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Diabetes and the Eye
Letters 2 Mandatory Rorting?
Dr Rob McEvoy
Dr Olga Ward
A GP With a Price Signal 24 Babies on Bikes Public Hospital Performance Pharmacy Blooper 26 Healthy Journalism in WA
Getting Behind Suicide Prevention
31 Conference Corner
Dr Michael Marsh
Racism a Two-way Street
Dr Julie Copeman
Mr Jake Millar
Ms Amanda Wheeler
A Stitch in Time
Dr Trevor Parry
23 Understanding Indigenous Health
A/Prof Amanda Bowen
Prof Pat Dudgeon and A/Prof Roz Walker
Caesareans are Great!
Name Withheld on Request
4 Spotlight: Prof Lyn Beazley 8 Have You Heard 10 Keeping Everyone Honest MF
13 Pitching For Rural Doctors Mr Jake Millar
15 Giving Practices a Fresh Look 17 Awakening GP Practice Market Beneath the Drapes 19 Surgery, At What Cost? Dr Rob McEvoy
Teaching Cultural Competence
21 Coming? Primary Care Reform in WA
News & Opinion
Cancer Research Funding
33 Early Intervention in Mental Health of the Young Dr Caroline Goossens
Clinical Focus 5 Severe Mitral Regurgitation Drs Eric Yamen & Chris Finn
7 Laboratory Diagnosis of Coeliac Disease Dr Mina John
31 Using Glycaemic Index with Weight Loss and Diabetes
Gordon Baron-Hay Grant
32 Awake Fibreoptic Intubation Dr Anthea William
34 Diabetes: Ophthalmic Manifestations Dr Bradley Johnson
35 In Tandem: Public Health and Medical Practice Dr Revle Bangor-Jones
36 Managing Rare Diseases in General Practice Dr Chris Fox
37 Rare diseases – Awakening Australia A/Prof Hugh Dawkins
43 Clinical Services Directory
Lifestyle & Entertainment 27 Humour 38 Competitions Humour 39 Wine Review: Zema Estate Dr Craig Dummond
40 Doctors Doing (Very) Different Things 42 Competition Winners – April Ancient Anecdotes Dr John Quintner
Ms Jo Beer
PUBLISHERS Ms Jenny Heyden - Director Dr Rob McEvoy - Director
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Letters to the Editor firstname.lastname@example.org
Mandatory rorting? Dear Editor In reply to Dr Sara Bird’s article (The Mental Health of Doctors, May edition), her comments appear reasonable at face value in a perfect world, but there are practical undercurrents not addressed in her article. She is assuming all employees in health services are honest and upright citizens, but research has shown that 1% of individuals in the workplace are sociopaths. Cognitive or unconscious bias is also a disruptive feature in the workplace and most of us, if we care to reflect on our careers, know of at least one individual we would wish to avoid. Framing of Mandatory Reporting legislation does not address the ever present potential for mischievous and vexatious complaints, and it is naive to leave such flaws in the legislation open ended, to the complainants discretion. Complainant fidelity in accusations and allegations made against medical practitioners is a joke, and must never be assumed. There must be stricter procedures incorporated in the regulations to prevent manipulation of the system, because of some initial perceived fault by a medical practitioner, and a backup mechanism that ensures steps in due process are strictly followed in a subsequent investigation. Qualified privilege should be suspended if this does not occur. Deliberate attempts to unjustly accuse a medical practitioner must be treated harshly to discourage this practice. The phrases “in good faith” and “to the best of my knowledge” place the accused medical practitioner in a precarious position, as it will lead to preliminary suspension and possible termination of their employment. I would like to see “the following factual evidence” and “the patient’s clinical outcomes” inserted into the legislation in its place. Anything less than this has the potential to lead to injustice. We all know that the written law can be an ass on occasions. Dr Michael Marsh, Floreat
A stitch in time Dear Editor There is now unquestionable evidence that the first three years of life are vital for healthy brain development for learning, health and behaviour (Kids Miss Crucial Health Checks, May edition). In
addition to established preventive measures it is clear that when there are concerns about developmental progress, early identification and intervention provides the best opportunity for a favourable outcome. Developmental surveillance in these early years is important and has been available in WA with an excellent service for many decades. However, with population increases not matched by staff increments in community and Child Health nursing, rationalisation has overridden professional priorities and some appropriate ‘health checks’ have been eliminated from the former schedule. In particular, the 18 month developmental screen has been omitted in favour of attention to earlier ages. This is a time when language development, symbolic play and increased problem solving are important to confirm – and if not emerging, an important time for further assessment and early intervention. Another concern is wait lists for appropriate further assessment and therapy, both in the public and private systems, and despite some recent improvements in services to Child Development Centres following some extra funding. However, there has been no significant increase in Child Health nursing – and insufficient ‘marketing’ to encourage young parents to attend for continued developmental surveillance for every child – when what is appropriate cannot be provided. It is known that $1 spent in the early years saves at least $17 spent in remediation subsequently. For the wellbeing of children now and for better outcomes for future society we need governments to adjust their priorities. Dr Trevor Parry, Paediatrician
Racism a two-way street Dear Editor Yes, Prof Stanley, racism is indeed a key issue (Research Explores Aboriginal Health Failures, March edition) – being called a ‘f*** white c*** ‘ is not acceptable especially when someone in Derbarl Yerrigan administration attempts to lightly dismiss it as part of my induction to Aboriginal health. Abuse of staff is rife within Indigenous health services. Having done a poster presentation at the RACGP Conference of 2008 I was stunned by the number of colleagues and ancillary health workers who wished to discuss how deeply traumatised they were by the experience of working in Aboriginal health. These staff were from all over Australia and stated they would never again work in Indigenous health.
Because of infighting within the Indigenous community and the tendency to lash out indiscriminately when a request is not acted upon in the manner the client desires, hundreds of thousands of dollars are being spent on security at our three metropolitan branches of Derbarl Yerrigan Health Service (DYHS) to try and stop staff being abused and attacked and to separate feuding clients. I have been informed that not a single local medical graduate now works in DYHS and they are paying huge sums for locums. If you lack accountability you are doomed to failure – for this reason the ‘merry go round’ continues with eight new CEOs at DYHS over the past few years and an ongoing inability to recruit and maintain staff. Hopefully, the answers as to why the major Metropolitan Indigenous Health Service is such a dysfunctional workplace will be within Prof Stanley’s research outcome report. Dr Julie Copeman, Malaga Ed. Dr Copeman demonstrates how racism impacts on people, whoever the protagonist. We understand she has a long-standing dispute with Derbarl Yerrigan - their spokesperson declined to respond. See p22 for a perspective on cultural competency training.
Indigenous Superclinics? Dear Editor I am fascinated by the intermittent political hype about so-called Superclinics. As far as I can see, these appear to be clinics containing a team of GPs and allied health workers, all under one roof, bulk billing patients for their services. Kind of like a shopping centre. Somehow this is supposed to transmute itself into magical great health for all the patients of such a service. I don’t know why the political movers and shakers think this is such a new idea. The Derbarl Yerrigan Health Service [formerly the Perth Aboriginal Medical Service] has provided exactly this type of one stop health shop since 1973, expanding and modernising its services along the way. Patients can obtain everything from dental care (the first five to arrive in the morning and prepared to wait) to medications dispensed on site, audiology, podiatry and a fantastic little treatment room and acute care facility. Not to mention a recall system that involves support from a team of dedicated Aboriginal Health Workers – all much needed, overstretched like the rest of us, and in constant demand. However, if facilities like this produce the results, surely our Indigenous population should be the healthiest in Australia?
Promoting Science for the Future For Prof Lyn Beazley, science has been a lifelong passion and she is now WA’s advocate for this field. From her early studies in zoology at Oxford University to a career in biomedical research, and her current role as WA’s Chief Scientist, Lyn’s life in science has not been without challenges – whether solving WA’s skills shortage, tackling gender inequality or juggling work and family life. Looking back, she said science was not the natural path for her to take. “I certainly wasn’t from a science-directed family. I was the first person in my family to attend university, though I’d always loved science at school. I initially went to university to read botany before swapping to zoology, and after that I had a career in medical research.”
quality research and said the shift towards translational research has been positive, but basic research should not be forgotten. “It’s very important to see a balance because there are often opportunities for the best basic research to be translated for the benefit of the state. In WA we have so much to be proud of and certainly if we want the best clinicians it means we need the best medical research because the two are always very closely linked.” She promotes technology, engineering and maths as well as mainstream science.
The catalyst for her science career was an evening lecture at Oxford by Prof Mike Gaze, who ended up as her doctoral supervisor.
“You start by having excellent science teachers. You really should be setting alight that love of science throughout primary school, and especially in the upper years because it will then flow through to high school.” Training scientists in WA is one thing; keeping them is another. What of the ‘brain drain’ that sees WA’s best talent moving interstate or overseas?
One daughter later – in fact it was 1976 and she was approaching school age – they looked past the horizon to Perth.
“We need to have the best people and infrastructure we can offer to ensure when people come they can really perform optimally.”
“We were both offered posts at UWA and we initially decided to come for two years to see how it worked out. We thought it was splendid, professionally and for our family, so we have stayed.”
In this regard, she is keen on the Premier’s Research Fellowship Program that offers a $250,000 annual package for four years. Nine fellows have been appointed so far and each has become a science ambassador, much like Lyn. Her enjoyment in that role is obvious.
With a successful career and now three daughters – all of whom are involved in science to some degree – balancing work and family life has been quite an act.
WA’s future is focussed on the resources boom, which cries out for good scientists. A greater uptake by women is part of the solution, particularly in fields like engineering where they make up as little as 20% of enrolments. Biology and medicine are better, but science still remains a male-dominated domain. Lyn has never found this daunting.
Just as her Oxford lecturer inspired her to pursue science, Lyn said teachers can be great motivators of children.
So she moved from zoology to neuroscience and to Edinburgh University to complete her doctorate and meet her husband, Clin/Prof Richard Tarala, current Director of Postgraduate Medical Education at Royal Perth Hospital.
Lyn’s work as WA’s chief science advocate is full-time. She remains enthusiastic about
“It’s very important that each state embraces the concept of a Chief Scientist because it gives an independent voice to governments. I passionately believe that with the challenges our planet faces, science will play a very important part in ensuring a good future.”
“It hasn’t been a disadvantage in the slightest and I’ve been extremely fortunate. UWA has a very strong program in supporting women in leadership roles but nevertheless there is still work to be done.”
“He spoke about the ability of some animals to regrow their nerves and regain function in a way that doesn’t happen in mammals. This was intriguing and it started my career in the area now known as neuroscience – it actually didn’t even have a formal name when I started.”
“It’s always a challenge but it also helps you set priorities and ensures you have time management well organised. For me, having a wonderfully supportive partner also made a huge difference; we’ve always been a very close family and I’ve always seen family life as paramount.”
Then there is the advice to governments on important issues.
I passionately believe that with the challenges our planet faces, science will play a very important part in ensuring a good future.
“It’s a tremendous chance to see what’s happening in WA from Kununurra right down to Esperance and Albany, and I was in Merredin recently to see the biggest wind farm in Australia being built there. I really appreciate the opportunity to see the potential of science across our great state.” “I’ve had a very busy life, but I would much prefer it that way.” l
14 Cardiologists, together with Ancillary Staff, provide a comprehensive range of private Adult and Paediatric Services.
Severe mitral regurgitation: the MitraClip device TM
itral regurgitation (MR) is the second most common clinically significant valvular disease requiring intervention. Each year in Australia, more than 4000 mitral valve replacements or repairs are performed for MR, which is a complex clinical entity. MR has several potential aetiologies, the most common being valvular degeneration (prolapse) and functional regurgitation from left ventricular (LV) dilatation or impairment. Severe untreated MR can lead to progressive LV dilatation, LV systolic impairment and heart failure, arrhythmias, pulmonary hypertension with right heart compromise and ultimately death. Open heart surgery is offered to patients with severe MR and symptoms, or asymptomatic patients with evidence of incipient or established LV compromise (dilatation or impairment). However, certain subgroups of patients (e.g. the elderly, those with prior heart surgery, significant LV compromise or other comorbidities) face greater risk from open heart surgery and thus may not be offered intervention; they are in need of a less invasive option for repair of MR.
The MitraClipTM system This is the first commercially available percutaneous device designed to treat mitral regurgitation. The clip is a polyester-covered mechanical device with two mobile arms and grippers used for capture of the valve leaflets (Figure 1). The device is passed into the left atrium via the femoral vein and across the interatrial septum. The arms of the clip then attach to and appose the central portions of the anterior and posterior leaflets, reducing regurgitation and forming a double-orifice mitral valve (Figure 2). More than one clip can be placed to achieve the desired reduction in MR. The procedure is performed with transoesophageal echocardiographic (TOE) guidance under GA, and takes 3-5 hours. Cardiopulmonary bypass is not required and the clip is placed on a beating heart, with the advantage of real-time assessment of reduction in MR. Greatly reduced postoperative recovery times are important in the elderly or sicker patients, with discharge at day 1 or 2 post-op. In the first months after implantation, the clip is endothelialised, and a tissue bridge forms across the mitral valve. Warfarin is not required, but can be used if the patient has a separate indication for anticoagulation. Aspirin and clopidogrel are used for the first three months.
By Drs Eric Yamen & Chris Finn, Western Cardiology
Worldwide experience and data
Almost 5000 MitraClip implantations have been performed since the first in 2004, predominantly in Europe. The landmark Everest II study1 was a randomised control trial comparing the MitraClip to traditional mitral valve repair or replacement and recruited 279 patients, mean age 65, with severe MR and an indication for valvular intervention (86% had a history of heart failure). Implantation success was 77% and while the degree of MR reduction in MitraClip patients was slightly worse than with surgery, among patients with a successfully implanted clip, outcomes were similar to the surgical cohort (i.e. persistent reductions in MR to two years, improved functional class and quality of life). Additionally, MitraClip proved safer than surgery, with lower rates of transfusion and stroke.
The MitraClip is the first commercially available device for the treatment of mitral regurgitation. Implantation of the clip is safer and less invasive than traditional mitral surgery, and in properly selected patients, can lead to marked improvement in symptoms and quality of life. The program at Sir Charles Gairdner Hospital, led by Western Cardiology doctors, is currently screening patients for the procedure. References: 1. Feldman T, et al. Percutaneous repair or surgery for mitral regurgitation. N Engl J Med. 2011 Apr 14;364(15):1395-406. Others available on request. n
The European experience has concentrated on high risk patients with functional MR, LV impairment and severe heart failure. In registries from high volume centres, procedural success is excellent (>95%) with very low complication rates and significant reductions in symptoms and heart failure hospitalisations.
The WA MitraClipTM program A multidisciplinary team has begun implanting the MitraClip, the first at Sir Charles Gairdner Hospital (and in Australasia) was in March 2011.
n Figure 1: MitraClipTM device
Patient selection: the procedure is not being offered to young healthy patients who are likely to have a good outcome from traditional open heart surgery. Instead, older and sicker patients, perhaps not previously considered for any cardiac intervention, are undergoing screening that includes TOE to determine if the valve is anatomically suitable for the device, and in most cases cardiac catheterisation. More details of selection criteria are available on request from eric.yamen@gmail. com.
n F igure 2A. Pre-operative 3D Transoesophageal Echo: This 3D view of the mitral valve, taken prior to device placement, is from the left atrial perspective which allows guidance of the clip into the correct position.
n F igure 2B. Post-operative 3D Transoesophageal Echo: The MitraClip has been positioned centrally resulting in a double orifice mitral valve and improved mitral regurgitation.
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 â€˘ 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
Charitable Deeds Doc of the Swan - Medical Forum
Sailors Bring PMH Pain Relief To celebrate the life of Dr Gordon Baron-Hay, Doc of the Swan will improve pain relief for children undergoing treatment at PMH. The Doc of The Swan charity sail has just raised $10,000 to kick start the Dr Gordon Baron-Hay Grant, awarded through the Princess Margaret Hospital Foundation. The 2011 recipient is Ms Vicky Corkish, a UK-trained nurse who is currently doing her masters to become the first Nurse Practitioner attached to the PMH Acute Pain Service, a role she knows well having worked as Clinical Nurse Consultant there since 2004. “The notification of being the first grant recipient came as a most unexpected and pleasant surprise,” she said, before outlining how she is keen to put the money to use. “I have recommended we explore procedural pain management, which will hopefully include resources for patients, parents, and staff alike. Painful procedures are a distressing part of medical care. We know that planning, preparation and providing information is essential to minimising discomfort and distress.” To teach all the people involved better ways of coping with pain, she must first look at what the hospital has – and there appears to be a paucity of relevant information, surprisingly – then find out from parents or carers what they want and develop or purchase resources at PMH.
For example, we are told that well-intentioned staff have been overheard threatening ‘the big needle’ to get child cooperation, much to the parents’ disgust. And parents are expected to accompany their child into a treatment room without really understanding what to expect, and with no clear guidance on how to be of help to their child. Vicki has other examples of how we handle pain situations suboptimally. “Children are routinely made to lie down for cannulation when they could sit on their parents lap, and we could inform parents how to hold them. I have also witnessed parents and other family members use language that is not helpful, false reassurance – something won’t hurt when it will – or using catastrophic language.” “For parents, we need information on how they can talk to their children, good words versus bad, and provide examples of distraction techniques. I want to find out what parents would like. For children, especially those having repeat procedures, we could develop a ‘procedure pack’ for them that includes a plan re use of drug and non-drug techniques, for all the staff to follow.” Apart from dressing changes, she said cannulation, aftercare for surgical procedures, lumbar punctures,
n Pain Nurse Vicki Corkish is the inaugural recipient of the Dr Gordon Baron-Hay Grant.
needling ports, and ‘wedging’ in the orthopaedic clinic, are all well-known pain scenarios that can be handled well or poorly. We asked Vicki for examples of the sort of ‘tricks’ available today. “There is a hand-held computer game that educates children about procedures and hospital life and I believe you can design the content of the game to your organisation’s needs.” “I would also buy some devices called Buzzy Bee, used to help distract children during cannulation – the massage the bee provides also help reduce pain as can the cooling pack that can be used with this. There are also distraction cards that slot into the device and can obscure the procedure and distract the child.” “I would purchase these as a base set for the wards and then provide sets to individual staff on completion of an education pack on procedural pain management.” l
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By Dr Mina John, Clinical Immunologist & Immunopathologist
Laboratory Diagnosis of Coeliac Disease T
hough the diagnosis rate of coeliac disease in Australia has increased over the last ten years, an estimated four in every five individuals with the disease remain undiagnosed, based on a population prevalence of 1%(1). The increased diagnoses worldwide may reflect a true rise in disease prevalence, not just improved detection, as exposure to gluten-containing food such as bread and pasta becomes globalised to populations whose historical dietary staples of rice, maize or millet are gluten-free.
and specific (90-99%) screening assays for coeliac disease, and have superseded previously used assays. A positive result has a high positive predictive value for presence of disease however absence of this antibody does not necessarily exclude disease if there are suggestive symptoms.
It is also increasingly recognised that clinical coeliac disease can develop in adulthood. While children are more likely to present with florid malabsorption syndromes, adults may present more incipiently with isolated iron deficiency anaemia, other vitamin deficiencies, persistent transaminitis, osteoporosis, infertility, recurrent miscarriage or uncommonly, with dermatitis herpetiformis and certain neurodegenerative symptoms. Indeed gastrointestinal symptoms may not be prominent nor associated with low body weight. Some individuals are asymptomatic but have other high risk factors such as a concurrent autoimmune disease, including type 1 diabetes and autoimmune thyroid disease.
Because of common genetic susceptibilities underlying both coeliac disease and selective IgA deficiency, anti-tTG IgA should be interpreted with reference to total serum IgA. If there is absolute IgA deficiency, testing for the alternative DGP IgG should be undertaken.
The contemporary view of coeliac disease is that of a clinically heterogeneous and frequently unrecognised disorder. Pathology services play a key diagnostic role. Effective use of serology and genetic tests is important in reducing unnecessary intestinal biopsies in those without coeliac disease and returning more confirmatory biopsies in those that do.
Diagnostic tests reflect pathogenesis of disease Like many autoimmune conditions, coeliac disease results from the confluence of genetic predisposition (most importantly in HLA-DQ genes but up to 39 other non-HLA genes) and external triggers (gluten in wheat, rye and barley, possibly enteroviral infections) (2). HLA genes encode molecules that bind and present peptides derived from pathogens, drugs or environmental proteins to the immune system. The reason why only particular HLA types (HLAâ€“DQA*0501, -DQB*0201, -DQA*0301 and â€“DQB*0302) are involved is because they are uniquely shaped to bind gluten-derived gliadin peptides.
There must be other, as yet undefined, reasons why only about 4% of those with these relatively common HLA types (i.e. ~25% of Caucasians) go on to develop an inflammatory response in the small bowel. An initial inflammatory response releases an intracellular enzyme called tissue transglutaminase (tTG). There is tTG-mediated modification (deamidation) of gliadin proteins that renders them more stimulatory to the immune system and this in turn promotes a self-amplifying cycle of reactions against deamidated gliadin and the auto-antigen tTG, release of pro-inflammatory cytokines, and further tissue damage. A gluten-free diet reverses the pathology by removing the antigenic stimulus of this inflammatory cycle. In the small proportion of patients with dietresistant coeliac disease, the inflammatory process broadens to involve aberrant cells and more innate immune system responses that operate non-specifically and therefore autonomously. Given this pathogenetic model, blood testing for antibodies to tTG or antibodies to gliadin/ deamidated gliadin peptides, provide the evidence of a gliadin-specific immunological reaction, and this predicts the final tissue pathology (lamina propria inflammation, intraepithelial lymphocytes, crypt hyperplasia, villous atrophy), which mediate symptoms and should be sought on intestinal biopsy. This also explains why HLA genotyping can only show that an individual has the genetic background that is necessary, but not sufficient, for development of disease.
Antibodies (along with the pathological changes on intestinal biopsies) decline during gluten withdrawal and it is therefore important that the person follows a glutencontaining diet for 6-12 weeks before test. HLA-DQ genotyping is not affected by gluten exposure and is useful in circumstances when the diagnosis needs active exclusion. First degree relatives have a 10-20% increased risk, so genetic screening can either exclude susceptibility or identify those for further clinical and antibody screening. Demonstration of characteristic and reversible small bowel histopathological changes is required for a diagnosis of coeliac disease. This provides the best evidence for lifelong dietary restriction. The challenge for clinicians remains to deliver the four out of five individuals with undiagnosed coeliac disease to confirmatory small bowel biopsy by awareness of less obvious clinical presentations and using available testing effectively. References 1. Anderson P et al. Coeliac disease is on the rise (Editorial). Med J Aust 2011, 194 (6);278. 2. Trynka G, Wijmenga C and van Heel D. A genetic perspective on Coeliac disease. Trends in Molecular Medicine 2010,16(11);537-549
Diagnostic testing The current anti-tTG IgA assay or the antideamidated gliadin peptide (DGP) IgA/ IgG assays are highly sensitive (80-90%)
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?
Charity checks in store When we surveyed WA specialists (October 2010) 55% said there were too many not-forprofit health organisations in WA. Now a new Australian Charities and Not-for-profits Commission will be introduced to crackdown on charities following this year’s Federal budget. National regulation is in the pipeline. The legal status of all groups wanting to be classed as charitable institutions will be reviewed. Minister says NFP tax concessions should only be used to assist disadvantaged people and not for unrelated commercial activities. FBT and GST concessions for commercial activities will be reviewed.
Boys’ HPV jab ruled out A CSL bid to have their HPV vaccination program extended to adolescent boys has failed due to uncertain cost-effectiveness. The PBAC was not convinced by some of the modelling from CSL that included evidence for the vaccine’s ability to protect against genital warts and pre-cancerous lesions, as well as penile and other cancers.
current national Medical Board requirements for ongoing CME and fees will drive many away once three-year period of grace on “Occasional practice – special purpose” comes up. It has been suggested that a third of the university-based medical educator workforce could be lost under the new rules. Remember Dr Bruce Shepherd and the Australian Doctors’ Fund (ADF). It is now lobbying to reinstate the rights of retired doctors (WA leads the way again) - a ‘senior active’ category with a $100 registration fee, a minimum CPD of 10 hours a year, self directed, and an annual medical certificate.
RACGP readies for e-Health Has anyone noticed how the latest accreditation criteria for the RACGP help position the college as a provider with the Federal Government, in the e-Health race? First, we now have a 70% (up from 50%) requirement that active patient records include a health summary (with standardised terminology or coding). The RACGP is promoting its health summary for the purpose. Second, patient identification should include three approved patient identifiers, presumably to improve data integrity and remove duplicate records. Third, a new criterion that practices maintain accurate medicines lists for patients.
Nice work if you can get it Hedland makes it official It opened doors in November, but Health Minister Kim Hames only recently officially launched the new $138m Hedland Health Campus, the newest regional hospital in Australia (Albany, Kalgoorlie and Busselton to follow). Commemorative plaques were awarded to, amongst others, Dr Malcolm McCallum, Dr Allan Vickers, Dr Philip House, and Dr Pascall Burton. Hedland Health brings the Pilbara 24/7 ED, obstetrics and paediatrics wards, day surgery, renal dialysis, medical imaging and outreach specialist services.
No stop to retirement qualms The ruckus around the working future of semi-retired doctors will not quieten. Many are involved in charitable overseas work for which registration in the country of origin is a requirement. Others take up teaching posts with UWA or Notre Dame, become an examiner for the MAC or even sit on the Medical Board. You would expect all of them to be registered to assume these positions but 8
YourLastRight.com is now on the campaign trail and a lot of high profile Australians are in their camp. You can see them on the website, along with the PollieScanner, which says in WA, six politicians support the concept, 21 are opposed and 91 have an unknown position. The latest is the national alliance of all State and Territory Dying With Dignity and Voluntary Euthanasia societies to campaign for legislation to allow rational, adult Australians experiencing intolerable and unrelievable suffering from a terminal or incurable illness, access to aid-in-dying from a doctor, after appropriate checks and reviews. They have released research findings from Oregon, where physician-assisted dying was legalised in 1997, saying the death experience as good as or better than non-assisted deaths.
Dr Neale Fong’s corporate experience in the health sector makes him an invaluable asset in mineral explorations. Chrysalis Resources Ltd (ASX:CYS) has Neale as its non-independent Executive Chairman. The company’s last quarter report has it spending more on administration ($200k) than exploration and evaluation ($150k). It is burning about $100k per month of cash reserves, having listed on the ASX in May 2008 and built $2.15m investor cash reserves by June 2010. The last annual report says Dr Fong receives $100k per year (plus 1.0m share options, value $158k), to which he can add $74k p.a. from his nonexecutive position on the Realms Resources (ASX: RRP) board, another mining company which also gave Dr Fong a $150K interest-free loan.
Euthanasia support alive and well Since the NT’s Marshall Perron introduced the Rights of the Terminally Ill Bill to Parliament in 1995 (and the feds overturned it in 1997) the campaign for the right of people to choose their end has died down (excuse the pun).
WA research going strong Overweight men with were less likely to develop dementia than those of normal weight according to a 10-year study of 12,047 men aged 65 and 84 years. The results from UWAbased WA Centre for Health and Ageing seem to support a review of BMI guidelines for the elderly. Another local study, this time from WAIMR, found desk jobs can double people’s bowel cancer risk. Those who work for a decade or more behind a desk have a 44% increased risk of rectal cancer. The twoyear study by UWA PhD student Terry Boyle involved men and women aged 40-79 and included 918 cases and 1021 controls. It was published in the prestigious American Journal of Epidemiology. In more good news for WA research, last month construction started on the $100m research hub at the QE II Medical Centre. It will house around 800 researchers when it opens in 2013.
What have you heard Share the news email@example.com or ring the editor on 9203 5222
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Ethics in Medicine MF
Keeping Everyone Honest Cleaning up the relationships between doctors and commercial medical interests is an ongoing struggle that requires diligence and determination. Australians are very lucky to have a judicial system and various codes that protect consumers from unscrupulous commercial conduct. What is more, the overseeing authorities are given some teeth, which results in a meaningful watching brief while attempts at self-regulation play out. In health, there is growing awareness around unethical practice and conflicts of interest, helped along by some legislated transparency. The relationships between doctors and the pharmaceutical industry have been closely scrutinised (and medical equipment providers and researchers are probably next in line). Some argue that transparency is not enough and articles such as this should be written by people with no conflicts of interest! One good example of system reform is the ACCC’s granting of three-year conditional authorisation to the Generic Medicines Industry Association’s (GMiA) Code of Practice. This code is a self-regulatory framework for the supply of generic medicines in Australia. The ACCC has responded to concerns by placing conditions that provided greater transparency around the relationship between manufacturers of generic medicines and pharmacists. Manufacturers are now required to publicly report on the hospitality and entertainment provided at educational events to both medical practitioners and pharmacists. Secondly, gifts and other non-price incentives
provided by manufacturers to pharmacists as an incentive for them to stock their brand of product must be reported annually. There was concern that the offer of loyalty programs or other non-price incentives to pharmacists undermined public confidence in the generic medicines industry, which can apply to S2, S3 and S4 prescribing. Most concern centred around brand substitution and some dubious ‘educational’ entertainment dished out to doctors and pharmacists in the past. Even Medicines Australia thought the GMiA code was too weak. A short time before this decision by the ACCC, the Australian Centre for Independent Journalism posted an interesting story around a biased report on a new drug treatment for leukaemia that appeared in a major Victorian newspaper.
the media, which has a tendency to uncritically report these endorsements. The fact that this happens to create illness or treatment awareness (without promoting a product), perhaps when the drug is being presented for PBS listing, is a striking coincidence. Indirect promotions (such as websites) are also problematic. Last year, Roche was fined $200,000 for offering a regional public health organisation funding for a nursing position in exchange for doctors in the region prescribing its hepatitis drug. A health professional complained to Medicines Australia. Normally, rival pharmaceutical companies complain. The code says no inducements should be offered that could interfere with a health care professional’s independence.
Even Medicines Australia thought the GMiA code was too weak.
It turns out that the press release that the report was based on came from a reputable clinic, but via a clinician who was not only on an advisory board for a pharmaceutical company but was passing on PR material that originated from that company, albeit via the company’s PR media outlet. The same media outlet had featured in Media Watch for promoting prescription medication to the public on behalf of its pharmaceutical clients. There is growing awareness that PR companies employed by pharmaceutical companies are being engaged to deliver drug endorsements to
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Roche was also fined $200,000 for making misleading claims about its renal anaemia treatment and was ordered to stop using all relevant promotional materials. Withdrawal of advertising, fines and published retractions are imposed under the voluntary code but the fines would be relatively small in comparison to the companies’ advertising budgets or potential earnings from a PBS listing. This is all about pharma-related promotions in Australia. But there is another angle. Many doctors are probably unaware that colleagues who travel to overseas conferences or meetings may be sponsored, or that clinical trials or training may be underwritten by industry. The recent announcement by GlaxoSmithKline (GSK) may have somewhat lifted the lid on this. The company has decided to go beyond the required reporting of sponsored Australian educational events to now disclose: • All consultancy arrangements (such as advisory board honoraria, speaker honoraria, speaker training, other types of consultancy) as well as travel to all of these, • Sponsorship of registration to attend congresses (international and local), travel to international meetings and overseas costs such as meals. • Grants and donations (non-monetary) to individuals and institutions. Is there is an element of “coming clean” in GSK’s decision? What has been happening?
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The flipside is that such blurring of boundaries would not happen if all doctors were unwilling to compromise their professional independence. We all assume doctors act, primarily in the patients’ best intersts. l
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Doctor Recruitment Mr Jake Millar
Pitching For Rural Doctors How far is too far and will it work? With such high demand for rural GPs throughout WA, large salaries and generous relocation packages are par for the course. The financial rewards being offered to lure GPs away from the city range from lucrative to astounding, but there are some regions looking to move away from the one-upmanship by promoting other unique benefits. Doctors looking to move to rural WA can expect to receive salaries anywhere from just under $200,000 through to $500,000 a year. They are also likely to have moving costs, a furnished home and a car thrown in.
including psychologists, practice nurses, exercise physiologists, physios and a pathology collection centre.” “Of course, we’re also offering them a lifestyle choice because they don’t have to be on-call every night. It’s one four-hour shift a week.” Notre Dame Director of Primary Healthcare Research Prof Tom Brett has studied medical workforce issues and said getting a doctor with links to an area is a big plus. “Those with a rural background are much more likely to work in rural areas. Also, if they have a spouse with a rural background, irrespective of whether the spouse is a doctor or not, it is also a huge plus to ending up working in the community.”
Southern Regional Medical Group CEO Mr Chris Swarts has been involved with doctor recruitment and says the situation is bleeding many areas dry. “Obviously it is not sustainable and that’s why we’ve been looking for an alternative solution. We’d like a flyin, fly-out service where doctors travel to these rural communities from a base that caters for their needs in terms of family support and lifestyle,” he said. “In the interim, while we try to get the necessary funding we’ve been managing their practice with n Mr Chris Swarts locums and that’s costing us $1800 a day, plus recruitment fees, which is 16% on top of that. Those locums get flights, accommodation and a car, so the whole situation is a bit ridiculous.” In addition to paying top dollar for GPs, Pilbara Health Network CEO Mr Chris Pickett said housing prices in some areas are making a difficult situation worse. “It’s a critical issue because you’re paying upwards of $1600-1700 a week for a house up here. Unless you can bring a doctor in with housing, you’ve got another $75,000-100,000 a year in house rental to find.” Although it is tough, Chris said they do try to promote the advantages of their region. n Mr Chris Pickett
“Our attraction’s the ocean and the fishing so we make sure the doctors can get some good exposure to the coastline up here because it’s pretty sensational.”
“We’ve also got a very strong focus on Aboriginal health and we get a lot of young doctors who like to get a grounding in Aboriginal health, so we try to attract them on that basis too.” Wheatbelt GP Network CEO Mr Paul West has been working with shires on doctor recruitment and agrees that rural areas should offer GPs more than just money.
n Prof Tom Brett
Tom said part of the solution is to actively seek medical students from rural areas, with a rural commitment in the selection process, along with both undergraduate and post-graduate training placements in rural practices.
“The last couple of years the good thing is that the community applications to rural stream training for GP registrars has been oversubscribed.” Other factors were the sort of work-life balance sought, the feminisation of the workforce, schooling facilities (especially high school) and community facilities. l
Important insurance advice Insurances fall within the category of a must have expense that one hopes they will never need. But as medical professionals know from experience, the requirement for insurance cover – whether it be health, life or trauma insurance – is far greater than most people realise. Financial adviser Murray McKinley says one of the least subscribed insurances among the general Australian population is trauma cover – an insurance which provides a tax free lump sum payout for major illness or injury.
Mr McKinley says the risk protection of child trauma cover provides the peace of mind that one will have the money to do whatever is needed to treat their child. “These events are difficult enough to deal with without adding the financial stress that may come from being away from work or out of the practice,” Mr McKinley says. Mr McKinley says Australians generally tend to be fairly careless about ensuring adequate life and trauma insurance cover for themselves and their families.
tralia’s Leadin “In Wyalkatchem they have an aviation flight academy, so they offer new doctors a scholarship to learn how to fly. It’s only $5,000 or so – chickenfeed compared to what a doctor’s earning but it’s a unique hook that gets interest.”
“At Yilgarn they negotiated with one of the mines to provide a seat on their aeroplane each way once a week. n Mr Paul West So they can live with their family in Perth and it’s just a 45 minute flight after breakfast on a Monday morning, and they’re home for dinner on Friday night.” Dr Brenda Murrison, Medical Co-ordinator at Brecken Healthcare in Bunbury said she has been working very hard on doctor recruitment.
“I have interviewed literally hundreds of doctors. It hasn’t happened quickly and it hasn’t been a miracle by any stretch of the imagination – we’ve recruited as a result of a long and protracted effort over a period of years.”
n Dr Brenda Murrison
Brenda said one area they have worked on is the style of practice. “We have a full multidisciplinary team on site,
Mr McKinley, a director of McKinley Plowman accounting and financial planning firm, says while many medical professionals have trauma insurance for themselves and their partner, a lot don’t have it for their children.
He says trauma cover, which provides a payout for up to $200,000, is available for children aged between two and 18 years and can be attached to a parent or grandparent’s trauma policy.
This relatively new insurance cover, which costs around $1 a month for each $10,000 worth of cover, is less expensive than most people’s car insurance.
“In my younger days I was quite sceptical about insurances and probably saw myself as invincible,” Mr McKinley says.
“However, my professional life has changed any reservations that I’ve had about insurances because I’ve seen a lot of clients claim on these policies. “Had these people not had insurance cover, their lives would have been even more stressful.”
Mr McKinley says before signing up for any sort of insurance cover it’s important to consult with a trusted financial or insurance adviser to find out which policy is most suitable for one’s circumstances.
For more information phone Mr McKinley on 9301 2200 or visit www.mckinleyplowman.com.au
Medical Real Estate MF
Giving Practices a Fresh Look Fitting out a new practice, or just updating the look of an existing one, does not have to be fraught with difficulty. Medical Forum discovered, preventing cost blowouts is a matter of good planning and getting an expert’s advice on building codes. As anyone who has renovated knows, cost blowouts can be a major issue, particularly if people stray from original plans. Mr Nathan Reid from medical design and construction company Medifit said they get around this with good planning and fixed-price contracts, where final costs are agreed ahead of time. “It needs to be mapped out solidly beforehand because there’s nothing worse than getting halfway through a project and then having it blow out because they want something that wasn’t identified in the first plan.” Planning for future expansion also means they do not find themselves revisiting practices a couple of years later to make costly new additions. “We take the current and future requirements into account and we try to design for what their needs are today, but also what they may be in five or ten years’ time. There’s been quite a few examples where people have come to us for a design and we’ve been able to identify if they can get an extra room for having another specialist on board.” Nathan said another way of controlling costs is by having design and construction done under one roof. “One of our selling points is that we’re a onestop shop, you’re only dealing with one set of
people, responsibility for costs right from the start through to the end. Because we design and construct, we can keep all of those costs in house.” Working alongside clients on the design ensures there are no surprises when the construction gets done.
n Use of colours, textures and sight lines gives a practice a personality of its own.
“We try to capture the personality of the practitioner and create an individual design that speaks to them, and puts across their unique offering to their patients. We allow them to put that through the full design process, so the practitioner gets a real feel for what their new practice is going to look like before we even put a nail in a wall.” Nathan said medical buildings often have unique requirements that many regular builders, or even doctors, may not be aware of.
n Clean, contemporary lines and a minimalist design of this refit convey a feeling of professional efficiency and reflect the personal style of the practice owner.
“There’s quite a bit of specialist knowledge that only people working in the industry are really fully abreast of. Most doctors don’t really know about them because it’s something that happens behind the scenes, they’re concentrating on providing the level of patient care.” “There are all sorts of statutory requirements for disability access, electrical areas and wastedisposal. We have found is with practitioners who have gone to an architect or a regular builder to get their practices revamped, they design these beautiful practices that don’t allow for ramps or proper plumbing, for example.” Where there is substantial change to the existing layout of a practice, owners may be required to meet current Australian standards. Practitioners looking to upgrade should seek professional advice on statutory regulations. l
n Warm neutral tones with a bold splash of yellow create an inviting waiting area while the arched windows respect the building’s heritage. n A new look can make a bold statement about you as a practitioner.
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Medical Real Estate Mr Jake Millar
Awakening GP Practice Market We take a look at shifting trends in the WA GP practice market, through the eyes of one established player.
Brad said the market for GP practices remains slow and interested buyers are not paying much for properties. In comparison, dentistry business sales have been booming. So why are more dentists buying than GPs? Brad explained it is comes down to the bottom line. “In general practice, people out there are paying employees 65-70 cents for every dollar of revenue they’re generating,” he said. “On the other hand, an employee dentist gets about 40% of the revenue they generate. So it makes sense that someone who’s an employee of a dental practice would rather own their own practice. Why would someone in medicine who is earning 70 cents in the dollar of their fees own their practice unless they had a burning desire to run a business?”
Beneaththe Drapes u Mr Chris Flynn has accepted the role of CEO at St John of God Hospital Geraldton. Chris has worked in the Catholic private health sector in regional Victoria and in Brisbane. u Dr Ronnie Hagan has been appointed new Medical Director at Mercy Hospital. u After 35 years as a Silver Chain volunteer, and almost 23 years as Silver Chain Albany Branch Committee President, Mrs June Hodgson will be retiring in July. u Three WA nurses and midwives each received a $20,000 fellowship from the Nursing and Midwifery Office to fund research projects to improve patient care. Ms Fenella Gill (Paediatric Intensive Care); Ms Ce Kealley, (Peri-operative Services, Kaleeya); Ms Sarah Nicholls ( Midwife, Kaleeya).
A good time to buy? However, Brad said this lull in the GP market means there are opportunities to find relatively cheap practices in good locations. “It’s probably a good time to get into the market because of the relatively low entry level price to buy a practice. They are selling for less than what you could set one up for from scratch, and they’re normally in reasonably good locations. “The corporates bought out all these practices and they have now shut the doors and amalgamated them into big super clinics. The people that have been working in those practices don’t want to go to these big super clinics because they want the smaller, familyorientated businesses.” “In the next three to five years we’ll find the value of a GP practice will increase.” Brad said this is partly because a lot of the interest for practices is coming from overseas doctors. “We had a shortage of doctors about ten years ago so we’ve got all these overseas-trained doctors who had to go to areas of unmet need in the country.” “Now they’ve done their service in the country and they want to move back to Perth and put their kids through school.”
Things to consider Brad shared a few basic tips for those looking to enter the market.
n Mr Brad Potter
“You’ve got to look at the motivations of why the guy’s selling and more often than not, they’ve just had a gut-full and want to retire. A lot of these people I’m dealing with are in their seventies and they’ve kept working because there’s been such a shortage of GPs.” He said it is also important to consider the technology in use, potentially a big ticket item, particularly paperless systems for patient records or scripts if this is a priority. It is also wise to look at the practice’s employment arrangements. “Look at what sort of contracts they have their doctors on because some people employ three or four doctors and some might not have them on any contracts. For a buyer to come, they’d want to have a restraint of trade which says they can’t open up within a certain radius. Certainly that can pull the bottom end of a practice out pretty quickly if people choose to open up themselves or move to another practice.” l
Bentley Rooms For Lease
Sp Ide ec al ial for ist A s a na Be s C esth ntl en et ey tra ic G Ho l R ro sp oom up ita s or l –O pp .
Things slowed up a lot after the heady days of corporate bidding for general practices, when goodwill payments largely evaporated. However, as some doctors came off contracts from within bigger practices, they had seen enough of modern lean practice management to apply it to establishing a smaller boutique practice, where they had more say in what went on. And the tide of overseas graduates is gradually drifting to urban areas and looking for a niche. Medical Forum spoke to Health Linc’s Brad Potter who has been more or less watching from the sidelines until more recent times.
This is a spacious purpose built Medical Centre capable of expansion to adjoining ¼ acre block. It is luxurious in its appointment with no expense spared in construction/fit out and has a minor theatre, industrial high quality carpets throughout with spacious waiting and consulting rooms and definitely the best in Perth. A rare opportunity to set up practice in a huge catchment area with Bentley Hospital set to develop further in the near future. Patient’s drain area extends over the entire South Metro and only 6klms from the CBD. Ideal for a large Anaesthetic Group or Specialist central rooms. No better value in town.
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Mandurah Private Hospital 12 specialist suites available for long-term lease
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General bariatric, vascular, ENT, plastic, urological, gynaecological and orthopaedic surgeons are invited to apply. General Physicians are also sought. Expressions of interest are also invited from Pathology, Cardiology, Fertility and Sleep Centre groups. Anaesthetists or an Anaesthetic group are invited to apply. MPH are seeking a resident gastroenterologist. . All interested specialists or specialist groups to forward indications of interest to Ms Bree O’Sullivan, Marketing Manager at firstname.lastname@example.org or phone (08) 9361 0559.
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3/03/11 1:46 PM medicalforum
Medical Market Forces Dr Rob McEvoy
Surgery, At What Cost? The pressures that bring more uninsured patients to ask for procedures privately should be responded to appropriately if the profession is to avoid criticism. May’s editorial looked at market forces applied to the private-public hospital debate and the activities of anaesthetists. Generalisation is always difficult, but in WA trends are emerging as the squeeze on health finances kicks in. As well, various financial changes have impacted on clinical practice, from no-gap health insurance products and benchmark pricing of prostheses to changes in accreditation standards and fly-in fly-out medicine.
Orthopaedic: Day Case Arthroscopy Surgeon Surgical Assistant Anaesthetist Theatre Day Bed Pharmacy Total:
Vascular: Abdominal Aneurysm
In May last year, an orthopaedic surgeon (who wishes to remain anonymous) wrote to us with a dilemma that is worth exploring here. The surgical scene is changing. WA has pioneered surgical audits in public hospitals, surgeons are now subject to credentialing at all levels, and the RACS encourages its surgeons to ensure informed financial consent before embarking on any procedure. It says “the imparting of likely financial implications of the proposed treatment is sound ethical, professional and business practice. It indicates respect for individual patients and their rights, and avoids negative perceptions of private medical practice” (Informed Financial Consent Policy, October 2009). To give an idea of how perceptions are changing, 124 specialists gave these responses to our statements back in September 2004: For elective surgery, the onus is on the surgeon to find out the anaesthetist’s fee and include this in the patient’s quote for surgery. Agree 29% Disagree 63% Uncertain 8% There is no excuse these days for not fully declaring to private patients the estimated outof-pocket expenses they will face from all those involved in routine elective surgery. This includes pharmacy, physio, dressings etc. Agree 66% Disagree 30% Uncertain 4%
When we surveyed 13.6% of all GPs in August 2007, they were quite vocal about the impact specialist out-of-pocket fees were having on them and their patients. While they thought only 11% of their patients put out-of-pocket expenses as the most important factor during referral, 79% of GPs said that patients complained about cost after their specialist encounter (consult or procedure), 7% very often, 26% often and 46% occasionally. If a patient complains about that specialist’s costs, just over half GPs said they would divert the referral, either by telling the patient to find a cheaper specialist (34%) or by finding one themselves (18%). A minority (17%) push on with the referral and tell the patient to take up costs with the same specialist. Only 13% of GPs thought it was their job to vet out-of-pocket specialist costs before referring a patient (16% uncertain) but 82% said patients should be better forewarned of specialist costs and a third said these specialties charged inappropriately high out-of pocket fees for private
$1380 $276 $560 $1332 $460 $40 $4,048
Graft cost $12-30,000 Surgeon $3300 Assistant $340 Anaesthetist $1800 CT scans $1000 Additional: Theatre fee, drug costs, bed days (2-3 with 1 ICU) Total >$22,300 patients (in order) – orthopods, dermatologists, anaesthetists, psychiatrists, obstetricians, and plastic surgeons.
Certainly, money concerns are currently at the forefront of patient complaints about surgeons, particularly unheralded ancillary costs. Now, the College of Surgeons (RACS) says the cost of the anaesthetist, surgical assistant, pathology, imaging and allied health should be part of gaining informed patient consent, in writing, and gap payments and Medicare refunds should be outlined. The reality is that some surgeons, for some procedures, are now competing on price. The whole scenario of informed financial consent comes into stark prominence as wait lists increase for both appointments and procedures in public hospitals, particularly where the person is young and is seeking an early return to work. If these patients do not have private health insurance but are earning zillions up north, a quick fix becomes top priority. Other situations apply, such as people in chronic pain. Our orthopaedic surgeon said he is seeing more uninsured patients wanting to self-fund private surgery. Some of his colleagues avoid such cases because the referring GP has often grossly underestimated costs to the patient, they say providing an accurate comprehensive quote for the procedure is problematic, and if complications arise the patient cannot handle the cost blowout. At other times, the patient wrongly believes that can get fast tracked onto the public list by seeing someone in private. The RACS says there is the potential for subtle coercion of patients into paying privately for some procedures. “Surgeons should give accurate advice about waiting times in public hospitals and accurate information about the
Orthopaedic: Hip replacement Prosthesis Bed days (up to 10) Surgeon Assistant Anaesthetist Theatre Physiotherapy Imaging Total
$10,468 $8540 $1822 $333 $900 $6026 $550 $82 $28,721
General: Lapbanding Prosthesis
Bed days (2 days)
Additional: Anaesthetist, Theatre fee Total
alternate forms of care and the subsequent costs. There should never be coercion (or the impression of coercion) for patients to be treated in the private health care system.” Our orthopod suggested that while most things could be worked through between surgeon and patient, Medical Forum would be doing a good job if it gave GPs a better idea of private hospital costs. We are not sure about that but here goes with some figures supplied by surgeons, some going back a year or two. We invite our readers to comment on these issues via medicalhub.com.au or editor@mforum. com.au. l
Primary Health Care MF Review
Coming? Primary Care Reform in WA Medical Forum looks at the HDWA’s discussion document along the road to primary health care reform in WA. Now is the time to provide feedback. WA Health Networks people, under the leadership of Dr Scott Blackwell, have come up with a plan to shape the future of primary care in WA. July 7 is the deadline for written feedback on the Primary Health Care Strategy – Consultation Document. There will also be urban meetings and workshops, and the WA Country Health Services will talk to their people but individual comments are welcome. You can get hold of a copy at 9222 0200 or www.healthnetworks.health.wa.gov.au/ network/future.cfm and to spur you on, we present some details here. First off, realise that primary health care providers include GPs, nurses, midwives, allied health providers, Aboriginal health workers and pharmacists. And the push primary health reform, no surprises, comes from: • More chronic diseases
• Inequalities, particularly for Aboriginal people • An ageing populace
• Obvious current service deficiencies and duplication • A lack of community services in mental health and drug/alcohol areas.
While national goals are echoed – integration and infrastructure, e-Health and IT, workforce, cost and performance – the WA priorities are mainly focused on Aboriginal health, aged care, mental and drug/alcohol health, and maternal/ child health. The ideas come from the Primary Care Strategy Working Group, the Primary Care Health Network established in 2008, and about 200 other groups/individuals – leading to around 80 strategies to achieve results. What are they? You have only 30 pages to digest, the bureaucratic jargon may be a pain and repetitive, but the print type is big and it is well laid out. Try these thought-provokers first…. • A consequence of or reason for building primary care capacity is to take pressure off the hospital system, and two pre-requisites will be “cultural change and mutual respect” and “embracing the development of e-Health”. p 8. • Reform urgency is underpinned by WA’s commencement of Activity Based Funding and Management, with a key principle being an emphasis on community-based care to reduce hospital service demand. p 10 • The establishment of GP Superclinics is an opportunity for the local community to have greater access to primary care and Medicare
Locals may provide a system to manage and deliver services in WA. p 15 • Reforms should be supported by evidence – perhaps by partnerships with universities, research organisations etc – with research encouraged and supported. p 18 • Strategies for regional integration include service delivery in areas of need or poor access, outreach specialist services, and reduced hospital-based care when communities can do it better. p 20. • Revise the Privacy Act to accommodate a statewide mandatory e-Health platform – a single platform that integrates with everyone and is compatible with the national unique patient identifier initiative. p 22 • Explore generic-based mental health workers and chronic condition co-ordinators within primary care. p 23 • Enhance workforce skills through appropriate Aboriginal cultural awareness training. p 26 • Introduce geriatric expertise to the management of patients presenting to EDs. p 29. l
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Medicine in Practice MF
A GP With a Price Signal He says it is more than a matter of supply and demand Imagine that your GP wrote to you to say he/she was moving practice and if you wanted to continue on his/her books and be guaranteed a certain level of service you would now have to pay an annual fee, as would anyone else in your family. How would you respond? That’s what confronted one patient who passed on the letter from Dr Gary Ward in Nedlands, and who was concerned about meeting the $425 annual fee for their family. A lunchtime discussion at Medical Forum concluded that the doctor’s motivation seemed the critical point. Dr Ward’s letter to patients spoke of his enthusiasm for providing “excellence in health care” and outlined how his personalised service would be delivered. One sentence raised eyebrows: “In order for me to provide the best quality service, I intend to limit the number of patients registered personally with me by introducing a nominal annual registration fee.” And this seemed definite.
annual registration fee to achieve this? “It seemed a good way for me to find out who really wants me to be their doctor and whether they value having me as their doctor; and to discover those that are perfectly happy to see any doctor. Having patients who choose and are willing to pay a registration fee motivates me even more to provide the best possible service,” he said.
Others point to needy patients denied ongoing services on price alone. But what if he fell off the perch tomorrow? Are GPs being consumed by a “free” Medicare? How much do consumers value their GP and in what ways? l
He told us he could do his promised sameday emergencies and home visits by reserving sufficient appointments each day for those purposes. He stressed that the registration fee was not an attempt to rid himself of a particular type of patient (even though most doctors probably dream of such a scheme!). And yes, he had some niggling concerns about the fee system when we suggested he might lose some families due to cost. “I do have a concern for some patients who feel they cannot afford the fee; but they do have access to many other good doctors and I will be happy to assist them to find someone else.”
A desire to limit the number of patients in order to provide best service is understandable, so we asked Gary why he had chosen an
Dr Gary Ward has set a new benchmark price for his GP services. Some would argue he can do this because he works in Subiaco-Nedlands.
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Indigenous Health Training
Where to with Cultural Competency? Dr Rob McEvoy relates his excursion into achieving ‘cultural competency’ through online learning. The Federal Government’s recent decision to ensure companies bidding for large government contracts in regions with a significant Indigenous population employ Indigenous Australians and use Indigenous suppliers, is one form of affirmative action to “bridge the gap”. An accreditation course in “cultural competence” is another. However, such initiatives will attract controversy against a setting of many years of failed attempts to assist 2.4% of the population out of its social, economic, cultural and health difficulties. Are doctors and other health workers “culturally competent”? While no course is going bring about a generational shift, is it a step in the right direction? Does it mean everyone else is culturally incompetent? I took a crack at the online Aboriginal and Torres Strait Islander Cultural Competence course from the Centre for Cultural Competence, Australia (www.ccca.com.au). It leads to TAFE NSW accreditation, there is a fee, and it has been endorsed by the NSW General Practice Network, the RACGP, the RCNA, ACRRM and The Australian Psychological Society.
Once online, the course is simple, and you can come and go at your own pace, resuming where you left off. There are 12 components, each comprised of videos or reading followed by questions, with an estimated overall course time of about six hours. Going into this with my prejudices, there were some aspects I found contentious, but overall I learnt heaps about Aboriginal cultures and events, and the likely impacts on the doctorpatient encounter. Some of the language will fuel prejudices, such as “Aboriginal nations”, but this is insignificant in the broader context. After years of experience, I have learnt that the person sitting opposite can easily have different values to you. This course teaches a little of Aboriginal values. Had I been armed with some of this information, there is no doubt my earlier encounters with Aboriginal people would have been more successful. The joys of hindsight! While it is impossible to properly evaluate the whole course here, it is helpful to look at some ‘teasers’.
Facts and figures that struck me
• In WA the Native (Citizenship Rights) Act, of 1944, forced Aboriginal peoples to choose either Aboriginality or citizenship
which they could achieve by proving to a magistrate they had severed all ties with their extended family and friends, were no longer associating with other Aboriginal people, were free of disease, would benefit from citizenship, and were of ‘industrious habits’. The practice continued until 1962 Commonwealth legislation. • Pinjarra is remembered because of an Aboriginal massacre there. • More Aboriginal and/or Torres Strait Islander people (37%) than non-Indigenous people (22%) do not drink alcohol at all. • Aboriginal and/or Torres Strait Islander specific funding represents 1.58% of total Government spending (roughly equal to foreign aid and about $1,500 spent per person). • The 1997 National Inquiry into the Separation of Aboriginal and Torres Strait Islander Children from their Families report concluded, amongst other things, that: between 10-30% of A&TSI children were forcibly removed from their families and communities between 1910-70; the majority were removed in infancy with all that flows from this; they are no better off
Indigenous Health Training
today so it was not in their ‘best interests’; many people now have nowhere to belong, and no sense of identity; at least 1 in 10 were sexually abused; grief amongst those left behind has greatly affected health and morale. • The Gurindji strike of Aboriginal stockmen for fair pay started the demand for a return of their lands, led to the 1976 Aboriginal Land Rights (NT) Act and was the inspiration for Paul Kelly’s song ‘from little things big things grow’
The Aboriginal world view
• The concept of ‘spirituality’ refers to a more holistic view of life – in particular an individual’s link with the land, sea and air. People are custodians of the countryside (not owners). • Health and wellbeing are linked holistically (not separated as environmental health, social wellbeing etc). • In a non-hierarchical society, knowledge of life, practical and intellectual, is what earns an individual respect and status (not achievements of status, power, academia).
Photo courtesy WA Country Health Service
• Resources are shared amongst everyone in the group (not just family, as ‘earnt’ and paid for). • Aboriginal society emphasises membership of a group (not the achievements of the individual). An intricate, interconnected system of relationships, with each person having responsibility and obligation for someone else within this system. • Kinship knowledge for many Aboriginal groups has been greatly affected by forced
removal to missions, placing disparate groups together, the removal of children from their families, and the forbidding of Aboriginal language and cultural practice. There is much more to learn online about ‘The Intervention’ in the Northern Territory, The Apology, Self-Determination, the relationship between appalling health statistics and social inequality, Myths and Misconceptions, and so on…understanding is a start. l
Understanding Indigenous Health Prof Pat Dudgeon and A/Prof Roz Walker from the Telethon Institute for Child Health Research discuss cultural competency. Traditional Western public health approaches continue to fail Indigenous people in improving health outcomes and the majority of interventions are developed and implemented with little or no understanding of Indigenous people’s realities. Many Indigenous Australians regularly experience racism and discrimination which impacts on their access to and trust towards doctors, hospitals and social services. This results in poor health outcomes and causes dramatic disparities in chronic diseases and palliative care compared to the wider population.
Why cultural competence is important Cultural competence is often defined as a set of behaviours, attitudes, and policies that combine to enable an agency or individual to work effectively in cross-cultural situations.1 Cultural competence is a critical component of clinical competence and can improve Aboriginal health outcomes and build organisational capacity. Each Aboriginal community is unique in its culture(s) and history, and services need to be provided in ways that respect this. Unresolved
trauma, grief, and loss are potentially volatile issues, which, if dealt with insensitively, may increase psychological distress in communities. So it is essential that all health practitioners have the cultural competence to effectively deliver services to Aboriginal people.
Current directions Fortunately, there are some very good initiatives happening across the health sector. The NHMRC Centre for Research Excellence at the Telethon Institute for Child Health Research is examining ways to enhance individual and organisational cultural competence throughout the professional arena and in association with bodies such as the Women’s and Newborn Health Network and the Australian Indigenous Psychologists Association. Cultural Competence Assessment Tools have been successfully trialled at KEMH and PMH and Cultural Competence workshops have been successfully held for mental health professionals.
Addressing racism in Aboriginal health Aboriginal people need to have access to Aboriginal initiated and controlled health services, and culturally appropriate mainstream services. All mainstream services need adhere
to sound principles underpinning organisational cultural competence. They need to be flexible and responsive to the community’s needs and should involve community members in the design, delivery, and evaluation of services. They need to provide social, emotional and mental healthcare in primary health care settings and be integrated with other health and specialist services to support referral and coordinated care. If we don’t commit to positive social change— if we don’t own the racism in our country and professions, we will never become a just, equal and well society in which we can all share and benefit from. Positive change will be achieved by increasing the number of Aboriginal people employed across the health sector and, through changing systems and the individual practitioners and professions within the systems. Reference 1 Cross, T.L. et al 1989. Towards a Culturally Competent System of Care: A Monograph on Effective Services for Minority Children Who Are Severely Emotionally Disturbed. Washington DC: CASSP Technical Assistance Center, Georgetown University Child Development Center. l
Public Hospital Performance
Babies on Bikes The Women & Infants Research Foundation invites you to recruit young pregnant mums into some blubber-busting diabetes-divesting exercise! Researchers know that regular exercise decreases diabetes risk during pregnancy, but this study will be a first in answering, ‘Does regular exercise prevent gestational diabetes?’ by putting women with prior gestational diabetes on their bike second time around. More specifically, study participants get a free exercise bike, an exercise program, and regular coaching visits from qualified trainers from the School of Sports Science, Exercise and Health at UWA.
Director General of Health Kim Snowball has praised the performance of tertiary hospital EDs under the Four Hour Rule. Certainly, public hospital performance is more open to public scrutiny than ever before. Take the HDWA website www.health.wa.gov.au/ emergencyactivity/home/ index.cfm. Here you can see listed the ED daily or weekly activity – attendances, admissions, ambulance attendances and diversions, waiting times, and that old political football, ambulance ramping. At the same website is a run down of hospital bed occupancy, including country WA. We await a set of key performance indicators for aspects of management!
Pharmacy Blooper This was sent in by Dr Don Reid, busy in retirement.
The two-year study will investigate other health and wellness parameters and Prof John Newnham is looking after the obstetrics side, while the exercise aspects are led by Dr Kym Guelfi at UWA.
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The Cycle Study, as it is called (although we prefer Babies on Bikes) will recruit 200 pregnant women at 12-13 weeks gestation, with a prior history of pregnancy diabetes. The study stages are 14 and 28 weeks, with half entering the exercise program after 14 weeks. Improved guidelines for exercise during pregnancy are one tangible result, so sing out if you have a likely mum (tel 6488 2602 or visit www.wirf.com.au/research).
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Medicine and The Media Mr Jake Millar
Healthy Journalism in WA Shorter deadlines, government bureaucracy and PR are just some of the things hampering accurate reporting but does it really matter? The West’s Medical Editor Cathy O’Leary and WA Business News Editor at Large Mark Pownall speak to Medical Forum. There is little doubt journalism is undergoing a serious change. The growth of the internet and 24-hour news channels mean stories can be broken around the clock, though does this mean we are getting quantity over quality? And are medical interests getting better at manipulating the media? Medical Forum spoke to two seasoned WA journalists.
Government bureaucracy, PR spin and shorter deadlines
“Sometimes it’s hard to chip away at the PR spin and work out what is the legitimate story, and the 48-hour news cycle means things come in and out of news pretty quickly.”
“Over most of the time that I’ve been involved in journalism I’ve been very cut-and-dry about objectivity. But the truth is, what is objectivity? Everybody comes in with a view and as they get older and more experienced, their views change for a variety of reasons.”
Uncertain times for print media
“The pharmaceutical industry has a fairly welloiled public relations machine now, as do other groups as well.”
However, he said objective reporting is not the only thing newspapers offer, as many readers are now also looking to the media for opinion.
In contrast, she said getting information out of government groups can be difficult, particularly when you are chasing a shorter online deadline and there is the bureaucratic vetting process to undergo. She tries to combat this by keeping a good network of close contacts.
“Consumers are getting smarter and they understand the media’s now a little bit more of that commentary and views game, so they tend to gravitate towards people who provide news and views,” Mark said.
“Often the people I deal with in government have to wait on responses from higher up in the pecking order, which can be a difficulty. There can be some logistical issues, particularly if there are different government departments or if it’s across federal and state jurisdiction, trying to work out who’s responsible for what.”
“People talk about newspapers and their demise and probably prematurely in my view. The organisations that can package the most views and commentary and add the most value to the news will probably be able to charge for it.”
“Journalism in general is at a bit of a cross roads. The traditional institutions are cutting back on their number of journalists and they’ve typically chased larger audiences with less high-brow content,” said Mark. “Against that you have the rise of electronic media, which allows new organisations to enter the fray and also a different group of people – the average person, the citizen journalist, as some people call it.” “Climate change is a really good example because where a debate may have been held 20 years ago in the pages of a couple of newspapers is now the domain of dozens of blog sites and specialist media.” Cathy has seen other changes in the last five years. “Online reporting has had a fairly big impact on paper reporting and how we operate. When I started out you wrote something that day and not much would change, whereas now news can change by the hour.” “People don’t necessarily religiously sit down and read a newspaper for an hour each morning, nor do they sit down and watch TV news for an hour at night. So people are often more interested in snippets.”
In her 22 years as a health reporter, Cathy said one of the biggest changes is the growth of the public relations industry.
Getting accurate information in the first place can be a challenge but Cathy said she has developed a fairly good sense of who is pushing their own agenda. “Everyone probably has their own vested interest and you just take that on board. If people clearly have an agenda, it’s important to make that apparent to the reader. At the end of the day you try to give everyone a fair say and leave it up to readers to make their own assessment.”
Objectivity versus opinion Although objectivity might be an ideal, Mark said it is more a theory than a practice.
In fact, he believes the rise in opinion has helped to keep newspapers relevant.
Cathy said health reporting is still of high interest to readers, mental health especially. Readily available news is pushing newspapers in a different direction. “Any medium can report news as it happens – people can read news as it happens on mobile phones – so I think the challenge for newspapers is to have more exclusive stories, with longer and more in-depth features,” she said. “I think that’s where newspapers and news magazines are headed.” l
n n n Doing ok
n n n Truisms
My mate’s missus left him last Thursday, she said she was going out for a pint of milk & never come back!
Light travels faster than sound. That’s why some people appear bright until you hear them speak.
I asked him how he was coping and he said, “Not bad, I’ve been using that powdered stuff.”
Everyone has a photographic memory. Some don’t have film.
He who laughs last, thinks slowest.
A day without sunshine is like, well, night.
n n n Bad news
Seen it all, done it all, can’t remember most of it.
The police came to my front door last night holding a picture of my wife.
Those who live by the sword get shot by those who don’t.
They said, “Is this your wife, sir?” Shocked, I answered, “Yes.”
I wonder how much deeper the ocean would be without sponges?
They said, “I’m afraid it looks like she’s been hit by a bus.”
Despite the cost of living have you noticed how it remains so popular?
I said, “I know, but she has a lovely personality.”
Nothing is foolproof to a sufficiently talented fool.
n n n Two Irishmen…
The 50-50-90 rule: Anytime you have a 50-50 chance of getting something right, there’s a 90% probability you’ll get it wrong.
Two Irishmen find a mirror in the road. The first one picks it up and says, “Blow me I know this face but I can’t put a name to it.”
The things that come to those that wait may be the things left by those who got there first.
The second picks it up and says, “You daft bastard it’s me!” Two lrishmen are hammering floorboards down in a house.
It recently was discovered that research causes cancer in rats.
He carries on doing this until Murphy says, “Why are you throwing them away?” “Because they’re upside down,” says Paddy. “You daft prat,” replies Murphy, “save ‘em for the ceiling!!”
“Well, ok,” says the nun. “But I have two rules: you have to be single and you have to be Catholic.” The cab driver is very excited and says, “Yes, I am single and I’m Catholic too!” “Ok,” the nun says and she fulfils his fantasy with a kiss that would make a hooker blush. Suddenly the cabby starts crying. “My dear child,” says the nun, “why are you crying?” “Forgive me sister, but I have sinned. I lied, I must confess, I’m married and I’m Jewish.” “That’s Ok,” says the nun. “My name’s Kevin and I’m on my way to a fancy dress party!”
If the shoe fits, get another one just like it.
Flashlight: A case for holding dead batteries.
Paddy picks up a nail, realises it’s upside down and throws it away.
She asks him why he is staring and he replies sheepishly, “Well, I’ve always had a fantasy to have a nun kiss me.”
A fine is a tax for doing wrong. A tax is a fine for doing well.
Everybody lies, but it doesn’t matter since nobody listens.
n n n The cabby and the nun A cabby picks up a nun and when she gets into the cab, the cab driver won’t stop staring at her.
n n n Always there A woman’s husband had been slipping in and out of a coma for several months, but she had stayed by his bedside every single day. One day, when he finally woke, he motioned for her to come closer. As she sat by him, he whispered, eyes full of tears, “You know what? You have been with me all through the bad times. When I got fired, you were there to support me. When my business failed, you were there. When we lost the house, you stayed right here. When my health started failing, you were still by my side. You know what?” “What dear?” She gently asked, smiling as her heart began to fill with warmth. “I think you’re bad luck!”
WA Research Funding MF
WA Cancer Funding – Small Fish? Cuts to research funding have taken up media time recently, bringing focus to bear on fragmentation within an ‘industry’ that relies largely on government funds for specific research ‘projects’. WA is relatively small fry in the international research community and researchers here struggle to maintain that critical mass of people to attract the resources it needs. While on the one hand this spawns innovation, on the other it puts researchers clearly in the spotlight to justify their public purse spend. WA Health is ahead of the game with its recent release of Cancer Research and Funding in Western Australia, an Overview From 2008 to 2010 , a comprehensive review which we have examine here, along with comment from Prof Lin Fritschi on some related issues.
Cancer Council WA’s 13% Research Funding Prof Lin Fritschi said that last year the Cancer Council found there are 28 organisations in WA asking for a piece of the cancer funding pie – most through private donations – but less than half support cancer research. Lin’s legitimate question as a researcher is where is the rest of the donated money going? Around half of cancer research in WA is funded by the NHMRC, followed by the WA Cancer Council (13%) and the State Government (6%). The Cancer Council relies on private donations alone to fund research projects, so in this regard, it competes for the donation dollar with the 27 other organisations in WA. (The State Government funding it receives is used for awareness campaigns, such as the Make Smoking History and Go For 2 and 5 healthy eating campaigns.)
Prof Lin Fritschi is not only Cancer Council Research Grants Committee Chair, she also heads the Epidemiology Group at the WA Institute of Medical Research. Her forte is occupational causes of cancer, particularly exposure assessment in epidemiological studies. Her apparent conflict of interest (both handing out and receiving research grants) demonstrates how relatively small and tight-knit the research community is in WA. It also highlights the need many researchers have to collaborate across Australia and internationally in order to succeed, something that was not examined by the recent report on WA cancer funding even though the reports admits “at this point in time there is little coordination of the provision of cancer research funding either at a state or national level”.
As well, there are around 13 national non-government organisations in Australia supporting cancer research. Lin said some of these were significant, such as the Prostate Foundation and the Breast Cancer
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Foundation, which contributed around $0.8m and $0.6m a year, respectively. However, many others contribute sums as low as $1000. Lin wonders if it is more sensible if smaller amounts were combined into big research grants. For mainstream government-funded research, each year a panel of 10 NHMRC experts from around Australia ranks all applications from best to worst. Lin said the state governments can improve the success of applications by funding infrastructure. “Particularly the biomedical, lab-based end of medical research – the machines they need that are outrageously expensive, which allow them to do particular experiments and gives them an advantage.” In any event, the NHMRC ends up funding the top 20% (it used to be 35%) and the Cancer Council uses the baseline science assessments of the NHMRC to look at unsuccessful applications, and perhaps tweak priorities towards research projects done more in WA with a particular WA relevance, before awarding grants. They also hand out a couple of research fellowships that pay the wages of researchers for a defined period. Lin said the rigorous funding process at the Cancer Council gives smaller non-government foundations better access to larger grants, and they are happy to combine efforts with other research grant bodies. “Last year we combined with the Lion’s Cancer Institute – they had enough money for one grant which was $70,000 and we supported it by putting it through our grant system.” “What worries me are charities that collect money and don’t do research, where is that money going? I went into a shop the other day and there was a very small children’s cancer charity collecting money. You do wonder how much use is it actually having, and if it is better to combine charities instead of creating new ones.” Not knowing is one thing but where we direct donations is another. Lin admitted that when the Cancer Council surveyed its donors a couple of years back, providing services for people with cancer was placed ahead of cancer research by survey respondents.
The Cancer Research Audit Cancer Research and Funding in Western Australia, 2008 to 2010 was produced by The Cancer and Palliative Care Research and Evaluation Unit (CaPCREU), a collaboration between Curtin University, Edith Cowan University and UWA. Ironically, this Unit was established with $4m funding from the WA Government during the time of the report, which temporarily inflated the State’s figures for cancer research at a time the report was expected to provide leverage for more state-based support. Report investigators were Prof Christobel Saunders (CaPCREU Director), Assist/Prof Claire Johnson, and Dr Toni Musiello, all from UWA School of Surgery. The audit was completed by acquiring information from, amongst others, organisations that fund or administer cancer-related research, and key researchers found via word-of-mouth, websites and clinical trial registers. Interestingly, less than one third (n=72) of the acquired masterlist of individual researchers responded to requests for information and one public hospital failed to respond at all. Cooperation with information on non-competitive research funding was limited. However, it found a total of 249 grants were awarded for 242 individual research projects, ranging from $1,058 to $4m – and 219 of the grants were regarded as competitive.
Some Key Findings
• 2008-2010 direct funding to WA cancer research projects and programs was $34.6m – NHMRC 50% and Cancer Council 13%, with 92% going on specific research projects, followed by scholarships, fellowships and chairs (7%). • Research allocation by research type (or Common Scientific Outline) was: Biology 40%; Treatment 23%; Cancer control, survivorship & outcomes 12%; Early detection, diagnosis & prognosis 8%; Etiology 6%; Prevention 6%; and Scientific model systems 5%. • Biology research or projects of a basic science nature (i.e. not specific to a particular cancer) received most funding – lung, haematological, genitourinary, breast and head and neck cancers were top of the list. • Lung, brain and leukaemia cancers all received larger amounts of funding than their incidence rates. Breast cancer showed relatively matched incidence and funding. In general, the pattern of funding by disease site did generally follow the level of burden of cancer by disease site. • When compared to person-years-living-lost (PYLL), disease sites that appear to be overrepresented in cancer research funding include prostate cancer (in competitive grants and clinical trials), leukaemia (in competitive grants) and breast cancer (in clinical trials). Areas that appear to be underrepresented in competitive grants are melanoma, liver, oesophagus, ovary, pancreas, stomach, kidney, and colorectal cancers. • The WA state government provides mainly non-competitive funding (79% of non competitive research projects) that is limited and nonrecurrent (mostly general research and in the area of cancer control, survivorship and outcomes). • Of the 110 clinical trials currently open in WA, 65% were in breast cancer, haematological, lung and genitourinary cancers (but audit information was limited). Mostly, the coordinating institutions responsible for administering clinical trial grants are located outside WA. • Report shortcomings: smaller funding organisations are likely to be under-represented in the report; researcher collaboration was not covered by the report – the National Audit in 2005 found that the vast majority of collaborations within the same institutions, city and states; it is possible that the number of grants and amount of funding awarded for infrastructure, equipment, and scholarships, fellowships and chairs is higher than presented. l
Workers’ Comp matters By Michelle Reynolds Chief Executive Officer, WorkCover WA
First Medical Certificate: getting it right One of the most critical tools in the workers’ compensation system is also one of its understated - the First Medical Certificate. The First Medical Certificate is used to start the process of payments to an injured worker. It provides vital information to employers and insurers on medical management of the claim. The certificate can also provide the employer with ideas of how they might modify workplace duties to accommodate the injured worker’s medical needs and help them return to work. Further still, these forms are the evidence used in disputes, helping everyone recall when memories or other information sources fail us. With such emphasis on the Certificate throughout the workers’ compensation system, the care taken by the treating practitioner to complete properly can have a significant bearing on the outcomes of both the workers’ claim for wages and payments, as well as their successful return to work. A successful First Medical Certificate: • accurately and objectively diagnoses the injury and the limitations caused by the worker’s incapacity • certify the worker’s fitness for work and gives clear guidance on any work restrictions that may need to be factored into their return to work planning • correctly records the date of the consultation, as post-dated or ante-dated certificates can result in a worker’s claim being rejected or delayed • outlines a plan for future appointments or other proposed medical management. While the temptation may be to sign a worker off as “unfit for work” for weeks on end, research shows that prolonged time off can actually risk a successful return to work. It is in everyone’s best interests for the treating practitioner to explore options to get the worker back into the workplace as soon as possible, whether that be undertaking alternative duties or reduced hours. In this way the worker can still participate effectively in the workplace, socialise with their colleagues, and maintain financial stability as they recover from their injury. WorkCover WA is keen to hear about how we can improve the certificate and other processes to make the workers’ compensation scheme more efficient. I encourage you to email your comments and suggestions to email@example.com or phone on 1300 794 744.
Workers’ compensation and injury management scheme Advisory Services call centre 8am – 5pm weekdays 1300 794 744
C L I N I C A L U
he glycaemic Index (GI) was promoted as a weight loss method in the 90’s by nutritionist Jennie Brand-Miller in books such as The New Glucose Revolution and GI Plus. It has also been introduced into popular culture through the weight loss game show The Biggest Loser. A number of advisory groups (including Diabetes Australia) now promote low GI diets for managing type 2 diabetes and reducing the occurance of ‘hypos’ in those with type 1 diabetes. . However, some authorities recently suggested that there is an overemphasis on the role of GI in diabetes and weight loss. They have also raised concerns that use of the low GI symbol can be confusing.
What is GI? The GI ranks carbohydrates according to their effect on blood glucose levels (BGL). The scale ranges from 1 – 100, with glucose scoring 100. Low GI food is rated 55 or less, medium 56 – 69 and high GI 70+. In general, the more processed a food, the higher its GI. High GI foods produce rapid rises and falls in BGL, provoking an insulin spike that long term can increase the risk of diabetes and weight gain. Slower sugar release from more complex carbohydrates (lower GI foods) moderates blood glucose and insulin levels, assisting in diabetes management and weight loss.
Pitfalls of a low GI diet Popularisation of the GI has led to some patients unnecessarily avoiding all high GI foods. For example, I have had several patients with diabetes who avoided potatoes for many years because of GI concerns. Jacket potatoes have a GI of 69, but at about 100 calories per 150 gm and less than 0.1% fat, they can still be a healthy choice and certainly favourable to low GI foods such as chocolate and ice cream! The GI also only measures the individual food and not the whole meal, nor the total amount of carbohydrate (the glycaemic load). Furthermore, protein and vinegar can reduce gastric emptying, effectively lowering a meal’s
By Ms Jo Beer, Dietitian and Diabetes Educator. Tel 0403 938 747
GI - adding a dressed salad or chicken to the potato can reduce the meal’s GI. It is a fashionable misconception that foods should be eaten or avoided depending solely on their GI. A low GI certainly should not be considered as a licence to eat unlimited amounts, or even that the food is necessarily healthy. A recent scheme to identify low GI foods with a symbol has been launched by diabetes interest groups. Foods also have to meet criteria for salt and saturated fat content, but this can create the erroneous impression that foods lacking the symbol must have a high GI.
What to advise
• Choose low GI foods most of the time – aim for one per meal – so choose oats for breakfast, add beans to a jacket potato or lentils to a vegetable soup. For more ideas visit the glycemic index website below or look out for one of the official glycemic index books at the library or in the book shop.
Useful patient resources:
• Control portions – see government recommendations below
• Choose unprocessed foods with abundant wholegrains, lean protein, fresh fruit and vegetables
• Exercise daily
www.glycemicindex.com/ www.health.gov.au/internet/healthyactive/ publishing.nsf/content/recommended-dailyservings n
Conference Corner Australian Diabetes Society & Diabetes Educators ASM Dates: 31/8/2011 31/8/2011 Venue:
Perth Convention Centre
Website: http://www.ads-adea.org.au/ For more information phone (03) 5983 2400 or visit the website.
Asia Pacific Autism Conference Dates: 8/9/2011 10/9/2011 Venue:
Burswood Entertainment Centre
Website: http://www.apac11.org/ For more information phone 9389 1488 or email firstname.lastname@example.org.
Visit www.medicalhub.com.au for more information and click on ‘Events’.
P D A T E
Using Glycaemic Index with weight loss and diabetes
PIVET MEDICAL CENTRE Specialists in Reproductive Medicine & Gynaecological Services
Medical Director Dr John Yovich
Egg Banking Viable The attached picture shows a human metaphase-II egg with polar body and sperm attached to the surrounding zona pellucida. This photo was taken in my Laboratory at the Royal Free Hospital in London in 1977, a unique feature at its time being a year prior to the first IVF success – Louise Brown in July 1978. Currently there are around 4 million babies from IVF and a large proportion are generated following embryo freezing with the first successes reported in 1984, PIVET following soon after in 1985. However the technique of egg freezing proved more difficult until my close colleagues in Tokyo – Osamu Kato & Masa Kuwayama whom I helped establish their IVF Clinic 20 years ago, working with our Professor Gabor Vajta, reinvented a Vitrification technique known as Cryotop. The Holy Grail was discovered with excellent results and PIVET has been reporting many pregnancies now from banked oocytes over the past two years. Eggs can be banked by young women deferring pregnancies for their own subsequent use or for other women requiring egg donation. In March this year our sister clinic Cairns Fertility Centre reported its first baby – a healthy girl – following a donor egg pregnancy derived from our Vitrification Egg Bank and others are now underway. In WA all assisted reproductive procedures are highly regulated under restrictive State legislation whereas Queensland functions under National regulation which enables far more freedom within the various donor programs.
NOW AT 3 LOCATIONS LEEDERVILLE, JOONDALUP & BUNBURY
For ALL appts/queries: T:9422 5400 f: 9382 4576 E: email@example.com W: www.pivet.com.au
Early Intervention in Mental Health of Young Faculty of Child Psychiatry Chair Dr Caroline Goossens explains why greater investment in child and youth mental health is a good idea. The Australian Research Alliance for Children and Youth (ARACY) delivered a damning Report Card in 2008 for child mental health and wellbeing. In the ‘lucky country’, our children and youth’s mental health outcomes are poor, being rated 18 out of 24 compared to other OECD countries. Shamefully, our indigenous children are ranked 23rd. What does this say about the priorities of our resource rich nation? Raising mentally and physically healthy children provides obvious benefits that flow on to all of us. It promotes increased productivity, greater social inclusion, and reduces public expenditure. The National Early Childhood Development Strategy, Investing in the Early Years, asserts that the shared vision of the commonwealth, state and territory governments is that by 2020 all children will have the best start in life to create a better future for themselves and for the nation. This rhetoric is yet to be transferred into effective policy. Those who raise children have the most powerful influence on their development, yet we skimp on evidence-based supports and interventions to families at this vital period and invest in services too little too late. Young children who experience recurrent abuse and neglect, witness violence, or live in homes with family dysfunction, substance abuse, and maternal depression are particularly vulnerable and at substantially increased risk of developing serious emotional and behavioural problems, learning difficulties and just as importantly, future major physical health problems. It is remarkable how little attention service planners devote to strengthening the capacity of child and adolescent mental health services, in view of the overwhelming data that supports the need for this. Increasingly, the needs of infants, young children and their families are being overshadowed by a focus on the mental health needs of youth, despite infancy and childhood being a more critical time in development. Only 10% of our mental health budget is allocated to child and adolescent mental health services, although children and adolescents make up more than 25% of the population. This provides resources for the most severe and complex mental health problems, ensuring GPs and other referrers struggle to get access for children who have less severe and entrenched disorders but no access to comprehensive services. This, despite all evidence that preventive early identification and treatment of emerging mental health problems is far more cost-effective. Effective and responsive early childhood services optimise universal, targeted and intensive services that need to be well-coordinated, interdisciplinary and flexible. The recent integration of Child and Adolescent Mental Health services into a single service within Child and Adolescent Health Service is an important opportunity to achieve this, but substantial further investment is required. To date the responsibility to provide responsive mental health services to infants, young children and their families has been ignored. We will again fail the next generation if we neglect their needs during this vital stage of development, at great future cost to our health system and society. l
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lthough ‘can’t intubate–can’t ventilate’ situations are uncommon for anaesthetists, the consequences can be significant. Pre-operative airway assessment helps identify a potentially difficult airway. The anaesthetist may then choose an ‘awake’ fibre-optic intubation as it may be the safest way to secure the airway. This technique is commonly performed in major centres and is generally well tolerated if the patient knows what to expect and the operator is skilled.
By Dr Anthea William, Difficult Airway Fellow, Fremantle Hospital
The technique allows passage of an endotracheal tube (ETT) under direct vision, whilst maintaining an open airway and spontaneous breathing in an awake patient. The ETT is passed via the nose or mouth over the top of a small flexible video-scope, through the vocal cords and into the trachea, after which the patient can be safely anaesthetised to allow surgery to begin.
Although ‘awake’ fibreoptic intubation may seem a daunting prospect for many patients, various techniques make it well tolerated. The most common indications are: anticipated difficult intubation and/or ventilation; patients with an unstable cervical spine; an earlier failed intubation (e.g. during previous GA).
Awake intubation technique Patient Preparation • Full discussion with the patient is aimed at full co-operation between anaesthetist and patient. • A premedication to minimise secretions (e.g. glycopyrrolate). • Patient either sits at 450 with anaesthetist in front or lies down with the anaesthetist standing behind.
n (1)Nebulised 4% lignocaine to anaesthetise the upper airway. (2) Direct spraying of the mucosa with 4% lignocaine via a micro-aerosol device. (3) Insertion of the fibreoptic scope via the nose. The anaesthetist may stand behind or in front of the patient.
• Patient refusal or lack of cooperation
• Allergy to local anaesthetic agents
• O2 via a cut-out face mask or nasal sponge; and patient monitoring (ECG, NIBP, pulse oximetry, capnography)
• Airway soiling (e.g. blood or vomitus) that prevent effective topicalisation and obscure the view
• Topical local anaesthetic is applied to the airway (with 9mg/kg lignocaine dose limit) via: nebulisation; direct spraying of mucosa with a micro-aerosol device; gargling; and/ or spraying directly via the endoscope.
• Peri-glottic masses – the fibreoptic scope may result in complete airway obsruction due to a ‘cork-in-a-bottle’ effect • Stridor signifies significant airway
narrowing. Coughing may precipitate complete obstruction • Local infection or inflammation reduces the effectiveness of local anaesthetics.
Complications These are infrequent but may need careful consideration in light of the patient’s presenting problems: epistaxis; hypertension; raised intracranial and intra-ocular pressure; over-sedation and hypotension; local anaesthetic toxicity; and technique failure. n
• Then, the videoscope is carefully passed under direct vision via the nose or mouth, through the nasopharynx or oropharynx, past the vocal cords and into the trachea. • The ETT is advanced over the fibreoptic scope, into the trachea, and position confirmed above the carina.
Use of sedation For patients who find it difficult to cope with an awake technique, controlled titrated sedation (e.g. remifentanil, propfol, dexmetatomidine and midazolam) is particularly useful whilst maintaining verbal contact with the patient. The ‘pros’ are: experience more tolerable for the patient; and reduces patient movement and coughing The ‘cons’ are: hypoventilation leading to hypoxia and hypercarbia; airway obstruction due to overdose; hypotension; and disinhibition.
Doctors – want to save time and provide a better service for your mental health patients? Then use us We help by: • Dealing with “Heart Sink” patients/carers • Saving doctor time through navigating the system and providing advocacy and support • Providing doctors with a “One Stop Shop” for referrals to community mental health services
• Educating carers on how to be the doctor’s “eyes and ears” • Supporting carers so reducing the chances of them developing mental health issues
Phone 9427 7100 or Freecall 1800 811 747 or email firstname.lastname@example.org FREE Services include counselling, support groups, phone support, information and referral services, youth services, school holiday programs, respite services and recreation services for consumers.
P D A T E
Awake fibreoptic intubation
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Diabetes: ophthalmic manifestations By Dr Bradley Johnson, Ophthalmologist, West Leederville. Tel 9381 3409
iabetes affects the eyes and diabetic retinopathy is the leading cause of blindness in our community. However, diabetes can affect the eyes in many different ways, as briefly outlined here.
the optic disc (NVD) or peripheral retina (NVE) heralds the onset of ‘proliferative’ diabetic retinopathy. This is a severe complication and requires urgent laser treatment to prevent vision loss.
Ocular infections such as conjunctivitis and blepharitis are more common in diabetics. Symptoms are often exacerbated by dry eye, which occurs more frequently due to poor tearproduction, reduced numbers of conjunctival goblet cells and reduced corneal sensitivity (probably related to diabetic neuropathy). Frequent lubricating eyedrops and eyelid cleaning may reduce symptoms. Antibiotics are usually not indicated. Patients should be counselled about meticulous contact lens handling to prevent infections.
n F ig 1. Diabetic retinopathy and maculopathy.
Lens Blood glucose fluctuations can influence the refractive index of the lens, resulting in refractive errors that usually normalise after control of the blood sugars.
Risk factors for retinal disease include poor long-term control of sugar levels and disease duration, as well as smoking, systemic hypertension and obesity. Type 1 diabetics usually have more severe disease. Lipaemia retinalis is a rare ‘curiosity’ sometimes found in diabetics, where abnormal lipid control results in transient severe hypertriglyceridaemia following a fatty meal. Retinal vessels appear creamy pink. It is visually insignificant (fig 2).
Cataracts are more common in diabetic patients and those with more severe retinopathy or maculopathy tend to have a worse outcome from surgery as there is an increased risk of worsening retinal disease if this is not adequately controlled pre-operatively.
Optic nerve and other cranial nerves Primary open angle glaucoma is more common in diabetics. Diabetic papillopathy is a benign swelling of the optic nerve head. There are no signs of optic neuropathy and no intracranial pathology. It resolves over time with improved blood sugar control.
Retina Diabetic retinopathy and maculopathy are most common. Macular disease tends to cause central vision loss. Pathophysiologically, there are many changes within the retinal vessels that result in ischaemia or oedema of the retina. Clinical signs of retinopathy include haemorrhages, cotton wool spots, beading of veins and other microvascular anomalies. The formation of abnormal blood vessels on
Maculopathy is the commonest cause of vision loss in diabetics – the central retina becomes oedematous or ischaemic. Signs of maculopathy include hard exudates and retinal thickening. Until recently, the only effective treatment for macular oedema was retinal laser. Now, intravitreal injections improve vision.
n F ig 2. Lipaemia retinalis before a fatty meal (top) and 30 mins after (bottom).
Other cranial neuropathies are common. Typically, diabetic 3rd nerve palsies are pupil sparing. Most spontaneously resolve after three months. This clinical update is supported by the Eye Surgery Foundation n
Eye Surgery Foundation Perth’s only freestanding Ophthalmic Day Hospital
Expert day surgery for • Cataract Extraction and Lens Implant • Pterygium • Glaucoma • Oculoplastic Surgery • Strabismus • Corneal Transplant • All types of Refractive Surgery – LASIK, LASEK, PRK, CTK, Phakic Lens and Refractive Lens Exchange (RLE)
• Supporting ophthalmic research and development • Certified to ISO 9001 Standard
Our Vision Is Improved Vision Dr Ross Agnello Tel: 9448 9955 Dr Ian Anderson Tel: 6380 1855 Dr Malcolm Burvill Tel: 9275 2522 Dr Ian Chan Tel: 9388 1828 Dr Steve Colley Tel: 9385 6665 Dr Dru Daniels Tel: 9381 3409 Dr Blasco D’Souza Tel: 9258 5999 Dr Graham Furness Tel: 9440 4033 Dr Richard Gardner Tel: 9382 9421 Dr Annette Gebauer Tel: 9386 9922 Dr David Greer Tel: 9481 1916
Dr Boon Ham Tel: 9474 1411 Dr Philip House Tel: 9316 2156 Dr Brad Johnson Tel: 9381 3409 Dr Jane Khan Tel: 9385 6665 Dr Ross Littlewood Tel: 9374 0620 Dr Nigel Morlet Tel: 9385 6665 Dr Robert Patrick Tel: 9300 9600 Dr Jo Richards Tel: 9321 5996 Dr Stuart Ross Tel: 9250 7702 Dr Andrew Stewart Tel: 9381 5955 Dr Michael Wertheim Tel: 9312 6033
Contact: Matthew Whitfield Ph: 9216 7900 Email: email@example.com 42 Ord Street West Perth WA 6005 34
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hose of us ‘at the coal face’ may be relatively oblivious of the laws under which we work. It is only when we challenge accepted practice that the weight of laws and regulations become apparent. The Regulatory Support Unit (RSU), a small section of the Department of Health (DoH) within the directorate of Disaster Management Regulation and Planning (DMRP), has as its main function the administration of regulations that fall under Public Health. We work closely with other areas in the DoH, as well as provide advice to other agencies, health professionals and the public. Here are some insights around the relevant Acts (see www.slp. wa.gov.au/legislation/agency.nsf/health_home.htmlx).
Opioids and stimulants: the Poisons Act 1964 These Schedule 8 drugs present a significant challenge not only to the prescribers and pharmacists, but also to the regulators! The Poisons Act provides the overarching legal framework, and RSU and Pharmaceutical Services Branch (PSB) work together to implement the Poisons Regulations. The signing of the ‘pinks’ (the pink authorisation forms) is a daily ritual that is part of a constant system of monitoring of prescribing and dispensing. We see our role as advisory and educational as well as being law enforcers, and believe in continual improvement of the system (watch this space!).
The Stimulant Assessment Panel In 2002, WA was the biggest prescriber of dexamphetamine in the country. Back then, the number of prescriptions per head of population was four times higher than the Australian average. This controversial discrepancy led to
By Dr Revle Bangor-Jones, Acting Principal Medical Officer, Regulatory Support Unit. Tel 9222 2380
a review of prescribing of stimulants in WA and recommendations for a regulatory scheme. The Stimulant Prescribing Code was the result – it sets out the clinical criteria for stimulant prescribing under the provisions of the Poisons Regulations 1965, as made under the Poisons Act 1964. Since the introduction of the Code, there has been a 10.6% decrease in the number of patients receiving stimulants, while other jurisdictions have continued to increase and indeed overtake WA. The Stimulant Assessment Panel is chaired by the Principal Medical Officer in RSU, and meets monthly to assess applications by prescribers for stimulant use for patients who do not meet the criteria set out in the Code. The panel consists of psychiatrists and paediatricians from the public and private sectors, as well as the pharmacist(s) responsible for administering the Code.
The latest Stimulant Regulatory Scheme report is at: www.public.health.wa.gov.au/ cproot/3605/2/Annual_Report_2009.pdf
For information about prescribing S8 drugs, see: www.public.health.wa.gov.au/1/872/2/ pharmaceutical_services.pm
Ed. The various statutory committees of most relevance to doctors will be outlined in a coming edition. n
Statutory notifications and committees: The Health Act 1911 Western Australia has the oldest Health Act in the country, at 100 years old this year. One relevant section for RSU is that concerning statutory notifications of conditions such as infectious diseases of public health significance, stillbirths and neonatal deaths and, more recently, stimulant-induced psychosis. Statutory medical notifications are specified in legislation or regulations and are mandatory under State Law. For information about notifications see: www.public.health. wa.gov.au and click on ‘licensing notifications and legislation’
A M A Z I N G
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P D A T E
In tandem: Public Health and medical practice
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Managing rare diseases in general practice By Dr Chris Fox, General Practitioner, Wembley Family Practice
eneral practitioners manage a huge spectrum of undifferentiated illness as well as supervise the complex care of patients with chronic disease and multiple morbidities. Good general practice is about caring, compassionate and consistent relationships with patients and carers. ‘Cradle to grave’ management, dealing with families, insights into coping skills and supports, and knowledge of local support services position them well to assist patients with rare diseases by building the appropriate therapeutic alliances. While there are no research figures, anecdotally I know that rare diseases are a common problem in Australian primary care. The European Organisation for Rare Diseases (Eurodis) gives rare diseases a prevalence of 6-8%. Extrapolated, that is around 1.22.0 million Australians affected, including around 400,000 children. Collectively, there are probably more people afflicted with rare diseases than with diabetes or with heart disease. Rare diseases are usually inborn errors of metabolism or of growth and development and tend to be severe, chronic, incurable and often have limited effective and available treatment. They have a profound effect on an individual’s capacity to fulfil their potential to lead active, happy, productive lives. They often result in intellectual and/or physical disability and foreshortened lives. There is a considerable burden of care on families and other carers, which can in turn lead to financial disadvantage.
Diagnostic difficulties The diagnosis of rare diseases is often delayed, which is not surprising. The Eurodis 2005 study reported that of 6,000 patients surveyed, 40% were initially misdiagnosed and many had unnecessary medical interventions - 16% surgery, 33% inappropriate medical treatments, and 10% labelled as psychosomatic illness. In metropolitan practice, if a child or an adult presents very unwell, GPs often refer them to specialists or ED, where a rare disease may be diagnosed. However, the more insidious, chronic or subacute forms present a challenge.
How GPs fit in Because GPs see the chronically unwell and disabled frequently, along with their families and carers, we often manage related medical issues, such as depression in the mother of a child with complex needs. We provide psychosocial support, suggest management informed by knowledge of the family and community supports, and interface them with specialists. Rare diseases, perhaps complex and demanding, are well suited to a multidisciplinary care team with the GP as a team member, at least at the end of a phone (fax or email).
GP as patient advocate GPs spend a lot of time communicating and interpreting medical jargon, helping patients understand and come to terms with the results of medical tests and the implications of their 36
disease. Good general practice is about seeing the illness from the perspective of the patient or carer, and understanding their unique capabilities and weaknesses so as to produce a well-tailored plan of care. Hospital admissions and outpatient appointments with specialists can be stressful and disempowering. A trusted family GP can be invaluable in assisting people process the sometimes complex information about disease management. (see Case Studies)
GPs also act as service enablers in dealing with health bureaucracy. We assist people to claim relevant Centrelink payments such as the Disability Pension and Carer’s Payment / Allowances. Through the EPC scheme we can access Medicare rebates for limited ancillary care, such as physiotherapy and podiatry. While clinical psychology referrals are more generous (12 per year), financially disadvantaged patients may find it difficult to pay the gap often charged. In practice, this means patients and families with complex needs are often reliant on tertiary facilities for much of their health care. n References available on request.
Case Study 1 I once looked after two brothers in their 50s with Lesch-Nyhan Syndrome.(hyperuricaemia, selfmutilation, choreoathetosis, spasticity and intellectual disability). The brothers were profoundly physically disabled with moderate cognitive dysfunction, both wheelchair and bedbound and living with their aged parents. Considerable support from Disability Services allowed the brothers to stay at home. The older brother died somewhat unexpectedly from a myocardial infarction, leaving the younger brother who was frequently very agitated and had chronic pain and depression. I prescribed a slew of analgaesics, tranquillisers and antidepressants with modest success. It was hard for his mother to relinquish his care and I spent much time supporting her. Disability Services carers did an excellent job in a sometimes intense situation. Eventually, the surviving son moved to a group home, a difficult process but a measure of independence improved his agitation, reduced his self-mutilation and elevated his pain threshold. Later, I cared for both parents until they too had to leave home for an aged care facility.
Case Study 2 A young girl with MCAD (Medium Chain Acetyl-CoA Deficiency) was referred to Silver Chain Hospice Care. I knew virtually nothing about this condition and was very grateful that her paediatrician rang me. She had presented at 11 months when a febrile illness led to severe brain injury and intractable epilepsy. Subsequently, she steadily deteriorated with recurrent aspiration pneumonia and severe lung disease and it became clear to her family and clinical staff that a palliative approach should be taken. She passed away peacefully and the family coped very well. With excellent tertiary hospital support and the community hospice nurses, relatively seamless community care was provided.
Wishlist for good care of Rare Diseases in the community • GP education to assist with early diagnosis, appropriate management and referral. • Improve information flow between hospitals and general practice for rare diseases – printed material is always welcome. • A one-stop national website with updated quality information on all disease entities, along with details of tailored health services and patient support groups. The internet makes this possible. • Assistance with the ‘tyranny of distance’. This includes communication with GPs and patients living in rural areas and families in local communities (so they do not need to
relocate close to a tertiary hospital). • Adequate remuneration and support for GPs who spend time dealing with the complex needs of patients and their families. Enhanced Primary Care items are complex and unwieldy, plus organising and/ or attending case conferences is difficult. Home visits should be encouraged and adequately remunerated. • Cut red tape. Access to expensive or orphan drugs is desirable. The PBS Authority Scheme is time consuming. Simplification of the Enhanced Primary Care Scheme would help.
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hronic debilitating or life-threatening, rare diseases have low prevalence but collectively affect 6-8% of the community. The financial and emotional burden on families is often catastrophic and they impact on health and social support services. A rare disease, by definition, affects less than one person in 2,000 and with over 7,000 such diseases currently identified (80% genetic), there are about 140,000 West Australians affected. WA recently hosted the inaugural national rare disease symposium Awakening Australia to Rare Diseases: Global perspectives on establishing a coordinated approach to a national plan. The symposium included the launch of “Rare Friends”, a non-partisan network of State politicians, formed to raise awareness of rare disorders in the community and to extend the network amongst state and federal parliamentary colleagues. The politicians who attended included Peter Tinley MLA, Peter Abetz MLA, Brian Ellis MLC, Sue Ellery MLC and Linda Savage MLC. The symposium brought together individuals and families living with rare diseases, health and disability service providers, policy makers and pharmaceutical industry representatives to develop a plan that would cater for their common needs. Director General of Health Mr Kim Snowball spoke of the impact of rare diseases on health services and he committed WA Health to improve services for affected people, with the symposium the starting point for a Western Australian rare disease strategy. Speakers from Europe, USA, UK and New Zealand spoke about their regional organisations. Several delegates presented personal narratives of experiences with muscular dystrophy and Fabry disease, and as parents of children with inherited rare or acquired conditions such as meningitis. Stories told of their diagnostic odyssey, difficulties in navigating through health and disability services and the formation of informal networks to share information – their dignity and determination was inspiring. One of the most poignant presentations was by a young man with a progressive neuromuscular disorder, who asked delegates not to focus on his genetic
diagnosis. His central message, “I don’t need to be cured, I just want to live the best life possible” captured the priority he anticipated for a rare disease strategy. For the general practitioner, the challenges are complex and demanding. Finding relevant information is a first step and GPs might start with Genetics in Family Medicine: The Australian Handbook for General Practitioners (www.nhmrc.gov.au/your_health/egenetics/ practitioners/gems.htm).
By A/Prof Hugh Dawkins, Office of Population Health Genomics, Department of Health WA.
The plenary talks outcomes were: to develop a national plan for rare diseases; to form a single overarching advocacy group that included the pharmaceutical industry and academic researchers; and support for the proposed National Disability Insurance Scheme. As one delegate wrote afterwards, “It was an excellent event and I’ve been telling people here how nice it was to attend a conference that was focused on actually doing something”. n
Number of Western Australians with a diagnosed ICD10 code genetic disease mutation Multisystem diseases conditions, including Down’s syndrome, Trisomies 13, 18 and 21, Pader-Willi, Noonan, Alport’s, William’s Marfan, Angelman’s and Turner’s syndromes. 1,157 Rare disorders of the glands, such as congenital adrenal hyperplasia. >385
Rare muscle diseases, including Duchenne muscular dystrophy and spinal muscular atrophy. >1,600
Immunological conditions, including Severe Combined Immunodeficiency (SCID), Wiskott Aldriich and DiGeorges Syndromes, and hereditary hypoglobulinaemia. >93 Rare cancer conditions, including Costello syndrome and familial adenomatous polyposis of the colon. ~ 100 Eye and ear, circulatory gastrointestinal and renal system as well as skin and teeth conditions. >3,460
Rare neurological conditions, including neurofibromatosis, Rhett syndrome, cavernous angioma and inherited ataxia. ~ 1,450
Blood disorders including thalassaemia, sickle cell anaemia and haemophilia. >3,184
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Rare diseases – awakening Australia
➧ [Click on “Competitions” in the left menu]
Opera: Tales of Hoffmann by Offenbach Win a Double Pass to Opening Night (incl. program voucher and 2 drinks vouchers). Ardent lover, poet and writer Hoffmann tells of his great loves, all ending tragically thanks to the meddling of his enemy, a supernatural villain. The perfect combination of fantasy and classical music with endless gorgeous melodies, seductive and tender love scenes, bizarre characters - comic, romantic or villainous - and tragic climaxes. Featuring Rosario La Spina, James Clayton and Rachelle Durkin, with the WA Symphony Orchestra and Opera Chorus. See www.waopera.asn.au. July 14-23. His Majesty’s Theatre. BOCS 9484 1133
Competitions ➧ To enter go to MedicalHub.com.au
funny side n n n Talking in code The kids have all their little SMS codes...like BFF, WTF, LOL etc. So here are some codes for the seniors: ATD - At the Doctor’s BFF - Best Friend’s Funeral BTW - Bring the Wheelchair CBM - Covered by Medicare CUATSC - See You at the Senior Centre DWI - Driving While Incontinent FWBB - Friend with Beta Blockers FWIW - Forgot Where I Was FYI - Found Your Insulin GGPBL - Gotta Go, Pacemaker Battery Low
Exhibition: Good Food & Wine Show
GHA - Got Heartburn Again
Win a double pass to WA’s largest food and wine exhibition. The Good Food & Wine Show is returning to our shores so you can succumb as you explore, indulge and sample good food, acclaimed local produce, enticing chocolates, luscious cheeses, and of course, award-winning Western Australian wines. To receive show updates, information or tickets visit www.goodfoodshow.com.au
HGBM - Had Good Bowel Movement
July 15-17, Convention & Exhibition Centre. Ticketek 13 28 49
ROFL...CGU - Rolling on the Floor Laughing...Can’t get Up!
Cinema: The Trip Win a double pass. Follow two good friends in this hilarious road movie as they tour the Lake District and the Yorkshire Dales of Northern England, eating, chatting and driving each other crazy. Starring Steve Coogan and Rob Brydon and directed by BAFTA winner Michael Winterbottom (Genova, A Mighty Heart, 24 Hour Party People, Tristram Shandy: A Cock and Bull Story). See www.madman.com.au/impressme In cinemas June 30
IMHO - Is My Hearing-Aid On? LMDO - Laughing My Dentures Out OMMR - On My Massage Recliner OMSG - Oh My! Sorry, Gas
TTYL - Talk to You Louder WAITT - Who Am I Talking To? WTFA - Wet the Furniture Again WTP - Where’s the Prunes WWNO - Walker Wheels Need Oil GGLKI - Gotta Go, Laxative Kickin’ in!
Cinema: Larry Crowne Win a double pass. Tom Hanks and Julia Roberts reunite for a dramatic comedy. Downsized, affable Larry Crowne heads to his local college for a fresh start. He joins the colourful community of outcasts, also-rans and the overlooked trying to find a better future and develops a crush on his public-speaking teacher, who has lost her passion for teaching and her husband. In cinemas July 21. See www.larrycrowne.com
Musical Theatre: Hakuna Matata – No Worries In her debut solo show, music theatre performer Rhoda Lopez invites you on a magic carpet ride of her favourite songs from Les Miserables, Miss Saigon, Singin’ in the Rain and legendary greats Barbara Streisand, Michael Jackson, Eva Cassidy, The Beatles, Alanis Morissette with a tap dance to match. Featuring Rhoda Lopez(Vocals), Craig Williams (Guitar, Didgeridoo and percussion), Tim Cunniffe (Piano) and special guest Ronald Lopez. July 20-23, His Majesty’s Theatre. BOCS 9484 1133
n n n Betty Sue A guy is reading his paper when his wife walks up behind him and smacks him on the back of the head with a frying pan. “Hey!” He says, “What was that for?” She says, “I found a piece of paper in your pocket with ‘Betty Sue’ written on it.” “Jesus, sweetheart,” he replies, “remember last week when I went to the track? Betty Sue was the name of the horse I bet on.” “Ok,” she shrugs and walks away. Three days later he’s reading his paper when she walks up and smacks him again with the frying pan. “What was that for?” He says. “Your horse called,” she replies.
Children’s Theatre: The Red Tree Win a Family Pass. Barking Gecko Theatre Company presents an adaptation of Shaun Tan’s book – a strange world of creatures and dream-like landscapes. A young girl, having a bad day, navigates a curious and unfamiliar world, followed by a single red leaf - a reminder of hope, resilience and inspiration. Her constant companions create a live soundtrack for her bold journey. For ages 5+ and families. July 12-23. Subiaco Arts Centre. www.bocsticketing.com.au
On the Grapevine
Dr Craig Drummond
Zema Estate `for the serious red wine lovers’ Coonawarra is one of Australia’s most prominent wine regions and hosts a number of quality producers, with Zema Estate being one of note. The Zemas immigrated to Australia from Calabria, Italy arriving in Coonawarra in 1959. Demetrio Zema had `wine in his blood’, with a family history of wine production going back to 1835. However, his involvement initially was limited to home wine making whilst he worked diligently as a painter in order to establish his family in their ‘new country’. What Demetrio dreamed for came to fruition in 1982 with the purchase of a 20-acre vineyard in the ‘red heart’ of the Coonawarra region. Today, with input from sons Matt and Nick, the vineyard and winery has flourished, and plantings are now over 150 acres. The choice of Coonawarra as the place to settle was fortuitous. Any Aussie wine lover would be familiar with the famous terra rossa strip – an area of soil just 15km long and up to a maximum 2km in width. The rich red-brown loams overlay limestone, the latter acting as a natural aquifer. Move away from this prized strip and the black and brown rendzina soils are not as optimal for vines. Together with this is Coonawarra’s unique maritime location with extensive cloud cover keeping summer temperatures low. The resultant climate is similar to Bordeaux, and it is of no surprise that the
Cabernet family grape varieties have flourished here. In the 1970s and 1980s Coonawarra and Cabernet Sauvignon became almost synonymous, but now of course there is serious challenge from Margaret River and some other premium regions. Zema Estate has wisely focused production almost entirely on Cabernet family varieties (Cab sav, Merlot, Cab franc, Malbec) and Shiraz. Five reds were presented for tasting, and collectively they all show wonderful concentration of fruit (which balances the high alcohol levels of up to 15.5%), and that great Coonawarra cool climate add backbone which results in firm structure, and hence longevity. Also it is great to see wines with ageing prerelease, with vintages back to 2005 available. Starting at the top, the Family Selection 2005 Cabernet Sauvignon ($40 cellar door) was great, and the Family Selection 2005 shiraz ($40) was sublime. The Cabernet is deep, complex, supple and long. It displays leafy cassis, a touch of leather, and the trademark Coonawarra mintyness. This wine will be great for another 10 years. I never envisaged placing a Shiraz ahead of a Cabernet from Coonawarra, but yes, this Shiraz was my favourite. Again
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it is concentrated, integrated and complex. There is a real zip and life force in this wine, with spicy plum, dark chocolate and liquorice. This vibrant wine will mellow over the next 15 years. The Estate 2008 Cabernet Sauvignon ($20) is medium bodied, with nice varietal expression, and good integration of oak. It shows blackcurrant, mulberry, and again the mint. A five year wine and great value for money. The Estate 2007 Shiraz ($20) is zippy and spicy with juicy flavours of plum and black fruits. With tight structure and firm tannins it also will reward cellaring. In contrast the Cluny 2006 Cabernet Merlot ($20) is a very different wine style. It is a `Bordeaux blend’, as it includes Malbec and Cab Franc. The restraint, and brooding bucolic characters are much more in the European mould. Mulberry, cranberry and red fruit flavours predominate. A great wine for medium-term consumption. These wines are all available at www.zema.com.au/
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Competition Rules: One entry per person. Prize chosen at random. Competition open to all doctors or their practice staff on the mailing list for Medical Forum. Competition closes 5pm, June 30, 2011. To enter the draw to win this month’s Doctors Dozen, return this completed coupon to ‘Medical Forum’s Doctors Dozen’, 8 Hawker Ave, Warwick WA 6024 or fax to 9203 5333.
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Getting Away from it all Dr Sharon Masel and Stonebarn luxury B&B
Doctors Doing (Very)
Whether running a boutique resort, starting a vineyard, producing olive oil or making chocolate, you have to find both the passion and the time outside medicine! The stories of these four doctors will fascinate.
Creating the perfect getaway Dr Sharon Masel and her husband Dion bought their Pemberton property with future kids in mind. “We both loved the big old trees of Pemberton and thought buying a big farm with river frontage could at least teach our future children there is more to life than DVDs and computer games,” Sharon said.
truffles and what I might see by day as a gastroenterologist. My brother, a dermatologist, tells me he spends all day trying to eradicate fungus while I try to grow it!”
But it was not long before Dion’s experience building a safari lodge in his native South Africa and Sharon’s entrepreneurial spirit took over, and the idea of creating the perfect country B&B was born. A conversation with friend and award-winning architect Aviva Shpilman sealed it. It would be in the style of an old European stone barn.
He always looks to push the envelope but he said flavouring chocolates is about subtlety. “Someone was doing a chilli relish so I developed a chilli chocolate for them using their relish inside. About 4000 chocolates sold within half an hour. You should enjoy the chocolate and then most of the flavours come through on the aftertaste – it’s got to be a chocolate first. At the most I’ll have one or two chocolates a day because I’m still getting waves of flavour two or three hours later. They’re just awesome things.”
“I was in Perth working as a gastroenterologist with two very young children while my husband worked five half-days a week on site for close to two and a half years... aarrgghh!” “Luckily, since we opened, we have had great managers on site who have returned my husband to me!”
But they are not about to rest on their laurels. Six years ago they planted their first truffles, and they are now expecting their second harvest in June. “My friends laugh at the similarities between the 40
“I find it totally relaxing. But chocolate melts at body temperature so once the weather’s above 30°, you’re in big trouble unless you’re in air-conditioning. You probably need specialised moulds but other than that, there’s not much. You can melt chocolate in a high-class melter or a microwave if you like!” “The biggest difficulty is getting access to good quality chocolate, not compound chocolate like Cadbury’s. There are all sorts, whether you’re using combinations or just chocolate from one particular plantation.”
They orchestrated an army of stonemasons and tradesmen to hand built it from scratch. Dion organised construction and Sharon designed the interior.
To their credit, Stonebarn has won many accolades since. The getaway was a finalist in the Australian Interior Design Awards after opening its doors in 2009. It has been twice shortlisted for the WA Tourism Awards, and they have been featured in magazines and newspapers around the world.
Tony was hooked and found making chocolate surprisingly simple.
His skills have been noticed.
Dr Tony Barr and his floral chocolate creation. Tony said it was “just general boredom” that started him on the chocolate road about five years ago. “I enrolled in a class thinking it was going to be only bored housewives, but when I turned up we had the number-three chocolatier in the world teaching us and I was thrown in at the deep end.”.
“I’ve taken out first prize at the Perth Royal Show for the last two years, and last year I actually sculpted my hand as part of a presentation. There’s always something else to try. The beauty about chocolate is it’s not just culinary, it’s chemistry and physics as well. You spend a lot of time learning the physical properties of sugars and gels, and which temperature to use.” “It’s spectacular and really good fun,” he said.
He was then half in medicine, half in winemaking before he linked up with Dr Kevin Cullen at his Busselton practice. Michael set up his first vineyard in 1979 and for the next 25 years practised fulltime – including obstetrics, anaesthetics and A&E – and ran the vineyard in his spare time. “The thought of being involved in the development of a major wine growing district from the ground floor was very exciting. It was pretty intense because I’d drive home from work and then I’d be at the vineyard for an hour or two in the evenings. All my holidays were taken up picking grapes and making wine.” He said things are much more relaxed these days, especially since he semi-retired in 2003 and is now virtually fulltime as Pierro’s senior wine maker and viticulturalist.
Peter’s award-winning Elkanah Grove olive oil. Dr Peter Rae and wife Christine.
A love-hate affair with olive oil Donnybrook GP Dr Peter Rae planted his first olive trees in 1996 and it has been a love-hate relationship ever since. “Our home at the time had a small orchard alongside it with about 40 fruit trees and a couple of olive trees. It always used to bug me that the fruit fly got into the stone fruit and the parrots ate all the apples – meanwhile nothing seemed to affect these two olive trees and they flourished, full of fruit.” “I thought why waste so much time with fruit? Why not put some olive trees in? I probably should have admitted myself to Graylands to get over it but I didn’t, and we ended up buying some 35 acres and put an olive grove in.”
“We’re renowned for making Chardonnay at Pierro and the reds are now also developing very well. But the reputation has been built on Semillon Sauvignon Blanc and Chardonnay.” He said they made the first SSB in Australia! And the Pierro Chardonnay is considered one of Australia’s top five. Michael’s tip for those looking to follow in his footsteps?
cess pruning them and so on.” No-one gets rich on olives, Peter suggests, pointing to the failure of the big investor groves. “But I really like the trees, because they’re just wonderful and the olive oil is great.”
Top end winemaking Dr Michael Peterkin, the number one bloke behind Pierro wines, said his interest in wine started in medical school. “A professor of paediatrics, Bill McDonald, took us to Houghtons in the Swan Valley when we were in fifth year, so we got an introduction to wine as part of our medical training.”
“Start young. It’s not as facetious as it sounds because they’re businesses that take a long time to really get up and running. Our aim has been to produce the best wines possible and you need mature grapevines to do that.” It has taken him 20 years to establish a successful wine business, and he says there is no substitute for a solid grounding in winemaking. “Otherwise you’re in the hands of the consultants and you don’t know whether they’re correct or not. There’s no substitute for knowing what you’re doing. I planted the grapevines and physically made all the wines myself for the first 15 years or so, so I know the business from the ground up. I’ve also had a lot of fun along the way as well.”
Peter now tends a handful of varieties and there is more to olives than meets the eye. “Olive trees are funny things, the same cultivar can have different names in different places and a lot of them are hard to tell apart without genetic testing. They have genetic mosaicism, where the genetics can vary from one part of the tree to another, so it’s a bit of a tricky business at times.” A full time rural GP, Peter finds time on weekends to tend his grove and once a year, spends two weekends harvesting and preparing most of the crop for pressing, before selling under his Elkanah Grove label. One is a Tuscan blend of five different olives, and the other is made solely from leccino olives. The latter won a gold medal at the Perth Royal Show last year. Peter’s advice for those looking to enter the olive oil business? “Don’t do it! I dream of bulldozers after every harvest!” he jokes. “We’ve got about 850 trees and it’s probably too much for me to look after, especially as they get bigger and it becomes quite a difficult pro-
Dr Michael Peterkin 41
Getting Away from it all
“I graduated in 1973 from UWA, worked for a couple of years and then I went to an agricultural college in South Australia in 1976-78 to study winemaking and grape growing.”
Competition Winners for April Good Food Guide 2011 – Dr Michael Benson, Dr Pek Goh, Dr Ken Collins, Dr Vijay Panicker & Dr Caroline Rhodes ½ Price Art Classes – Dr Rebecca Doedens: Murdoch, Dr David Borshoff: Joondalup & Dr Mina John: Claremont Something Borrowed: Movie – Dr Yin Yin Wee, Dr Sharyn Bennier, Dr Maria O’Shea, Dr Sara Gibberd, Dr Hui Jern Loh, Dr Sue Sparrow, Dr Mik Parola, Dr Ted Khinsoe, Dr Mike Bray & Dr Paul Kwei Babies: Movie – Dr Daniel Heredia, Dr Christina Wang, Dr Martin Ibach, Dr Fiona Whelan, Dr Helen Mead, Dr Annette Finn, Dr Angelo Carbone, Dr Wei Ying Chua, Dr John Williams & Dr Vincenza Frisina Get Low: Movie – Dr Richard Riley, Dr Brad Jongeling, Dr Andrew Kam, Dr Andrew Lim, Dr Ben McGettigan, Dr Luca Crostella, Dr Peter MelvilleSmith, Dr Winston Choy, Dr Lydia Peter & Dr Robert Weedon
Doctor’s Dozen Winner Dr Charles Armstrong is an obstetrician who works mostly at Mercy Hospital, and he recently dropped by the Medical Forum office to pick up his fine selection of wines from Old Kent River. He kindly told us he enjoys reading the magazine and takes particular interest in the wine review and lifestyle section.
But if the woman escapes with dear life the ailments incident to puberty, other perils are before her. In the common order of events, the matrimonial relation is formed. Then come child-birth and nursing, with all their joys and sorrows. Lucky is the woman who can, on these occasions, escape the doctor’s lancet and drugs. During pregnancy she usually suffers more or less of nausea, cramps, constipation, vertigo, etc., for which she is bled, physicked and narcotised, predisposing her to hemorrhage, milk-leg, broken breast, and other sequelae, and multiplying the occasions for taking more medicines. From: The Health and Diseases of Women by RT Trall MD, 1872.
A loving husband once waited on a physician to request him to prescribe for his wife’s eyes, which were very sore. “Let her wash them,” said the doctor, “every morning with a small glass of brandy.” A few weeks afterwards the doctor chanced to meet the husband. “Well, my friend, has your wife followed my advice?” “She has done everything in her power to do it, doctor,” said the spouse, “but she never could get the glass higher than her mouth.” From: The Doctor, Dec 31, 1834
Although he’s often busy, he does try to find time to open a nice bottle of wine and enjoy the occasional glass. Now he has got a dozen of Old Ken River’s finest on his hands, he’ll have to make a special effort.
Drugging during pregnancy
Advice well received
When he’s away from work and has a spare minute or two, Charles said he enjoys photography but he also has four children who take up most of his time.
LE A S
By Dr John Quintner
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