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WA’s I n d e p e n d e n t M o n t hl y f o r H e al t h P r o f e s s io n al s
Medicare Locals Inside SJGHC Heath Black
Children Bearing Burdens • Children in Detention • Foetal Alcohol Spectrum Disorder • Epoll: Unhealthy Sports Sponsorship & Teen Sexual Health and more... www.mforum.com.au
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Contents Heath Black: Back from the Brink
Dr Michael Stanford: What Makes SJGHC Tick?
News & Opinion Dr Michael Watson
A/Prof Prudence Manners: Childhood Arthritis
2 Letters. Good Telehealth A Must.
Dr Mal Washer: Drug Prohibition Law Reform
4 Kids and Computers. Dr Johana Stefan
16 Reorganising Remote Paediatrics Dr John Boulton
Dr Andrew Kennedy
Early Intervention Needed.
Dr Donna Mak
Ms Michelle Ray
36 Public Health and Medical Practice (Part 3).
24 Children in Detention: Bad for Health.
Dr Timothy Cooper
Mental Health Funding.
Mr Eddie Bartnik
Prof Roger Hart
35 Lifting WA School-Kids’ Immunisation Coverage.
22 Having Patience With Your Patients.
Ms Angela Hartwig
34 Early Life Events – Impact on Future Reproduction.
Dr Revle Bangor-Jones
Dr Gervase Chaney
37 Stem Cells and Cerebral Palsy. Dr Anna Gubbay
28 Strong Spirit, Strong Future. Ms Judi Stone
Disease Watch Online.
Dr Paul Armstrong
4 An Eye for a Good Photo. Straight Talk About Aboriginal Health 6 Have You Heard? 10 E-poll: Kid’s Sport, Teen Talk, and Medicare Locals. 13 John Quigley MLA: The Fight for His Life. Dr Rob McEvoy
17 WA Adolescent Sexual Health Website. 19 Medicare Locals: Small on Detail, Big on Potential? 23 Beneath the Drapes. 25 Getting onto the PBS. 27 A Voice for Murdered Girls. Ms Tellisha Dunlop
Lifestyle & Entertainment
Clinical Focus 5 Otitis Media.
Dr Michael Watson
7 Dabigatran: “New Warfarin” for AF Patients. Dr Paul Stobie
38 The Funny Side. Competition Winners – June edition. 39 Wine Review: Cullen Wines. Dr Louis Papaelias
40 E-poll: Parenting Regrets and Retirement Plans. 41 Chipping In For The Bush. 42 Competitions. Recipes.
29 Why We Say ‘No’ to Alcohol in Pregnancy. Dr Desiree Silva
30 Health Concerns Around Competitive Sport in Children. Dr Carmel Goodman
31 Who Can Access Children’s Medical Records?
Dr Sara Bird
33 Children’s Equity CEDARS Centre
37 Event & Conference Corner.
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Mental health funding Dear Editor,
Regarding the call by 71% of surveyed doctors to allocate more community resources to mental health (Male Medicos Comment on Men’s Heath, July edition), the WA Mental Health Commission is working towards a community where people who experience a mental health problem are supported to live successfully in the community. We need to reduce the stigma and create an “ordinary” conversation about mental health as something that affects each one of us directly or indirectly.
People need the support of their family, friends, and colleagues and access to good information and support services. If specialist service intervention becomes necessary, it should be responsive, respectful, and of a high quality. This means strengthening primary care, boosting community mental health services, increasing funding for prevention and early intervention, and relocating resources closer to home, including inpatient hospital beds.
The recent State Government budget allocated an additional $50m for mental health, the highlight being personalised housing and support packages for 100 people who have been stuck in hospital awaiting discharge, with an additional 44 intermediate care beds for people as a step down from acute hospital care. An additional $6.5m will be allocated to the Department of Health for new mental health services and a further $4.2m to community organisations. We have allocated funding for a Mental Health Coordinator position at the WA GP Network, which will support access to psychological services funded through Medicare. This position will also strengthen partnerships with Medicare Locals and GP Divisions.
The new Statewide Specialist Aboriginal Mental Health Service will become fully operational, with an additional 60 staff across the state. We are investing $13m over four years into the implementation of the WA Suicide Prevention Strategy, in which men are identified as a priority target group, and an additional $500,000 funding has been provided for the Lifeline Crisis Care Line. Health professionals play a key role in reducing the stigma surrounding men’s mental health. By asking questions and encouraging them to talk, and supporting and referring them on if needed, we are educating men that asking for help is a courageous and acceptable way to solve problems.
Mr Eddie Bartnik, WA Mental Health Commissioner
Disease watch online Dear Editor,
Since 1991, the Communicable Disease Control Directorate of the WA Department of Health has been keeping health professionals informed of the latest communicable disease issues in Western Australia via its bi-monthly bulletin Disease WAtch (formerly the Western Australian Communicable Diseases Bulletin).
Disease WAtch has traditionally been published in print, but it is now only available online at www.health.wa.gov.au/diseasewatch. Subscribers who have previously received Disease WAtch in the post will need to renew their subscriptions to ensure future editions can be sent straight to their inbox. Subscriptions remain free.
plastic surgery and ENT surgery.
It was interesting to see the prices that they quoted for these procedures, comparing Australian prices with Malaysian prices. For breast reduction, they were quoting $25-30k Australian dollars for a breast reduction in Australia versus $9-11k in Malaysia. It is possible to have a breast reduction in Australia for considerably less than what was quoted.
I am not proposing that we can in any way ban people from undergoing medical tourism procedures, but I think the public needs to be aware of the risks involved – and these are not inconsiderable. Also, the cost saving when undertaking this is often false economy and these medical adventures are promoted as holidays with five star hotels thrown in the mix. I do not believe that any medical procedure should be confused with a holiday. I agree, however, from the tone of the article that it is indeed very confusing to sort out fact from fiction in this story. However, buyer beware.
Dr Timothy Cooper, Plastic Surgeon, Nedlands
Dr Paul Armstrong, Director, Communicable Disease Control Directorate
Buyer beware! Dear Editor,
With regard to medical or cosmetic tourism (More Cosmetic Tourism, July edition), I am reminded of this virtually every week when patients come back to me with problems following their foray, usually to South East Asia, for some sort of cosmetic procedure. It is hard to gauge the true incidence of adverse or unsatisfactory results of surgery in South East Asia, but certainly when Australians suffer injury abroad, the cost savings pale into insignificance when one is trying to fix their problem. When misadventures do occur, these patients often end up in the public hospitals for corrective surgery. The article got onto the issue of PIP implants. I have firsthand knowledge of the PIP implants, having used a number myself some five years ago. The French regulatory authority in March 2010 placed a ban on these implants and TGA rapidly followed suit. Suffice to say, my understanding is these implants had been recalled worldwide since April 2010. I was then intrigued to read about a healthcare provider www.surgicalalliance.com.au promoting treatment in Malaysian hospitals. One of their promotions was that they were using local surgeons as go-betweens. Both Australian surgeons mentioned are general surgeons and are most likely eminently qualified in their field of general surgery. However, many of these procedures are not general surgery and include things such as
Early intervention needed Dear Editor,
The Male Medicos Comment on Men’s Heath article in the July edition of Medical Forum highlights that ‘family breakdown and ‘a violent up-bringing’ were identified as the two most primary reasons that led to an increase in violent behaviour of young men on the streets. Children and young people will model what they see and learn from home, school, and television, film, advertising, and electronic games. Experiencing, witnessing, or being exposed to violence in the home is an extremely traumatising experience for children and young people and will have both short and longer term effects. Growing up in the climate of fear that violence in the home creates is harmful and very unhealthy for the physical, emotional, developmental and social well-being of a child.
Adult survivors of domestic and family violence and child sexual abuse may carry the psychological wounds for many years. Often this has been taboo subject and one that carries immense pain, shame and guilt to talk about. Unless victims can have access to early intervention programs there can be devastating consequences such as violent behaviour, depression, substance use (often to self-medicate or escape the confusion and memories of the violence), PSTD, self-harming, and suicidal thoughts.
Drug and alcohol do not cause domestic and family violence; the use of substances can lower inhibitions in turn leading to escalation in the frequency and severity of assault. However, in most cases, men who use violence while under the influence are also violent men when not affected by drugs and alcohol.
However, in order to truly make meaningful changes in our society, there needs to be multilayered approach to which is well coordinated and integrated approach so as to challenge the glamorising and normalising of violence and aggressive male stereotypes in the media and internet and in turn perpetuate negative attitudes and behaviour towards women; and reject definitions of ‘being a man’ or notions of masculinity that are associated with violence for boys and men.
Ms Angela Hartwig, Women’s Council for Domestic and Family Violence Services (WA)
Ed. References available on request
Good telehealth a must Dear Editor,
I am responding to the excellent article on Telehealth (Eyes on The Screen – Telehealth, July edition), which highlights the diverse range of weaknesses and limitations of Telehealth medicine, and all the points made are valid and well taken.
However, I think we need to pause for a moment and think of the enormous opportunity this program presents for disadvantaged people who are denied access to specialist health care through isolation in remote communities or immobility in nursing homes. The tyranny of distance can be reduced with this technology, and it presents an extra-ordinary opportunity for city folk such as myself who are tied to the city to make a significant contribution in the bush. So can good telehealth be done? Of course it can! The Canadians have achieved excellent outcomes using telehealth for remote communities. The opportunities for health education are unprecedented. Country GPs, practice nurses, and Aboriginal health care workers can now be paid to directly participate in specialist consultations with opportunities to learn from a broad range of specialised skill sets. The technology will also promote enormous opportunities for group discussions and interactive educational programs for patients and health care staff in the bush. This technology promotes much more than specialist health care and education, it also promotes regular high quality communication between the doctors in the city (who have the ear of government) and our bush colleagues so that we can see and experience first-hand
the extraordinary difficulties our colleagues and patients face in the bush. Through this improvement in our understanding, hopefully we can convince those in power to spend the money and resources needed to improve things. Let’s all get behind this initiative and have a go at making it work for the disadvantaged people who currently find it difficult or impossible to access the specialist health care and help promote a little equity in health care in this state. If we miss this opportunity, it may be a decade before we get another!
Dr Michael Watson, West Perth
Underlying causes Dear Editor,
I read with interest the results of your survey of male doctors on men’s health (Male Medicos Comment on Men’s Health, July edition), in particular, the first few questions on violence.
A couple of colleagues and myself run an adolescent health clinic at Princess Margaret Hospital. The upper age limit for new referrals is 16, so we see a younger cohort, no doubt, than some of your respondents who I believe were mostly GPs [Ed. We have no way of telling if this is true but roughly similar numbers of male GPs and specialists received our broadcast]. Patients referred to our clinic are a heterogeneous group with referrals coming from GPs, schools, paediatricians, psychological medicine, and Killara youth support services. The latter is a diversionary service within DCS aimed at supporting families where youth are getting into trouble with police.
cause the behaviour or the violence but in fact are often used to self medicate the underlying issues. I am, of course, aware that in older males there is clearly a link, especially between alcohol use and violence.
Our approach is, where possible, to involve appropriate support and therapy (e.g. psychological services), family therapy, and importantly, our Hospital School Services to help keep or reintegrate these young people back into school. Lack of school attendance or declining attendance is probably the most common unifying “symptom” that we encounter among the young people attending our clinic. We rarely, if ever, recommend ‘anger management’ therapy as the problems are complex and multilayered and this sort of therapy is unlikely to be effective in isolation. Evaluating our service is difficult but anecdotally many of our patients do return to school and report improved behaviour and functioning within the family.
It may be a long bow but perhaps if there were more services such as ours to identify and help manage these issues earlier, we may reduce some of the violence that is seemingly so present in young adult males in our community.
Dr Andrew Kennedy, Paediatrician and Adolescent Physician PMH
Ed. The survey results from our E-poll of male doctors got some coverage in The West and on 6PR, where the predominant messages were that doctors are concerned about what underlies the violent behaviour of young men, and in helping them, and that drugs and alcohol were the disinhibitors.
A recent audit of our patients showed that 23% of all referrals are for behavioural problems. About one third of our referrals are for unexplained medical symptoms. Although a broad generalisation, many of these are female, whilst the majority of patients with severe behaviour problems are male, and the Killara referrals are almost exclusively male.
Not all the behavioural problems involve violence but a significant proportion do. To put it bluntly, girls tend to internalise their concerns and symptoms are more likely to be mood related, often with somatic complaints (e.g. chronic abdominal pain) whereas boys tend to externalise and express their distress through violent or antisocial behaviour. When we look further into the underlying causes we often find exactly the sort of things listed by your respondents. For example family breakdown, exposure to domestic violence or neglect, bullying, and mental health problems. From time to time, we also identify learning difficulties, Asperger’s syndrome, ADHD, and other contributing conditions. The reasons for the symptoms and behaviours are invariably multifactorial.
Our experience is not that drug and alcohol use
Ms Jenny Heyden RN and Dr Rob McEvoy would like to thank everyone for their ongoing support. Medical Forum comes to you free each month thanks to the hard work of a small dedicated production team, our sponsors and advertisers, and us. As an integral part of the WA medical community for over 20 years, we take pride in our reputation for ethical journalism and a publication that both entertains and informs. Please enjoy this edition. 3
Kids and Computers New technologies are influencing our kids’ health, forcing GPs to keep up with the trends, says Paediatric Psychiatrist Dr Johana Stefan. Dr Julian Dooley’s captivating presentation Kids, Computers, and Safety hosted by the AMA on 26 July prompted me to consider the medical perspective on the topic. As technology spreads, doctors are not only required to keep updated for everyday life and work, but they are also called to recognise the effects it may bear on their patients. Over the past few years, children’s access to a variety of communication technology has increased dramatically: in the USA, up to 75% of teenagers own a mobile phone and similar numbers are engaged in online social networking. The developmental task in adolescence is to define identity and purpose, and the ego quality gained is fidelity. Teenagers have an unstable self-image and are therefore vulnerable to the opinions of others and to peer pressure.
If roughly 30% of patients are kids, we are likely to see technology-related problems frequently, and an evidence base is starting to emerge. Mobile phone usage is possibly linked with brain tumours. We have already seen the devastating effects of cyberbullying, heard of teenagers with eating disorders sharing tips on
internet, and self-harming teens looking for new means or challenging each other to take risks online. Exposure to violence appears to desensitise kids and participation in chatrooms has been associated with an increase in suicide. Sexting, sexual solicitation, and online grooming are concerns with potential impact on child sexual abuse. Recent literature describes “internet addiction”, which is not a recognised entity in DSMIV, but shares features of other types of addiction.
If roughly 30% of patients are kids, we are likely to see technology-related problems frequently. It’s not all bad, however; mobile phones keep us in touch with our kids, while the internet provides entertainment and quick access to a vast amount of information, with claims of positive effects on cognitive development. Not to mention the convenience of having somebody in the household who knows how to work the various gadgets we acquire these days …
An Eye for a Good Photo Perth ophthalmic photographer Chris Barry was recently announced the winner of the 2011 AIPP Australian Science Environment & Nature Photographer of the Year (worth $2,500). Chris, who is best known to the WA medical profession through his work with the Lions Eye Institute, was one of 850 photographers who submitted images for this year’s competition. In total, there were over 3,000 images submitted by national and local photographers, competing for various photographic awards. l
GPs are in an ideal position to identify technology-related problems – keeping in mind that kids will most likely present with vague, non-specific complaints or with completely unrelated issues, the best strategy is to ask all patients! Ask about mobile phone and internet use, preferred online activities, length of time spent online, and whether they are harassed by anyone. This may give some insight into their emotional needs, an appreciation of eventual risk to self, risk to or from others, and an opportunity to intervene. The privilege of information comes with great responsibility and the GP may be faced with the dilemma of reconciling the child’s right to confidentiality with duty of care, and as mandatory reporters, with duty to inform. Intervention also includes the involvement of parents, of school, and if significant mental health issues are identified, referral to specialist services, either private or public.
Ed. For the Northern catchment area, CAMHS (tel: 92339366) provide a centralised triage service under the supervision of a consultant psychiatrist, with duty officers available every day. l
Straight Talk About Aboriginal Health More than 170 medicos attended Rural Health West’s annual Aboriginal Health Conference recently. Keynote speaker Mr Mick Gooda (pictured right, with RHW CEO Belinda Bailey), the Aboriginal and Torres Strait Islander Social Justice Commissioner, spoke about his aims and goals, while Miles Franklin Award Winner Dr Kim Scott (from Curtin University) presented on mandatory education in Indigenous culture and health. l
By Dr Michael Watson, Clinical Microbiologist
Otitis Media O
titis media is common in general practice, yet until recently, controversy still surrounded the role of antibiotic therapy in the management of this disease. At last, the definitive randomised controlled trial has now been published in the New England Journal of Medicine (NEJM) that clearly demonstrates the benefit of antibiotics in this disorder.
Why such past difficulty demonstrating benefit? The answer is that there are many different causes of otitis media, many of which either do not respond to antibiotics (e.g. respiratory viruses) or in the majority of cases will spontaneously resolve without recourse to therapy (e.g. Moraxella catarrhalis).
What was the underlying problem?
Those children with: • high fevers;
• who are younger;
• who have been pulling at an ear; and
• who on examination demonstrate a bulging red inflamed drum would warrant antibiotic therapy.
The principal villain in this tale is Streptococcus pneumonia. We know that only a minority of patients who have culture-proven pneumococcal ear infection spontaneously resolve, and it is these patients that go on to develop early complications such as ear drum perforation and mastoiditis, or longer term complications such a glue ear.
If the child fails to respond at 48 hours or worsens on amoxycillin alone, then there is the possibility of a pneumococcal strain with reduced sensitivity to penicillin or a beta lactamase containing pathogen such as Haemophilus influenzae, Staphylococcus aureus and occasionally Moraxella catarrhalis.
Adjusting dose in poor responders
In the pre-antibiotic era as many as 1 in 100 children with otitis media went on to develop mastoiditis, which was a potentially fatal complication in those days. Now, we estimate that approximately 1 in 1000 children with untreated otitis media will develop this condition (and interestingly, one child in the control group of the NEJM study did just that).
Early conjugate pneumococcal vaccine trials demonstrated the importance of pneumococcus in the etiology of glue ear. There was a 20% reduction in the incidence of grommet insertion in patients who received the vaccine and this was at a time when the vaccine probably only covered about 80% of otitisrelated strains.
Should all children with otitis media be treated with antibiotics? The answer is still no! The key lies in the clinical diagnosis, which unfortunately is not straightforward. Those children who are afebrile (or with a low grade fever), are older and have an obvious viral illness and who have not been pulling at their ear or complaining of ear pain (if old enough to do so) and have only mild bilateral erythema of the ear drums should not usually receive antibiotics in the first instance.
basis that it is well tolerated and absorbed, has good penetration into the middle ear and good activity against the most important pathogen, Streptococcus pneumonia. Pneumococci never contain beta-lactamase genes and the addition of clavulanic acid confers no additional benefit for treatment of this organism. Amoxycillin in this dosage should cover fully penicillin sensitive strains of pneumococcus.
Although simply switching to an 8 hourly dosing regimen of amoxycillin/clavulanate has been recommended, I find the higher dose of the clavulanate component results in significant diarrhoea. My personal preference is to increase the total dose of amoxycillin to 90mg/kg/day, in 4 doses now, as:
The difficulty lies in all those clinical scenarios that fall between these two extremes. I guess this is the area that calls for the clinical judgement that we provide as medical practitioners. At least there is now a study showing that antibiotics do show benefit for this condition and reduce the duration and intensity of symptoms particularly in those children with true bacterial otitis media. Choosing to withhold antibiotics is a reasonable approach, however a review at 24 hours is probably wise in case the problem has progressed.
What antibiotic is best to treat otitis media?
My recommendation, in the first instance, is to treat empirically with amoxycillin 15mg/ kg/dose (45mg/kg/day) oral 8 hourly on the
• Breakfast - amoxycillin/clavulanate (standard dose of 22.5+3.2 mg/kg)
• Lunchtime - amoxycillin (22.5mg/kg)
• Evening meal - amoxycillin/clavulanate (22.5+3.2 mg/kg)
• Just before bed - amoxycillin (22.5mg/kg)
The increased daily amoxycillin dose of 90mg/ kg has been shown to be effective against most pneumococcal strains with reduced sensitivity to penicillin in uncomplicated otitis media, while a standard dose of clavulanate is less likely to cause diarrhoea while at the same time covering the beta-lactamase producing pathogens. Otitis media remains a diagnostic challenge however at least we have the re-assurance now that there is benefit in the selective and judicious use of antibiotics in this condition.
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.
Have You Heard?
Medical coordinator with the Communicable Diseases at HDWA, Dr Paul Effler, is pleased with general practice uptake of over 5000 Pertussis vaccines since Kim Hames announced that the free vaccination program was being extended to grandparents and parents of any child born within the last six months. The program, thanks to the efforts of GPs, aims to increase herd immunity and stop the circulation of the virus in vulnerable populations. It adds to Pertussis vaccines already offered through community hospitals, health centres, and maternity hospitals.
country hospitals, although they are uncertain as to what needs upgrading where, as yet. That’s Katanning Hospital ($35.43m), Northam Hospital ($31.2m), Narrogin Hospital ($39.86m), Merredin Hospital ($17.45m), Warren Hospital Manjimup ($14.86m), and Collie Hospital ($8.63m). An extra $36.5m is going to Telehealth. The WA Country Health Service has the job of finding the extra private GPs from across Australia and internationally. Thank God for Brendon and the Nationals.
MDA truly National
MDA National, a West Australian enterprise since 1925, is transferring registration in line with its growing national reach. The original doctor group that made up the Medical Defence Association of WA (MDAWA) under the Associations Incorporation Act 1987 (WA) now becomes MDA National Limited, registered as a company limited by guarantee under ASIC (as is its insurance arm, MDA National Insurance). The EGM approval on July 15 coincides with the MDO’s move into wholly-owned premises in West Perth, the head office for its national operations, now servicing 24% of Australia’s doctors. Retired members will be entitled to vote for the Mutual Board (previously ‘Council’) under the new Constitution.
Dropping the ball
An alliance appears to have emerged between the Curtin public health unit, AMA WA, and Healthway. Encouraged by their success with anti-tobacco lobbying, the alliance now have their sights set on junk food promotion on TV and through sport. However, they have a harder fight on their hands as sport has its own health messages (when tobacco didn’t) and diverting support funds from mums-and-dads sports to research and the promotion of healthy messages alone, without increasing sports participation rates amongst kids, is going to be hard to justify. See page 10 for our e-poll of healthy sponsorship of kids’ sports.
Remember when all the regional hospitals were closing down due to lack of staff and perceived inefficiencies? Royalties for Regions has changed all that with $147m now earmarked to upgrade 6
Other post-budget regional health spending in WA includes: $182.9m to fix workforce problems to improve resources and 24-hour emergency response; $43.4m for the Primary Health Care Demonstration Program, where local communities get to deliver health services better; $20m to encourage private operators to expand residential aged care and dementia care across the southern inland area; and $108.8m for capital works on small hospitals and nursing posts, to improve services where there is no GP.
Telethon Institute for Child Health Research will retain its current building in Subiaco but will get $65m from the State and $40m from the Commonwealth to co-locate with the new PMH at the QEII site. We are talking the end of 2015. Having research facilities for clinicians has always been a key factor for attracting the right people, and vice versa, of course. Institute Director Prof Fiona Stanley said the Institute facility within the new building would be a state of the art design that caters for more than 500 researchers, staff and students.
Here’s one for the anti-tobacco lobby. A study of 226 Italian women aged 25-50 years found 14% with acne, distinguished by comedonal, low level inflammatory acne on the lower third of face, with relative non-involvement of jawline. The correlation with cigarette smoking was strong – 72.9% smoked vs 29.4% with papulopustular type acne and darker skin. The association was put down to the hyperkeratinisation and non-neuronal Ach pathways effects that cigarette smoke has on the epidermis.
Working under influence
Using data collected from 23,000 Australian residents aged 12 and over during the 2007 National Drug Strategy Household Survey
(NDSHS), researchers now report that 8.7% of respondents reported usually drinking at work (5.6% said under the influence) and 0.9% usually use drugs at work. Workplace drugs were most commonly painkillers, amphetamines, and methamphetamines, followed by cannabis and ecstasy. Young, male, never-married workers with no dependent children were more likely than other groups to work under the influence of alcohol or drugs. No wonder our mining mates up north do spot drug and alcohol checks.
Levels of stress are increasing amongst Australians and Lifeline is concerned. Comparing their survey over the last four years, an alarming amount of us are experiencing high levels of stress at work and at home – up from 43% last year to 48% this year. Natural disasters were called upon to explain the increase, but poor stress management, very long work hours, thoughts of the future, finances, health, and personal relationships were also in the mix. Women are more stressed than men, big cities are worse – no surprises – but>60% of 18 and 19-year-olds are very stressed (when we thought they were the ones who have never done a hard day’s work in their lives!).
WA seems set for some consolidation amongst Pathology providers. As we go to press, it has been reported that St John of God Pathology is putting out feelers for a purchaser and amongst those doing due diligence, Sonic Healthcare, owner of Clinipath Pathology, Bunbury Pathology and SKG Radiology, is front runner. St John of God Pathology reportedly private bills around 15% of services, regarded as moderately high in the industry. With the burgeoning collecting centres across all providers since deregulation in early 2010 (centres more than doubled for some), plus the squeeze on Medicare rebates, pathology providers are looking for economies of scale. St John of God, with 55 collecting centres, does not have the vertical integration that ownership of medical centres provides. Plus the not-for-profit status affords tax advantages that need to be discounted by any for-profit purchaser. Any amalgamation of providers will likely see redundancies amongst scientific and ancillary staff such as couriers, although clinicians – SJOGP lists 22 pathologists – are still high in demand.
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14 Cardiologists, together with Ancillary Staff, provide a comprehensive range of private Adult and Paediatric Services.
Dabigatran: “new warfarin” for AF patients
Dr Paul Stobie, Cardiologist, Western Cardiology
trial fibrillation (AF) is a major risk factor for stroke and systemic thromboembolism. Warfarin is recommended (with target INR 2.0-3.0) for stroke prevention in patients with certain risk factors, that is, CHADS2 score ≥2 (see table). However, the limitations of warfarin result in only ~60% of eligible patients being prescribed this therapy. Furthermore, only ~60% fall into the therapeautic range at any one time. Recently, an alternative in dabigatran (Pradaxa ®) has been approved for use in AF patients for stroke prevention and has several potential advantages over warfarin. Importantly the drug appears as safe and well tolerated as warfarin in the trials. Overall the advantages appear to outweigh the disadvantages for most AF patients.
Dabigatran approval is based on the RE-LY trial in which over 18000 AF patients were randomly assigned to 3 treatment arms: warfarin (adjusted to achieve INR 2.0-3.0); dabigatran 110mg bd; and dabigatran 150mg bd. The major findings were:
Consider who for dabigatran?
• Dabigatran 110mg bd has similar efficacy for stroke prevention to adjusted dose warfarin with a lower risk of bleeding complications.
• Dabigatran 150mg bd is superior to warfarin for stroke prevention with a similar risk of bleeding complications.
An important finding was a lower risk of cerebral bleeding for both dabigatran treatment arms.
Dabigatran difference from warfarin?
Dabigatran is an oral direct inhibitor of the active site of thrombin, the final effector in blood coagulation. The anticoagulant effect is sufficiently predictable to make laboratory monitoring unnecessary. Advantages of dabigatran over warfarin?
• Reduced risk of intracranial bleeding
• Faster onset of action (bridging parenteral anticoagulation avoided)
• Does not require laboratory monitoring
• Does not require dosage adjustment
• Fewer drug interactions
Disadvantages of dabigatran over warfarin? • Twice daily dosing
• Faster offset of action (compliance is important, missed doses etc)
• Dyspepsia in about 10% patients
• Renal excretion – contraindicated in severe renal impairment (creatinine clearance <30ml/min)
• No reliable easy method of reversal if there are bleeding complications
For most patients this is 150mg twice daily. Evidence suggests that this dose is superior to warfarin for stroke prevention. For patients with moderate renal impairment (eGFR 30-50) and elderly patients (>75 years), 110mg bd is recommmended. This dose may also be preferred for those at high risk of bleeding or moderate risk of stroke (CHADS2 score 1), though this strategy has not been formally evaluated.
There are no known clinically significant interactions with proton pump inhibitors, ACE inhibitors, ARBs, statins or digoxin.
Can patients have cardioversion?
A sub-analysis of patients undergoing cardioversion within the RE-LY trial demonstrated a low risk of stroke, similar to the warfarin arm and similar to historical trials (<1%). A dosage of 150mg b.d. may be preferable in this situation. The usual recommended durations for anticoagulant therapy prior to and after cardioversion apply.
Antiplatelet therapy and dabigatran together?
How to prescribe?
Concomitant use is associated with a small increase in bleeding risk. No guidelines are yet available for dabigatran use after angioplasty or stenting. Dabigatran would be expected to have a lower bleeding risk than adjusted warfarin therapy, however, if dual or triple therapy (with clopidogrel) is required.
What about renal impairment?
Dabigatran was as effective as warfarin for the treatment of DVT and pulmonary embolism in the RE-COVER trial (but is not yet approved for this use in Australia). Warfarin remains the preferred anticoagulant for patients with prosthetic valves.
While not yet approved for PBS prescribing, dabigatran is available via a Product Familiarisation Program whereby prescribing for appropriate AF patients is free for up to 12 months. Registration packs have already been provided to most GPs and specialists treating patients with AF.
• Possible superior efficacy for stroke prevention
• No significant food interactions
It is indicated for the prevention of stroke and systemic thromboembolism in patients with non-valvular atrial fibrillation and at least one other risk factor (see CHADS2 score risk factors). Newly diagnosed AF patients and those currently on warfarin therapy should be considered.
prescribed for AF patients. Suggest specialist input for co-administration with amiodarone (increases plasma level of dabigatran). The doses of dabigatran and verapamil should be separated by two hours.
Renal function (eGFR) should be checked prior to therapy. Contraindicated in patients with severe renal impairment. For patients with mild to moderate impairment, renal function should be periodically monitored and therapy reviewed if there is deterioration.
Changing from warfarin?
Warfarin should be discontinued. The INR should be monitored daily and dabigatran commenced once INR <2.
Important drug interactions?
There are important drug interactions with amiodarone and verapamil, both commonly
What about prosthetic valves, DVT or pulmonary embolism?
Table:* CHADS 2 Criteria C
Cardiac failure (left ventricular dysfunction)
History of stroke or TIA
*Recent European guidelines suggest more widespread use of oral anticoagulation based on the CHA2DS2VASc score.
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 medicalforum
Spotlight By Shane Cummings
Back from the Brink Ex-Docker bad boy Heath Black fought an uphill battle with undiagnosed bipolar disorder for many years. Having learned from his mistakes, he shares his experiences as a patient and his brushes with disaster. In his 192 games for Fremantle and St Kilda, feisty midfielder Heath Black was known for his guts and determination, but since his retirement from the game in 2008, disturbing stories have surfaced of a man hell-bent on his own destruction. Now on the road to recovery from alcoholism and bipolar disorder, Heath was an inspirational speaker at the recent Men in Black Ball to raise funds for men’s mental health. Although Heath now sees the light at the end of the tunnel, his prospects weren’t always so bright. He said the triggers for his downward spiral were retirement from AFL footy and his divorce, but the signs started during his playing career. A cocktail of intense pre-game nerves and post-game highs led
to a “social anxiety disorder”, mania, and a legacy of explosive anger and drinking. He freely admitted he wanted to “totally destroy” himself.
“I put myself into violent situations where I thought I’d get myself into some sort of harm – or vice versa – other people getting hurt as well. Predominantly, I’d put myself in situations where I knew I’d be outnumbered. I mean, rushing a guy with a gun in Thailand probably wasn’t the greatest decision to make,” he said. But the Thailand incident wasn’t Heath’s lowest ebb. He pushed the limits of the law until it finally caught up with him.
“The turning point was one of my last incidents – drink driving, which led to a fight outside a Perth nightspot for no apparent reason. Someone gave me a bit of banter, and I retaliated inappropriately, and I ended up in East Perth lockup for six hours. I lost my job from Channel 7, which I loved dearly, and I lost a directorship in a property management was the most business. I was on the bones of my arse financially.”
That exhilarating time of my life, to actually be given a diagnosis. It was like kicking a goal after the siren.
Heath knew something had to change, but he didn’t embrace that change wholeheartedly.
“There was a family intervention from my mum and stepfather in Melbourne in conjunction with the AFL player’s union. They all got together and I ended up at the Cambridge Clinic in Leederville to do an alcohol course for 12 weeks. I managed to address that problem, but was I 100% committed to the course? No, but it did bring home some home truths about alcohol.” With his alcohol problem in check, Heath – already a high energy guy – found his troubles were compounded because he was on the wrong medication (for depression), which served to fuel his mania and sent him “totally out of control”.
“I booked myself into a psychiatrist, who was fantastic, and within 20 minutes of that meeting, I was diagnosed with bipolar and medicated appropriately. I can say that was the most exhilarating time of my life, to actually be given a diagnosis. I can’t explain the relief. It was like kicking a goal after the siren.”
Heath’s visit to the psychiatrist changed his life for the better. 8
“I was very forthright with the psychiatrist. I’d had enough of getting misdiagnosed. But in defence of the medical profession, bipolar is very difficult to diagnose. We just had a fantastic frank conversation. For some reason, he could relate.”
The final step in Heath’s path to recovery was weaning himself off his depression medication, Aropax, over Christmas. “It felt like having the flu. It was terrible, and I was lucky I had the support of my family and friends at the time. If I had tried it on my own, I would have been extremely depressed. Having a support network in place was a bonus.” Now that Heath’s life is back on track, he has been devoting his time to a tell-all memoir, Black, and sharing his experiences as a motivational speaker. He was also keen to share his experiences as a patient.
“When a patient with bipolar is in front of a psychiatrist, if that patient hasn’t come to the realisation they want to get better, they’ll lie. They will lie their way out of the consultation to get their next fix, whether it’s drugs or alcohol. If I was a doctor, I would be extremely wary about whether they were lying to me. It must be hard to diagnose someone who is lying, but I would be very apprehensive to let them out of my office if I had any inkling of that person not being properly medicated.” Although he is settled and stable now, Heath is careful about his medication. His manic highs were alluring yet dangerous. “Being manic is like you’re wearing a Superman suit, and you are an extremely dangerous person on the street if you aren’t medicated properly. Throw in the fact that you’re a fit person, that’s just adding to the fire.”
In fact, bipolar disorder has cast a shadow over Heath’s entire playing career. Like many great performers, he felt bipolar may have added a creative flair to his endeavours. “I’ve only just started asking myself this question – if I was medicated like I am now, would I have been any good at playing AFL footy? You see all these high profile people who the media labels as bipolar, but half of them don’t take their medication because it quells what makes them great.”
However, despite the fond – and not so fond – memories of his highs, Heath knows he is on the right track.
“My time has gone and football is done and dusted. If I didn’t get on the proper medication, I was well and truly on my way to gaol, there’s no doubt about that.” l
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Kid’s Sport, Teen Talk, & Medicare Locals We asked GPs to comment on sports sponsorship for kids, adolescent sexual health encounters, and Medicare Locals. Topics are in line with our Child Health theme for August. The adolescent questions were partly prompted by the Health Department, who are keen to give children access to good information (see our review on page 17) given that sexual health education is not mandatory in schools. Sports sponsorship has been in the news with the wrangle between the Sports Federation of WA and Healthway – many of our surveyed GPs did not see this as a ‘black and white’ issue. Off theme, Medicare Locals have been causing disquiet among GPs, so we added questions about this vague but important topic as well. 103 GPs participated, thanks, despite mid-year school holidays, and Dr Susan St Clair has won our wine prize draw after putting her name in the hat (optional). Not a worry
“Advertising by McDonalds (e.g. vouchers for food after a swim term) I feel has no more impact than the Golden Arches by the highway or what is on TV. If the profits get put into children’s sports, I feel that it is a worthwhile thing!”
Encouraging Children in Sport nD o you believe Healthway funding for particular sports should be withheld altogether where those sports are also sponsored by fast food or unhealthy beverage companies? Yes����������������������������������������������������������������39% Maybe, with conditions�������������������������������30%
n If a children’s sporting body drops advertising sponsorship from a fast food or unhealthy beverage company, do you believe Healthway or government should make up the difference? Yes����������������������������������������������������������������45% Maybe, with conditions�������������������������������33% No�����������������������������������������������������������������19%
n Is/has your child participated in a sport that has been visibly supported by advertising for what you believe is an “unhealthy” product? No�����������������������������������������������������������������47%
Uncertain�������������������������������������������������������6% Doesn’t apply�����������������������������������������������28%
nC are to comment on unhealthy sponsorship of kids’ sports? 32 GPs commented, and intriguingly, while a quarter of comments were dead against unhealthy food sponsorship of kids’ sports, one fifth were either ambivalent or unconcerned about who sponsored sport. Four suggested parents should be the arbiters when it comes to fast food, while another four suggest we have a ‘fast food culture’ of dishing out vouchers as a reward.
Adolescents: Sexual Health and Blood Borne Viruses nH ow often do adolescents (say 12 to 16 years) ask you about issues relating to sexual health? Rarely (once every few months or less)����������38%
“Sports are sports, no matter who sponsors.”
Occasionally (once a month on average)��������30%
“Sponsorship money is always useful. Unhealthy products on and off are a treat. It is the duty of parents to supervise good eating habits at home, but a weekly treat of junk food is often a luxury.”
“Foods are ‘unhealthy’ mainly because they are taken in excess. We need more responsible parenting and health professionals encouraging healthy lifestyle with the occasional day off.”
“Any sponsorship should be welcomed in order to promote increased activity amongst children. Parents should be smart enough to guide their children’s habits.”
Commonly (at least once a week)�������������������26% Doesn’t apply������������������������������������������������������ 3%
n If they do, what sort of topics do they ask you about [select up to THREE]? Contraception/safe sex�������������������������������������88%
Pregnancy����������������������������������������������������������48% Relationship issues/problems��������������������������� 33%
Blood borne infections������������������������������������� 15%
“The problem with this question is that almost all brands have something which is unhealthy and healthy. The bottom line is you cannot control the choices people make except to educate them on the healthy option. What brand is completely healthy or unhealthy? MacDonalds has salads and water.”
“In the remote and rural sports clubs, McDonalds and KFC are big partners in the championships and matches, and without those funds and support, it would not be possible to run the tournaments unless Royalties for Regions steps in to make up for the difference.”
nD o they usually ask in private or with their
“Surely anything that contributes to encouraging or supporting them to do more sport is worthwhile? Let’s be pragmatic not just politically correct.” An unnecessary evil
“I hated the fact at state-level championships sponsorship of Little Athletics was from a fast food company, although the actual club he attended had more ‘ethical’ sponsorships. Linking Healthway grants to getting rid of fast food sponsorships will make clubs able to turn down large financial gifts, rather than take both grants.”
“Healthway’s reason for existence is to provide sponsorship in exchange for removal of unhealthy advertising in association with sport.”
* 70% of the ‘Other’ responses mentioned STIs or chlamydia. One commenter told us straight up “The common STIs! Where have you been?” Other responses were “period problems”, “mental health”, “sexual assault – and note that these ones do not come in with the parent, mostly.”
parents? In private�����������������������������������������������������������68%
With a parent�����������������������������������������������������25% Uncertain������������������������������������������������������������� 3%
Doesn’t apply������������������������������������������������������ 4%
n If parents talk to you about engaging their adolescent, what do they most commonly seek from you? Your advice on health or relationship issues (e.g. sexual health, blood borne viruses)�����������������58% Referral to another provider (e.g. counsellor, family planning, school).���������������������������������� 18% Printed material they can give to their child.��� 3%
A good website or web-based product they can recommend to their child�����������������������������������2% Doesn’t apply���������������������������������������������������� 15%
Other*������������������������������������������������������������������ 4% * We received a handful of mixed-bag answers, including “communication skills with their
adolescent”, “Hey, it’s not 1986!”, and “The Grim Reaper is not an issue for heterosexual teenagers!”. Two said “contraception”.
nC are to comment on the issue of conversing with adolescents over health issues? Judging by the above answers, most GPs have regular contact with adolescents, and pregnancy and contraception are the top topics, usually discussed in private. Parents seeking advice is also common. Amongst the 23 GP comments, six felt talking with teens went smoothly when approached with openness and maturity, while another six complained of their struggles to engage this difficult demographic. The mature stance
“Talk to them as equal human beings, but with you knowing more than they do. But they know things that I don’t. Give them a chance to be the knowledgeable party.”
“Don’t patronise and don’t betray confidentiality unless there are danger issues.”
“Reassurance regarding confidentiality is very important, and developing a rapport – which is not always easy. Use of website recommendations helps.” A prickly proposition
“A difficult subject and often has to broached by the doctor because adolescents are uneasy about it.” “Lots of adolescents find it hard to talk their parents about sexual health, relationships, and bullying at school etc.”
The amount of funding they attract������������������2% Other*���������������������������������������������������������������10% * About 40% of the ‘Other’ responses had no idea about Medicare Locals, with one GP even admitting they were “not familiar with this term”, while another said, “I still have no idea what Medicare Locals are!” A more articulate response was “Practical programs to help patients and form an additional resource for GPs who remain at the centre of care”, while one female GP (perhaps confused with GP Super Clinics?) said, “I think all of the above should apply … GPs should be rewarded professionally and financially for their contribution to primary health care. It is not worth me getting out of bed to attend to the clients of bulk billing practices.”
nW hich sentence do you most strongly identify with in describing Medicare Locals? They are a ‘work in progress’ that I am undecided about�����������������������������������������������39%
They are in reality GP Divisions by another name�����������������������������������������������������������������20% They are government’s attempt to create efficiency in a health system under pressures15% They will better combine various service providers without adversely affecting GPs������2%
They offer GPs some real input into shaping effective service delivery���������������������������������� 1%
“They are Julia Gillard’s and Nicola Roxon’s hope for sanity in the health system, but really, they have few good ideas.” A waste of time and money
“They are practically not necessary and the government has spent a good amount of fund for this. Ideally, it should spend in other areas like mental health care plans, GP surgery development, etc.”
“Have not been interested to find out more as it sounds like more bureaucracy we do not need!” “Abolish them and fund/support GPs properly.” “Probably a waste of money except for their employees and Board Directors.” Government interference
“Another completely unnecessary layer in the bureaucracy.”
“Another huge investment by the Gillard Government in an untried and vague concept which is drawing funds away from direct patient care.” “Another example of government attempting to control the Medical profession.” l
Your comments on Medicare Locals
“Easier than it is made to be. They are very receptive to your moral opinion.”
“It is important to raise issues when adolescents present with other issues (e.g. immunisation, viral infection, sore throat).”
“We need to work on the correct and relevant model for the various jurisdictions within WA in consultation with all relevant stakeholders.”
“They are really receptive if engaged properly.”
“At this stage, disregarded as political stunt making with no clear defined benefit yet apparent.”
Given the contentiousness of Medicare Locals, it was not a surprise that third of polled GPs (n=30) had a say. About 40% of these responses were “not sure” about Medicare Locals. Amongst the remainder, there were strong negative opinions.
Or is it?
compared with the Divisions, nor how it is to make life more efficient, nor what services are intended to deliver.”
Tackling all the issues
“Usually young female comes to see me about UTI, STI, and unplanned pregnancy or pregnancy scares. Occasionally, it may be related to sexual assaults. Most of them either come in alone or with their current sexual partner. Not many come with their parents.”
“I think they could help coordinate and improve care of patients but they also could be manipulated by governments for electoral and ideological reasons.”
For a complete assessment and management of your patients palmar and axillary hyperhidrosis.
“Let them do all the patient setup for e-health records. That may be a useful activity which otherwise will fall to GPs if GPs are not careful.” “It would be better to build on GPs practices.” Confusion and suspicion
“Has anyone really defined who they are and what they do? I get the feeling that they are just another bureaucratic body! I hope I am wrong.”
Medicare Locals n How do you think the profession should gauge the success of Medicare Locals? The improved delivery of services to patients������� ��������������������������������������������������������������������������� 61%
The degree to which they shift focus of care from hospitals to primary care�������������������������������18% The amount of direct GP leadership involvement ��������������������������������������������������������������������������8%
“I find the whole kerfuffle confusing, to be honest.”
“I’m really worried about GP engagement and their role in holding and division of funds.”
“Despite the vague political ‘feel good’ statements no-one has yet clearly explained exactly what they will do – and how this will be achieved.” “I don’t trust this process as far as I could spit it. There has been no detail at all as to what this extra layer of bureaucracy is intended to do
Dr Sanjay Sharma (Cardiothoracic Surgeon)
Suite 35, 146 Mounts Bay Road, Perth. Ph 6162 0233 Fax 6162 0543 Mob 0404 890 414
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The Fight for His Life Politics and wrangles with the legal establishment aside, John Quigley has been quietly battling T-cell lymphoma and this fight has given him some important insights, as Medical Forum discovered. John Quigley’s battle with T-cell lymphoma has been very public in one sense. Most of us remember him appearing on TV with visible skin blemishes, talking to the media over the Mallard case. He is now in remission, but his story is testament to him and the medicos he enlisted. “The scientists are really starting to deliver to the medicos some silver bullets. Like some of the stem cell research going on at the moment, it’s fantastic; treatment regimes that weren’t on the horizon in the 90s,” he said. Being diagnosed with T-cell lymphoma visible in a third of his skin was a shock, especially as “it was burning very fast”. After talk of thalidomide and risky UV light treatment, it was a fortuitous invitation from Dr Phil Swarbrick that swung things in his favour. He became the thought-provoker at the monthly dermatology clinical meeting at Fremantle Hospital. “I remember going down there with my wife at 7pm and sitting with a hospital gown on, and two by two, dermatologists and registrars would come in and examine me. It was the next day that Swarbrick rang and said, ‘One of the doctors here says there’s a dermatologist in Melbourne doing something with T-cell lymphoma, and you should give him a ring.’” John did just that and agreed to meet him the next morning. A trip on the red eye with his wife and taxi ride to St Vincent’s Hospital connected him with dermatologist A/Prof Chris McCormack and haematologist Prof Miles Prince.
“They explained they were doing a trial of a new drug for an American drug company that the FDA had approved for trial in 100 humans, having been tested in the lab. As luck would have it, Prof Prince had just returned from America, and obviously impressed with his capabilities, they had given him a cohort of 10 of the 100 people.” John would be his tenth patient. Travelling from WA was going to be a problem, but because John was a treatment ‘virgin’, this made him attractive for the trial. John was prepared to sell his home to fund the weekly flights to Melbourne for his 8-10 hour infusions. A friend told him of PATS, he qualified for assistance, and for nearly 12 months, he flew to Melbourne each week, returning to Perth to be in Parliament the following day.
“So I’d fly out of Perth at about 4pm on Sunday, getting into Melbourne about 8pm. I stayed at the Peter MacCallum apartments next door to the hospital and right next door to the Park Hyatt where I would have what I called
‘the last supper’ – grilled chicken breast and steamed vegies that was easy to puke up. I’d always start chundering during the last two hours of the infusion.”
head because I’m a fighter and I’d just given up and the whole thing between my ears had just collapsed. But I got back on the bike and saw it through.”
John agrees with many doctors who say access Having experienced first hand Perth’s medical to mental health care could be improved. isolation, John worked with Prof Prince to establish an Australia-wide network for T-cell “That is perhaps the only area where private lymphoma treatment. health cover and a Haematologists around little bit of money may Australia were linked I remember sitting in Fremantle give the patient a bit of up with the Prof, and an edge because you Hospital with a gown on, and his head nurse travelled can access psychiatric to other states. He also services privately that are two by two, dermatologists and worked with SCGH’s just not available in the registrars would come in and Dr David Joske to get public health system.” approval to use the drug examine me. “Mental health is such in WA. a big driver of crime “What I found the most and the criminal justice uncomfortable part of the whole experience system. We still haven’t got anywhere near was that my diagnosis was nine months after adequate funding into the mental health I married. At this time, my wife was 24 and I services. The GPs are so over-worked, you go was 57. We were told treatment wouldn’t be a into waiting rooms and they’re all snuffling good idea for pregnancy and it would not be and sniffling, so people with depression don’t a good idea to have kids after. We only had get the long interviews that you need to deal hours to discuss all this by the way, because I with depression other than by taking drugs.” had to catch the plane.” Ed. In case you missed it, the first Spotlight “So I rang up Hollywood Fertility Clinic, and interview with John (concerning his battles as I had less than an hour to get down there and a lawyer and pollie) was published in the July put the sperm away. That was a bit of pressure! edition (page 6). l I’ve got all this other stuff running through my head. Lance Armstrong wrote that this was perhaps the most uncomfortable part of his treatment, too.” “When I hit remission, we went down to see Dr Simon Turner and did the IVF. We had baby Ruby, now 4. Then we thought from what we’d been told there was little prospect of ever having another. We had a warm cuddle on New Year’s Eve 2008 and my wife got the flu, or so she thought – she was pregnant with our second.”
We wanted John to reflect more on the profession. He obliged by relating how a year into his treatment he “hit a brick wall” and found himself needle shy. He booked to see psychiatrist Dr Dennis Tannenbaum, who convinced him it was a normal reaction to his illness and diagnosed him with depression.
“Generally, I’m not a depressed person, and I had to put my hand up. It was more than just a steel needle, it was a whole trip inside my
Feature: Hospital Care By Dr Rob McEvoy
What Makes St John of God Health Care Tick? Subiaco and Murdoch hospitals are flagships for St John of God Healthcare and part of its national expansion under the management of Group CEO Dr Michael Stanford, interviewed by Medical Forum. ourselves as having more in common with the church and charitables than the for-profits, which come and go.”
Dr Michael Stanford’s work in hospital administration – public, for-profit and now, not-for-profit – spans most of his working life and includes the last nine years as Group CEO of St John of God Health Care (SJGHC). A non-Catholic, Michael is mindful of the religious culture that has allowed him and others to fashion St John of God into a visibly successful, WA-centric operation. During his term, service growth and improved management has seen gross revenue increase from $350m to $940m, but he stresses no profits are returned to the Catholic Church. “We are Catholic Church owned, which has a whole set of implications, but we see ourselves as a church trying to provide good for the community. We are not-for-profit, which by definition means 100% of what we earn goes back into the community – about 85% goes back into facilities and equipment and we spend a fair bit on our staff,” he said. As a manager, he is no doubt pleased to have extra resources to put into 9,500 staff across the organisation’s 13 hospitals (seven regional) and other facilities, including pathology. With practising Catholics well under the 25% declared during a census, plus a tax-exempt charitable status that implores a whole-ofcommunity benefit, church influences over management decisions become important.
“The church, per se, with bishops as co-owners, has little to do with us on a dayto-day basis. They just want the Trustees to assure them it is being run with the culture and approach of the Catholic Church ministry. We don’t ask employees or patients if they are Catholic because it is not relevant, and the Sisters have always insisted it is not about this,” he explained.
The role of growth
Michael’s declared aim is to make the organisation a role model in management, performance, and community standing, for which growth is a key.
“I’m trying to drive growth in all aspects. When I started, I didn’t think we did enough in social outreach; it was less than a million a year. About $14m last year was funded by us. We are trying to grow our hospitals, pathology, and home nursing centres, and for social outreach, we have developed new ideas around the country. If you value what you do, you should try and do more of it.” “For example, we are big provider of disability services in Melbourne – 750 intellectually disabled people, 26 houses of supported accommodation, day clients, and a disabled people’s employment service that loses $0.514
Improving management a sign of the times
Ironically, the emerging “profitability” of SJGHC that comes from good management will place it under the spotlight, given that forgone taxes are an important part of the operational bottom line. Some readers might remember how the mantra for the organisation changed from “charitable” to “not-for-profit”, reflecting the evolution in management about the time Michael arrived.
1.5m a year. There are no for-profits lining up to do that work.”
Hospitals are centre stage
Hospitals are their core business, generating 85% of the $940m revenue last year (with WA’s two metropolitan hospitals contributing 57% of the group’s hospital revenue). Successful non-public hospitals are all about high bed occupancy and patient through-put (55% of SJGHC patients are day cases). Around 90% of income is from private health insurers, and in essence, hospital earnings swing on keeping particular visiting consultants happy, encouraging private health cover, and putting on facilities and services that draw in patients. “The gap between the public sector and the for-profits is important for the church sector. The for-profits have to have the bottom line return and an eye on the share price or you disappear, so there are some things they can’t do. The public sector’s got the whole political accountability, limited funds, managing costs, and managing demand. There is quite a big gap between the two of them where we sit,” he said.
He used their Bunbury hospital as an example. They provide medical oncology, public and private, along with all the palliative care and dialysis. Government could do it but an exchange of mutual benefits meant one party was doing it well instead of two doing it badly. But SJGHC has no plans to share care with non-Catholic players in the charitable sector. “We do a lot of clinical, health and safety, and efficiency benchmarking with groups like the Seventh Day Adventists Hospital in Sydney, the Uniting Church in Queensland and the Epworth Group in Melbourne. We see
The group has moved on since the Sisters of St John landed in Perth in 1895 to answer the call of the local bishop to nurse typhoid cases in the Goldfields. Michael outlined their rationalisation of services as fewer nuns and priests led to amalgamations with the Brothers of St John of God, other Catholic groups, and the nine bishops in relevant diocese. He said management revival sprang from a near collapse of the business in the 1980s, when the Subiaco Hospital redevelopment needed a $30m thirty-year loan from the Charles Court government. “They didn’t have the money because they hadn’t been business-like enough in the way they managed things,” Michael explained, adding that equity is required to get finance, which is required for expansion and refurbishment. Therein lies the Catch-22. As a not-for-profit, the Catholic Church now has to explain $300m of capital assets, which brings us to the recently announced Murdoch Hospital expansion.
“Let’s talk about the Murdoch $234m – the bank’s money and five years’ profit of around $150m. At the end of April, we had a commercial bank debt of $62m, which we think will be $70m at the end of June. Right now, we are renegotiating with banks and we have a borrowing capacity of up to $250m – the banks see us as low risk with an ability to pay.”
“We don’t get anything other than the warm inner glow from providing the [Murdoch] service. We are looking at what’s happening with the local community 20 years out, in terms of ageing, population, utilisation rates and technology, and what’s likely to change,” he said, pointing to Murdoch and South Perth Community Hospitals as the only private hospitals servicing the growing southern corridor and preventing a load on the public system.
“Murdoch plus Fiona Stanley, plus the State Rehab Centre, plus State Path Centre, plus WAIMR with Murdoch Uni across the road, has unbelievable potential. There are going to
be over 1300 beds in that precinct, which is a fantastic place for doctors to work.” This idea is behind the 10,000 square metres of medical clinic space they are building, intending to sell most to the specialists. But it is the juxtaposition to public patients at Fiona Stanley Hospital that highlights one perception.
Charitable status a constant reminder
Murdoch could not survive without a 30% government subsidy on private hospital insurance and tax-exemption as a ‘charitable’. SJGHC will meet a growing demand amongst those privately insured, but should it redistribute tax dollars in a more whole-ofcommunity way? To answer that, you have to look at SJGHC’s denominational stance, the demographic of its hospital patients, and its current social outreach programs (fixed at 2% of revenue; $16m this year) – see inset. “We are a charity and are tax exempt, and the basis is we are not-for-profit dealing with sick people; a public benevolent institution. If we paid payroll tax, we wouldn’t have to worry about company tax because there wouldn’t be enough earnings left.” He said that community benefit was a prime motivator for SJGHC’s growing involvement in undergraduate and postgraduate teaching, currently 51 medical specialty registrars nationally and room for 30 interns in Perth facilities alone if public hospital places fall short.
“When it comes to the core hospital care, we definitely feel we are the quality hospitals with good equipment and good staff, and we spend a lot more than the for-profits on the training and development of staff both as people as well as professionals.”
“We want the community to say we are a great community organisation, we value them and we don’t want it changed. If they think, ‘Don’t know why they’re in it, Ramsays do as well or Healthscope’, then our owners should pull the plug and say we shouldn’t be in that space.” SJGHC’s competitors argue it is not a level playing field. However, the arguments are complex, with inevitable bias. Even public hospitals compete for insured patients by offering no-gap care that might involve taxpayer subsidy.
“In WA, 52% of people have private insurance and in our experience it is more age related – people over 50 who are worried – not so much income related. We know it’s an allegation that ‘you are looking after the top end of town’, but in truth, we have about 1000 beds in this state that 52% of people want access to and we are just adding to it so more people can have access.”
Influence of Catholicism
Catholicism shapes clinical practice in two ways. First, things like IVF work, pregnancy termination, prescribing of contraception, and tubal ligations are excluded by lease agreements and hospital bylaws. Michael’s management view is: “We worry about our brand and we have a whole lot of stakeholders in the community, similar to members of the church, who we have to take into account.”
Second, examination of values and ethics are integral to operations. “It’s nice to have an ethical basis for the way you think. There is no requirement for people to be of any faith – we are more focussed on values,” Michael said. Staff professional development reflects that. While he is a great believer in doctors and their attention to ethics, he says we all need
Things to Consider
• 56.5% of Western Australians over 65 years have private health insurance (60% with HBF; a higher proportion of older people than most funds). 51.5% have private hospital cover and payouts are increasing (e.g. 12.7% in December 2010).
• Insurance is made more affordable by the 30% rebate on Private Health Insurance, Lifetime Health Cover, and the Medicare Levy Surcharge. Single parents only make up 3.3% of those insured nationally.
• SJGHC puts 2% of revenue (not profit) each year into Social Outreach and Advocacy (SOA) - $12.7m last year ($8.6m in WA). SOA is aimed mainly at youth, Aboriginal health, nursing and pathology in East Timor, and newborn services. The group received $8.3m in donations/bequests and about $80m from state and commonwealth contracts and grants last year. • Charitable status means the Group does not pay income tax or payroll tax and 74% of staff take advantage of salary packaging that avoids FBT (same as government employees). There are 9,500 employees.
reminding in today’s more materialistic society.
“If you want to work in our hospitals, you have got to fit our behaviours, our beliefs. You have got to want to be personally involved in social outreach, or support it in some way. We want you to be involved in the teaching and we would like your patients to be part of clinical translational research.” l 15
Reorganising Remote Paediatrics Paediatrician Dr John Boulton offers his ideas to help remote North-West services share the workload, perhaps into the future. The graph showing China’s future economic growth prediction in comparison with the US is echoed by the diverging lines between the demand for health services in WA, in part due to the ageing population, and projections for workforce. Although the best brains in WA Health are taken up with the challenge for the metro area, in the remote north outside the few commercial and tourist centres, vacant positions in all disciplines add another barrier to the delivery of quality care. Whilst the metro population grows older, in remote Aboriginal Western Australia it grows younger, with 40% of the population under age 15 years in many communities. This demographic imperative acts in synergy with the appalling childhood morbidity and mortality to present us paediatricians with a wicked problem. However counter-intuitive it may seem to metro GPs and specialists, emerging strategies in remote areas might provide alternatives for the city. For example, the resource distribution is according to need, based on childhood
population, and adjusted for poverty through an index derived by dividing the population by the fraction of household income (ABS data). So if the average income is half the national median, which is typical for Aboriginal communities, this doubles the adjusted population. This index probably underestimates the health needs, but gives a guide to it. In Level 4 Units, paediatric specialists manage casemix in the central part of the spectrum but then fly out cases at both the hi-acuity end (e.g. preterm neonates), and at the lo-acuity highcomplexity end (e.g. child sexual abuse). In remote locations we have to manage the whole spectrum. Yet there is greater overlap in skills between hospital generalists (DMOs) and us paediatricians in the management of typical Level 4 casemix (acute organic illness) than in either Neonates, Child Protection, or Behavioural and Developmental Paediatrics where there is enormous morbidity from, in particular, endemic Foetal Alcohol Spectrum Disorder.
overall efficacy through a shift in activity: not doing what a DMO can do if given some supportive collegial advice.
Meanwhile, Paediatric Nurse Practitioners can take a key role in supervision and provision of management of low acuity long-term care patients, such as children undergoing nutritional rehabilitation for malnutrition, treatment for serious bone and soft tissue infection, and the development of the hospital-in-the-home model.
This approach is aimed at allowing paediatric specialist resources to be shifted from the usual one of responding to acute life-threatening illness to allow focus on work in remote communities and developing partnerships with Aboriginal organisations. This is to achieve the fundamental improvement in parenting skills, a pre-requisite to reducing endemic growth problems from insufficient food energy intake from six months of age, and hygiene-related lifeshortening illnesses such as ARF and nephritis. To get a renewed perspective on your insoluble problem, you don’t need to go to Africa and work for an aid organisation. Make a two or three year commitment to your fellow citizens who live in places which are hard to get to, and harder to live in. l
By analysing the greatest differential in skill between paediatricians and the highly skilled procedural hospital DMOs, we can improve
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Public Health PHAA Public Forum
Prohibition Counterproductive in Drug Law Federal MP Dr Mal Washer says harm minimisation, not prohibition, is needed to reform drug use in the community. But this will be a hard sell amongst his political colleagues. As Chairman of the Parliamentary Group for Drug Law Reform, Liberal MP Dr Mal Washer came out swinging against the “war on drugs” and prohibition as an unsound policy. He was speaking at a UWA public health forum. “Prohibition actually increases drug usage. It is high time that drugs were re defined primarily as a health and social problem,” he said before highlighting prohibition’s failings. Illicit drug prices are down and purity is up, he said. There are more to choose from. Volume is up, driven by lucrative profits. In 2009, 87% of Australian users surveyed said heroin was “easy or very easy” to obtain. Australia spent $3.2b in 2002-03 on drug related matters, 75% on supply control, 10% prevention, 7% treatment, 5% health costs, and 1% to harm reduction. Even enforcers want change, partly because extensive police corruption has been linked to drug law enforcement. The need for drug reform is backed by a former head of N.S.W. DPP, a former Justice of the Supreme Court in the A.C.T., and 19 world leaders meeting in New York. Lawyers, and prison and custom officers have added to the debate, recognising that prohibition has not kept communities safe (almost 40,000 Mexicans dead since their war on drugs started in 2006).
Mal said Australia needed to improve its harm minimisation national drug policy, started in 1985 – supply reduction, demand reduction and harm reduction. One strong argument has been the stemming of HIV and HCV spread in Australia through education, needle exchange programs and injecting centres. Harm reduction is already applied to legal and illegal drugs, to some degree – alcohol, tobacco, prescription and illicit drugs. “It makes more sense to see abstinence as a special sub set of harm reduction – the most
complete way to reduce harm. However some drug users do not want to become abstinent while others are unable to achieve abstinence. For these groups, harm reduction is the only option.” For illicit drugs, he recommends a vigorously implemented package: • Needle and syringe programs;
• Education to change harmful behaviours; and • Replacement therapies, such as opiate substitution with methadone and/or buprenorphine (with the jury still out on naltrexone implants).
The controversy around the opening of the Medically Supervised Injecting Centre (MSIC) in Sydney 10 years ago, has given way to impressive evidence for its effectiveness. But he said Australia has gone from international leader in harm reduction to being excessively cautious. “Only half the heroin dependent population in Australia is able to obtain methadone or buprenorphine treatment and then only at very high prices for this low income population. Heroin Assisted Treatment (HAT) has now been proven in trials in six countries. Australia should introduce HAT. There is a strong case for more MSICs. There is a strong case for making medicinal cannabis available. We have no needle syringe programs in any of our prisons.” For illicit drugs he supports decriminalisation over prohibition, but says legalisation is the only way to overcome the problems of a huge black market.
“Many people who use illicit drugs commit no other crimes. Yet they often end up buying drugs from violent criminals. Why push otherwise law abiding citizens into the arms of criminals and organised crime? Governments cannot afford to keep raining gold bars down
n Dr Mal Washer is presented with a certificate of appreciation by Dr Capolingua (on behalf of ACOSH, the Heart Foundation, Cancer Council, AMA WA and ASH) for his work lobbying federal parliament for tobacco reform. Mal was speaking on drug law reform at the Public Health Association of Australia (WA Branch) public forum Public Health: What I am Passionate About, recently held at the University Club and also featuring Dr Capolingua (young people and mental health) and Ms Sally Carbon (sport and health).
n Dr Mal Washer (right) is pictured with another keynote
on customs, police, courts and prisons. The results of this generous funding have been continuing high levels of deaths, disease, crime and corruption.” “Meanwhile drug treatment and social measures, which could make a real difference, are starved of funds. If the purpose of prohibition has been to make toxic substances readily available to anyone who wants them in a flourishing market economy controlled by violent organised crime, then current policy has been a roaring success!” He said while it was difficult to identify benefit from the large spend on enforcement, yet each dollar spent on a needle exchange program saves $4 in health care costs and $27 overall. Mal posed four questions. If we cannot keep drugs out of our prisons, how can we keep them off the streets? If alcohol prohibition failed spectacularly in the USA, why would drug prohibition be different? If a kilo of heroin costs $1,000 in Bangkok and $300,000 in Kings Cross, how will you stop it arriving? And if prohibition is such a good idea for the drugs responsible for 3% of drug-related deaths, why not extend prohibition to drugs responsible for 97% of drug-related deaths – alcohol and tobacco?
His proposed model for legalised drugs included cannabis, which must be taxed, regulated with health warnings, political donations and advertising banned, no sales to under-18s, and consumer information provided that includes THC concentration. He said when criminals are the providers, none of this happens. “People dependent on currently illicit drugs should be treated like people dependent on alcohol and nicotine - as patients not as criminals,” he said. That meant simple treatments first, and if needed, a suitable
Public Health Dr Rob McEvoy
Mental Health Amongst Youth Dr Rosanna Capolingua spoke of her concern for the mental wellbeing of youth and the need for the profession to invest in the mental health of the next generation. She told the story of Dan, a 22-year-old with marked anxiety and loss of confidence, and the influence of his supportive family in helping him meet his mental health problems. She related his
missed opportunities in relationships and education due to abuse of alcohol and both illicit and prescription drugs and recalled other experiences with youth who became socially isolated, depressed and withdrawn. She pointed to the wide array of things that could impact on the mental health of young people, from the mother’s maternal health or parenting in the formative years to society’s expectations on drugs and mateship.
Passion in Sport & Life
speaker Ms Sally Carbon and moderator Prof Mike Daube.
substitution drug such as for methadone and nicotine replacement therapies. He proposed treatments with proven effectiveness, safety and cost-effectiveness. He said keeping the small group of severely dependent consumers in treatment benefits them, their families and the community. Treatment also reduces new users. l
Mrs Sally Carbon spoke on her passion, sport and health, with plenty of experience to draw on as past Hockeyroo gold medallist and current Australian Sports Commissioner. From her sporting career and working amongst elite athletes, she outlined five attributes she felt were essential ingredients for success. Happiness was top of her list – being happy or seeking it out led to success, not vice versa. She said “happiness points” were a measureable item with a measureable economic impact; someone had worked out
that a $900 gift or an Australian winning a gold medal were equivalent to 1 or 2 ‘happiness points’, respectively. Second, was mental toughness because it made people unshakeable through any situation, allowed you to bounce back after setbacks, and offered you an advantage in high stress situations. Third was bias for action, the desire to get on with the task without necessarily being tide down by rules. Fourth was the ability to recognise opportunities. She outlined how history offered up many examples of how opportunities were born during crises. Last was a recall of history or an empathy for the past. l
Having Patience With Your Patients Workplace relationships expert Michelle Ray relates her experiences of good – and bad – customer service when interacting with the medical profession. Last week, I had an appointment to see my doctor, who was running about 20 minutes behind schedule. Global research indicates that the average waiting time for a GP is about 22 minutes. Most people understand GPs are run off their feet, so they expect to wait – and they’re often not surprised if the wait is longer. I am fortunate with my doctor. She takes genuine interest and apologises for any delay. Her pleasant manner is also reflected in her staff. They smile when a patient enters the waiting area, and they acknowledge each patient as they enter and leave. There are three other doctors in the same practice, and it is a very busy. What happened after that visit activated my “service excellence radar”.
During my visit, my doctor recommended that I have an x-ray. She suggested a medical building one block away with an x-ray centre where the wait time would be minimal. I arrived to find a packed waiting room. As I approached the receptionist window, there was a hand-written sign in thick black texta: “55 minute wait: One technician on duty”. The office assistant barely looked up and threw a
glance at the sign. She suggested that I either wait or come back the next morning.
I chose the latter. When I returned the next day, there was no wait and the “55 minute” sign was gone. However, the receptionist provided minimal eye contact when I asked about the process as well as the timeframe for my doctor to receive the report. If I wanted to show the actual x-ray to another practitioner (a chiropractor), I would “have to call” because “we don’t deal with chiropractors”. When I asked for a card so I could have the telephone number, I was told “we don’t do cards”. She tore off a piece of paper from an examination request form. Their office locations with phone numbers were on the back of the form, as well as the company motto: “Care, Confidence, Comfort”.
It is important to understand the difference between these two service encounters. The first (the GP) was relational. The second experience was purely transactional. Whether it is the doctor, the receptionist, the lab technician ... the patient is left with a lasting impression of your medical practice. With the power of technology, they can instantly express their dissatisfaction online!
Tips to create a relational service experience with patients
• Personally acknowledge unanticipated delays. Patients will feel the difference and be more accepting of the situation.
• Practise preventative maintenance to manage wait times (e.g. expect no-shows for booked appointments and be mindful of over-booking). • Create a friendly, patient-centric waiting area. Invest in a cappuccino machine and good quality coffee.
• Establish a service-first culture and research best practises. • Smile! It’s the most cost-effective way to reduce stress – for you and your patients.
Ed. Michelle will be speaking at the upcoming AAPM National Conference (October 17 to 21 at Burswood Resort Convention Centre – for more information visit www.cdesign.com.au/ aapm2011/). l
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Beneaththe Drapes u On International Women’s Day, the inductees to the WA Women’s Hall of Fame included Prof Lyn Beazley AC, Dr Penny Flett, Prof Fiona Stanley, Dr Fiona Wood AM, Dr Maureen Phillips, and Dr Margaret Smith.
u No election at the AMA again this year. A/Prof David Mountain has been re-appointed AMA (WA) President. GP Dr Richard Choong and Obstetrician/ Gynaecologist Dr Michael Gannon are the new Vice Presidents.
u Dr Felicity Flack of the Population Health Research Network was one of 12 West Australians (from 101 applications) and 107 Australians (from more than 1000 applicants) to be awarded a 2011 Churchill Fellowship by the Churchill Trust.
u Construction giant John Holland has beaten two other construction groups to win the State Government contract to design and build the new $1.2b children’s hospital at the QEII Medical Centre. u Kimberley nurse and Walmatjarri woman, Grace McCarthy, was selected as the 2011 Nursing and Midwifery Rhonda Marriott NAIDOC Award winner. u Diana Salvaris has been appointed the new manager of Donate Life WA. She brings senior government management experience from education and business.
u Dr Mike Civil is chair of the RACGP Telehealth Standards Taskforce which has been asked to produce standards for GPs by October. u Mal Beacham has returned to WA from NSW to take over Healthscope Pathology management, replacing Brendon Ball, who is now managing the group’s 12 general practices and six Molescan clinics.
u Mr Grahame Marshall has been appointed as the new CEO of the Royal Flying Doctor Service of Australia (Western Operations). Grahame was previously the Deputy Chair of the RFDS Central Operations board in the Northern Territory. He brings to the role extensive senior management experience from prior positions at Westpac, the Territory Insurance Office, Lynch Meyer Lawyers, and WorkCover SA. The previous CEO, Tim Shackleton, leaves after five years’ service to develop his own health services management advisory business.
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Your Magazine, Your Say! Medical Forum maintains its role as the independent voice of WA’s GPs and specialists through the goodwill, cooperation, and support of you and your colleagues. To ensure your magazine goes from strength to strength, we’re actively looking for more contributors. If you have suggestions for a Clinical Update, please contact our Medical Editor Dr Rob McEvoy (email@example.com or 0411 380 937) If you have a news lead or would like to write a letter to the editor or an opinion piece (guest column), contact our Managing Editor Shane Cummings (firstname.lastname@example.org or 9203 5222). Our upcoming clinical/editorial themes are: September: Allergies and Respiratory Health. October: Musculoskeletal, Sports, and Pain. November: Aged Care and Palliative Care. Deadlines fall on the 10th of each month (e.g. August 10 for the September edition). l
Children in Detention: Bad for Health Paediatrician Dr Gervase Chaney says the senseless politics that leads to thousands of incarcerated children is a national shame that the profession is seeking to reverse. this approach often fail to recognise:
The 2004 Human Rights and Equal Opportunities Commission report National Inquiry Into Children in Detention: A Last Resort1 was heavily critical of the Howard government’s policies and practices in regards to the management of asylum seeker children and their families. In particular, it called for the immediate release of children and their families from detention into the community. Gradually the government responded and did so.
• Australia’s treatment of asylum seekers breaches many international human rights covenants. Those regarding children are detailed in the UN’s Convention on the Rights of the Child, to which Australia is a signatory. Article 22 states appropriate protection and humanitarian assistance is to be provided by the state for refugees or those seeking refugee status – something clearly not met by the current system.
• The deleterious mental and physical health effects of detention on children and their parents are well documented, significant and extensive. I have personally witnessed the distressing impact on patients and their parents of their current or previous detention.
Despite a 2007 election promise for a humane approach and to use detention as a last resort, the Gillard Labor government now has thousands of asylum seekers, including children, in detention both off shore and in Australia. For most of 2011 there have been more than a thousand children in detention, something highlighted by advocacy groups such as Chilout2. The government responded to increasing community criticism by promising the transfer of all children and their families to the community by June 2011 but many children remain in detention.
• Australia has a small number of asylum seekers compared to most western nations and “boat people” are outnumbered by those who arrive by plane and deliberately overstay their visa. In addition, the vast majority of asylum seeking children and their families are found to be genuine refugees and eventually become Australian residents.
Sadly, much of the community, especially on talk back radio, is supportive of the so-called tough approach to “boat people”? Proponents of
• Given this last fact, it is not in Australia’s interest to keep children and their families in
detention, as the damage done costs the health care system and society as a whole.
The College of Physicians Paediatrics and Child Health Division released its policy Towards better health for refugee children and young people in Australia and New Zealand in 2007, included in which was a call for the abolition of legislation that allowed children to be held in detention3. Both the RACP and the Royal Australian and New Zealand College of Psychiatrists continue to actively campaign for the release of children and families from detention, including providing submissions to the HREOC Inquiry. For those of us involved, it is disturbing that despite the best evidence these abuses of human rights are again being perpetrated by a new government that once criticised the same practice of its predecessors. As a country that purports to champion international human rights, we should be ashamed that thousands of children are amongst those suffering.
Unfortunately, children’s rights are rarely prioritised in Australia. The RACP Paediatrics and Child Health Division continues its call for a national Commissioner for Children and Young People. l
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5/07/11 11:34 AM medicalforum
Medical Market Forces
Guest Column By A/Prof Prudence Manners
Misconceptions in Childhood Arthritis Getting onto the PBS? Ms Liliana Bufonte from the Pharmaceutical Benefits Advisory Committee (PBAC), speaking at a recent Perth conference, applied her background in pharmacy and health economics to explain the process by which new drugs or formulations do or do not gain PBS acceptance. Cost-effective health outcomes needed to come out of any submission, she said. Innovation was not enough. New drug submissions were most often rejected due to inadequate evidence to support clinical and economic claims and unacceptable cost-effectiveness. So when is a drug too expensive, given that resources are limited and value-for-money is a primary concern? This all comes down to an economic analysis that takes into account: Cost offsets of forgone treatments,
The targeted patient groups or clinical settings, with altered success rates, and initiating or continuation criteria, Estimate reduction in use of substituted drugs and associated resources, Estimated extent of use of proposed drug and associated resources.
Just how many of our children have inflammatory arthritis? This question still puzzles. And while we are on the subject, what should we call this condition? It seems it will take ages for the term “juvenile rheumatoid arthritis” to disappear and the sooner it does the better. Whilst we know this to be a condition of undetermined aetiology, and sometimes very nasty, it is not well-appreciated that childhood inflammatory arthritis comes in several kinds, all different, with some forms mild and some severe. Parents who hear “rheumatoid” think only of severe adult RA, and become understandably upset. The more precise term is “juvenile idiopathic arthritis” (JIA), often shortened to “juvenile arthritis”, with seven different subgroups under the umbrella term. Parents are relieved to know it is different from adult RA. Only 5% of children with arthritis are positive for rheumatoid factor or anti-CCP antibodies. How odd that even now parents are told testing can be done for arthritis in children, or worse still, parents of a child with swollen joints are told, “The child does not have arthritis because the test is negative”! Childhood arthritis is diagnosed on clinical examination and not on tests. I have been privileged to teach nearly every UWA medical undergraduate over the last 2 or 3 decades a little paediatric rheumatology. Now, I have them take an oath that they will not say that to parents! But even so it happens! With regard to prevalence, for years 1 per 1,000 had been quoted, based on frail evidence. In 1996, results of a WA epidemiological study of
JIA were published – a community study (not from medical records) that showed prevalence of 4.01 per 1000. Initially these figures caused shock, and were dismissed by many. The credibility of the study was saved and the figure verified by the world guru on paediatric rheumatology who was passing through Perth at a critical time – it happened that many children in schools had JIA, previously undiagnosed. He could hardly believe it! Slowly, since then there has been a shift in thinking. It is now well accepted that many cases remain undiagnosed and any study that does not include previously undiagnosed cases will significantly underestimate prevalence. This means JIA is not rare! Every family doctor seeing children can expect to see it. We need to accept this. When a swollen joint is seen, it may be due to JIA.
It is sad that children with JIA may not be diagnosed for years. There are two main reasons: JIA is perceived as rare; and children tend not to have pain and seldom complain – unbelievable, but strangely true! It is hard for me not to take it personally when I see a child in this situation! Preventing this from happening has been one of my lifetime goals and I have nowhere near succeeded yet. Paediatric rheumatology is still an orphan sub-speciality: not enough resources, not enough teaching.
Our totally on-line, one year graduate course in paediatric rheumatology with its mid-year intake (Graduate Certificate of Paediatric Rheumatology, UWA) may help to change things. It is now entering its fourth year and we remain hopeful! l
The PBAC was keen to measure costeffectiveness in terms of patient quality life years (QALYs) gained. Although there was no nominated threshold, a retrospective review of PBAC decisions indicated that incremental cost of $50 000 per QALY was generally acceptable. This equates fairly closely to a per capita increase in GDP of $55,000. If treatment gives someone back a productive year, then this sort of threshold makes sense. However, a host of non-financial factors are considered as well. They include a systematic review of the totality of all efficacy evidence, how research translates into clinical practice, as well as political and social considerations. Since early 2010 the federal government has applied cost recovery to the PBS assessment process. Drug companies seeking to list their drugs on the PBS must pay upon lodgement of their application and at the pricing stage. Any company that fails to get a PBS listing and wants an independent review of a PBAC recommendation faces a fee of $119,500. The Australian Government spent $7.68b on pharmaceutical benefits in 2008-09. l
RADIOLOGISTS Dr. Aparna Baruah Dr. Elizabeth Dillon Dr. Arockia Doss Dr. Ashok Kumar Dr. Jo Lagerberg Assoc. Prof. Vincent Low OPERATIONS MANAGER Joe Gauci
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Children Overseas By Tellisha Dunlop
A Voice for Murdered Girls The alarming rate of female infanticide in India has stirred the ire of neonatologist Dr Sanjay Patole enough for him to write the screenplay for a film on the subject. Dr Sanjay Patole is WA medico who is trying to address through film rampant systemic infanticide and the killing of baby girls in his native India. Sanjay, who co-wrote the film Riwayat, is a neonatologist at KEMH who spends his days with babies. He is passionate about slowing the dangerous anti-girl trend in India and relates it to his work at the hospital.
masala films, song and dance, entertainment, a couple of laughs, some comedy, a textbook villain … that kind of entertainment. Day-to-day life is so stressful and traumatic for the common man, so why would he spend $10 or $15 and see something which is going to be painful, sad, and depressing? Maybe some sort of escapism is probably needed as a treatment for their sad souls. That’s the tragedy, it’s almost like it’s a mistake to make a sensible film.”
It’s almost like it is a mistake to make a sensible film in India.
He is also having difficulty interesting Australian distributors.
“There are almost no distributors interested in buying the copyrights for Indian films and taking them to theatres, unless you get in touch with the Arthouse cinema distributors. But once they find that it’s an Indian film with English subtitles, they lose n Dr Sanjay Patole interest. And yet Bollywood films reach every city of Australia regularly. My problem is that they are not interested in such a small film with a limited audience.” For more information on Riwayat, visit: http://www.riwayatmovie.com/ l
“When you see a sad mum [at KEMH] who has just lost her baby despite our best efforts, it really hurts that here is someone who is probably going to do anything to have just one baby, and on the other hand, you have millions and millions that have been killed [in India] regularly since 1984. And that’s why this point has to be raised, and the best way to do this was to make a film. Film is a very powerful medium for the common man, woman, and family in India.”
Sanjay talked of the popularity of Bollywood films in India and said they have “tremendous power” when it comes to reaching the general public.
As the topic is confronting, it seemed to him there was little point in making a “dull, boring, dark film which no one would want to see”, so his challenge was to make an entertaining “typical” Indian film and then insert the serious message in a subtle way, which the whole family could sit together and watch. This was his hardest task. Statistics on India’s balance of the sexes reveal a stark increase in “son preference”. “Shockingly, the 2011 census data shows the numbers have again gone down to 915 girls for every 1000 babies, so how do we explain that when the country has progressed so much in every other area?” Sanjay said.
“Everything has prospered in India, including education, engineering, technology, the military, and so on, so why is this getting worse? It means no one wants a girl, everyone wants a boy. When these mothers go through this termination of pregnancy or someone kills their baby girl … no one knows their grief. God knows what goes on in their soul for the rest of their life, and that’s exactly what I’ve tried to show in our film.” Despite the film’s powerful social message, Sanjay has struggled to get Riwayat distributed in India. “India makes about 1000 to 1200 films per year and they are usually
Strong Spirit, Strong Future Social worker Judi Stone outlines the Drug and Alcohol Office’s program to reduce alcohol harm in newborn Aboriginal children. The Drug and Alcohol Office (DAO) has received funding* over four years to implement state-wide programs that will increase awareness about preventing Fetal Alcohol Spectrum Disorder (FASD) in Aboriginal communities. The Strong Spirit Strong Future - Promoting Healthy Women and Pregnancies project, which commenced last July, is developing culturally secure resources, training people and raising community awareness. The television media campaign, which targets Aboriginal communities, will be launched later this year. We know health professionals are in a good position to influence many women’s drinking behaviour, just by providing a little bit of information in a sensitive way. During consultation, we discovered two things: confusion in the community and within health professionals about the NHMRC 2009 Australian Guidelines to reduce health risks from drinking; and discomfort amongst health professionals about raising the issue of alcohol use.
Surprisingly, myths such as “a glass or two of alcohol a few times a week is fine during pregnancy” can come from health professionals. The NHMRC Guidelines are clear. There is no known safe level of alcohol consumption during pregnancy or breastfeeding, so it is extremely important that the correct message is promoted to all women of childbearing age - no alcohol during pregnancy, planning a pregnancy or breastfeeding is safest.
We discovered discomfort amongst health professionals about raising alcohol use. All health workers who work with Aboriginal women, their families and communities, including doctors and nurses in primary care, can learn culturally secure brief interventions with women. We will also train those working with women unable to cut down or stop drinking.
shame or blame these women. Often there are a lot of other psychosocial stressors that make change really hard, so any reduction in drinking is positive. Encouraging women into antenatal care earlier, collaboration across services that support women, contraception and pregnancy planning are all in the helpful mix. Including Aboriginal men in the process becomes important as they can provide a lot of support for women to change their behaviour. A holistic approach is important. To support health workers and Aboriginal communities, in the next year DAO will also be offering some small community grants to help agencies and communities localise resources and carry out health promotion aimed at preventing FASD.
* Made available through the Council of Australian Governments (COAG) Indigenous Early Childhood Development National Partnership Agreement. Contact judi.stone@ health.wa.gov.au l
It is important that health workers don’t
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By Dr Desiree Silva, Head of Paediatrics, Joondalup Health Campus
n casual conversation with a senior colleague regarding his advice to a family friend on alcohol consumption in pregnancy he commented that “occasional social drinking in pregnancy was absolutely fine”. I realised that before we can educate the population on the potential devastating effect of alcohol we need to educate health professionals to be very clear what their advice should be and why this advice is so important. alcohol use in pregnancy. Health professionals resistant to standard therapy resulting in The association of heavy binge drinking in should understand that the level of alcohol in lifelong complications. pregnancy and fetal alcohol syndrome has been the maternal and fetal circulations is the same, well established with set diagnostic criteria of hence just one glass would be one glass too Recently published Australian data reported facial features, growth restriction and central much for a fetal brain! Drinking alcohol in that 59% of women drank alcohol when nervous system structural (eg microcephaly) pregnancy should be recognised as preventable pregnant and 4% binge drink, which is and/or functional abnormalities. What is form of child abuse, although 40% of women higher than reported in the USA. Alcohol less well known is the alcohol related neurowho have unplanned pregnancy will be in pregnancy is a well known teratogen and developmental disorders associated with fetal unaware of the possible harm. there is recent evidence suggesting that the alcohol spectrum disorder (FASD). expression of a large number of placental I strongly advocate that all health professionals mRNAs is altered after moderate drinking FASD is often misdiagnosed as other complex should be consistent in advising that “no during pregnancy. The NHMRC guideline mental health disorders, such as ADHD, social alcohol in pregnancy is the safest choice”. for pregnancy (2009) clearly states that ‘No and behaviour problems, autistic spectrum Pregnant women are well known to be drinking is the safest option’. disorder and anxiety disorder. There is often motivated for change and keen to do what is a delay in diagnosis and recognition of the best for their unborn child. With changing A recent national survey noted that 61.5% of association of these neurobehavioral disorders drinking patterns in Australian women we all women of child-bearing age had heard about as they manifest later in life and often in have a responsibility as health professionals the effects of alcohol on the fetus; 97% were a dysfunctional environment, hence the to ask about drinking patterns and provide keen that health professionals advised on association with drinking in pregnancy tends accurate information to women about alcohol alcohol intake in pregnancy, and 90% strongly not to be made. in pregnancy and its lifelong effects on the suggested that health professionals should fetus and child. I think the fetus/child would be advise women to give up drinking alcohol if In my paediatrics practice there are a large very happy with this suggestion! they are pregnant or planning a pregnancy. number of children with very complex behavioural issues including autistic spectrum Recommended resource: www.ichr.uwa.edu. Only 77% of obstetricians, 69% of general disorder and ADHD who have had alcohol au/alcoholandpregnancy. practitioners, 41% of community nurses and exposure in pregnancy and also seem to be 23% of paediatricians routinely asked about References available on request. n
A M A Z I N G
When you come tumbling down. hollywoodprivatehospital.com.au
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Why we say ‘no’ to alcohol in pregnancy
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Health concerns around competitive sport in children By Dr Carmel Goodman, Medical Director, WA Institute of Sport
ver recent years I am seeing more children, often highly motivated and from high achieving families, who present with problems of ‘chronic fatigue’ or disordered eating. It brings into question the increasing demands put on children at younger ages. As doctors, we can do little about society’s expectations and pressures, but we can identify early signs, intervene appropriately, and improve awareness among teachers, coaches and parents.
Presentation and aetiology of fatigue
This may present as a decrease in performance or lack of motivation when training or competing, difficulty concentrating at school, being too tired to get up in the morning, or being unable to attend school regularly for for a variety of reasons. Recurrent respiratory tract infections, abdominal pain and depressed mood may be part of the picture. School results, sports performance and social interactions suffer.
The common theme seems to be unrealistically high expectations for the child from parents, teachers, coaches and sometimes the children themselves. This may become apparent in the disappointment of parents when rest or a graded return to training is prescribed – they attempt to negotiate something more rapid. Alternatively, understanding and supportive parents relate their child’s own unrealistic expectations, perhaps passed on from sports or academic teachers or private coaches.
At risk children appear to be those identified at an early age as being very good athletes, those receiving extra sports coaching, and those expected to continue to achieve academically. Precipitants can include a recent change in schools (with its social and academic upheavals) or a significant viral illness.
Management of fatigue
Fatigue can be difficult to manage. There has to be a balance between overdoing things and doing too little.
Following viral infection, too rapid a return to high level physical activity may delay overall recovery and precipitate post-viral fatigue. In high achievers, it is best to be very prescriptive with exercise. If symptoms of respiratory tract infection are “below the neck” (fever, GIT, fatigue), exercise should be delayed until these settle. Start
with alternate day exercise, heart rate <110120 (using a portable heart rate monitor), for 15-20min per session, and only if symptoms do not worsen after each session. If symptoms worsen, stop exercise until they improve, then retry. Otherwise, increase exercise duration to 30mins per session over the next 2-4weeks and thereafter increase intensity, depending on the severity of fatigue and response to the program. A daily diary of morning heart rate and fatigue ‘score’ is reviewed at follow up.
Where ‘fatigue’ seems disproportionate and there are no signs of physical weakness or causal illness, it may be counterproductive to allow these children to do too little and stay away from school. Keeping social and academic contacts by attending school (even for a few hours) each day, plus a slowly graded exercise program, and maybe the assistance of a clinical psychologist is the preferred mangement in this patient group.
Department of Veterans’ Affairs
More choice for GPs when referring veterans for mental health services
Eating problems in children
These are occurring at a younger and younger age and with increasing severity. Often, the problem is first picked up by friends, teachers or coaches and then brought to the attention of the parents who may ignore early warning signs.
GPs can now refer DVA clients to mental health professionals registered with Medicare Australia. These include clinical psychologists, psychologists, mental health social workers and mental health occupational therapists. Mental health professionals no longer need to contract separately with DVA. For more information visit: www.dva.gov.au/service_providers For information about veteran mental health issues go to www.at-ease.dva.gov.au and click on the Resources for Health Professionals tab.
Prevention is best. This means educating schools, sporting groups/clubs, coaches and parents to be alert for these signs. They include avoidance of specific food (particularly fat and carbohydrate), compulsive exercise, bathroom visits after meals, avoiding social situations that incorporate food, wearing loose clothing to hide weight loss and frequent mood swings. A team approach is most effective – GP (to exclude underlying pathology), psychologist (for CBT/counselling), family, teachers, coach and others (e.g. Sports Physician). The GP is best placed to make the diagnosis and then coordinate management. n
C L I N I C A L
U P D A T E
by Dr Sara Bird, Manager Medico-legal Advisory Services, MDA National Insurance
Who can access children’s medical records?
Eye Surgery Foundation Our Vision Is Improved Vision
ou have been managing Jason, 9 years of age, over the past few months. You are aware that Jason’s parents are separated and he has always attended his consultations with his mother. Your practice manager receives a phone call from Jason’s father demanding that you send a complete copy of his son’s medical records to him as soon as possible because he needs the records for a Family Court hearing.
What should you do?
In general terms, either parent of a young child is able to obtain information about the medical management of their child. However, exceptions may apply when there is a Court order that grants sole responsibility for the medical care of the child to one parent, or where the doctor believes that disclosure of the information may pose a serious threat to life or health of any individual.
The amendments to the Privacy Act 1988 (introduced on 21 December 2001) give patients a general right of access to their health information, including the medical records. In the case of children who are not capable of giving consent, the doctor can disclose health information to a ‘person who is responsible’ for the child, including a parent. The Privacy Act does not specify Either parent of a that a parent must be a ‘custodial young child is able to obtain parent’. In the case outlined above, the practice manager should ask Jason’s father to put his request in writing. While it is not a legal requirement that requests for access to medical records be made in writing, in more complex cases such as this, it is preferable to do so and this allows for more clarity about the information to which access is sought.
information about the medical management of their child. However, exceptions may apply
The Privacy Commissioner recommends the following approach for handling requests for access to medical records:
• Acknowledge the request within 14 days of receipt – including an indication of costs involved in providing access;
• Assess the information to make sure there are no details that should be withheld – in this case, it may be prudent to check with Jason’s mother that there are no Court orders already in place that would prohibit access, or that provision of the information to Jason’s father would not present a serious threat to the life or health of any individual, and/ or have an unreasonable impact on the privacy of another person (for example, access to the mother’s address); • Provide access – the total time for processing a request for access should be no more than 30 days.
When considering a request for access to children’s medical records, if in doubt about how best to proceed, you should seek advice from your Medical Defence Organisation to avoid potentially becoming involved in a dispute that should not involve you or your practice. Ed. This article provided by MDA National is intended as a guide only. They recommend you always contact your indemnity provider for specific advice in relation to your insurance. n
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Children’s Equity CEDARS Centre W
e value our children above all else. Children with developmental challenges need extra help to lead healthy, happy and productive lives. Some extraordinary people work in this field, however, demand vastly outweighs their capacity to deliver services, both in the private and public sectors, and this area is woefully under-resourced despite welcomed funding increases in recent times. It takes years to train professionals in this complex area of health and unless we change the way the current system operates, things will not improve for families for many years to come.
One of the biggest problems is delay in obtaining tangible support, which only becomes available after a diagnosis is made. Diagnostic pathways are tortuous, with long wait lists to see relevant professionals. Parents may wait 12 months for support and as the outcome is heavily dependent on the age at which the child commences therapy, this is clearly unacceptable. As the parent of a child facing developmental challenges, I have been humbled by the willingness of professionals to address the issues. A small group of paediatricians, child health nurses, allied health professionals and child care workers have collaborated to develop a streamlined triage system to help guide parents through a most stressful and challenging period.
Careful evaluation of current bottlenecks and feedback from parents engaging the system has led to a pilot program now underway in the private sector. The new model addresses a number of key issues outlined in this article.
Children’s Equity Developmental Assessment, Review and Support (CEDARS)
The CEDARS Centre will lever off information technology to improve the speed and quality of critical information flowing across the healthcare system. CEDARS is using top IT developers in the private sector to help build practical solutions for this area of medicine. Ages and Stages 3 online developmental screening tool.
CEDARS Centre plans to make available to GPs a simple, practical and affordable online developmental screening tool. Referral for the online service will be offered to general practices as capacity to review children generated from these screens increases. The online ASQ3 screening is used directly by parents, reviewed by trained CEDARS centre staff, and reports issued to GPs with recommendations for follow up.
Difficulty assessing children with strangers present
Most parents are aware how their children’s behaviour can transform in the presence of a stranger. During the initial paediatric visit, this can make assessment very difficult. CEDARS, in partnership with private business and Curtin University, has developed a model for rapid video assessment of children with their parents in the clinic, in a ‘natural’ setting. This will allow a developmental paediatrician
By Dr Michael Watson
and downstream allied health providers to thoroughly assess a 20 minute video in under five minutes, gain valuable and valid information, and used it to triage patients into allied health services. Opportunities for GPs to gain hands-on experience
The CEDARS Centre model will offer general practitioners opportunities to work closely with a developmental paediatrician in the assessment of children with developmental concerns. Long wait lists for developmental paediatricians
In private practice, a paediatrician usually takes 60-90 minutes for an initial diagnostic consultation. This creates long wait lists and few opportunities to triage the most needy children. The CEDARS Centre model aims to split the paediatric assessment into an early initial 40min triage meeting to identify the key issues that parents face, prioritise children and provide detailed quality information to downstream allied health providers (which includes secure online access, with parental consent). Prior detailed information will be collected from parents using standardised online and ASQ3 questionnaires. Children can then have paediatric follow up done in half the time (perhaps by a different paediatrician) and families may be fast-tracked for a formal diagnostic work up if required. Early effective engagement with allied health providers
An allied health focus group’s model consists of: children are seen early for five sessions that focus on providing parents with a better understanding of their child’s issues and ways for them to deliver therapy; and a series of 10 talks over 5 evenings, covering important issues identified by parents (the series run 8 times per year, providing rapid access, and made available to health care providers and child care workers). Rapid referral for diagnostic services
Children and families at greatest need will be fast tracked for diagnostic services to help reduce delays in access to full intervention services. In the meantime, parents will have been empowered to start therapy themselves and to deal with the most important day-to-day problems. Coordination of services and child health nurse practitioners
The CEDARS Centre will train the next generation of child community health nurse practitioners to guide parents through the developmental health care system. Portable video conferencing facilities will be available for the nurse practitioner to facilitate parent involvement in multi-disciplinary case conferencing. Opportunities to collaborate
The CEDARS Centre, in its pilot form, currently only involves a small focus group of GPs, paediatricians, allied health professionals and nurse practitioners who are shaping the model of care. Over the next 6 to 12 months we would like to scale up to full services and we aim to partner with all health care professionals that share our philosophy, whether single practitioners or large organisations. Those interested in becoming part of the effort or who seek more information, are invited to email Dr Michael Watson on firstname.lastname@example.org. This feature is supported by Hollywood Private Hospital. n
Developmental paediatrics lacks the equivalent of the ACAT nurse in geriatric medicine.
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Early life events: impact on future reproduction By Prof Roger Hart, Reproductive Medicine UWA School of Women’s & Infants Health, Medical Director Fertility Specialists of WA.
he WA Pregnancy Cohort (Raine Cohort) was established in 1990 following on a study to assess the impact of intensive antenatal ultrasound surveillance. The founders of the study, Profs John Newnham, Fiona Stanley and Lou Landau, had the foresight to follow-up the offspring into adulthood (now aged around 20 years), which has provided researchers from many disciplines the opportunity to explore many health issues in this controlled group. Until the age of 10, over 1,500 children were assessed yearly and every three years thereafter. When the girls’ ages averaged 15, we reported that those who were smaller than expected at birth but underwent catch-up growth to have an above-average BMI at aged 8, would undergo an earlier menarche. We understand from other work that this is a risk factor for early sexual debut, teenage depression, loss of ultimate adult height, an increased risk of breast cancer, obesity and the metabolic syndrome. More research is needed on outcomes. Our study also demonstrated that girls exposed to maternal smoking while in-utero had a reduction in ovarian and uterine size in adolescence. The implications of a smaller uterus are unknown but one may speculate it has implications for conception and potentially, miscarriage. The implications of smaller ovaries will almost certainly relate to a reduced ovarian reserve and possibly a reduced reproductive lifespan.
An interesting- hypothesis challenged by our ECU6381 Medical Forum – 00/08/2011
work, is the influence of in-utero higher exposure to maternal androgens leading to Polycystic Ovary Syndrome (PCOS) in adolescence. This hypothesis came from animal models where exposure of females in-utero to supra-physiological levels of testosterone led to later polycystic ovaries, insulin resistance, disordered LH pulsatility, anovulation/anoestrus and insulin resistance in adulthood. Our study appeared to refute this hypothesis in girls, although higher than normal testosterone exposure in-utero did lead to higher than average anti-Mullerian hormone levels in adolescence, a marker of increased ovarian reserve and PCOS.
Metabolic syndrome is particularly associated with cardiovascular risk.
It is interesting for doctors to reflect now how early life events such as not reaching one’s in-utero growth potential, or in-utero exposure to maternal smoking, may have significant implications for the reproductive prospects of offspring. Our interest in the reproductive assessment of the Raine Cohort has now turned to analysing testicular function of the boys (aged 20-21) using testicular ultrasound and semenalysis, and relating results to the same in-utero events. n
A concerning recent finding relates to metabolic indices of adolescent girls - one third of girls with PCOS in adolescence appeared to be at risk of developing the metabolic syndrome, and the most significant predictor of developing metabolic syndrome was an above average serum testosterone level.
Which one of these patients has an STI? STI e-learnIng Any of these people in your waiting room could have an STI and not know it. Visit sti.ecu.edu.au to learn more about sexually transmitted infections. Edith Cowan University and the Department of Health WA have developed a free online learning program for medical practitioners, nurses and other health professionals to improve your knowledge and skills in managing sexually transmitted infections. Visit sti.ecu.edu.au or contact us at email@example.com
These activities have been approved for continuing professional development by the RACGP and RCNA. 34
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By Dr Donna Mak, Public Health Physician, Communicable Disease Control Directorate, HDWA
Lifting WA schoolkids’ immunisation coverage
PIVET MEDICAL CENTRE Specialists in Reproductive Medicine & Gynaecological Services
Medical Director Dr John Yovich
Ps and practice nurses are being urged to help lift WA school-kids’ immunisation coverage at the critical times of school entry (age 4) and year 7 (age 10). School-aged children are an important target for vaccination programs because schools are a high risk setting for transmission and outbreaks of infectious diseases due to close contact between large numbers of children, many of whom have not been exposed to common infections. In addition, school-aged children may be a conduit for the spread of infections from school to vulnerable groups such as infants and the elderly.
WA children should be fully immunised against the following infections by 4 years of age so they are protected from vaccine-preventable infections before school entry: • diphtheria, • Haemophilus influenzae type b, • hepatitis A (Aboriginal children only) • hepatitis B, • measles, • meningococcal C, • mumps, • pertussis • pneumococcal disease, • polio, • rotavirus, • rubella, • tetanus. WA’s immunisation coverage of 4-year-olds is 86.0% (data supplied by the Australian Childhood Immunisation Register [ACIR], March 31, 2011), which is below the Australian average of 89.6% and the 90% target achieved by ACT, Qld, Tas and Vic. Completion of the 4-year-old vaccination schedule triggers an automated mailout from ACIR to the child’s parents. Parents should be advised to keep this record as evidence of their child’s vaccination status for school health records. Department of Health WA urges GPs, practice nurses and other immunisation providers to remind parents of 4-year-olds of the benefits of having their child fully vaccinated before school entry. Children who are unvaccinated or incompletely vaccinated may be excluded from school for their own protection and to prevent ongoing disease transmission in the event of a disease outbreak.
Right ovarian dermoid cyst 6cm Rolling the cyst out of the incised diameter. ovary.
Dermoid cysts of the ovary, also known as cystic teratomata, are almost always benign but nonetheless they can be quite nasty ovarian cystic tumours. This is because they contain a diversity of tissues including hair, teeth, bone, thyroid etc. The cysts are mostly detected in women during their childbearing years, with average aged around 30. They are often bilateral (15%) and we recently removed four dermoids in one patient (three in one ovary and one in the other). They can range in size from 1cm to 45cm diameter! The challenge to Gynaecological Surgeons is to remove them without spilling the highly irritant greasy, sebaceous contents and without losing ovarian tissue. This case which I supervised with a young Registrar at Cairns Base Hospital last month, was performed slickly at day-case Laparoscopy with no spillage or loss of ovarian follicles.
Year 7 vaccinations
Year 7 students are offered vaccination against hepatitis B and varicella, and booster doses of diphtheria, tetanus and pertussis vaccine. Girls are also offered HPV vaccination. In 2010, 91% of WA year 7 students received dTpa and 80% of female students completed a course of HPV vaccine. These figures compare favourably with those from NSW where 68% of students received dTpa and 69% of female students completed a course of HPV vaccine.(1)
Since 1st July 2011, The Department of Health has made year 7 vaccination program vaccines available to GPs to catch-up students who were absent from school when vaccines were being administered. These vaccines can be ordered via the usual on-line vaccine ordering system at http://colors. csldirect.com.au/. Those ordering are asked to complete the accompanying reporting form so that the student’s Year 7 vaccination record can be updated. 1. Hull B et al. NSW annual immunisation coverage report, 2009. NSW Public Health Bulletin 2010; 21: 210-223. n
Morcellating the cyst in a Laparoscopic Bag.
Normal pelvic appearance after suture of right ovary.
NOW AT 3 LOCATIONS LEEDERVILLE, JOONDALUP & BUNBURY
For ALL appts/queries: T:9422 5400 f: 9382 4576 E: firstname.lastname@example.org W: www.pivet.com.au
C L I N I C A L
Public Health and medical practice (Part 3)
Workers’ Comp matters By Michelle Reynolds Chief Executive Officer, WorkCover WA
Impairment assessment in WA Assessments of the extent of impairment arising from workrelated injuries are required for certain lump sum benefits and for establishing access to the common law systems. These assessments are carried out by medical practitioners trained in the use of the evidence based American Medical Association’s Guides to the Evaluation of Permanent Impairment, Fifth Edition (the Guides) and approved by WorkCover WA to act as Approved Medical Specialists or AMSs. Registered medical practitioners from any field can apply to become an Approved Medical Specialist. There are currently 192 AMSs in Western Australia, drawn from a range of medical specialisations. WA workers’ compensation legislation requires a worker’s injuries to be evaluated as percentage of whole person impairment, and the application of a consistent injury assessment methodology ensures that clinical evaluation is objective and aims to deliver the same percentage score for the same injury, no matter which AMS conducts the assessment. It is a process which makes sure that an injured worker is assessed in a fair and impartial manner. The current methodology has been in place since 2005 and has been accepted as a credible and equitable assessment process. Very similar assessment methodologies, also using the American Medical Association’s Guides, are used in a number of Australian and international jurisdictions. WorkCover WA recently revised the criteria for designation as an AMS to assist in building the number of AMSs available to injured workers residing interstate and therefore improving access to impairment assessment experts. In recognition of the important role that AMSs play in the WA workers’ compensation system, WorkCover WA hosts several training events for AMSs each year to assist in developing skills and understanding of the assessment process. I encourage interested practitioners to visit www.workcover.wa.gov.au and see the Approved Medical Specialists page under the Health Providers section for more information on how to be approved to work as an AMS and to obtain a copy of the Guides.
U P D A T E
By Dr Revle Bangor-Jones, Regulatory Support Unit. Tel 9222 2380
e finish our series on the Public Health laws and regulations that work for the welfare of the community. The Regulatory Support Unit (RSU) assists the Department of Health administer a larger number of Public Health regulations – as well as provide advice to other agencies, health professionals and the public (see www.slp.wa.gov.au/ legislation/agency.nsf/health_home.htmlx).
Repatriation of bodies
The airlines require a letter from the DoH before they will transport a body for burial or cremation in another state or country. Our small department handles all these requests and requires this information: • Certified copy of registration of death
• Medical cause of death certificate or Coroner’s release Form 4 • Certificate of embalming
• Medical doctor’s letter regarding freedom from infectious disease (if applicable)
Anatomy Act 1930
The Anatomy Act 1930 (the Act) provides for the establishment and regulation of schools of anatomy. The DoH provides guidelines to the Schools of Anatomy, and each school is required to develop their own policies in support of the objectives of the Act. The Act requires the Executive Director, Public Health (EDPH) to inspect Schools of Anatomy from time to time and to report to the Minister on the outcomes of each inspection. Every year, each School of Anatomy must apply to the DoH for a licence to continue to operate and must provide the following documents: • A Certificate of Good Standing for the licence holder, provided by the University.
• A copy of the current policy document
• A list of the contact names and location details for organisations that receive loans on a regular, or recurrent basis, and details of the types of specimens (e.g. bottled or plastinated) that each organisation receives.
Reporting on bodies for disposal
The Anatomy (Forms and Fees) Regulations 1933 sets out the forms required for the donation and disposal of bodies. A quarterly report is provided by the EDPH via RSU to the respective School of Anatomy, listing the bodies still at the School and the bodies disposed of since the previous report. The School of Anatomy is required to advise the office of any discrepancies in this report so that they can be investigated.
Donations of body parts, and post mortems: the Human Tissue and Transplant Act 1982
RSU maintains a database of the Delegated and Designated officers under this Act. With the rotation of registrars through departments and between hospitals, the database is constantly changing and RSU must ensure that it is accurate at all times.
We are keen to move into the 21st century, after working within the confines of some very old Acts! Changes that are currently underway include: • Updated and electronic cremation forms
• A new Medicines and Poison’s Act • A new Public Health Act
• Improved and more efficient systems within the unit
• An updated and more user-friendly website: www.public.health.wa.gov.au/
Workers’ compensation and injury management scheme Advisory Services call centre 8am – 5pm weekdays 1300 794 744
You may not be aware that every letter or email addressed to the Department of Health requires a response. RSU plays a significant role in responding to some of this correspondence. It often triggers investigation into some very interesting areas. We welcome enquiries from Medical Practitioners. You can contact us on 9222 2295. n
C L I N I C A L U
dvances in stem cell technology support the hope that stem cell treatments can be applied to many human diseases. This includes chronic debilitating conditions such as cerebral palsy (CP). Affected families increasingly want to know about any benefits from stem cell transplantation for their child and they will consider travelling overseas for treatment, where the stem cell therapeutic sector has a net worth in the billions. What can we tell these parents?
While acknowledging that parents want to maximise their child’s opportunities, there is insufficient scientific evidence to support stem cell CP treatments and families should be counselled against this. They can be referred to the website of the International Society for Stem Cell Research to evaluate efficacy, safety and ethical concerns (www. closerlookatstemcells.org).
Possible mechanisms of action
One idea behind stem cell transplantation for CP is that stem cells might restore or replace neurons in the damaged central nervous system. A second possibility is that transplanted stem cells may differentiate down the glial lineal pathway (i.e. astrocyte, oligodendrocyte and microglial pathways) and make the existing neural connections more effective. Other theories suggest stem cells might promote neovascularisation in the brain or lead to enhanced survival of existing intrinsic brain cells by increasing the expression of neuronal growth factors
Studies examining transplanted adult stem cells in animal models of brain injury show minimal survival and few, if any, markers of functionality in the transplanted cells. Animal studies using embryonic cells have demonstrated both survival of the transplanted cells and differentiation into neuronal cell types. Induced pleuripotent cells might have a greater potential for cell replacement and transformation but no animal models have been studied to date.
A limiting factor of many animal studies is that animal models tend to reflect an acute brain injury state as opposed to the chronic brain injury of cerebral palsy.
There are two human stem cell clinical trials underway in the US for children with CP, with around 200 recruited subjects. Both studies have used autologous (own stored umbilical) cord stem cells with double-blinded crossover protocols. They examine both safety and efficacy, but results have not yet been published or presented. A similar study in Australia is soon to enter its recruitment phase.
‘Stem cell tourism’
Despite the lack of scientifically proven benefit, some Australian families have already travelled overseas to receive stem cell based treatment for their children. The web-based information available regarding these overseas treatments reveals enormous variation in treatment in the different centres. Different cell types are used, including human (fetal, cord, adult) and animal derived cells. Curiously, non-autologous transplants are invariably given without immunosuppressive agents. Administration methods also vary widely with intramuscular, intravenous, intrathecal and in some cases direct intracerebral injection. It is of great concern that these unauthorised overseas clinics lack rigorous clinical safety standards that are set and overseen by a regulatory authority (like the TGA). Outcomes are not published in peer-reviewed journals but are instead reported via patient testimonials. It is clear however that there are significant
By Dr Anna Gubbay, Paediatrician, Department of Paediatric Rehabilitation, PMH. Tel 9340 8886
risks with these treatments. They include exposure to infective agents, direct damage to infiltrated tissues, and malignancy (especially with undifferentiated stem cells). Last year an 18-month-old child with CP died following an injection of intracerebral stem cells that took place in Europe’s largest stem cell clinic, and has resulted in the centre being shut down.
• Stem cell derived neural progenitors may one day have a role in treating damaged brain tissue.
• Currently there is insufficient evidence to support the use of stem cell treatment for CP. • Overseas experimental treatments are not clinical trials and involvement in the former may exclude the latter. • www.closerlookatstemcells.org is a resource you can recommend to enquiring parents. References
Carroll JE & Mayes WM Update on Stem Cell Therapy for Cerebral Palsy Expert Opin Biol Ther (2001) 11(4) Amariglio N et al. Donor-Derived Brain Tumor Following Neural Stem Cell Transplantation in an Ataxia Telangiectasia Patient (Research Article) PLoS Med. 6, e1000029 (2009)
Lindvall O et al Medical Innovation Versus Stem Cell Tourism. Perspective Science 2009 Vol 324 n
Event and Conference Corner Visit www.medicalhub.com.au for more information and click on ‘Events’. ustralian Diabetes Society & A Diabetes Educators ASM Date: August 31 Venue: Perth Convention Centre Website: www.ads-adea.org.au More info: (03) 5983 2400
National Men’s Health Gathering Dates: September 19 to 22 Venue: Pan Pacific Hotel Website: www.workingwithmen.org.au More info: (02) 4984 2554 or email@example.com
Asia Pacific Autism Conference Dates: September 8 to 10 Venue: Burswood Entertainment Centre Website: www.apac11.org More info: 9389 1488 or firstname.lastname@example.org
AGPN’s State Forum 2011 (Highway W to Health - Travelling Together) Dates: September 20 to 21 Venue: The Boulevard Centre, Floreat. Website: www.wagpnetwork.com.au More info: 9472 2922 or email@example.com
Burns Challenge Ball Dates: September 10 Venue: Perth Convention Exhibition Centre Website: www.mccomb.org.au More info: firstname.lastname@example.org
The Brian Gardener Pink Ribbon Gala Ball Dates: October 14 Venue: Perth Convention Exhibition Centre Website: www.momentumwf.com.au More info: 1300 175 388 or email@example.com
APM National Conference A (Performance, Persistence, Perfection) Dates: October 17 to 21 Venue: Burswood Resort Convention Centre Website: http://www.cdesign.com.au/ aapm2011/ More info: (03) 6231 2999 or firstname.lastname@example.org ustralian Conference of Science and A Medicine in Sport Dates: October 19 to 22 Venue: Esplanade Hotel, Fremantle Website: www.sma.org.au More info: (03) 9674 8703 or email@example.com
P D A T E
Stem cells and cerebral palsy
Parenting Regrets and Retirement Plans With their super savaged by the GFC and the demands of the profession upending their worklife balance, male medicos were downbeat about the past and the future. Last month, 197 male specialists and GPs had their say on men’s health, violence, and chaperones. Questions about fatherhood in the profession and retirement plans in the wake of the global financial crisis (GFC) were held over for this edition.
Looking Back: Fathering Regrets n
If you have children, do you have regrets that your work commitments have not allowed YOU to parent them enough? Total........................ Doctors with kids* Yes, a lot................ 32%
Yes, a little............. 31%
Not at all................. 15%
Doesn’t apply*...... 21% *After removing the male doctors without children (n=42), 80% of the 155 fathers had regrets (41% had “a lot” and 39% had “a little”).
The Effect of Your Work on Your Parenting? About half of GPs are male, as are 90% of specialists, and with doctors commonly displaying ‘type A’ traits and perhaps a bit of OCD, they can fall prey to work overload and a troubled work-life balance. For many, the realisation that they have been largely absent from the lives of their children comes too late as they are heading for retirement. Others grapple with the dilemma and make adjustments according to their life circumstances. Those adjustments are highlighted by the 25 male doctors who commented on our E-poll question last month. Of most interest is that over half expressed regret that their work had got in the way of their desire for parenting. This is what they said: I was wrong “Too much work, little pay, not enough time spent with my children!” The harsh reality “Long hours were a problem when the kids were young.” “I am often exhausted and cynical at the end of the day, and I am impatient with my children.” “My obstetrics at times has pulled me away from family events.” “I’m left to do all the night shifts/weekends as the female doctors don’t want to!” “Near nil parenting; tearing apart any relationship with wife, too.” Torn about what to do “It can be very difficult to combine medical work with on-call commitments and always be available for your children when they need you.” “Work-life balance is important, and it is up to the person to draw that line.” “The significant demands placed upon my time and the stress emanating from my work often intrudes upon time available for my family.” 40
“Guilt – I’m seen as not fully committed at work and seen by other parents as not committed to my children, therefore I lose out from all angles.” Falling back on your spouse and others “Most of the parenting is left to the spouse.” “Work, training, and parenting do not go hand in hand. Kids go to day-care. That’s that.” “We agreed that my wife shouldn’t work (as a teacher) as to guarantee a proper upbringing for the kids. My work is 38 hours per week and allows enough time to be with them as well.” “Only the dedication of my wife (who was available) prevented disasters.” I did a pretty good job “Always went to every assembly, sports meeting, or performance, though the kids tell a different story!” “I worry about this point as I get older, but when I raise it with my three sons, they do not reproach me and recall those special times of which there were some great satisfaction.” Another solution “I’m putting off having children till my thirties. It means I’ll probably have fewer children with an older spouse!” “One of the several reasons I gave up GP obstetrics and after-hours work was the impact it had on the time I could spend with my family.”
Comments on Your Retirement Plans With an ageing workforce that had invested heavily into super, the medical profession in WA was vulnerable to the depredations of the GFC, as confirmed by the results above (1 in 4 medicos retiring on less). 28 doctors commented on the issue, and the consensus wasn’t positive: Forced to work “At this rate, I don’t have much money to retire on at all!” “As I am a foreign trained specialist, I have only lived in Australia for the past few years. I thus have to achieve as much financial security as I can, in as short a space of time as possible. This has placed significant pressure on me to achieve security for my own and my family’s future. I shall be working until I fall off the perch.” “As a recent immigrant, I have no spare cash to put into super.” “I am cactus. I will have to work to 70! (at least).” Rage against the system “Public salary wages and politics are horrible! GESB isn’t much better.” “Superannuation is institutional theft!” Retirement? Who’s retiring? “I have no plans to retire unless infirmity forces me to do so!”
We can do it
“Current plan includes slowing down, not retiring.”
“I’m fortunate that, despite long hours, I have managed to maintain excellent relationships with my three children.”
“I just hope to live long enough to actually retire! And I would prefer to work as long as possible. I really don’t want to retire at all.”
“I doubt they would be any different if I had spent a lot of time with them. I reckon they like my wallet more than me even though they would deny this.”
“I’d just like to remain active and enjoy teaching med students.”
“I have always put my children first. How hard is that?”
A long way off
Looking Forward: Retirement Plans and the GFC
“So far away.”
“I would work part time till I am physically or mentally incapable of working.” “I still have 20 years to go, and hopefully, I would not see another GFC again.” Being philosophical
Arising from the global financial crisis (GFC), about 24% of the value has been wiped from self-managed super funds since 2008. How has the GFC impacted on your retirement plans?
“I still have more than most of my patients.”
I’ll be retiring on less than I anticipated�������� 26%
“I retired at 72. I really enjoyed the last 7-10 years of work. Patients would urge me to see them out, before retiring.”
I’m forced to work past my desired retirement age������������������������������������������������������������������ 19% I’m retiring in a better position than I anticipated. �������������������������������������������������������������������������� 3% Not affected��������������������������������������������������� 34% Doesn’t apply������������������������������������������������� 18%
“At present, medicine is too interesting to leave behind. It would be even better if the bureaucrats sat back for a while and gave us all a chance to collect our thoughts!”
“I am now 60, and although still capable of doing all I have done except anaesthetics, I find the taking on of heavy responsibility less attractive. I am looking forward to retirement to do some of the things I want to do, not have to do to make a dollar.”
Out and About
Tips for Medicos Buying Their First Home You’ve just graduated from medical school and have entered the real world. This means fulltime work and independence. This also means buying your first home. Real estate is a tricky topic at the best of times, but here are a few helpful tips that may make the process more bearable and less time consuming: 1. Calculate your budget. See how much you have to spend. There’s no point looking at houses, falling in love with them, and then realising that you can’t afford them. 2. Inspect as many houses as possible (within your price range, of course). The more real estate you look at the better! This will help you get a better idea of what’s available.
n Team “HPS Pharmacies” (l to r): Dr Ted Khinsoe, Mr Chris Shenton, Dr Mark Pallot, and Mr Chris Wilson. n Pretty in pink: Silver Chain staffers take a break between holes.
Chipping In For The Bush As part of Silver Chain’s fundraising event to support the health of West Aussies living in rural and remote areas, the 2011 Silver Chain Cup was held in late June. 92 keen golfers took part in the fundraiser, an Ambrose tournament at Lake Karrinyup Country Club. Naturally, when there’s a round of golf at stake, local doctors were eager to lend a hand (or a five iron). The event was MCed by former Eagle Glen Jakovich.
3. Do some research. Look at different sites and guides to see what’s out there, like www.domain.com. au/firsthomebuyers and www. myhome.com.au 4. Pay fortnightly, not monthly. By doing this you can save money on the mortgage. 5. Read the fine print! As monthly service fees and charges are likely to be hidden away in there. This should assist you in finding the best home loan available to you. 6. Take a good, hard look. Don’t take the potential property on face value. Look out for imperfections and problems, like cracks, leaks, odd smells, and mould or pest infestations. By spotting possible disasters now, you will save yourself in the long run. 7. Get assistance. Discover if there are any first home buyer benefits or grants around that could apply to you. These may help you save money, get a home with a smaller down payment, and qualify for rebates. 8. Be clear. Make sure you know what is included in the total price of the property.