractions.

General practice treatment

GPs can initiate and provide treatment in most patients, where options include:

• Physiotherapy. A specialised pelvic floor physiotherapist can be invaluable.

Individualised treatments may utilise – pelvic floor exercises, bladder retraining, fluid and dietary management, voiding dynamics, and electrical stimulation (e.g. sacral nerve and tibial nerve TENS). Typically, physiotherapy will be trialled for three months and 50-75% success rates are reported. Patient motivation and compliance are important factors in successful treatment.

• Vaginal estrogen therapy. Patients who have signs of vaginal atrophy will particularly benefit from improvement in the quality of the tissues of the vagina, urethra and bladder neck, which have high concentrations of estrogen receptors. Vaginal estrogens are usually applied nightly for two weeks, then maintained at two nights per week. Symptomatic improvement will take at least six weeks. Incontinence in perimenopausal women may respond to vaginal estrogen therapy even before there is overt vaginal atrophy.

• Treat other potentially reversible causes such as chronic cough, smoking, obesity, constipation, and UTIs. Two studies have shown that weight loss in the morbidly obese patient can reduce both stress and urge incontinence.

n A cadaver dissection of mid urethral sling, providing a sub urethral hammock that replicates the pubourethral ligaments (see anatomical drawing). Defect in this mechanism, typically after childbirth, causes urethral hypermobility and stress incontinence.

What tests can a GP organise?

• MSU – important in every patient, with proof-of-cure repeat MSU a week after any treated UTI.

Recurrent UTIs can present with irritative bladder symptoms, urge and stress incontinence. Subclinical cystourethitis can be difficult to diagnose and may cause urinary symptoms without an acute bladder infection. Hence, an MSU is very important in the assessment of urinary incontinence. Recurrent infections are common, particularly in patients with voiding dysfunction and faecal incontinence.

• A post-void residual (PVR) – e.g. pelvic ultrasound examination (N.B. may be raised due to diuresis from preassessment fluid intake).

• Anticholinergic medication (e.g. VesicareTM) can often be commenced by the GP provided that voiding dysfunction has been excluded with a postvoid residual and other contraindications such as narrow angle glaucoma are accounted for. Newer generation anticholinergic medications generally have fewer side effects (e.g. dry mouth, blurred vision and constipation) but in the elderly, cognitive side effects may limit the tolerability.

Women who can benefit from specialist referral

• Bladder diary – a three-day bladder diary is useful to identify excessive fluid, high caffeine, alcohol, and diet softdrink intake (which may cause urge incontinence), as well as document voiding volumes and incontinence episodes.

• Previous incontinence surgery. More complex urinary incontinence will require urodynamic investigation.

n Urodynamics: Bladder pressure (Pves) and abdominal pressure (Pabd) are measured with catheter pressure transducers. The difference between these two determines detrusor pressure (Pdet). This patient’s cystometrogram shows multiple detrusor contractions with episodic increases in detrusor pressure and associated urinary incontinence.

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• Recurrent urinary tract infections.

• Urinary tract malignancy or calculi – known or suspected.

• Suspected voiding dysfunction. Common symptoms include slow urine flow rates, straining to void, the sensation of incomplete emptying or the need to reduce a vaginal prolapse to void. If a post-void residual is raised then urodynamics will help differentiate obstructed voiding from a hypocontractile bladder or urine retained by a large bladder prolapse.

• Irritative bladder symptoms (e.g. urethral or bladder pain, marked increased urinary frequency and haematuria) need to be assessed by a specialist to exclude other less common conditions such as interstitial cystitis, urethral diverticulum, malignancy and calculi.

• Failed conservative therapy.

The role of urodynamics Bladder symptoms may not correlate with actual urodynamic findings. Urodynamics help differentiate stress from urge incontinence and are particularly useful for evaluating voiding dysfunction. Results assist in the choice of incontinence procedures (e.g. a retropubic vs obturator mid-urethral sling) and tape tensioning .

Most specialists perform urodynamics before considering surgery, in cases where simple bladder management has been ineffective and in complex/repeat cases.

Treatment options for urinary urge and urge incontinence • Physiotherapy.

• Anticholinergic drug therapies.

• New developments: Intravesical BotoxTM (botulinum toxin A) injections reduce bladder contractions and lasts for about six months.

Its use in neurogenic detrusor overactivity is well documented, work on its use in idiopathic detrusor overactivity shows promise, but treatment may occasionally cause voiding dysfunction; sacral nerve stimulation (SNS) with an implanted lead to the 3rd sacral foramina has recently been approved with urge incontinence, non-obstructive voiding disorder and chronic pelvic pain – recent studies have shown efficacy of over 75%.

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• Concomitant large pelvic organ prolapse (i.e. prolapse beyond the introitus or symptomatic prolapse).

Management of stress incontinence • Physiotherapy

• Mechanical devices (e.g. Contiform pessaries) useful in younger women who only experience leak with specific activities such as exercise.

• Mid urethral slings – slings such as the TVTTM (tension free vaginal tape) have become the most common surgical procedure for stress incontinence performed by gynaecologists. The key principles include: a mid urethral location (not at bladder neck), minimally invasive dissection, tension free placement and use of a biocompatible synthetic mesh. Long-term data suggest a durable 90% efficacy and low complication rate.

• Fascial slings – performed by urologists rather than gynaecologists, with comparable efficacy.

• Peri-urethral bulking agents – may be used in recurrent incontinence or in patients who are unfit for a larger surgical procedure. n

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uberty is marked by the appearance of secondary sexual characteristics and the transition from a sexually immature to mature stage. Puberty onset follows the new pulsatile release of gonadotrophin releasing hormone from the hypothalamus, this in turn activates pituitary release of LH and FSH, which activate the ovaries.

Hypothalamic activation can be modified by a number of factors that result in early or late pubertal onset. CNS disorders and insults such as hydrocephalus and head injury may, for example, be associated with early pubertal onset.

Understanding the norm The first clinical sign of normal pubertal onset in girls is usually breast development or thelarche but may be pubic hair development. The average age for thelarche is 11 years, although onset ranges from 9 to 13 years. The average age of thelarche has reduced over the last 100 years in Western countries. Recent data suggest the age has fallen further over the last 20 years but it is controversial as to whether this recent change is associated with earlier menarche (i.e. the onset of periods).

Precocious or not, peripheral or central?

Although it is an arbitrary definition, precocious puberty in girls is defined as an age of onset of breast development or pubic hair development before 8 years. Menarche usually occurs toward the end of pubertal development at an average age of 12.5 years. Many parents are unaware of this and it is often important to reassure them that periods will not closely follow the onset of breast changes. Parents may notice behaviour changes such as moodiness along with the physical signs of pubertal onset.

Early pubic hair development is commonly seen as a variant of normal development (benign premature adrenarche) but adrenal pathology needs to be excluded.

In most cases, precocious puberty is caused by early central or hypothalamic activation such as may result from CNS insult, tumour or congenital malformations but occasionally pubertal changes result from “peripheral” causes such as an ovarian or adrenal source of hormone. Investigations are aimed at detecting these causes of so called “pseudopuberty”.

By Prof Tim Jones, Head, Department Endocrinology and Diabetes, Princess Margaret Hospital

Key Clinical Points

• Precocious puberty is marked by breast or pubic hair development before age 8, and/or menarche before age 9.5 years.

• Early puberty may result from early central activation (true precocious puberty) or peripheral causes (pseudopuberty) such as an estrogen secreting ovarian tumour.

• Untreated true precocious puberty can result in premature arrest of bone growth and short stature.

• Early breast development or early pubic hair development alone is usually harmless.

no treatment other than reassurance. The cause of this is unknown but may result from transient pubertal activation during early life.

Girls presenting with vaginal bleeding require thorough evaluation to rule out vaginal lesions, trauma (which may be associated with child abuse) and vaginal foreign body. This is particularly important if the bleeding occurs at a pubertal stage not consistent with normal menarche. n

Standard investigations Measurement of estradiol, LH and FSH helps determine whether puberty is activated and a gonadotropin stimulation test may also be required to determine whether puberty is centrally activated. Elevated serum androgens point to a pathological cause of isolated pubic hair development. Pelvic ultrasound may reveal uterine stimulation or ovarian development and rarely tumour.

Head MRI is performed to look for CNS pathology but in most cases no underlying cause is found and the early puberty is labelled “idiopathic”.

Management Untreated, precocious puberty is associated with eventual short stature (due to premature closure of epiphysial growth plates) and may produce significant psychological morbidity.

In true precocious puberty due to central activation, consideration is given to blocking further development with gonadotrophin releasing hormone analogs. These agents are highly effective and specific.

If pubertal changes are found to be a variation of normal development and are non-progressive then reassurance is all that is required. In particular reassurance that menarche is not imminent is important.

Related issues Breast development in infancy, premature thelarche, when not associated with other evidence of pubertal activation is self limiting and requires

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Review: Endometriosis

By Dr Atef Saba, Obstetrician & Gynaecologist, PIVET Medical Centre. Tel 0451 044 410

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ndometriosis causes subfertility, painful intercourse and chronic pelvic pain with obvious impact on quality of life, employment and relationships. Up to 10% of all women in their reproductive years are affected by endometriosis from as young as age eight to post menopause.

In Australia alone, about 600,000 females suffer from this condition.

Endometriosis is functioning endometriumlike tissue outside the uterine cavity that undergoes hormonal and immune inflammatory interactions. Common locations include the ovaries, fallopian tubes, utero-sacral ligaments, Pouch of Douglas, and pelvic peritoneum.

Most common symptoms

• Pelvic pain before and during periods. The amount of pain is not necessarily related to the extent of the endometriosis lesions.

• Pain during or after intercourse, perhaps worse around the time of periods.

• About 30-40% of women with infertility have endometriosis.

• Heavy bleeding.

• Preterm birth, pre-eclampsia and antepartum haemorrhage are more likely to happen in women with endometriosis (especially those with ovarian endometriomata). This has implications for prenatal care and assisted reproductive technology procedures offered.

Diagnosis Medical history looks for symptoms that come and go in relation to the menstrual cycle.

• Oral contraceptives.

• Progesterone derivative drugs.

• Testosterone derivative drugs (e.g. danazol, gestrinone).

• Gonadotropin-releasing hormone drugs.

2. Encourage pregnancy.

3. Surgery (from conservative to radical).

4. Symptom relief until menopause.

Clinical examination to detect endometrial nodules is more successful if performed during menstruation.

5. C omplementary treatments (e.g. high frequency TENS, acupuncture, magnesium and Vitamin B1 in dysmenorrhoea).

The diagnosis of peritoneal endometriosis is generally considered definitive after laparoscopy and visual inspection but histological confirmation of at least one lesion is ideal. In cases of ovarian endometrioma and deeply infiltrating lesions, histology helps in excluding malignancy. There is no evidence to support particular timing of laparoscopy, except not to perform within three months of hormonal treatment, to avoid under-diagnosis and understaging.

Key points in management*

Treatments

In minimal-mild endometriosis, hormonal treatments are not effective to treat infertility, but ablation of endometriotic lesions plus adhesiolysis is effective compared to diagnostic laparoscopy alone.

With no known cure for endometriosis, treatment varies, depending on the type and intensity of symptoms. Most common treatments are: 1. Hormonal treatments aim to stop the ovaries producing cyclical hormones that endometriosis tissue reacts to. Although these drugs can force disease remission during treatment and for months or years afterwards, their side effects and preventing fertility are a problem for some women. Hormonal treatments include:

Women with suggestive symptoms can be treated with an empirical trial of a hormonal drug to reduce menstrual flow.

All hormonal drugs studied are equally effective if used to suppress ovarian function for 6-months, although their side effects and costs differ.

Ablation of endometriotic lesions reduces endometriosis-associated pain.

Surgical excision of moderate-severe endometriosis does not generally enhance pregnancy rates but IVF is appropriate, especially if there are coexisting causes of infertility and/or other treatments have failed. *From European Society of Human Reproduction and Embryology Guidelines. n

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ince the launch of the first combined oral contraceptive pill over 50 years ago, we have seen a variety of formulations released in an effort to minimise adverse effects and offer non-contraceptive benefits, while maintaining contraceptive efficacy. Reduction in oestrogen dose, multiphasic regimens, different progestogens and novel delivery systems (e.g. vaginal ring) have all been in the mix.

Dosing changes More recently, we have seen a move away from the conventional 21/7 regimen to those with shorter and/or less frequent hormonefree intervals. Various extended cycle and continuous dosing (i.e. 365/365) regimens have been released overseas and the Australian market has seen the addition of the lowdose monophasic 24/4 pill, Yaz®, and the quadriphasic 26/2 pill, Qlaira®.

Qlaira® contains estradiol valerate (instead of ethinyloestradiol) and dienogest, which has antiandrogenic activity. Qlaira® is an effective treatment for heavy and/or prolonged menstrual bleeding, with good cycle control. A study comparing Qlaira® with an EE 20 μg /LNG 100 μg pill showed that scheduled withdrawal bleeds occured less often and were less predictable in thoes taking Qlaira®. Absence of withdrawal bleeding may be regarded as an advantage or disadvantage by certain women.

The rate of un scheduled ‘breakthrough’ bleeding was similar. At this stage, it is not clear whether there will be clinically significant benefits over other combined hormonal contraceptives. Because of its complex dosage

regimen, it has its own ‘missed pill’ guidance that differs significantly from that for other pills and may limit its use. Neither Yaz® or Qlaira® are PBS listed.

Recommendations change on OC and antibiotics After advising a cautious approach for years, there is now international consensus that women taking the combined oral contraceptive pill no longer need to be advised to use additional contraceptive precautions when taking most antibiotics. Evidence shows that antibiotics that do not induce liver enzymes do not affect the contraception provided by combined oral contraceptives.

In contrast, rifampicin and rifabutin, both potent enzyme inducers, require a caution if given to women taking combined oral contraceptives. Other hepatic enzyme-inducing medication, including St John’s Wort, can reduce the efficacy of all combined hormonal methods, progestogen-only pills (including emergency contraceptive pills), and implants.

Suitable alternative contraceptive methods for those using liver enzyme-inducing medication include depot medroxyprogesterone acetate,

Dr Maria Garefalakis, Medical Director, FPWA Sexual Health Services

hormonal or copper-bearing intrauterine devices (IUDs), and barrier methods.

Women using enzyme-inducing medication (or within 28 days of ceasing them) who require emergency contraception should be advised of the potential interactions with oral medications and be offered copper IUD insertion. Those who request oral emergency contraception should be advised to take a total of 3mg levonorgestrel (two x 1.5mg tablets) as a single dose as soon as possible after unprotected intercourse.

It is important to discuss correct contraceptive use during illness. Unless there are contraindications, women should continue to take their pills. However, in case of persistent vomiting or severe diarrhoea, instructions as for missed pills need to be given. Advice is based on the timing of symptoms and how many active pills she has already taken.

Further detailed information is available in the UK Clinical Effectiveness Unit guidance ‘Drug Interactions with Hormonal Contraception’ January 2011: www.ffprhc.org.uk/admin/uploads/ CEUGuidanceDrugInteractionsHormonal.pdf n

A M A Z I N G

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What is new in proliferative glomerulonephritis?

By Dr Doris Chan, Renal Physician, Sir Charles Gairdner Hospital

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roliferative glomerulonephritis (GN) describes a histological pattern of GN characterised by increased number of endothelial, mesangial, epithelial or inflammatory cells in the glomeruli. It can be the underlying histological feature of a variety of primary renal disease and systemic autoimmune disorders (see Table 1). Proliferative GN may present clinically with nephritis with or without renal failure, rapidly progressive GN, or end stage kidney disease. Early diagnosis and referral is paramount given that early treatment can prevent permanent renal injury. While the intricate details are the domain of renal physicians, this article highlights some recent advances around IgA nephropathy (IgAN), class III/IV lupus nephritis (LN) and anti-neutrophil cytoplasmic antibody (ANCA)-associated GN.

IgA Nephropathy

Pathogenesis. First described in the 1960s, the pathogenesis of IgAN remains a mystery. Recent evidence suggests that abnormalities in the sugar residues in the hinge region of IgA1 molecule lead to defective polymerisation with impaired clearance and generation of IgG autoantibodies resulting in immune complex formation and glomerular injury (Figure 1). Ones genetic makeup plays a role in the body’s immune response and two gene polymorphisms (related to multiple atherosclerotic disease) were noted as independent predictors of renal progression in IgAN. Classification. A new clinicopathological classification for IgAN has been developed to standardise reporting and identify histological features that predict of renal outcomes. Biopsies are scored based on the presence of mesangial (M), endocapillary (E), and segmental (S) hypercellularity, along with tubular atrophy/ interstitial fibrosis (T).

Treatment. IgAN has a variable clinical course and treatments are based on the individual’s risk for progressive renal disease. Non-specific therapy (i.e. ACE-inhibitors or ARBs) has been advocated in those with significant renal impairment, whereas other treatments (steroids +/- cytotoxics) may be considered in those with better preserved renal function. ACE-inhibitors or ARBs together with fish oil, can effectively preserve renal

Table 1 Causes of Proliferative Glomerulonephritis Primary Renal Disease IgA Nephropathy Post-infectious GN Mesangiocapillary GN

Systemic Disorders Class III and IV lupus nephritis ANCA-associated GN (e.g.

Wegener’s granulomatosis) ANCA-negative GN Anti-glomerular basement membrane (GBM) disease Viral hepatitis Paraproteinaemia

function and reduce proteinuria in patients with IgAN and significant proteinuria. Steroid therapy is considered in those with minimal change lesions and if there is ongoing proteinuria despite initial therapy. Although the use of cytotoxics is currently being studied, some have reported improved patient and renal outcomes with the addition of mycophenolate mofetil (MMF) but not azathioprine (AZA).

Proliferative (Class III and IV) lupus nephritis (LN) Patients with proliferative LN require immunosuppressive therapy to prevent kidney failure. This takes the form of induction therapy, followed by maintenance. The choice of drug

n Figure 1: Proposed pathogenesis of IgA nephropathy

depends on both efficacy and side effect risk, and race can influence the response to some drugs.

Clinical response, toxicity and relapse rate determine maintenance drug choice, with many still under trial to assess the best type and duration of maintenance therapy. Future therapies for refractory/relapsing LN may involve procedure/drugs that alter T- and B-cell function, such as stem cell transplantation, belatacept, belimumab etc.

ANCA-associated GN A new nomenclature, based on the presence of ANCA (MPO, PR3, negative), organ involvement and glomerular pathology, has been proposed for the vasculitides across what is a spectrum of clinical disorders. Similarly, a new histological classification focuses on focal, crescentic, mixed and sclerotic patterns, with the aim of improving reporting, prognostication, and immunotherapy.

For induction therapy, drugs such as cyclophosphamide (CYC), rituximab, and mycophenolate mofetil (MMF) are in use. The degree of renal disease influences choice. For maintenance, AZA, methotrexate and MMF are standard therapies that are being assessed in different clinical scenarios. Future therapies may include the addition of TNF-a blocker (i.e. adalimumab). n

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Great news. The new Day Surgery at the Hollywood Fertility Centre is opening soon. Patients will no longer have to go to hospital to have standard procedures done. We will offer a full range of infertility investigations and treatments including diagnosis, advice, IVF and other infertility treatments such as PGD. Ongoing counselling and support will also be available. To find out about all the other things that set Hollywood Fertility Centre apart call 08 9389 4200 or visit www.hollywoodivf.com Hollywood Private Hospital, Monash Avenue, Nedlands. Phone: 08 9389 4200. www.hollywoodivf.com RS/SIVF1444_MF

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11/11/10 4:46 PM medicalforum

W omen G P s on C aesareans

Conference Corner

Continued form page 29...

Aged and Community Services WA Conference

“I had the privilege to work in a rural city with an excellent obstetrician dedicated to reducing the caesarean section rate, which she did by having a committed team of GP obstetricians and midwives to actively manage labour and support women in their quests for safe vaginal births after caesareans.

Dates:

12/5/2011 13/5/2011

Venue:

Burswood Entertainment Complex

“If a woman is happy with the outcome and the caesarean for their first birth and if they have the same obstetrician, they would be highly likely to have another caesarean.

For more information contact 9389 1488, eecw@eecw.com.au.

Dates:

15/5/2011 18/5/2011

“Many women are keen for a trial of scar but for country patients this can be difficult to achieve in an appropriate centre.

Venue:

Perth Convention Centre

Website:

Website:

http://acswa2011.com.au/

This year’s conference is in partnership with Alzheimer’s Australia WA. It will feature international and nationally renowned speakers who will provide the latest information on the aged and community care industry, dementia and technology.

“In my practice of anaemic, diabetic, alcohol-consuming grand multis in whom PPH is common, I am surprised they all don’t have caesareans.”

“Women have a right to request a caesarean. I did however have two vaginal births and would do so again!. Too often, labour and delivery is still far too paternalistic with women being told what will be best for them, with little choice over their bodies.

“When normal pregnancies are managed by specialists it is bound to happen. They should go back to managing complex or complicated cases that are referred to them by GPs managing normal labour as happens in rural areas.

“We’re not much of a species if 1/3 of us cannot deliver without a caesarean! I had three normal deliveries including twins after a caesarean, so I am probably biased!

“Medicolegally, it is not acceptable to have a perinatal death due to uterine rupture and this is a real risk of trial of scar (even if rare), and avoidable by caesarean. n

Australasian College of Dermatologists’ 44th ASM

http://www.dermcoll.asn.au

The meeting attracts a large gathering of dermatologists from Australia and other countries in the region. It is an opportunity to make contact with the principal prescribers of medicines and other healthcare products to dermatological patients and consumers.

For more information contact (02) 8765 0242 or 1300 361 21, rsheaves@dermcoll.asn.au Congress on Innovations in Nursing

Dates:

18/5/2011 20/5/2011

Venue:

Perth Convention & Exhibition Centre

Website: http://www.icin2011.com/

This year’s congress will showcase innovation and leadership in clinical practice, research and education. Delegates will gain knowledge and insight into how to manage the challenges faced by nurses in today’s complex healthcare environments.

For more information contact (08) 9389 1488, lexie@eecw.com.au

Visit www.medicalhub.com.au for more information and click on ‘Events’.

BreastScreen WA moves to digital mammography BreastScreen WA (BSWA) officially launched the roll out of full-field digital mammography at BSWA’s Perth City Clinic on International Women’s Day, Tuesday 8 March 2011.

The use of digital technology is expected to improve screening capacity and enhance the screening experience for women. Fullfield digital mammography can be more sensitive to detecting breast cancer in younger women with dense breasts.

Australian women have a 1 in 9 risk of developing breast cancer in their lifetime and early detection and treatment can save many lives.

BreastScreen WA provides a FREE screening service to women aged over 40 and targets women aged 50 to 69 years. These women are encouraged to have a mammogram every two years.

Phone 13 20 50 for an appointment. www.breastscreen.health.wa.gov.au

Metro locations: Cannington, Fremantle, Joondalup, Midland, Mirrabooka, Padbury, Perth City and Rockingham. Rural locations: Check your local media for mobile visit dates.

Helping Deliver a Healthy WA

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On the Grapevine

Dr Craig Drummond

Old Kent River Wines It was in 1985 that Mark and Debbie Noack first planted vines in order to diversify their sheep property in the Rocky Gully area of WA. Having known them over the many years that I worked in the area I came to admire their grit and determination – real ‘Aussie battlers’, who started with little knowledge of the industry , and progressively went from strength to strength , establishing themselves a real niche in this difficult and competitive industry. They increased their plantings year to year and in 1991 produced their first wines – amazingly ,and in keeping with their character, choosing the most difficult wines with which to succeed- Pinot Noir, and sparkling wine from Pinot Noir and Chardonnay. By 1994 they had added Chardonnay, Sauvignon Blanc and Shiraz to their range.

As well as hard work they are fortuitous that their 15 Ha. main vineyard is located in the wonderful vine growing area of Frankland River in our Lower Great Southern region.

They have also more recently added a small 2 Ha. vineyard in Denmark, and over the years have built a reputation for their Cellar Door and Slow Food Cafe located between Denmark and Walpole. In typical style this cafe serves marron, lamb and salads all produced on their own home property.

Their ‘sparklie’ is called Diamondtina. I tasted the 2007 ($25 cellar door). I was impressed.

It showed a fine persistent bead,

and was very lively in the mouth. The 70% Pinot fruit is very evident, giving rich rounded flavours and generosity, with a hint of strawberry on the nose, and red berry flavours. The Chardonnay adds finesse, and the autolytic yeast is evident without being dominant. Refreshing, complex and great current drinking.

The 2010 Sauvignon Blanc ($16.25 cellar door) is a good balanced wine, with lifted guava and kiwi fruit aromas, and tropical fruit flavours. The fruit is soft and round with a hint of savoury, making for a great wine to accompany seafood.

Early picking (alcohol of 12.5%) has retained acidity giving a nice clean finish.

If you are looking for bargains then go for the 2008 Shiraz (only $16.25 cellar door). It has rich, ripe aromas of mulberry and spicy plum, and

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Which of the wines reviewed has guava and kiwi fruit aromas?

Answer:

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plenty of oak. This leads to integrated flavours of black cherry, oriental spices, and nutty oak. I feel this wine is a couple of years off its peak, and has a few years left in it yet. Amazing what we can get for our money in the current market.

Old Kent River’s reputation has been largely built on its success with the difficult Pinot Noir variety. The 2006 ‘Burls’ Reserve Pinot Noir ($45 cellar door) is one of their limited release wines, made from the best fruit, given 12 months quality French oak, and made only in the best vintages. The example tasted is a big style of Pinot showing developed secondary fruit characters, aimed at fans of this variety. It needs decanting and breathing to show its best. It is loaded with spicy/savoury red fruit and cherry kernel flavours, and has a complex earthy forest floor undertone. The firm drying tannins make it rather robust. A great wine which I feel is at optimum drinking now.

The wines all reflect the hard work and application of these producers. They can be ordered on www.oldkentriverwines.com.au or through some Perth liquor outlets.

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Please send more information on Old Kent River offers for Medical Forum readers.

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Lifestyle Feature

Dining Out in Perth As restaurant critic for The West Australian, Rob Broadfield is feted - and feared - for his incisive accounts of Perth’s best and worst dining destinations. For this month’s feature, Rob gave us his top five picks for restaurants that are must-visits for any WA gourmet worth their salt.

Balthazar Balthazar has reputation for inconsistency, but it’s never worse than very good, and the current brigade is on top of their game at present. It’s dark, moody semi-industrial interior speaks more of Flinders Lane (Melbourne) than the somewhat culinarily-barren bottom end of the Perth CBD. It’s perfect for an assignation, a slap-up dinner with a drug rep or for a bunch of wine aficionados out for a good time (the wine list is utterly brilliant!). The food is modern Australian without lurching into the silliness of foams and the like. The black garlic liquorice ice cream is sublime. So to are the simple, but keenly executed entrées and mains.

types and those who simply can’t live without chef Vincenzo Soresi’s roast meats, impeccable pastas and pan-cooked wonders. It might pay you to have a little lap band procedure before you go, otherwise you will eat too much. Vincenzo is famous for his meat balls (ask him to cook a few as a pre-entrée, just so you can taste these marvels). There’s lots of Italian stallions on the wine list too.

Located at 199/203 Onslow Road, Shenton Park, 6008.

For bookings, phone 9382 3343.

Located at 6 The Esplanade, Perth, 6000. For bookings, phone 9421 1206.

La Lola

Galileo

Speaking of sexy Italians, this Nedlands nosh-house – perilously close to AMA HQ on Stirling Highway – is channelling all the cool of a Milan trattoria. The food’s simple but well cooked. But it’s the hustle and bustle and damned sexiness of the place that gets you. La Lola doesn’t take bookings, which has seen some western suburbs grandees stalk off in a huff (talk about not getting it!). For the rest of us the wait for a table in the moody back room is all part of the fun. Chef Tony Garita hits all the right notes and is uncompromising in his adherence to Italian flavours and techniques. Having said that all his dishes have been “pimped” for a modern Australian audience. Get your Manolos on, slip into your vintage Fiat and get on down to Hampton Road where La Dolce Vita is alive and well at La Lola.

This Shenton Park tuckshop feeds the great and the good on a weekly basis. The Chief Justice dines there as do other lawyers, business leaders and a Rabelaisian coterie of private investigators, criminal barristers, media

 Healthy Body  Healthy Mind  Healthy Life

www.createhealthfitness.com.au Our specialist team offers the following services at affordable prices, convenient locations and when it suits you!  Personal Training  Group Training  Nutritional and Weight loss Advice  Events to motivate, inspire and help you  Specialist products to assist you in creating your healthy lifestyle.

Located at 25A Hampden Rd, Nedlands, 6009.

For bookings, phone 9386 5554.

Nahm Thai Oh my God! Nahm Thai is Perth’s ground zero for Asian flavour. Every dish cooked by the supernaturally talent Kevin Pham packs weapons grade flavour. His pork hock is a crispy, fudgy, dark, salty, sweet, sour, slow-cooked stairway to heaven. So to is his duck in red curry with lychee. The service has improved dramatically in recent times (no more two-hour waits for your meal) and the food just keeps getting better and more refined. It says “Thai” in the name, but in fact, the flavours go crosscultural with enormous success: it’s Thai meets Vietnam meets southern China meets Bali.

Located at 223 Bulwer Street, Perth, 6000.

For bookings, phone 9328 7500.

Rockpool Brilliant. Perfect for a romantic dinner to get you in the mood. The staff are so solicitous and professional, you wonder why we’ve been putting up with such comparatively shoddy service in Perth all these years. Rockpool though is all about Neil Perry and his philosophy, particularly when it comes to great produce, treated simply. His steaks are the best in town – bar none. The cocktail bar makes the best cocktails in Perth. The side dishes and condiments are superb – try the macaroni cheese or any of the salads. Did I mention the steaks? Brilliant. Oh, and don’t let the Burswood address put you off. Get over it. It’s worth the arduous route march from the western suburbs.

Located at Burswood Entertainment Complex, Great Eastern Highway, Burswood 6100. For bookings, phone 6252 1900 or visit http://www.rockpool.com.au/rockpool-bar-and-grill-perth/

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medicalforum

Eating In

A Simple & Tasty Recipe to Make at Home

Russell Blaikie, Chef and Partner of the award-winning Must Winebar and Must Margaret River, gives readers a sneak peak at a tasty recipe from his new cookbook, Must Eat.

Black Olive & Gruyère Toasties Everyone loves a toasted sandwich. This ‘deluxe’ version combines the richness of gruyère with the savoury-saltiness of freshly made tapenade.

For the toasties (Makes 12 toasties) Ingredients: 1 baguette 40 g Comté (or gruyère) cheese, grated 60 g tapenade (see below) Extra virgin olive oil Directions: Preheat the oven to 200ºC. Slice the baguette into 24 x 1 cm thick pieces.

Combine the cheese and tapenade together in a bowl and stir well to combine. Spread a generous quantity of the mix onto one slice of bread, then sandwich together with another; keep going until all of the bread is filled. Lay the sandwiches onto a baking tray and drizzle generously with the olive oil, turn over and repeat.

Place into the oven and cook for approximately six minutes until the toasties are crispy, golden brown and the cheese filling has melted.

For the tapenade (Makes about 6 serves) This Provençale condiment is such a tasty invention. At home I often chop the ingredients with a sharp knife, which gives a rough, rustic texture to the earthy flavour. If you’re using a food processor, don’t blend the ingredients to a fine purée – keep it coarse.

Ingredients: 120 g best quality black olives, pitted 1 teaspoon capers 1 anchovy 1 teaspoon thyme leaves 1 small garlic clove 2 tablespoons extra virgin olive oil, plus extra to drizzle over the top 1 teaspoon lemon juice Twist of freshly ground black pepper Directions: Blitz the ingredients in a food processor until a coarse paste is achieved. Scoop into serving dish, drizzle with extra virgin olive oil and serve with fresh crusty baguette.

ust Eat by Russell Blaikie is published •M

by UWA Publishing ($49.95). Russell is chef and partner of Must Winebar Perth (9328 8255) and Must Margaret River (9758 8877). Visit www.must.com.au for more information.

WIN a copy of the Good Food Guide 2011 Medical Forum is offering readers the chance to win one of five copies of The West Australian Good Food Guide 2011.

Edited by Rob Broadfield, this is the definitive guide to dining out in WA, with reviews of almost 200 of the state’s best restaurants, cafes and bars.

To enter the draw, simply email your name, address and contact number to competitions@medicalhub.com.au

by April 30 with the text “Food Guide Competition” in the subject line.

The book is available for direct purchase for $19.95 from https://www. westgoodfoodguide.com.au/

medicalforum

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For more competitions Go to medicalhub.com.au

Prizes drawn at random. Competitions end 30/04/2011

Unleash Your Inner Artist The Extraordinary Mind Project is an art class for everyone from complete novices to professional artists, and aims to get people expressing themselves on paper by tapping into their creative side.

“We have a wide range of people from those who consider themselves stickman drawers to practising artists,” Ms Jan Cross told Medical Forum.

“You hear sports people talking about ‘flow’, and when that happens things seem to go perfectly and effortlessly at a superior level. So we’re actually learning to use that part of the mind more strongly and deliberately to draw.”

n Project founder Ms Jan Cross

Jan said many people are amazed at how much creative talent they have when they put their minds to it.

n n n n Her first child?

As his wife begins to go into labour, her panicked husband phones the hospital to ask what he should do, “My wife is pregnant, and her contractions are only two minutes apart!” he tells the doctor.

“Is this her first child?” the doctor queries.

“No, of course not!” the man shouts down the phone. “This is her husband!”

n Courtroom cross examination Q: Doctor, before you performed the autopsy, did you check for a pulse?

A: No. Q: Did you check for blood pressure?

A: No.

Half-price Course Offer

Q: Did you check for breathing?

Jan is offering readers the chance to win a half-price Draw Your Way to Creativity course at each of the four course locations.

Times, dates and locations are listed below: Mondays 7-9:30pm May 23-July 18 Murdoch

A: No. Q: So, then it is possible that the patient was alive when you began the autopsy?

A: No. Q: How can you be so sure, Doctor?

A: Because his brain was sitting on my desk in a jar.

Tuesdays 7-9:30pm May 31-July 26 Midland

Q: But could the patient have still been alive nevertheless?

Wednesdays 7-9:30pm May 18-July 27 Claremont

A: It is possible that he could have been alive and practising law somewhere.

Saturdays 10am-12:30pm June 4-July 30 Joondalup To enter the draw for a halfprice course, email your name, address and telephone number – along with your course location preference – to competitions@ medicalhub.com.au, with “Art course prize” in the subject line. n Students examine their progress Deadline for entries is April 30.

Competition Winners – February Gilbert’s Wines Doctor’s Dozen A/Prof Per Flisberg is anaesthetist at Royal Perth Hospital who originally hails from Sweden.

When he is not working, Per said he can typically be found on the golf course, and says he would be classified as a “golfoholic”. He also enjoys swimming and loves Perth’s warm climate – a pleasant change from his native Sweden – though he said he does miss being able to ski.

In addition to the weather, Per reckons Australia has a lot to offer when it comes to wine, “I do like wine a lot, and I have learned a lot about it by being in Australia,” he said. No doubt a dozen fine wines from the Gilberts selection can only help to further his education.

n n I can hear just fine Three retirees, each with a hearing loss, were playing golf one fine March day. One remarked to the other, “Windy, isn’t it?”

“No,” the second man replied, “it’s Thursday.”

And the third man chimed in, “So am I. Let’s have a beer.”

n n n n A woman’s work...

John thought housework was a woman’s job, but one evening his wife Janice arrived home from work to find the children bathed, one load of laundry in the washer and another in the dryer. Dinner was on the stove and the table was set. She was astonished!

It turns out that John had read an article that said, “Wives who work full-time and had to do their own housework were too tired to have sex.”

The night went very well. The next day, Janice told her friends all about it. “We had a great dinner. John cleaned up the kitchen, helped the kids do their homework, folded all the laundry and put it away. I really enjoyed the evening.”

“But what about afterwards?” asked her friends.

“Oh, that…” she said, “John was too tired!”

Tripod v The Dragon – theatre: Dr Jenny Hart, Dr Sally Price & Dr Dani Paterson Kool & the Gang – concert: Dr Sara Chisholm, Dr Julia Charkey-Papp & Dr Kwok-Keong Lam Conviction – movie: Dr Yien Peng Chin, Dr Yuping Chen, Dr Moira Westmore, Dr Philomena Fitzgerald, Dr Anne Donnelly, Dr Gareth Mann, Dr Patrick Lai, Dr Ted Khinsoe, Dr Fiona Whelan & Dr Mathew Carter

medicalforum

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