Medical Forum 05/11

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WA’s I n d e p e n d e n t M o n t hl y f o r H e al t h P r o f e s s io n al s

Doc of The Swan More at www.mforum.com.au

INSIDE

Mental Health : Training, The Minister, Carers, Detention Guest Opinion: Caesareans, Mandatory Reporting, Shanks’ Pony Clinical Updates: Colitis, Aortic Valve, Depression The Funny Side: Exercise, Stress Puppies

Aust Australia’s Leading MDO

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Contents 6

Spotlight: A/Prof Anne Bourke

&

doc of the swan 2011

2 Letters Caesarean Rates Back in Focus Dr Louise Farrell Ms Pip Brennan

Asthma Management in Community Pharmacies

Dr Carl Schneider A/Prof Peter Kendall

Medicare Locals

19 Mental Health Traiining and

News & Opinion

8 36

Medicare Items 20 Suicide Prevention Back in Focus

Dr Rob McEvoy

29 On Shanks’ Pony

E-Poll Question Quibble

Dr Rob McEvoy

Dr Pam Quatermass

Guest Columns

Doctors’ Mental Health

Dr David Oldham

Exercise and Non-compliant Patients

Mr Simon Cummings

22 Mental Health and Involuntary Care Ms Debora Colvin

Ms Tracey Parker 30 Mental Health Carers in the Picture

12 ‘Caring’ Doctors Not Constrained

by Time

33 Connecting With Youth

Mr Jake Millar

15 Have You Heard?

17 Women in the Medical Workforce

Dr Tony Barham

27 The Mental Health of Doctors Dr Sara Bird

31 Support Group: Women’s Health and Family Services 32 Bicuspid Aortic Valve - Most Common Congenital Valve Abnormality 34 Rethinking Our Approach to Depression Dr Dennis Tannenbaum 41 Clinical Services Directory

25 Perinatal Mental Health Support

11 House Training for Stress Puppies Ms Wendy Wardell

Clinical Focus

Dr Mark Hands

GP Bias Clouds Termination Advice

Dr Judith Nash

21

Community Voice in Mental Health

5 Microscopic Colitis

Mr Jake Millar

24 Farming the Media During Health Campaigns 25 Editorial: Private or Public Health…

Your Vote?

28

Mr Mike Seward

Ms Nikki Marshall

35 Mobile Work - No Easy Ride Dr Jennifer Bowers PhD

Lifestyle 23 & 26 The Funny Side 36 Photo Gallery: Doc of the Swan 2011!

38 Competitions Competition Winners – March 39 Wine Review: Irvine Wines

tralia’s Leadin Dr Louis Papaelias

Dr Rob McEvoy

40 Recipe of the Month

Beneath the Drapes

Mr Neil Perry

18 Kids Miss Crucial Health Checks

Ancient Anecdotes Dr John Quintner

Cover: Doc of the Swan 2011 - Dr Baron-Hay Celebratory Sail. Heading for the buoy: Smoke on the Water crew do not seem too worried as they are being run down by larger yachts Mulberry and Red Fever.

PUBLISHERS Ms Jenny Heyden - Director Dr Rob McEvoy - Director

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

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

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

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

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

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

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

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

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

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

ISSN: 1837–2783

@

Letters to the Editor editor@mforum.com.au

E-Poll question quibble Dear Editor

I have just completed the online questionnaire for women doctors but was annoyed at the question asking if I thought patients were correct in being annoyed by the lack of continuity of care provided because of the high rate of part-time, female doctors.

My response is that patients have the right to be concerned about the lack of continuity of care. However, I don’t think the number of female part-timers is to blame. Most GPs are part-timers these days, because so many of us have to cross-subsidise our GP work by better paid work elsewhere.

Dr Pam Quatermass, Mosman Park

Caesarean rates back in focus Dear Editor

I read with interest the survey of WA female GPs on caesarean section rates (April edition).

Clearly, a marked change in rates of caesarean rates from the far lower rates of previous decades should prompt reflection.

After more than 25 years as a consultant obstetrician, I have seen a great change over my career in the rates and reasons for caesarean section. When I entered practice, it was normal practice to conduct vaginal breech deliveries and deliver most twins vaginally.

Using a pair of Kiellands expertly was a rite of passage in becoming an obstetrician.

Now, almost universally, breeches are delivered abdominally and this is also fast becoming the trend with twins. The younger generation of obstetricians has not been taught to use Kiellands; rather to regard them as obsolete, dangerous instruments. Additionally, the most reliable risk factor for caesarean section is maternal age and our obstetric population is ageing.

All of this does not fully explain the increase in caesarean section rates. We have become risk averse. Whenever there is any sort of adverse outcome, there is a chorus of ‘why didn’t she have a caesarean section?’ There is also an increase in patient demand. Society’s expectations are different. We have smaller families and parenthood is regarded as a right that must be afforded to all through reproductive technology. As a result of this 2

technology, parenthood has been available to many who previously could not have accessed this gift.

Surgery for all manner of conditions has become commonplace in our society – to prevent ageing, to improve appearance and to lose weight. If having surgical intervention results in a healthy baby and a happy mother, is it not something to rejoice?

Maybe we should concentrate less on how babies come into the world and more on ensuring we provide the best possible world for them.

Dr Louise Farrell, Obstetrician, Subiaco

Dear Editor

The comments from women GPs on caesareans (April edition) highlights that there is a broad range of opinions among women as to how they would like to birth, which is what you would expect across any group of women.

While a woman may be able to request a caesarean that is not clinically indicated, it is important that a woman understands the risks not only for the current pregnancy but also for future pregnancies.

Many more women want to birth naturally. It is vital that our health system is also able to respond to these women and, if their plans are not achievable for whatever reason, work with these women so that they are still supported and able to have a birth which they find satisfying and empowering.

Whatever a woman’s choice around her birth it is important that women are supported and encouraged by all her caregivers during her pregnancy and labour. She also needs to be provided with information to enable her to make informed choices.

It is encouraging that many of your respondents in your article are explicitly committed to supporting women in their choices, have reflected on why women make their choices and acknowledge that other issues may be at play. It is also encouraging that at least a third of those surveyed are worried or alarmed at the current caesarean section rate in WA.

This is really the crux of a positive birth experience – women need to feel in control and able to make decisions that are right for them without coercion.

CMWA is committed to educating, informing and empowering women about their birth choices. We are inclusive of all women and all birth choices.

Ms Pip Brennan, Manager Community Midwifery WA

Ed. At the back of everyone’s minds must be the low vaginal birth rate of 12% following

previous caesarean. With the current caesarean rate at 33%, a gradual increase in caesareans must be imminent.

Asthma management in community pharmacies Dear Editor

Re: Perth Pharmacies Fail Asthmatics at Risk, April edition

Respiratory disease is a leading cause of morbidity and mortality in Australia. The aim of the 2007 study was to act as a baseline measure of pharmacy practice in order to determine whether practice improvement interventions are effective. In this study we found that the direct involvement of a pharmacist as well as adequate assessment were the key factors associated with an appropriate outcome. Good practice does not need to take more time.

The pharmacy profession has since used the results of the research undertake the following practice improvement strategies:

1. Use pharmacist interns to educate pharmacy staff on provision of asthma reliever medication to the public. We have published a 2009 study to demonstrate there is a significant improvement in practice with a doubling of the referral rate for patients with poor asthma control to the majority of occasions.(1)

2. The second intervention, referred to in your article, was to improve asthma care by co-operation across the health care sector. The patient card that contains an Asthma Action Plan and Asthma Medication Card was designed in collaboration with the Respiratory Health Network and the Department of Health for use by all health care professionals. The challenge is to have all health care professionals working together to improve the decline in patients that have an Asthma Action Plan as not only is it recommended by the NAC and the Asthma Management Handbook, but having an Asthma Action Plan improves asthma outcomes.(2) The decline in the proportion of patients with an Asthma Action Plan as Dr McEvoy reports is a statistic that sheds a poor light on all healthcare professionals.

All of us need to improve our efforts in this regard.

The ongoing challenge is to reach out across the professional divide in order to collaborate to improve asthma care in the interests of the patient. As Dr McEvoy has concerns regarding the design of the card then we welcome his comments and invite him to be

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part of the stakeholder group overseeing the implementation and potential revisions of the card.

Refs

Dr Carl Schneider, Lecturer in Clinical Pharmacy, Birmingham, UK

1. Schneider et al,. Intern pharmacists as change agents to improve the practice of nonprescription medication supply: provision of salbutamol to patients with asthma. Ann Pharmacother.

2010;44(7):1319-26.

2. Gibson PG, Powell H. Written action plans for asthma: an evidence-based review of the key components. Thorax. 2004;59(2):94-9.

Dear Editor

It is pleasing to see Medical Forum helping to grasp the nettle, namely an extremely low usage of Asthma Action Cards by doctors here in WA. There is plenty of evidence that these assist in improving patient outcomes and we lag behind every other state by a significant margin. We are letting our patients down.

As part of a state-wide consultation process in the generation of the Asthma Model of Care, which included GPs and consumers, one of the key recommendations was to produce a more user-friendly Action Card than that produced by the NAC, which is flimsy and, as you mentioned, not used widely.

et al [refer above], shows nicely that intern pharmacists can be change agents in doubling the rate of medical referral. Hence launching the card to community pharmacists as well as through general practice. The ‘change agent’ work is a world first.

We are trying to improve the lot of the patient with asthma and there is no doubt that Action Cards contribute to better outcomes. We are well aware of their deficiencies. However, the last 5-8 years has seen an increase in asthma mortality, in GP encounters for asthma and asthma hospitalisation rate. The complacency following decreases in all these factors since the early 1990s must be swept aside and our efforts rejoined.

A/Prof Peter Kendall, Clinical Lead Respiratory Medicine, HDWA

Ed. During my early involvement with the National Asthma Campaign, I failed to be impressed by the ‘top down’ approach to implementation of ideas when ultimately, uptake by family doctors and health consumers was the key. The new Asthma Action Card also requires a rethink, from the user perspective.

GP bias clouds termination advice Dear Editor

Further, it is apparent that the community pharmacist is the health professional most frequently accessed by patients with chronic asthma. Hence the inclusion of the pharmacist in the ‘loop’ of professionals assisting the patient through their chronic disease management.

Re: E-poll: WA’s Female GPs, April edition

As a provider of abortion services, I frequently see evidence of personal bias by GPs in the way patients have been treated when requesting

Another paper in the series by Schneider,

referral for abortion. Some GPs allow their personal feelings or religious beliefs to influence their approach to this situation.

Many patients report feeling judged when requesting a referral and feeling uncomfortable at their appointment. Some women have ended up seeing several GPs before obtaining a referral (a legal requirement in WA), which added to the stress of the situation.

While GPs are under no obligation to provide this referral, the HDWA information booklet Termination of Pregnancy: Information and Legal Obligations for Medical Practitioners states; “Medical Practitioners are under no obligation to participate in a consultation and referral for pregnancy termination. However medical practitioners should demonstrate respect for the patient’s values and assist the patient to access care which is consistent with the patient’s values and wishes. This would involve referring the woman as soon as possible to another medical practitioner who can provide information and referral if she wishes”. (This booklet also outlines the Abortion Act, timing of referrals to GPs, ethical and legal obligations, medical and surgical terminations and the risks associated, full-term pregnancy risks, and guidelines for counselling.)

There are numerous reasons why a woman may choose to have a termination and no matter what the reason, it is always a most difficult decision.

It is often a complex situation as there may be underlying problems such as domestic violence, substance abuse, mental health issues, foetal abnormalities, difficulties with contraception and relationship problems. It is also a good time to check on other sexual health matters e.g. Pap smears, STIs. I find being able to assist women who are often in difficult circumstances extremely rewarding, despite the negative views of many.

Dr Judith Nash, GP Proceduralist, Balcatta.

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Letters to the Editor editor@mforum.com.au

Exercise and noncompliant patients Dear Editor

I read with interest GPs’ responses to your E-poll on exercise refusal and weight loss as related to CVS health (March edition). I would like to respond with these non- compliance-withexercise recommendations:

Lack of personal motivation. This is a tough one to deal with. Assuming that this cohort are ‘pre-contemplators’ are they fully aware of the health benefits of exercise to prevent and treat a whole range of diseases and conditions?

Too busy. How do they currently spend their time? “Those who have no time for exercise had better find time to be sick!”, author unknown.

initial low volume and intensity program or refer to an exercise physiologist.

GPs have a crucial role in letting the great majority of their patients know that they can perform meaningful exercise program to enhance their health and treat specific medical issues despite their fears and other problems.

Most walking and/or other simple activities can be undertaken and for those with a greater need (e.g. significant lower limb involvement), a targeted exercise program can be developed.

Mr Simon Cummings, Clinical Exercise Physiologist, Murdoch

Doctors’ mental health Dear Editor

Too expensive. What does it cost to walk, the ‘king of exercises?’

Lack of support. Be a leader and bring your family and friends along with you.

Weight loss emphasis. Exercise for health first and weight loss second. Aim for process (regular exercise) versus outcome (wt loss) goals.

Fear of exercise. Reassure and prescribe an

Since January 1 this year, Colleague of First Contact has been renamed Doctors Health Advisory Service (DHAS) of WA. The phone number remains the same - 93213098.

DHAS (WA) provides help for doctors in crisis, or those who are not sure where to go for personal or health problems. It is confidential and independent, not affiliated with any medical organisation, and BRAND HOLLR0008 available to all medical students and doctors. It may also be contacted by a concerned family member, colleague, friend or staff member.

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A M A Z I N G LIFESTYLE

Junior and Senior House Officers Career Medical Officers General Practitioners

DHAS (WA) is staffed by a volunteer panel of experienced GPs

who are available 24/7. It is exempt from the mandatory reporting requirements of the new Medical Board of Australia. Callers do not need to identify themselves if they do not want to.

Problems dealt with include stress, depression, suicidal thought, substance abuse, grief or concerns about illness. Sometimes the contact can be about impaired performance of a colleague. Other callers want to discuss a matter they are too embarrassed to raise with the MBA or another medical organisation.

Panel GPs usually discuss the options available to callers when they are faced with a dilemma, or advise the caller on the most appropriate referral services. DHAS may make de-identified inquiries with organisations such as MBA on behalf of callers who want to remain anonymous.

There is a DHAS in each state. They are independent of each other though meet to discuss common issues. Some states provide other services such as health check ups, or treatment of drug addiction. Preliminary discussions are being held with MBA to discuss the role of doctors’ health programs in the future, with a view to developing some treatment models that may be implemented in 2 to 3 years’ time. It is likely that regardless of what model is developed, there will continue to be a need for a 24 hour helpline independent of MBA.

Dr David Oldham, Convenor, Doctors Health Advisory Service of WA

@ LETTERS INVITED Letters over 300 words may be subject to editing. Deadline: May 10th for the next edition.

Send to editor@mforum.com.au All letters must be accompanied by a highresolution image of the author, and those over 300 words may be subject to editing, Go to www.mforum.com.au to send us a lead for your story.

Permanent Full Time, Part Time and Casual Positions We are seeking qualified medical practitioners to form part of our medical workforce. You will be involved in the care of medical inpatients, pre and post operative surgical inpatients, as well as the assessment of new patients. A variety of shifts are available, including weekday evenings, weekday nights and weekends.

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Dr Tony Barham Dr Tony Barham graduated from Newcastle University and worked at several NSW hospitals before moving to WA and commencing specialist pathology training in 2000.

After receiving his FRCPA in 2005 he was a consultant histopathologist and cytopathologist for six years at Western Diagnostic Pathology.

Tony’s areas of interest include skin, gastrointestinal, breast and gynaecologic pathology, cytology and fine needle aspiration.

Perth Pathology (Perth Medical Laboratories Pty Ltd APA) 152 High Street Fremantle WA 6160 Ph 9433 5696 Fax 9433 5472

www.perthpathology.com.au Collection centres throughout the Perth metropolitan area including: Fremantle (Main Lab); Perth CBD, Atwell, Bedford, Belmont, Bentley, East Perth, Ellenbrook, Hilton, Joondalup, Kardinya, Kinross, Maddington, Malaga, Palmyra, South Lake, South Perth, Southern River, Subiaco, West Leederville

Microscopic Colitis

By Dr Tony Barham, histopathologist and cytopathologist

P

atients who have normal colonoscopic findings but abnormal histology on colonic biopsy are said to have “microscopic colitis”. This term is not entirely satisfactory. It has been used as a catch-all category for colitis of any cause (for example, inflammatory bowel disease or infectious colitis) in which colonoscopy is normal. More recently, however, the term has been increasingly restricted to two distinct but probably related diseases, collagenous colitis and lymphocytic colitis. To avoid ambiguity, it is preferable to use specific diagnostic terms where possible.

Clinical features

Both collagenous and lymphocytic colitis are relatively uncommon, although some studies suggest they may account for 10% or more of cases of chronic diarrhoea in the elderly. They typically manifest as chronic, watery and non-bloody diarrhoea. Collagenous colitis has a striking female preponderance (female to male ratio 10:1), whereas lymphocytic colitis is equally common in women and men. Most patients are over 40 years of age and peak incidence is in the sixth and seventh decades. There are associations with certain drugs (such as aspirin or NSAIDs) and disorders of immunity (notably coeliac disease). At colonoscopy, the colonic mucosa appears normal or displays at most minor oedema.

Pathologic findings

n Fig. 1. Histology of normal colonic mucosa.

n F ig. 2. Collagenous colitis. Note the markedly thickened fibrous band immediately below the surface epithelium.

Lifestyle changes such as avoidance of precipitating medications and reduction of dietary fat may be of value but many patients will require medical treatment. This depends on the severity of symptoms and may include anti-diarrhoeal agents, anti-inflammatory medications or steroids (either oral or targeted eg. Entocort). In approximately 20% of patients, the condition resolves spontaneously.

In both conditions, there are also increased inflammatory cells within the lamina propria and damage to the surface epithelium. It is the latter feature that is responsible for the secretory diarrhoea characteristic of these diseases.

The histologic changes of collagenous colitis are often most prominent in the right colon and the distal colon may be spared, potentially leading to under-diagnosis if multiple sites are not sampled. Lymphocytic colitis, in contrast, tends to affect the entire colon uniformly.

As both conditions are There have been reports of defined by histologic n Fig. 3. Lymphocytic colitis. The surface patients with lymphocytic alterations, diagnosis can epithelium is peppered with lymphocytes. colitis who subsequently only be made by colonic developed histologic features of collagenous biopsy. The hallmark of collagenous colitis colitis, suggesting that the two entities may is an increase in the thickness of the fibrous represent different phases of a single disorder. tissue layer immediately deep to the surface epithelium. In normal subjects the thickness Management of this fibrous layer is at most 5 to 7μm Although collagenous and lymphocytic colitis (approximately one red blood cell diameter; are essentially benign conditions, morbidity see figure 1). In collagenous colitis, a broad can be significant, with some patients fibrous band at least 10μm, and sometimes up experiencing severe diarrhoea and, particularly to 50μm thick is present (figure 2).

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amongst the elderly, faecal incontinence.

Symptomatic management is the primary aim of treatment.

In lymphocytic colitis, the subepithelial collagen layer is unaltered but there is a striking increase in lymphocytes within the surface epithelium (20 or more lymphocytes per 100 epithelial cells, compared with 4 to 5 in the normal colon; see figure 3).

Perth Pathology General Pathologist / Managing Partner: Dr Wayne Smit

0410-488736

Histology / Cytology: Dr Dr Dr Dr

Michael Armstrong Tony Barham Bruce Latham Ai Rene Kee

0417-094799 0416-577619 0407-080608 0402-101318

Infectious Diseases (Microbiology): Dr Laurens Manning

0400-783194

Haematology: Dr Rebecca Howman 0417-935873

Laboratory Director: Paul Schneider

0417-931850

Providing phone advice to clinicians and a comprehensive range of medical pathology investigations, including: • • • • •

Histology (Skin, GI, etc) Cytology (incl. Paps and FNAs) Haematology (yes, we do lab controlled INRs) Biochemistry (including hormones and markers) Microbiology and Serology

Professional personalised service from a non-corporate, pathologist owned and operated laboratory practice

5

Spotlight

Evolution of Hospital Nursing A/Prof Anne Bourke reflects on how nursing has changed during her four decades in the profession, and what lies ahead for child health in WA. Anne Bourke has been the Executive Director of Nursing and Patient Support Services at Princess Margaret Hospital for the past five years. A registered nurse for 42 years, she has moved from clinical nursing of neonates and adults to management, and has both experience and postgraduate studies in Health Service Management and a Masters Degree in Clinical Nursing. These shape her comments, as she discusses with Medical Forum the changing role of the nursing profession and paediatric care in WA.

Nurse Training Varied

Nurses now interact differently

Nurses are increasingly seen as health professionals in their own right and in that regard, Anne says the relationship between doctors and nurses needs to be improved.

“It’s still an issue in terms of the hierarchy in the system. Nurses should be equal partners working with doctors in the delivery of care; they’ve got university training and they’ve got experience with patients. This is changing to a more collaborative approach but some older doctors can be a little bit arrogant and pompous in where they sit in the world.”

She said the old experienceversus-theory comparison between hospital-trained and universityeducated nurses is now largely outdated. Gone are the days of the ‘triple certificate’ nurses (general nurses also trained in midwifery and child health), to be replaced with training in nursing subspecialities that involve hospital experience early on.

“We expect that there will be a workforce problem in the next three to ten years because the Baby Boomer nurses will be retiring and that’s a big loss of corporate memory across the board, not just in paediatrics.”

“We need to make sure that we can retain nurses because now Generation Y likes to move around and do other things.”

“So we’re looking at putting in the junior-type support for nurses that should release them to do more real nursing as opposed to feeding and bathing patients, right up through the system to the nurse practitioner expert in their field. An example of a nurse practitioner role that is really useful is diabetes and I think nurse practitioners should run diabetic clinics, so I’m really advocating that.”

Targets to improve child health

Anne said the future looks bright for child health in WA. “The Child and Adolescent Health Service has grown from being a hospital to having Child and Adolescent Community Health, which is a community-based service with school health nurses, special education nurses, child health nurses, and child development services.”

“After 25 years of having university-educated nurses, we’ve ironed out all of the problems that people had to start with.

The universities are trying very hard to make sure the practicum aspect of the nursing degree is catered for by the hospitals, and we have undergraduates at PMH so they can work with a Registered Nurse and get used to the hospital environment.”

“In community health they’ve developed an Aboriginal health team and they’re doing very good stuff, they’ve got ‘Closing the Gap’ n A/Prof Anne Bourke, Executive Director of Nursing and Patient Support, PMH money and they’re working well with Aboriginal people employed to She said this growth in the number She said nurses have had to adapt to the changing look after Aboriginal people in the community.” of formal nursing courses means the profession is face of hospital medicine.

Anne said Aboriginal health still needs attention, on its way to getting the recognition it deserves.

“Patients in hospitals are sicker than they used to something she has personally sought to address.

“There are Bachelor of Midwifery courses at be because as soon as they look the slightest bit “I’m looking at increasing Aboriginal universities now, so you can become a midwife well, they’re transferred home through things like employment in the hospital to actually target without becoming a Registered Nurse. That the Hospital in the Home Service. So nurses are areas of ‘The Gap’ within families that come means they focus purely on midwifery, but there educated to actually critically reflect and analyse here. So we’re looking for Aboriginal people are now midwifery specialists and registered their practice.” not only to get gainful employment, but also be nurses who have worked in midwifery.”

Contrary to the belief that nursing protocols get supportive of Aboriginal patients.”

“There is a whole range of professional journeys in the way, Anne says they actually help nurses Other targets for improvement include nurses can have. One we’re working on is the do their job. immunisation rates, communication between nurse practitioner role, which is a Master’s “Guidelines and pathways are really important hospitals and GPs through things like discharge preparation. That’s a very senior expanded for patient safety. They let nurses know the limits summaries, and preventive medicine. clinical role.” of their practice and they give nurses the ability “All kids need a whole series of assessments to As specialisation increases, non-academic to refer to a medical person if they need to, while make sure they’re reaching their milestones. For nursing is also evolving, including in-practice they assess and analyse what’s happening,” example, if you can identify a hearing deficit in a pathways.

Workforce shortages the next big newborn and introduce a hearing aid or implant, “I do think that nurses are born, and they can be you can get that child to a normal school. If you challenge made. The Chief Nurse and Midwifery Officer pick it up at 12 months when they should be Anne said nursing is bracing itself for a shortage is engaging with TAFE to set up an Assistantsstarting to talk, it’s very likely they will only ever that was temporarily delayed by the global In-Nursing program so they can come in as an be able to go to a special school.” l financial crisis, when many professionals stayed enrolled nurse and work towards a Registered Nurse degree,” she said.

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Doc of the Swan 2011

Landmark Charity Sail The recent death of Gordon Baron-Hay has saddened many. However, in line with his cheerful disposition, giving nature, and involvement with the event over many years, the organisers of this year’s Doc of The Swan decided to celebrate Gordon’s life with a couple of landmarks.  Gordon Baron-Hay Perpetual Trophy (Fastest Time)

Gordon was a major organiser of Doc of The Swan and a keen sailor. It is his wish that Doc of The Swan continue as a landmark charitable sailing event each year. The organisers this year have struck a perpetual trophy in honour of both Gordon’s involvement with the event and the generosity of the Royal Freshwater Bay Yacht Club. It will go each year to the yacht with the fastest event time.

This year, the main event was preceded by an Etchell class sail past that included Gordon’s brother John Baron-Hay on Screaming Plum and Gordon’s yacht Z-ipi, now bequeathed to his previous crew in Dr Ric Bergesio, Gus McBriar and Anthony Vlachou.

n Gordon Baron-Hay

Doctor-owners whose boats entered the event were Drs David Roberts (Norsk), Helga Weaving (Tamatea), Brian Galton-Fenzi (Take Time), John Wheeler (Darling Do), Ian Hewitt (Red Fever), Malcolm Thompson (Smoke on the Water), Warren Pavey (Javelin) and nurse owner was Kieran Byrne (Quasheba).

Thanks go to these people and the other generous owners from RFBYC who made up the 24 yacht entries that accommodated the 90 or so doctors who were “skippers for a day” or crew in this light-hearted, protest-free charity event. This includes the two spectator boats Nikomis (Craig Grundmann) and Ardesea II (Geoff Bingemann).

Entry fees and income from donations and product used in the major prize, raffle, live auction and silent auction, meant the event reached target to assist sick kids at PMH.

 The Gordon Baron-Hay Grant

In celebration of Gordon’s working life as a paediatric surgeon, the Doc of The Swan charity sail raised $10,000 to kick-start the Gordon Baron-Hay Grant, presented through the Princess Margaret Hospital for Children Foundation. The PMH Foundation will generously fund and award this Grant annually for the next nine years, awarding it to a worthy recipient who:

• Is involved in an endeavour that is closely related to paediatric surgery; • Is involved directly in patient care as Gordon was;

• Is a member of clinical staff, doctor or otherwise; and

• Can demonstrate that the money will be used to benefit patients.

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n The inaugural Gordon Baron-Hay Perpetual Trophy winner: Tony Mitchell (owner of Sled) with Dr Jenny Downs (skipper on the day), pictured with Pat (Crowie) Baron-Hay, Rear Commodore Ian Clarke and organiser Chrissie Jordan.

Medical Forum WA magazine and Venosan WA remain proud major sponsors of Doc of The Swan

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Satire Ms Wendy Wardell

House Training for Stress Puppies TV magazine programs have been reduced to inciting fear over household objects; from bacteria on our chopping boards to bikies under our beds.

Society has always embraced ‘cure-all’ remedies. Leeches, herbs and general elections have all had their turn in the spotlight and have only rarely failed to disappoint. (Although overall, the leeches polled better than the politicians).

If ‘one-size-fits-all’ doesn’t work for cures, why don’t we try it for diagnoses instead?

‘Stress’ is a diagnostic blanket that can be thrown over even the most relentless heartsink patient. It’s a relatively recent clinical diagnosis not because it didn’t previously exist, but because historically, factors that have caused stress tended themselves to be more terminal.

Take this scenario: Cavewoman to friend: “Your husband Ug look terrible today. He still stressed about being bad hunter?”

Friend: “No – his stress cured by sabre-toothed tiger that ate him.”

The cramped convict ships en route to Van Diemen’s Land didn’t have weepy sailors lining up to see the ship’s doctor about insomnia, because cholera, malnutrition and ten-metre waves can overcome night-terrors

about weevils in the Weetabix. History is silent on how many members of Attila the Hun’s invading hordes were ever granted Stress Leave when their kitten died.

Kids living in sanitised environments get asthma because their immune systems have nothing more challenging to deal with.

Similarly our nervous system will unleash adrenaline on the merest provocation because there are few physical perils left in life, if you discount riding in Sydney taxis.

Even air travel is so safe now that instead of screaming “arrgghhh’ as they plunge to their death in a fireball, people work themselves into a lather of stress over the tiniest invasions of personal space. Hitler may have taken over France with ease but would have been given no quarter today in a skirmish over a few square centimetres of luggage compartment. Wars break out over the breach of a no-fly zone in the airspace above a passenger’s knees when a chair-back is reclined into it. Maybe in space no-one can hear you scream, but at 30,000 feet the angst is deafening.

teams, TV magazine programs have been reduced to inciting fear over household objects; from bacteria on our chopping boards to bikies under our beds. There’s water in our meat and dead meat in our water. There’s no longer anything we can eat without fear and by going to bed hungry, we’re just a light supper for the bedbugs. Those that haven’t developed OCD yet are simply not paying enough attention.

The media is a major stress carrier. It would never have occurred to us to adopt the foetal position when faced with a domestic dishcloth before, but images of oozing petrie dishes and men with scientifically credible facial hair provide apparently overwhelming evidence and we learn to worry.

Prescribing your patients a large tube of Harden Up and telling them to apply it liberally won’t win any awards for bedside manner. Perhaps though, agitated souls will be consoled by the knowledge that at least being stressed is a pretty good indicator that they aren’t yet dead. l

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11

Feature Article Emergency Medicine

‘Caring’ Doctors Not Constrained by Time Caring does not lose its importance in the bustling high-tech world of ED, according to recent WA research around patient perceptions A friend gave ED registrar Dr Sarah Limbourn the research idea by commenting after a trip to emergency that their medical treatment was good but they felt their doctor could have been more caring. Sarah decided to research how a ‘caring’ doctor impacts on patient satisfaction and results were recently published in Emergency Medicine Australasia as part of her advanced training in emergency medicine. She said she has been surprised by the interest it has generated.

Under the guidance of current head of Emergency Medicine at UWA Prof Antonio Celenza, Sarah arranged to survey ED patients on how ‘caring’ they considered their doctor to be through behaviours that included attentiveness, respect, courtesy and compassion.

Sarah said having a ‘caring’ attitude is particularly important in EDs.

“Most of us like to think that we’re compassionate and listening, giving good information and involving patients in the decision-making process” she said.

“I think there’s a good role for it to be included in medical student and junior doctor teaching.

There are times when someone is not all that unwell, when we’re not going to make a diagnosis in the ED, and our role is just to exclude life-threatening things. You need to have a rapport with a patient to explain, ‘today we’ve managed to do these things, but you need further care or investigation through your GP’.”

“If you’re able to explain that to patients they go away with a sense you’ve taken steps along a path towards a diagnosis, and if you’ve got a rapport with a patient then that’s much easier to do.”

The more urgent and severe the problem, the less time to build rapport, she suggested, and patients may not expect it.

“If someone’s significantly unwell, they’re probably not going to be all that worried about whether you introduce yourself politely,” she added.

Yet Antonio told Medical Forum that the perception among doctors that a busy ED offers less opportunity to build a relationship with patients may not be true. Surprisingly, the study by Sarah found an ED’s level of activity had no significant bearing on how ‘caring’ patients thought their doctors were.

“Although people might be disgruntled at times with the waiting times, once they’re actually seen by the emergency doctor, the majority are quite happy of how they’ve been cared for – they feel like they’ve been looked after in a compassionate way; they didn’t generally think people appeared busy or uninterested,” Sarah explained, adding she would like to research the effects of the newly introduced four-hour rule on these findings.

The Survey Details

• 467 ED patients, average age 51, men and women equal • ED visitations split between day (39.8%), evening (31%) and night (29.1%) • Over 95% thought their doctors displayed a ‘caring’ attitude

• Almost all patients surveyed said their medical assessment and treatment was good (34.6%) or excellent (58.7%)

Any survey delivered at the point of care has the potential for bias, and surveyed patients may have responded to the overall care given

by ED staff when assessing the doctors. Where possible, researchers sought to minimise these effects.

“Certainly that is a potential limitation of the study, but we did try to emphasise that the emergency department doctors were the ones wearing the emerald green shirts and the study related only to the care that they got from them,” Sarah said.

For patients who saw more than one ED doctor, the survey assessed the doctor who saw them first. “We were trying to establish that first point of care and trying to get a snapshot of how busy the department was and how busy the staff were at the time the patient was first seen by a doctor.”

The survey was given to (less severely ill and compliant) patients to complete as they exited the ED encounter, and was returned by selfaddressed de-identified envelope. l

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Have You Heard?

Aboriginal health info sources

Looking for a reputable resource for Aboriginal health info? Try www.healthinfonet.ecu.edu.au including a yearly overview of indigenous health. The aim is to provide access to evidence for people interested in improving the health and wellbeing of Indigenous Australians.

Access is free, available to all, and funded by the federal government. Online “yarning places” encourage information-sharing among practitioners, policy-makers and others, including one for Indigenous social and emotional wellbeing, nutrition, substance use and health workers. Go to www.yarning.org.au/ index.php/groups. The HealthBulletin online journal on indigenous health is at www.healthbulletin.org.au.

Forum will tackle the issue of Aboriginal competency training for health workers in our next edition.

Fresh Start gets government tick

cholecystectomy that wasn’t has received much press coverage and health consumers must be wondering how so many signs came to be ignored by medicos, from the previous scar to her medical records. Human nature and error explains most plane crashes, despite numerous safety and warning systems in place, and this surgical ‘crash’ appears no different. There is a bogus ultrasound result as the conflicting information that may have prompted other warning lights to be ignored.

The Fresh Start drug and alcohol recovery program run by Dr George O’Neil has secured $1.5m from the State Government. The centre is operated by the Australian Medical Research Procedures Foundation and treats patients with heroin, opiate and alcohol addictions. Naltrexone implants, central to treatment, are seeking registration through the TGA. The State Government has contracted researchers to assist with this application. $500,000 to support the centre until June 30, with $1m to last until June 30, 2012.

This covers 244 treatments. The struggle for legitimacy seems almost over.

Changes for workers’ comp

A bloody good idea

With a unit of blood costing $700 it makes sense to minimise transfusions so WA Health has launched the Patient Blood Management (PBM) program – presurgical correction of anaemia and iron deficiency, low loss surgery techniques, and revised thresholds for transfusions. Fremantle Hospital successfully trialled the system and PBM clinical nurse consultants will now drive it in each major hospital. Between 5-75% of patients presenting for elective surgery are anaemic, and of those over age 75 with normal Hb levels, 20% of men and 17% of women are iron deficient.

Transfusing to correct this perioperatively only increases morbidity, hospital stay, readmission rates and mortality. See www.health.wa.gov.au/ bloodmanagement

NFP mental health funding

The Western Australian Association for Mental Health (WAAMH) received $1.695m over two years – to pass it to 75 NFP agencies that assist those with mental illness to self-direct their support, and avoid the helplessness that government intervention creates (says Minister Helen Morton). It’s for the agencies to develop workforce training in leadership and mental health first aid. Agencies will be encouraged to group together and a directory will be developed for consumers.

No safeguards for human error

The Walden case is showing what an e-Health record will not do. The post-op death of this lady from complications following the

medicalforum

With our ageing population and people being asked to stay on beyond normal retirement age, the Workers’ Compensation Amendment Bill 2011 was introduced so these older workers would not be disenfranchised. Instead, they can seek workers’ compensation entitlements without age limitations, and go for common law recompense for serious injury. The WC dispute resolution arrangements and some longstanding technical issues have also been addressed. You can read the Bill on the Parliament Website.

E-health scramble continues

As the shuffle for e-Health supremacy quickens up, Communicare Systems Pty Ltd and the UWA’s Centre for Software Practice will seek to combine systems – Communicare and MMEx – to service remote areas in particular. MMEx has a foothold in regional hospitals and centres as the communication portal with community doctors and others. The web-based information sharing and clinical patient management systems will be aimed at chronic disease management and telehealth, two areas government wants to create savings for using e-Health. Communicare software is used extensively in Aboriginal community health services primarily.

Aboriginal involvement, top down

HDWA has allocated an extra $0.5m over three years in its partnership with the Aboriginal Health Council of WA (AHCWA). The money will be used to ensure more Aboriginal people become “actively involved in key leadership and strategic decision-making roles” in healthcare delivery. AHCWA was established in 2005 and is the peak body for 19 Aboriginal medical services across the state. Medical

AHPRA discontent response

Someone in AHPRA has woken up to the mess the national system has created. We guess there were consumers not getting Medicare rebates from consulting non-registered practitioners or nurses not turning up to work because cumbersome and poorly thought out systems had left some health practitioners more than a month past their registration date. This meant AHPRA had no option but to de-register them. Then follows a mountain of paperwork to get re-registered. Now, we have fast-track applications to re-register these people, with no additional fees and much reduced paperwork. Service delivery improvements include WA office phone response by more experienced personnel, a simplified website, and an online tracking system for renewals/applications (aiming for >60% renewals online).

?

What have you heard Share the

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

15

2011 Doctors’ Service Awards

Special Awards recipients, from left: • Dr Allan Walley, Margaret River • Dr Julie Graham, Christmas Island • Dr Barney McCallum, Kalgoorlie

Congratulations to this year’s award recipients Special awards Dr Allan Walley Dr Julie Graham Dr KA (Barney) McCallum

MARGARET RIVER – The Award for Outstanding Service to Rural and Remote Health CHRISTMAS ISLAND – The Award for Remote and Clinically Challenging Medicine KALGOORLIE – The Award for Extraordinary Contribution to Outreach Services

30 or more years of service to rural and remote medicine in Western Australia Dr Peter Beaton Mr Antony Beeley Dr Walter Byrne Dr Mary Collins Dr Haydn Dyer Dr Malcolm Exley Mr William Hall Mr Steven Lai Dr John Lindsey Dr John Male

NARROGIN BUSSELTON ESPERANCE BUNBURY HARVEY DUNSBOROUGH BUNBURY NARROGIN ALBANY BUNBURY

Dr Michael Peterkin Dr Frederik Pretorius Dr John Robinson Dr Geoffrey Ryan Dr Darcy Smith Dr Colin Smyth Dr Randolph Spargo Dr May Ure Dr Robert Watt Dr Christopher Wood

BUSSELTON BUNBURY BUSSELTON MANDURAH ALBANY NORTHAM JIGALONG ALBANY FALCON ALBANY

20 or more years of service to rural and remote medicine in Western Australia Dr Carol Angeloni Dr Bernard Chapman Dr William Chow Dr Tom Cottee Dr Graham Dale Dr Graeme Findlay Dr Christine Hartley Dr Simon Hemsley Mr Martin Hudson Dr Ivan Jansz Dr Ronald Jewell Dr Sam Khamhing Dr Colin Lee Dr Hugh Leslie Dr Sirje Maar Dr Andrew Marsden Dr Douglas McCarthy Dr James Murray

MANJIMUP MOORA MANDURAH BUNBURY BUNBURY KALBARRI AUSTRALIND KUNUNURRA GERALDTON DALYELLUP BUNBURY MANDURAH RFDS - JANDAKOT KONDININ BUNBURY KUNUNURRA HALLS HEAD GERALDTON

Dr Charles Nadin Dr David Pate Dr Grant Rigby Dr Lorraine Smith Dr Jane Talbot Dr Graeme Taylor Dr John Taylor Dr Peter Terren Dr Roderick Thompson Dr Catherine Thorne Dr Norm Tuppin Dr Peter Van Duren Dr Ann Ward Dr David Waycott Dr Leo Winlo Dr Stephen Woods Dr Warren Young

BUNBURY DERBY BUNBURY BUNBURY KUNUNURRA MANDURAH BUSSELTON BUNBURY BUNBURY BUNBURY WILUNA SOUTH HEDLAND KUNUNURRA BUNBURY LAVERTON MARGARET RIVER KARRATHA

Nominations are now open for 2012.

For more information visit www.ruralhealthwest.com.au/go/awards

Medical Report Dr Rob McEvoy

Women in the Medical Workforce Beneaththe Drapes u Dr Allan Walley of Margaret River received the Rural Health West Doctors’ Service award for Outstanding Service to Rural and Remote Health.

Allan has 32 years’ experience in rural medicine in WA.

u Christmas Island GP Dr Julie Graham won the award for Remote and Clinically Challenging Medicine. Last December she was instrumental in the rescue attempt and medical care of asylum seekers whose boat collided with rocks off the island. She has been practising on Christmas Island for the past five years. u Kalgoorlie-Boulder obstetrician-gynaecologist Dr Barney McCallum received an award for Extraordinary Contribution to Outreach Service.

He is a specialist who has worked in the Goldfields community for many years.

u UWA has announced Prof Paul Johnson will succeed Prof Alan Robson as Vice-Chancellor at the end of the year. Paul has led Victoria’s La Trobe University for four years and was previously Deputy Director of the London School of Economics for three years. u Mr Clive Macknay has been elected as the Chair of St John of God Health Care Trustees.

Born in Perth and educated at UWA, Clive was an inaugural member of the SJOG board in the early 1990s and joined the Trustees in 2009.

In 2008, the national working doctor split was 38% primary care (44% female), 35% specialists (24% female), 14% specialists-in-training and 12% hospital non-specialists. Last year’s federal Medical Workforce Census shows there has been a steady increase of women in medical practice (both GP and specialist) over the last decade. In 1998, women accounted for just over 28.1% of medical practitioners, a number that grew to 35% ten years later. This figure is surely set to rise, as women now comprise nearly half (48.6%) of the medical workforce aged under 35.

Are part timers having a major impact? Not much. Between 2004 and 2008, despite a 2.9% decrease in average hours worked, medical practitioner supply increased from 318 to 341 full-time equivalents (FTE) per 100,000 population (based on a 40-hour working week), due to an 18% increase in employed medical practitioner numbers.

Women are even making inroads into the surgical specialties but it is still very early days. The number of women entering surgical specialties has increased in every division. Nationally, substantial increases were seen in general surgery (up 77%), neurosurgery (up 91%), otolaryngology (up

75%) and plastics (up 33%). Overall, the number of women was up over 60% from 2005.

While percentages sound good, the actual figures tell a story. Women accounted for just 23 or 337 active surgeons in WA in 2009 (compared with 38% of the GP workforce).

The national pool of vascular surgeons saw a 200% increase in the female take-up from 2005 to 2009, but this equated to only six extra women – there are still more than 15 times the number of men in the division. We understand that there has been a large influx of female trainees into the ENT training program in WA in the last few years. l

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17

Medical Report Dr Rob McEvoy

Kids Miss Crucial Health Checks

They are free but preventative health checks for children are not happening for a variety of reasons.

There are about 200,000 children aged 0-6 years living in WA and around 17% of them have some developmental problem that requires intervention. For them, development checks during their first five years could prevent problems having a negative impact on their health, education and social integration. Poor school performance, behavioural problems, and juvenile delinquency carry a social and economic cost that WA Health is keen to reduce through the free universal child health check program. This offers seven free health and development checks to children aged between birth and school entry (4 years old) under the auspices of the Child Development Services.

The dilemma is that any problems detected will increase immediate demand for treatment but if neglected, may involve more protracted treatment later. Moreover, the 12% rise in births between 2005-08, plus increased migration to WA has increased the pool of children eligible for free health checks, for which the State Government allocated $60m in 2010‑11. The systems devised in metropolitan

18

and rural areas to deal with child health checks differed, according to the November 2010 Auditor General’s Report (which had trouble fathoming rural services).

The audit, which was of metropolitan services, found that many children are missing out on key health checks between birth and school entry. While 99% of newborns are checked in the first month, only 30% of 18-month-olds and 9% of 3-year-olds received checks in 2009-10.

Of course, the take-up of universal child health checks is voluntary, yet the audit found that WA Health had done little to improve accessibility or create consistency across metropolitan services. The audit also found there is a shortage of 105 child health nurses in WA, which Children’s Commissioner Michelle Scott said could have serious longterm consequences for children’s mental and physical health.

Moreover, collection of information was inadequate, which hindered planning. More administrative support for child health nurses was needed.

The audit recommended WA Health should set performance targets for each child health

check and report its performance against these in its annual report. The aim is to increase the number of children receiving checks, which means promotion, as all child health checks rely on parent engagement. In response to increased demand, service delivery models would need improvement, including support for child health and school nurses as the core business, and partnering with other agencies and complementary services (e.g. parenting information) needed more consideration.

Of course, being a government department, administrative support and more IT were also on the priority list, with the rider that administrative tasks such as appointment scheduling needed a fix. l

medicalforum

Professional Development Mr Jake Millar

Mental Health Training and Medicare Items As we head into a new triennium of mental health training, Medical Forum takes a look at what’s on offer in WA. There are two tiers of mental health training that allow GPs to access MBS Items; Mental Health Skills Training (MHST), and Focused Psychological Strategies Skills Training (FPSST). Doctors who have completed MHST are eligible to access MBS Item 2710, and for FPSST Items 2721, 2723, 2725 and 2727 are available. Courses permitted to award these item numbers are determined by the General Practice Mental Health Standards Collaboration (GPMHSC), an arm of the RACGP. Approval for training is given in three-year blocks (trienniums). The last triennium expired on March 31 this year, which means most courses are currently awaiting approval for the 2011-13 triennium. Applications for training approval closed on April 15, and organisations will not be able to receive further approval for training until the outcome of the GPMHSC meeting on May 3.

RACGP’s online GP Learning site had three MHST courses approved for points under the last triennium, and presumably they will receive approval for new courses (e.g. course planned for July 2, with costs and content still to be finalised).

At present there is just one approved face-to-face mental health training course in WA this year. This three-day FPSST course costs $330, and will be held at the RACGP WA’s West Leederville centre on May 20-22. It is subsidised by DoHA, and RACGP also hopes to receive funding for a series of FPSST courses this year, most likely in Mandurah at the end of June.

ThinkGP is currently the only company offering online MHST courses approved for RACGP or ACRRM points for the 2011-13 triennium. Their course is free of charge.

ThinkGP’s course “Anxiety Across the Ages and Stages of Life” focuses on identifying and treating anxiety disorders in patients of all ages.

“We’ve got six hours of education on anxiety disorder that’s been commissioned by the DoHA, and GP NSW. It also teaches GPs how to do a mental health care plan, which is what they need to do to access the Medicare subsidy for their patients,” ThinkGP Director and Owner Dr John Crimmins said.

“Our registration base from WA is sitting at about 1200 GPs, so it’s quite strong. We ran some MHST education in the last triennium and had about 1700 GPs complete it.”

“If GPs meet all the requirements of the course then we report results to

whatever college they’re with – whether it’s the RACGP or ACRRM – and they’ll report them to Medicare so they can access the higher rebate.”

“It’s free to access because we’re funded through sponsorship, mainly by divisions and by health standards bodies, such as Cairns Council, Victoria, NSW, Queensland, Andrology Australia, and hospitals in a couple of states.”

Australian Doctor does not have any MHST courses in WA, though its website offers some online quizzes that contribute 2 CPD points. Some of these cover mental health issues, including depression, anxiety and schizophrenia.

More information Visit http://www.racgp.org.au/gpmhsc for more information on mental health training.

ThinkGP online courses can be accessed here: http://thinkgp.com.au/ l

Tax planning for medical professionals Medical practitioners have much to gain through effective tax planning.

Whether employed in the public health system or running one’s own practice, the April-May period represents an ideal time to visit the accountant to discuss tax planning.

Financial adviser Murray McKinley says this time of the year should be utilised to prepare interim financial statements and estimate income for the remaining quarter of the financial year.

Mr McKinley, a director of McKinley Plowman financial planning and accounting firm, says once an estimate of a tax position is made, a financial adviser will be able to discuss the most suitable tax planning measures.

• General Practice Mental Health Standards Collaboration approves training

He says while medical practitioners on incomes above $180,000 attract a top marginal tax rate of 46.5 per cent, there are many ways to legally minimise tax payments while also growing personal wealth.

• Focused Psychological Strategies Skills Training (FPSST) offers items 2721, 2723, 2725 and 2727

The range of tax-saving strategies may include prepaying business expenses such as rent, insurances and materials or fixing and prepaying investment

Mental health training in WA

• Mental Health Skills Training (MHST) allows GPs to access MBS item 2710

• No face-to-face MHST in WA this year • Some MHST available online

• One FPSST course on 20-22 May at RACGP, West Leederville

medicalforum

loans 12 months in advance.

Other strategies include increasing superannuation contributions to up to $25,000 for those under 50 and $50,000 for people over 50.

“There is a tax of just 15 per cent on superannuation contributions, so paying at this rate results in a huge saving for those medical professionals who are paying a top marginal tax rate,” Mr McKinley says.

Mr McKinley says professionals working in the public health system may use salary packaging to reduce tax payable.

Deductable expenses for medical professionals include fees for professional journals, memberships, self education, business travel, supplies and equipment, professional indemnity, workers compensation and general office insurance.

He says it’s essential to seek advice from an accountant or financial adviser to ensure tax saving strategies are relevant to an individual’s circumstances.

For more information phone Mr McKinley on 9301 2200 or visit www.mckinleyplowman.com.au 19

Mental Health Report Mr Jake Millar

Suicide Prevention Back in Focus Education, support services and community feedback are helping to fight suicide under the Mental Health Commission’s Suicide Prevention Strategy.

Having been given $500,000 a year by the Commission to implement the strategy, Centrecare now has the task of resourcing and educating communities to tailor specific suicide prevention plans for their regions.

A significant element of the State Government’s ‘One Life’ Suicide Prevention Strategy is the introduction of Community Action Plans (CAPs) to assist and educate communities to stop suicide.

Mental Health Minister Helen Morton explained how CAPs will focus on training to identify and respond to the symptoms of suicide, as well as integrating services, and providing better support services for those affected by suicide.

The Suicide Prevention Strategy will focus on key high-risk groups including Aboriginal people; men; youths; migrants; patients discharged from mental health services; and same-sex attracted young people.

Communities are required to complete a CAP application form to identify the areas in need of funding. These applications are reviewed

by Centrecare which will work alongside the Ministerial Council for Suicide Prevention (MCSP) to fund initiatives. The Mental Health

Commission plans to develop 50 CAPs across WA by mid-2012 and is currently working with 14 communities to develop CAPs in high-risk areas.

Community Coordinators are nominated by the communities and approved and funded by the Minister for Mental Health and the MCSP. They will direct the implementation of the CAP to meet the area’s suicide prevention needs.

Helen said their main role will be to “support their communities by working with their people and agencies in mapping existing suicide prevention activities and determining the need for future initiatives.”

“If preferable the Community Coordinators are from non-government organisations with strong community networks,” she added.

When Medical Forum spoke to then Mental Health Minister Graham Jacobs last year, he said identifying ‘suicide clusters’ was a key concern, and Helen said this will continue.

“Information on suicides is compiled by the Office of the State Coroner’s database after investigations have been finalised. More immediate reports of suspected suicides is obtained from front-line services including the Department of Health, Department of Education, WA Police and a range of community organisations,” she said.

Last month Helen travelled to Broome to announce $1.36m funding to expedite the State

Suicide Prevention Strategy in the region. The funding comes after 13 young people in the Kimberley region took their own lives in just a few months. It included $560,000 for temporary 24-hour counselling staff for families and communities directly affected by the suicides.

The remaining $800,000 will be used to fund Community Coordinators for 12 months to develop CAPs in the Wyndham and East Kimberley Region; Fitzroy Crossing and West Kimberley; and Broom; Derby; and Halls Creek.

In a recent radio interview with RTR FM, Helen said the main challenges for the Kimberley region were children suffering abuse; drug and alcohol abuse; and low employment.

To address the unique requirements of those bereaved by suicide or who have attempted self-harm, the Mental Health Commission also supports community mental health services Standby Response (in the Kimberley/Pilbara) and ARBOR, a federally funded suicide support service.

For patients at risk of suicide

GPs referring patients at risk of suicide are directed to the Mental Health Emergency Response Line for assessment, support, response and referral. Call 1300 555 788 (metropolitan); 1800 676 822 (Peel); or freecall 1800 552 002 for rural and remote areas. More information is available at the Mental Health Commission website: www.mentalhealth.wa.gov.au l

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medicalforum

Mental Health Feature Mr Jake Millar

Community Voice in Mental Health While the new commissioner is learning the ropes, we talk to Mental Health Minister Helen Morton about the progress of the Mental Health Commission.

“At the moment there are about 16 different organisations that represent mental health consumers but they’re not joined up very well, so an election commitment of ours is to provide assistance to a not-for-profit organisation to create a consumer peak body for the state.”

The Mental Health Commission will rely on input from community groups, mental health consumers and a new advisory board to manage its $500m annual budget and drive reform across the state. Mental Health Minister Helen Morton spoke to Medical Forum about the Commission’s plans for mental health.

Helen said they have committed $250,000 a year to make the WAAMHC self-sufficient.

Applications close on May 20, and the tender will be announced in June.

Advising the Commission

It has taken a year but Australia’s first Mental Health Commission is now beginning to take shape. It has been preceded by numerous plans, reports, summits and reviews and everyone is hungry for some action.

Commissioner Eddie Bartnik (appointed August 2010) will be guided in his role by the Mental Health Advisory Council (MHAC).

Council Chair Barry Mackinnon and Deputy Chair Dr Judy Edwards will be accompanied by an 11-member board that is soon to be finalised.

Mental Health Minister Helen Morton says people outside the public service will be heard and the board will be unlike the typical policy advisors.

“It’s about balancing the information the Commission receives around service delivery and reform. They’re not bureaucrats; they’re consumers of mental health services, carers, and not-for-profit organisations that provide community-based support. It’s a group of people whose voices need to be heard by the Commission, alongside the voices that come through the bureaucratic and clinical channels.”

Over 200 people applied from around WA to become members of the board. A short-list has been drafted and the final members to be announced will include those with lived experience of mental health. The needs of young people are also a key focus.

“We’ve talked about how best to tap into young people to provide services at an earlier age and at an earlier stage within their illness,” she said.

Medical Forum’s April E-Poll of WA female GPs found young women’s mental health was a major concern. Helen said there are a number of programs targeting young women’s problems, including eating disorders and perinatal depression, but they were just part and parcel of a range of programs targeting all young people.

Funding contracts will be reviewed, including HDWA

The Commission will use advice to manage contracts and ensure they deliver the best outcomes. They also promise its budget will be publically available.

“The Commission is not a service provider;

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Primary care a main focus

“Our objective is to keep mental health services in the primary care sector wherever possible and GPs are integral to that,” Helen added.

“We are introducing personalised support and self-directed services. We are going to significantly enhance the level of communitybased options to keep people out of hospital and stay connected with the primary healthcare sector, so we’re looking for many more community-based options.”

n Mental Health Minister Helen Morton, MLC

Our objective is to keep mental health services in the primary care sector and GPs are integral to that. it has a responsibility to purchase services, so all of the funding for mental health services is appropriated from Treasury to the Commission.” Helen explained.

“The number of service providers contracted by the Mental Health Commission is in the hundreds in WA, and the Mental Health Commission allocates near-on $500m a year.

The biggest service provider is the Department of Health and up until now it hasn’t been accountable to the Commission, so we are seeking to rebalance the level of investment that goes to community providers.”

“We will refocus those resources to meet the needs of people with a mental illness, and Eddie will consider whether the services we contract from the Department of Health are the best services to achieve mental health outcomes.”

New mental health consumer body

The Commission will also hold forums around WA to hear directly from communities in need of mental health support. Last month they invited applications from organisations interested in forming a new united peak body for mental health consumers called the WA Association of Mental Health Consumers (WAAMHC).

Helen said the Commission has been working closely with the Drug and Alcohol Office to support programs such as Dr George O’Neil’s Fresh Start addiction treatment centre. The centre recently received a $1.5m State grant, and Helen said it is a cause she has personally backed. l

Mental Health Facts & Figures

• One in five Australians experience some form of mental illness

• Around 3% will be seriously affected • An estimated 1m adults suffer from depression • Depression affects around 100,000 young people • Majority of mental illnesses begin between ages 15-25

• An estimated 1.8m Australians have long-term mental or behavioural problems

• Approximately 2/3 of those with a mental illness do not receive treatment • Mental health disorder and suicide account for over 14% of the national health cost • 75% of those with drug and alcohol problems also have mental health issues

• Reports indicate up to 85% of homeless people have a mental illness

Mental Health Council of Australia www.mhca.org.au

21

Guest Column

Mental Health and Involuntary Care Council of Official Visitors Head Ms Debora Colvin invites readers to consider alternatives to involuntary mental patient care.

Imagine if the law did not allow us to lock up people because of a mental illness. Take some time to think about it. How would our mental health system be different?

We would have a lot more early intervention and community programs, many more supported accommodation options and the wards would be much nicer places in order to entice people to stay in them because we could no longer force them to do so.

More money would need to be spent on mental health because we would no longer have the “easy option” of locking people up and forcing treatment on them.

For example, more money would be spent maintaining the wards so they don’t have mouldy bathrooms, walls full of paint chips, rickety beds and gardens with nothing but dead weeds and grass. These are the things Official Visitors see in far too many wards when they do their monthly inspections.

More doctors would be employed so people could choose a doctor they can have a therapeutic relationship with because (if for no other reason) the doctor treating them is not

R FO

LE A S

the doctor who locked them up on the ward against their will. Country people wouldn’t be relying on fly-in-fly-out doctors or be sedated, catheterised and brought to Perth by the Royal Flying Doctor Service.

Many more allied mental health professionals would be employed too (in hospitals and the community) so there is access to psychosocial recovery oriented programs to help people recover quickly and to stay well, to find them housing and employment.

No longer will Official Visitors have patients complain about being bored; or go to Mental Health Review Board hearings where they and the patient have been given a copy of the medical report only an hour or two before the hearing and where everyone has access to the patient’s file.

Official Visitors would not have voluntary patients (who they cannot help under the Mental Health Act) say on a regular basis: “I am voluntary but my doctor says if I leave he will put me on the locked ward”. Nor would they visit some supported accommodation facilities and have residents say: “I can’t tell

you anything because I will get thrown out and I have no where else to go”. And they are right, there is usually nowhere else for them to go.

Let me make clear: I am not arguing to do away with the Mental Health Act but does being able to lock people away and force medical treatment on them allow society to do less? Does it make it easier for us to accept substandard accommodation and care for our most seriously and chronically mentally unwell people? Can we dream about a different world for people with a mental illness?

Ed. The Mental Health Act requires the Council to inspect authorised hospitals and licensed psychiatric hostels to ensure they are “safe and suitable” and to visit “affected persons” to resolve any complaints. For Annual Reports and more information visit www.ccov.org or freecall 1800 999 057. This opinion piece does not necessarily reflect the views of the Council. l

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the

funny side!

n n n Irish sausage Everyone seems to be in such a hurry to scream ‘racism’ these days.

A customer came into the shop and asked, “In what aisle could I find the Irish sausage?”

The clerk asks, “Are you Irish?”

The guy, clearly offended, says, “Yes I am. But let me ask you something: if I had asked for Italian sausage, would you ask me if I was Italian? Or if I had asked for German Bratwurst, would you ask me if I was German? Or if I asked for a kosher hot dog would you ask me if I was Jewish? Or if I had asked for a Taco, would you ask if I was Mexican?”

“No, I probably wouldn’t,” the clerk admitted.

The guy says, “Well then, because I asked for Irish sausage, why did you ask me if I’m Irish?”

The clerk replied, “Because you’re in Bunnings.”

n n n Punny thoughts n The

fattest knight at King Arthur’s round table was Sir Cumference.

He acquired his size from too much pi.

n I

thought I saw an eye doctor on an Alaskan island, but it turned out to be an optical Aleutian .. .

n She

was only a whiskey maker, but he loved her still.

n A

rubber band pistol was confiscated from algebra class, because it was a weapon of math disruption. dog gave birth to puppies near the road and was cited for littering.

The fourth said, “You know how Mama loved reading the Bible and you know she can’t read any more because she can’t see very well. I met this preacher who told me about a parrot that can recite the entire Bible. It took twenty preachers 12 years to teach him. I had to pledge to contribute $100,000 a year for twenty years to the church, but it was worth it. Mama just has to name the chapter and verse and the parrot will recite it.”

The other brothers were impressed.

After the holidays their mother sent out her thank you notes.

“She wrote: “Milton, the house you built is so huge. I live in only one room, but I have to clean the whole house. Thanks anyway.”

“Marvin, I am too old to travel. I stay home, I have my groceries delivered, so I never use the Mercedes. The thought was good.

Thanks.”

“Michael, you gave me an expensive theatre with Dolby sound, it could hold 50 people, but all my friends are dead, I’ve lost my hearing and I’m nearly blind. I’ll never use it. Thank you for the gesture just the same.”

“Dearest Melvin, you were the only son to have the good sense to give little thought to your gift. The chicken was delicious. Thank you.”

n n n There’s always a way out of it A police officer pulls a guy over for speeding and has the following exchange:

n A

Officer: May I see your driver’s licence?

n A

Driver: I don’t have one. I had it suspended when I got my fifth drink driving charge.

grenade thrown into a kitchen in France would result in Linoleum Blownapart flies like an arrow. Fruit flies like a banana.

Officer: May I see the registration for this vehicle?

Driver: It’s not my car. I stole it.

n Time

Officer: The car is stolen?

n Two

Driver: That’s right. But come to think of it, I think I saw the registration in the glove box when I was putting my gun in there.

hats were hanging on a hat rack in the hallway. One hat said to the other: “You stay here; I’ll go on a head.”

n In

a democracy it’s your vote that counts. In feudalism it’s your count that votes.

n When n If

cannibals ate a missionary, they got a taste of religion.

you jumped off the bridge in Paris, you’d be in Seine .

n A

vulture boards an airplane, carrying two dead raccoons. The stewardess looks at him and says, “I’m sorry, sir, only one carrion allowed per passenger.”

n Two

fish swim into a concrete wall. One turns to the other and says “Dam!”

n Two

hydrogen atoms meet. One says, “I’ve lost my electron.” The other says “Are you sure?” The first replies, “Yes, I’m positive.”

n Did

you hear about the Buddhist who refused Novocain during a root canal? His goal: transcend dental medication.

n There

was the person who sent ten puns to friends, with the hope that at least one of the puns would make them laugh. No pun in ten did.

n n n Four brothers…

Four brothers left home for university, and they became successful doctors and lawyers and prospered. Some years later, they were talking after having dinner together.

Officer: There’s a gun in the glove box?

Driver: Yes sir. That’s where I put it after I shot and killed the woman who owns this car and stuffed her in the trunk.

Officer: There’s a BODY in the TRUNK?!

Driver: Yes, sir.

Hearing this, the officer immediately called his captain. The car was quickly surrounded by police, and the captain approached the driver to handle the tense situation: Captain: Sir, can I see your licence?

Driver: Sure. Here it is.

It was valid.

Captain: Whose car is this?

Driver: It’s mine, officer. Here’s the registration.

Captain: Could you slowly open your glove box so I can see if there’s a gun in there?

Driver: Yes, sir, but there’s no gun in it.

Sure enough, there was nothing in the glove box.

Captain: Would you mind opening your trunk? I was told you said there’s a body in it.

Driver: No problem.

Trunk is opened; no body.

The first said, “I had a big house built for Mama.”

Captain: I don’t understand it. The officer who stopped you said you told him you didn’t have a licence, stole the car, had a gun in the glove box, and that there was a dead body in the trunk.

The second said, “I had a hundred thousand dollar theatre built in the house.”

Driver: Yeah, I’ll bet he told you I was speeding, too?

They discussed the gifts they were able to give their elderly mother who lived far away in another city.

The third said “I had my Mercedes dealer deliver an SL600 to her.”

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23

Preventive Health Dr Rob McEvoy

Farming the Media During Health Campaigns Breaking through the ‘noise’ of health campaigns is proving difficult and is resulting in some borderline claims by some protagonists.

Increasingly, pharmaceutical companies or medical organisations use communication or marketing agencies to promote stories around products or services. This raises consumer awareness, which indirectly lobbies government, increases sales or achieves some other end. Take one example of a press release from the Cancer Council of Australia that lobbed on Medical Forum’s desk. Its purpose is to increase the uptake of subsidised HPV vaccination (Gardasil) amongst young girls, hopefully before they become sexually active, to prevent the 70% of cervical cancers due to HPV types 16 and 18.

The press headline is a classic… “Quarter of girls missing out on life-saving vaccine”.

No, that does not mean 1 in 4 girls will die if they go without vaccination, it means, according to Cancer Council spokesperson Kate Broun, that “the cervical cancer vaccine is potentially life-saving and as such we are concerned that some girls are missing out.”

The emotive headline seeks to overcome other campaign barriers.

First, the Cancer Council still recommends Pap Smears to cover potential cancers not prevented by the vaccine. If that is the case, why don’t women just stick with Pap Smears which have always been promoted as preventive detection? Why are we double dipping?

“The vaccine is a preventive medicine,” we are told, but Pap smears are no longer preventive because they “detect these abnormal cell changes once they have occurred, and may then need treating” and while most “can be treated easily and successfully, it can be a …cost to the public health system.”

It is hard to get people excited about preventing a common infection that is probably going to be asymptomatic

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and is likely to be cleared from the body by the immune system without serious consequences.

So how can you strengthen a ‘maybe’ argument? The answer might be to add a fringe benefit, this time a vaccine that will also “stop 90% of symptomatic warts”. There is some fine print though. Although GPs may have seen some bad cases that stick in memory, STD clinics only report 10% of their new clients with genital warts.

The Cancer Council admits that a lack of parental consent is stopping many school aged girls from getting the vaccine on the government’s scheme. Why is it happening?

“Many parents have low knowledge about what HPV is and how the vaccine works, while others are concerned about side effects and the vaccine ‘condoning’ sexual activity, despite evidence to the contrary.” To this you can add mistrust of vaccines generally and the $450 cost for three jabs if the 12-13 age, free vaccine window is missed.

Fear of STIs and whether girls or their parents consider this a good deterrent against early sex is another barrier to vaccination.

Give them (the young ones) a vaccine and one barrier to sex goes, particularly sex without a condom.

“We know that as girls move into their teens, increasing numbers become sexually active,” Kate says, adding, “Research shows that vaccinated girls do not have sex at an earlier age than non-vaccinated girls, and nor do they have more sexual partners when they do. Having the vaccine at a young age is about protecting women in the future, and if teamed with sexual health education should not affect their current health behaviour.”

The main purpose of the media release was to announce cervicalcancervaccine.org. au - to improve parent knowledge about the vaccine. They may not say it outright but the kids are a target as well. Why? A representative survey of 3000 Australian students aged 15-17 revealed only 33% had heard of HPV, 54% didn’t know that HPV is transmitted through sexual contact, and 62% weren’t aware that HPV causes cervical cancer. Knowledge amongst younger girls is probably dismal.

Footnote: Our repeated enquiries failed to reveal any connection between CSL Biotherapeutics, the manufacturers of Gardasil, and the current Cancer Council campaign. l

For further information, please contact Dr Tony Taylor on 0418 945 047 24

medicalforum

Editorial Dr Rob McEvoy

Private or Public Health…Your Vote?

The medical profession responds to market forces and so does health care, but hopefully with a social conscience.

The private-public debate over health services will remain in the spotlight while the Liberals privatise ancillary public hospital services, subcontract public patient care to private hospitals, and go into partnership with private builders and operators. Around the table, issues for discussion include the best return for the public purse vs. creating wealth for political mates, reducing waste and bureaucracy vs making the dollar King, and maintaining equity in access vs a user-pays system for the well off. There are arguments in both directions, with people willing to take political sides. Underneath, the milieu of market forces come into play, emphasising the importance of decisions at the top in shaping what eventually happens.

Take two current examples, anaesthetists and the announced SJOG Murdoch extension.

Anaesthetists in the public sector enjoy a good lifestyle, and many forgo work in the private and public sectors because they prefer to spend more time with family etc. Full-time specialist anaesthetists in public hospitals receive over $260,000 base salary (40 hours), 3 weeks paid annual study or conference leave, 3 weeks paid

holiday leave, 80 hours paid sick leave, salary sacrificing opportunities, various loadings for on-call, call back, travel etc, and a separation bonus for contract non-renewal after five years.

All have limited rights of private practice which they can forgo to receive a pay bonus.

Some take on administration as heads of department or suchlike, and work a 1.2 FTE. Many regularly work three long days (12 hours, specified 80% patient contact), which makes up their working week of a 0.8 FTE, which then frees them up to enjoy other things.

Those ‘other things’ might include private anaesthetic lists where the income is better but there is no registrar cover, no paid mealbreak, no paid holidays or the ability to take a day off on short notice. Unfortunately, there are too many “lifestylers” and not enough hungry for the private lists, which contributes to a shortage of anaesthetists in the private sector.

This leaves surgical practice managers ringing around for ad hoc cases, and private hospital rosters that spread the after hours workload. In the private sector the anaesthetists grapple with no-gap health fund products or chasing invoices and they seek lists that are income protective (avoid neurosurgeons!) and are easier to do (limited pre-anaesthetic checks).

What about hospitals? The apparent irony of the announced SJOG Murdoch expansion has not been lost on some. Right next door to the public Fiona Stanley Hospital, a not-for-profit health provider that enjoys substantial tax discounts, can find $234m ‘profit’ to increase hospital capacity in the next four years to allow it to service (primarily) those with governmentsubsidised private health insurance. The redevelopment will add 165 beds, eight theatres, medical clinic, and comprehensive cancer centre by 2015, with an anticipated extra 25,000 patient admissions per year.

The counter argument is that other private hospitals find similar profits, without as much government assistance, but profits go to shareholders and not back into improving health services. Others want taxpayer funds to go directly to depleted public hospitals. The medical profession generally wants it both ways.

Whatever their management structure, private hospitals are enjoying a cycle of high occupancy in WA with high private insurance rates and little ebb in demand for services. This should continue for coming years. l

Guest Column

Perinatal Mental Health Support From the Heart WA President Mrs Tracey Parker says her struggle with postnatal depression opened her eyes to the need for better perinatal mental health support.

Aged 23, I fell pregnant unexpectedly with my first child and being unprepared for parenthood in many ways, I really struggled.

I had a prior history of depression and began to experience symptoms during pregnancy. Once my daughter was born, extreme anxiety set in. Not wanting to look like I wasn’t coping with my tiny new bundle of joy, I put on a mask and thus fell through the cracks of the health system.

I was never asked by my obstetrician about my psychological state during pregnancy or at my postnatal check up. I gave false answers on each Edinburgh Postnatal Depression Scale administered by hospital staff and my child health nurse. To most people who knew me, I was a young, happy, well-adjusted new mum.

Meanwhile, isolated at home, I was frightened to be with my baby, terrified to leave the house and so exhausted that I thought of taking my own life more than once. Luckily, time is a

medicalforum

great healer and I am now a contented mother of three.

However, my story is not uncommon.

According to beyondblue, 1 in 11 women suffer depression during pregnancy and 1 in 7 after birth. About 1 in 10 men also suffer depression in this period. Anxiety in the perinatal period is also common and can be just as debilitating as depression.

My message to GPs and other primary health professionals is the critical role they can play in the early diagnosis and treatment of perinatal mood disorders. It is so important that doctors ask questions about the new parents sleeping and eating patterns, as well as those of the baby! How are they feeling? What is going on for them at home? Do they have a support network of family and friends to help out? These are just some questions that might get a parent talking.

If a diagnosis has been made, empower parents by offering them choices in treatment.

This may or may not include medication, counselling or a referral to a psychologist. A doctor might then set follow-up appointments with the parent as a way of monitoring progress and encouraging them to return.

There is a lot of comfort in hearing that someone else has been through a similar journey and has recovered. The women’s peer support groups run by From the Heart WA are facilitated by trained volunteers who have their own experience of perinatal mood disorders. I was unable to attend such a group throughout my own illness, however I have found so much strength and healing in facilitating a group and being a part of this wonderful organisation.

Ed. Mrs Parker is current president of the NFP organisation From the Heart WA (see www. fromtheheartwa.org.au), a group providing perinatal mental health support for women in Perth. They have their own code of ethics and receive private and public sponsorship. l

25

the

funny side

….of Exercise n W alking

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n I

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n I

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have to walk early in the morning, before my brain figures out what I’m doing..

n I

joined a health club last year, spent about 700 dollars. Haven’t lost a kilo.

Apparently you have to go there.

n E very

time I hear the dirty word ‘exercise’, I wash my mouth out with wine......

n T he

advantage of exercising every day is so when you die, they’ll say, ‘Well, she looks good doesn’t she.’

n I f

you are going to try cross-country running, start with a small country.

n I ’m

on a strict running program. I started yesterday. I’ve only missed one day so far.

n Y ou

ever do the Lifecycle? You know, you’re on there for hours. It’s a stationary bicycle: you pedal, you go nowhere for hours. They should call this the ‘get a life-cycle.’

n J oggers

tell you that when they run, they get a runner’s high. I’m not sure what they mean by that, but if they mean puking all over yourself and collapsing, I was pretty wasted recently.

n M y

grandmother started walking five miles a day when she was 60. Now she’s 97 years old and we don’t know where the hell she is.

n I

have flabby thighs, but fortunately my stomach covers them.

n Y ou

could run this over to your friends but why not just e-mail it to them!

n A nd

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last but not least: I don’t exercise because it makes the ice jump right out of my glass.

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he beyondblue report of August 2010 (see inset) indicates there are significant barriers to medical practitioners seeking their own health care. One possible barrier­– fear of being reported and thereby risking livelihood - has been reinforced by the recent introduction of the mandatory reporting legislation. However, the Medical Board of Australia’s guidelines indicate that the threshold to be met to trigger a mandatory notification of a medical practitioner is high. As well, in WA only, the national legislation has been amended so that health practitioners who are providing health services to other health practitioners are exempted from the mandatory notification requirements.

beyondblue Report

In part, the WA amendment was introduced to try to reduce any perception that medical practitioners should be fearful of seeking their own medical care, in that treating doctors are not legally required to report their health practitioner patients. However, in all other situations in the course of practising their profession, WA medical practitioners are required to report ‘notifiable conduct’ involving their colleagues.

The Mental Health of Doctors – A Systematic Literature Review [1] found that: • Depression and anxiety disorders were identified in medical students and practitioners at rates comparable with the general population.

• While alcohol use amongst medical practitioners was lower compared to the general population, higher rates of prescription drug use (e.g. sedatives) were observed and self prescribing was common.

It is important that the new legislative mandatory notification requirements involving ‘notifiable conduct’ are not seen as an additional barrier to medical practitioners obtaining their own health care.

For the purposes of the legislation, impairment is defined as a person who has ‘a physical or mental impairment, disability, condition or disorder (including substance abuse or dependence) that detrimentally affects or is likely to detrimentally affect the person’s capacity to practice the profession’.

Importantly, the practitioner’s impairment must place the public at risk of substantial harm for the threshold for mandatory notification to be met. In other words, making a mandatory notification is a serious step to prevent the public from being placed at risk of harm and should only be taken on sufficient grounds [2].

In reality, this legislative requirement is no different to the longstanding ethical obligation of medical practitioners to act if they believe a

By Dr Sara Bird, Manager, Medico-Legal and Advisory Services, MDA National

colleague’s actions are putting patients at risk of harm.

Medical practitioners are encouraged to contact their medical defence organisation for advice if they are uncertain about their obligations under the mandatory reporting legislation.

References

[1] The Mental Health of Doctors – A Systematic Literature Review. Available at www.beyondblue. org.au [2] Medical Board of Australia: Guidelines for mandatory notifications. Available at www. medicalboard.gov.au n

• In Australia, medical practitioners have a higher suicide rate compared with the general population, with female medical practitioners more than twice as likely to suicide as females in the general population.

• A significant proportion of medical practitioners (including 34% of medical students) reported that they would not seek help for depression. Barriers for help seeking included concerns about stigma in the profession, embarrassment, possible impact on career development and concern about being allowed to continue to practise as a medical practitioner.

• There is limited research around the mental health of medical practitioners in the Australian context, with no studies examining Indigenous or rural and remote medical practitioners.

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P D A T E

The mental health of doctors

Medicare Locals Mr Jake Millar

WA’s GP Divisions Re-invented?

The Federal Government is spending millions to get the Medicare Locals scheme up and running but where this money will go, and whether it is enough remains to be seen.

The announcement of WA’s Medicare Locals (MLs) scheme has seen many groups jostle for a slice of the $475m pie, though some GPs say the scheme will bring bureaucracy rather than results, and will fail to deliver improvements where they are needed most.

The National Health Reform aims to replace WA’s 13 GP Networks (or divisions) with six MLs by 2012. These will be run as independent companies with a board of directors and will be responsible for coordinating primary healthcare in their region.

Many details are yet to be finalised, though the scheme will see most primary healthcare funded by the Federal Government and managed by MLs. The Federal Government has allocated $475m over four years to establish MLs across the country. They are yet to reveal how much of this will be for WA which has 10% of the national population, but considering the State Government has allocated $166m to redevelop Albany Hospital alone, the ML budget seems well short.

Chair of the Osborne GP Network Prof Alistair Vickery is optimistic the scheme will improve WA health care and believes many of the boundary changes will aid service coordination between hospitals but he does have some reservations.

“I think the disappointing thing for us was the amount of money. I’m not sure that all of the objectives will be easily met with essentially what is a doubling of the current GP Network money,” he said, adding it was a shame the scheme fell foul of the political process.

“The hope that this would lead to a single, integrated health solution has faded somewhat with the hostility of the state governments, but I’m still

optimistic. This is the first time we’ve really had a focus on primary healthcare from the Federal Government. Although it’s still broad brush and we don’t really know what the outcomes will be, I think it’s a really good opportunity.”

Dr Mostyn Hamdorf from GP Downsouth is the interim chairman of the Southwest Health Alliance – a coalition between his division, Greater Bunbury and Great Southern GP Networks – which is positioning itself to run the Southwest ML. He is enthusiastic about the potential of the scheme and thinks it will give rural divisions a chance to target specific areas of concern.

“Over time you’ll end up with national health targets focusing on, say, Aboriginal health or childhood obesity, and MLs will seek local solutions to make sure you get the best outcomes to meet those goals,” he said.

Should his tender for the Southwest ML be successful, Mostyn said he will work closely with allied health providers such as Silverchain, WACHS and SJOG southwest to provide care in the region.

Dr Duncan Steed is the chair of the Wheatbelt division and supports the Southwest Alliance’s bid to run the Southwest ML. He believes the real challenge of the scheme is to attract GPs to rural areas, which will require sufficient investment.

He is concerned the current budget will not be sufficient, though he said it is still better than the funding currently available to GP Networks.

“It’s more than they’ve been putting into general practice to date but it has been chronically underfunded in Australia for the last 20 years,” he said.

The Australian Practice Nurses Association (APNA) is another organisation hoping to benefit from the ML scheme.

“The strategic objectives really fall in line with what APNA has been advocating for health reform from the start,” Association President Julianne Badenoch told Medical Forum.

She hopes nurses will not simply be involved in health care delivery, but that they will have a say in how the MLs are run.

“We have lots of ideas and we believe nurses play an integral part in this from a position of governance of these organisations,” she said.

Although there are many people hoping to gain from the scheme, other GPs remain unconvinced. Dr Ian Taylor of Midwest GP Network is sceptical it will achieve its goals.

New Ways to Better Mental Health

“I’m really anxious for it because there doesn’t seem to be any way it will be representative of GPs anymore.

I’m concerned it’s just going to put another layer of bureaucracy in the system.”

His GP division will be become the Country North ML, which will cover a region including Geraldton, Kununurra and Esperance.

“It’s a massive area and logistically I’m not sure how they’re going to manage it,” he said.

9481 1950 sentiens.com

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Ian is also worried the government will be too prescriptive in its funding, rather than allowing MLs to target the issues specific to their area.

“Siloing funds is a very inefficient way of doing things – some things will be overfunded, some things will be underfunded, depending on the needs of the area. You need more flexibility to allocate funding to your areas of greatest need,” he said.

The WA GP Network told Medical Forum it will continue as a locally governed organisation under the ML scheme. It will still operate Primary Healthcare Education Solutions. l

medicalforum

Medical Report Dr Rob McEvoy

On Shanks’ Pony Selling community exercise for health.

The recent closure of the freeway and major roads for cyclists may have seemed a bit ‘in your face’ but the health message is getting to consumers – we are not exercising enough to stay well. Friday May 20 will be Walk Safely to School Day, a national event that last year saw 24 schools and 50,000 students participate, and there are more events to follow (see below). Myriad government departments, programs and community groups are now promoting exercise, for which a coordinated approach is badly needed. Just ask the WA boss of the Heart Foundation, who reckons we have only come 50% of the way after 10 years’ effort.

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WA’s answer to a lack of coordination is the Physical Activity Task Force, which is attempting to coordinate policy across government, monitor levels of physical activity, measure results of programs and advise whoever needs advising. It has funding from Healthway, HDWA, Dept of Transport, Dept of Sport & Recreation etc. Tagged on are researchers from the UWA School of Sports Science, Exercise & Health and ECU. While it sounds like more bureaucracy to most, their attempt to bring things together and make exercise for health ‘sexy’ is visible at www.beactive.wa.gov.au.

Medical Forum attended a Walk Week Seminar end of last year, with wellintentioned people in one room trying to compete with the other various health messages about your prostate, Chlamydia, eating vegetables, etc.

We gleaned this interesting information:

• The aim is 30 mins of exercise most days. The proportion of those exercising for health has declined in the last 10 years for a variety of lifestyle reasons.

• Most people (80%) chose walking, either for recreation or to transport.

More people are cycling (up from 7% to 31%). Main Roads only spent $85m on cycle ways in the last 10 years (major arterial roads usually).

• High density living (>35 houses per hectare) is needed for a good transport system that people will walk to. Otherwise, they average 2.4 car trips per day of < 1 km. A US study around installation of light rail (tram), showed that people within 1.5 km of the route lost an average 2.9kg per year, equivalent to walking 1 mile per day.

• People walk more if: they have nice places to walk to (local park); more connecting pathways; bus stop within reasonable distance; and school drop-off habits are altered.

• Perceptions of fear can limit physical activity. Fear is influenced by neighbourhood maintenance, social incivilities (noise, alcohol abuse, local crime), property crime (vandalism), neighbour friendly cohesion, and house and suburb design that allows visual surveillance.

• The notion of community co-benefits is important – safer, more transport, less pollution, healthier, active kids learn better, etc. In the Netherlands they legislated so that anyone who hits a cyclist is automatically at fault!

• For walk groups contact the Heart Foundation. For cycling For cycling information visit www.transport.wa.gov.au/cycling

Coming Events

May 20, Walk Safely to School Day (National) www.walk.com.au May 22, HBF Run for a Reason www.hbf.com.au

August 28, Rebel Sport City to Surf www.citytosurf.activ.asn.au September 11-17, Stay On Your Feet Week www.iccwa.org.au

September 18, Trek the Trail – Walk www.trekthetrail.com.au

September 1 – October 9, Kings Park Festival Walking Display www.bgpa.wa.gov.au/festival October, Online Corporate Walking Challenge www.transport.wa.gov.au/walking/19718.asp

October 7, Walk to Work Day www.walk.com.au October 31 – November 9, Walk Week www.transport.wa.gov.au/walking/1546.asp l

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Guest Column

Mental Health Carers in the Picture Arafmi Director Mr Mike Seward says mental health carers can help relive pressure on time-poor GPs. When I was the CEO of two divisions of general practice I got this consistent message from GPs: We are time poor and spend too much time on unnecessary things. They told me they welcomed the assistance of other health professionals, specialising in their area, who would not only enable the GPs to provide their patients with a better service but also freeup GP time.

Since joining Arafmi, a mental health carer agency set up by concerned carers in 1976, I have been talking to GPs and hospital-based doctors about how working with us can lead to a win-win situation for doctors and their patients.

Mental health carers normally get to hear about the services Arafmi provides through other providers of mental health services, including GPs and hospital-based doctors, and we would like more doctors to refer. This would help doctors in a number of ways, some of which are: • Help with “heart sink” patients/carers.

Doctors who talk about certain mental

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health patients or their carers as “heart sink” patients/carers, can refer to us to ensure carers are well informed, supported and engaged. This will in turn lead to more realistic patient/carer expectations to reduce or eliminate that “heart sink” feeling.

• Saving doctors’ time. Referring mental health patients and their carers to us for support and advocacy services, including helping them navigate the often complex mental health system, saves doctors time so they can get on with what they do best, that is, provide clinical services to patients and not spend time contacting multiple services for a referral.

• Provide a ‘one stop shop’ for mental health referrals to community mental health organisations. We assist mental health carers to get the best for their loved ones suffering with a mental health issue, and we have knowledge of and links to the full range of community mental health organisations. Arafmi can arrange the best service for patient and carer.

• Educating carers on how to be the GPs’ ‘eyes and ears’. Well educated carers can

monitor the patient’s illness, check for changes, look out for drug side-effects etc, and report back to the doctor. We aim to educate carers to do this for you.

Well educated carers can monitor the patient’s illness, check for changes, look out for drug side-effects etc, and report back to the doctor.

• Help to reduce carers’ mental health issues. Many mental health carers are themselves beginning to exhibit depression and anxiety. Support aids in reducing or eliminating these problems.

Ed: Mr Seward is currently Executive Director of Arafmi (www.arafmi.asn.au), which provides free services including counselling, phone support, youth services, and information and referral services for families. l

medicalforum

Support Group Profile

Women’s Health and Family Services For nearly 35 years Women’s Health and Family Services has been providing a full range of counselling and support services to women in need.

Women’s Health and Family Services (WHFS) was established to support disadvantaged women, children and families in rural and metropolitan WA. They provide a range of assistance including: • Medical and Clinical Services • Counselling

• Perinatal Services

• Mental Health Community Service

• Alcohol and Other Drug Services to Women, Children and Families • Aboriginal Family Support Service

• Community Development and Education • Physical Activity Programs

• Domestic Violence Advocacy Support Service

• Multicultural Womens Advocacy Service

Their annual budget of $4.5m allows them to provide services throughout metropolitan and rural WA, with an average of 60,000 contacts a year from women and families. The most common enquiries relate to reproductive and sexual health, post-natal depression, drug and

alcohol issues, and domestic violence.

WHFS began in 1977 as the Women’s Health Care Associate, which established Women’s Health Care House (WHCH) to provide assistance to socially disadvantaged women.

In 1989 the organisation identified a growing number of women presenting with drug and alcohol issues, and lobbied the government to fund a service to support these women and their families. This led to the opening of the Perth Women’s Centre (PWC) in 1990, and five years later PWC and WHCH merged to become Women’s Health Services. This year the organisation rebranded itself as Women’s health and Family Services.

WHFS is currently working towards its fifth national accreditation review, and its latest national accreditation in 2008 saw all standards either met or exceeded.

The organisation has an excellent working relationship with the medical profession, and they receive regular referrals from GPs seeking to manage women’s health issues. They are thankful for the quality care provided by all their doctors, including Dr Nicky Endacott who has been with the service for 35 years.

WHFS has recently relocated to its new centre on Newcastle Street, where positions will be offered for female doctors with interests and training in sexual and reproductive health, and drug and alcohol issues.

n Ms Joan Forward, Manager of Clinical Services

Contact information Contact hours: 8.00am to 5.00pm Contact person: Ms Joan Forward Address: 227 Newcastle Street, Northbridge 6003 Phone: 9227 8122 Email: jforward@whs.org.au Website: www.whs.org.au

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Bicuspid aortic valve - most common congenital valve abnormality

By Dr Mark Hands, Interventional Cardiologist. Tel: 9346 9300

B

icuspid aortic valve is the most common congenital cardiac valve abnormality, present in an estimated 2% of the general population. In screening a large population of young men (mean age 18) with bicuspid aortic valve, aortic regurgitation was the most common haemodynamic abnormality (being moderate to severe in 12%), while mild aortic stenosis was present in 5% and the ascending aorta size was increased compared to normal controls.* Bicuspid aortic valve may be functionally normal. That said, thickening and focal calcification can often be detected echocardiographically as early as the second decade. Many patients are now diagnosed with bicuspid valve when asymptomatic, due to the increased use of echocardiography. However, almost all patients with bicuspid aortic valve eventually develop symptoms due to either regurgitation or stenosis.

valve and may be independent of a degree of aortic stenosis. The presence of aortic regurgitation is strongly correlated with the ascending aortic root size.

Aortic root disease

Progressive fibrocalcific degeneration results in stenosis. Calcium deposits originate at the base of the cusp and extend outwards towards the free edge. Nearly all bicuspid valves eventually become stenotic. Clinical risk factors for this development include hypercholesterolaemia, systemic hypertension and cusp inequality.

Symptoms associated with bicuspid aortic stenosis correlate with severity. Once the symptoms have developed aortic valve replacement is recommended.

Bicuspid aortic valves are often associated with dilatation of the aortic root, which can lead to aneurysm formation and/or dissection.

This aortic root disease, independent of the functional state of the bicuspid valve, is mediated by co-existing defects in aortic media, including fragmentation of elastin, loss of smooth muscle cells and increase in collagen. Transthoracic echocardiogram should be performed in all patients with known bicuspid aortic valves to determine the diameter of the aortic root and ascending aorta. If this cannot be accurately assessed by this technique then cardiac MRI or CT is recommended. It is now suggested that the aortic root should be replaced in bicuspid valve disease when it is 5 cm or more in diameter.

Aortic regurgitation

Infective endocarditis

Aortic stenosis

This is relatively common in bicuspid aortic

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The bicuspid aortic valves are particularly

susceptible to infective endocarditis. The risks increase with age.

Inheritability

There is increasing evidence for familial clustering and therefore inheritability of bicuspid aortic valve. In studies, bicuspid aortic valve has been present in approximately 9% of first-degree relatives and 37% of families with a patient with bicuspid valve have at least one additional member with a bicuspid aortic valve.

In some cases autosomal dominant inheritance is indicated.

Associated cardiovascular anomalies

Patients with bicuspid aortic valve may have other congenital aortic and cardiac anomalies and these include coarctation of the aorta, ventricular and atrial septal defect, hypoplastic left heart syndrome, patent ductus arteriosus, bicuspid pulmonary valve, Epsteinâ&#x20AC;&#x2122;s anomaly and dilatation of the aortic root (see above).

* Reference: 1. Nistri, S, Basso, C , Marzari , C , et al. Frequency of bicuspid aortic valve in young male conscripts by echocardiogram. Am J Cardiol 2005; 96:718 n

medicalforum

Guest Column

Connecting With Youth Registered psychologist Nikki Marshall explores how brief forward-looking conversations can assist adolescents in turmoil.

A year or so ago, Youth Focus began offering two sessions of Solutions Focused Brief Therapy (SFBT) to clients on our waitlist as a way of providing ‘ballast’ prior to accessing a counsellor.

Youth Focus is a counselling service for 12-25 year olds and their families. What we discovered is that up to 30% of these young people felt that this was all that they needed, that those two sessions had met their immediate support needs.

I was sceptical but on evaluation it was clear this was the case. This brief model appears to work especially well for adolescents who appreciate a ‘quick fix’ in the ‘here and now’ to manage whatever crisis has presented itself. It’s empowering to know you have the resources to deal with the situation and the fact is we do, we are all experts in our own lives.

One of the assumptions underlying SFBT is that people come to therapy motivated and have all the resources they need to manage their issues.

I’ve learned that effective therapy doesn’t have to be drawn out. In some cases, an approach focused on strengths and resources is all that is required. This has been a revelation to me as a registered psychologist, I mean, shouldn’t therapy take ages? Don’t you need to sift through the past for answers and understanding? Don’t people expect to, indeed want to, talk about their problems when they come to therapy?

You’ll never find out where someone wants to get to by asking them where they’ve been.

In some cases yes, but the reality is as ‘helping professionals’, most of the time we only have a small window of opportunity to help someone and brief interventions are called for.

Words are powerful tools and motivation can be created through the use of language. When people can clearly articulate what they want (rather than what they don’t want), they are much more likely to get it.

Some questions using this approach may be: What are your best hopes for this situation/meeting? How would your life be different if your hopes were realised? What would your partner notice? What parts of your life are already working that can help you towards this?

Helping people to build a clear picture of their preferred future is constructive process that puts the individual in the driver’s seat, looking straight ahead, not in the rear-view mirror. Using all the senses to help ‘construct’ this vision is another tool – what will you See? Hear? Feel? Think?

Working from this approach is a craft, and like all crafts, is honed with practice. As professionals in the helping field, we want people to be surprised by their own answers, if they keep saying the same things to you that they say to everyone else, they will stay in the same place. l

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FERTILITY NEWS

Medical Director Dr John Yovich

Male Fertility Obstructive azoospermia includes obstructions in the upper tract (eg obstructed ejaculatory ducts & prostatic utricle) or lower tract (eg post vasectomy cases & failed vasectomy reversals, epididymitis, rete testis obstructions & CBAVD - congenital bilateral absence of the vas deferens).

Some cases are well amenable to microsurgical reconstructions and PIVET results on carefully selected cases has led to 90% successful reversal of vasectomies performed within the recent 3 or 4 years before anti-sperm antibodies arise.

Most other cases are best managed by sperm recovery procedures which can be performed either by testicular needling or scrotal exploration to collect the most mature sperm directly Dr Sweta Agarwal in PDSC from a vasa efferential duct undertaking scrotal exploration within the caput epididymis.

PIVET prefers open scrotal exploration to minimise surgical trauma to the testis or epididymis and to carefully access the caput epididymis for MESA (microsurgical epididymal sperm aspiration). Such cases only ever need a single collection (unlike needling) as 10-15 straws of motile sperm are usually cryopreserved.

We recently presented our excellent results at the Fertility Society of Australia Meeting in Adelaide in October 2010 and these are published in an ANZJOG supplement (volume 50) showing that sperm collected from the epididymis produced the same high pregnancy rates as proven donor sperm (around 50% pregnancy chance per cycle). If good quality epididymal sperm could not be recovered, testicular sperm was collected but the results were around 10% less. The good results of epididymal sperm were achieved regardless of anti-sperm Aspirating sperm from the caput antibodies or SCSA rating epididymis in the IVF Theatre for DNA fragmentation.

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Rethinking our approach to depression

By Dr Dennis Tannenbaum, Psychiatrist, Sentiens

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ecent major trials in the US and UK, along with huge meta-analyses, have examined the epidemiological, genetic and metabolic issues underlying depression. The key aspect of depression treatment is a proactive approach, using a variety of methods, and not simply prescribing a single drug (often an SSRI) and then waiting for an effect or non-effect without measuring response.

It was believed that depression was episodic and self-limiting, and that most people recover really well from an isolated episode. There is now more evidence that depression follows a path similar to chronic inflammatory conditions [1], which is probably why there is so much overlap between depression and heart disease. Rather than episodes, many patients have peaks and troughs in chronic symptomatology. Long term follow-up trials show depression recurrence rates of 60% in five years and by 20 years, most have relapsed [2].

Most antidepressant trials measure a 50% improvement as significant but patients are still disabled at that level. One of the major reports to come from the Sequenced Treatment Alternatives to Relieve Depression trial (STAR*D) showed that remission rates were 36.8%, 30.6%, 13.7% and 13.0% for the first, second, third and fourth treatment attempts respectively. Simply put, treatment interventions reach a point of diminishing returns quite quickly [3, 4] Depression is a worse illness than most of us believe and it is not easy to get a good result. We now aim for patients to be asymptomatic, which needs a greater push – anything less results poor function, more complicated lives and less performance at work. Early focussed treatment is best, and with full remission the aim, this requires monitoring with regular questionnaires.

Drug treatment often requires higher doses

of antidepressants as well as augmentation with second antidepressants, lithium or valproate to deal with secondary and tertiary neurotransmitter systems. The trend is towards use of a variety of medications to minimise side effects and achieve full remission. As mentioned above, the symptom remission rate from antidepressant mono-therapy is poor at 36.8% [4].

A range of treatments should be offered.

Factors that affect treatment response need to be considered, such as psychosocial issues.

People gravitate towards psychological treatments that resonate with their personality.

Mindfulness type approaches as well as cognitive behaviour therapy and psychoeducational approaches in themselves have an enormous benefit. One of the outcomes of the STAR*D trial was that switching to or adding Cognitive Therapy after the first unsuccessful medication is often as effective as switching to or adding another medication, even though remission may take longer, in fact, more than double (55 days vs 26 days) [4].

Treating depression is always more difficult when people have had recurrent episodes and if they do not eat healthily and do not exercise. There is substantial evidence that the availability of nutrients such as folate, zinc, magnesium and vitamins B, C &D, will affect the response to antidepressant drugs [5-7] or symptoms [8]. There is also evidence that various forms of exercise, even stretching, have

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a strong antidepressant effect [9].

Drug treatment in itself is far from perfect and people really help their chances of remission if they stick to a treatment plan and remain active. In the future, there will be more genomic predicators of medication response as well as the metabolic response. There is also no single ideal psychotherapy, and many different therapies work well for different patients. As far as psychosocial treatments, the concepts and integration of spirituality into therapy should have a greater role.

References

1. Shelton, R.C. and A.H. Miller, Eating ourselves to death (and despair): The contribution of adiposity and inflammation to depression. Progress in Neurobiology, 2010. 91(4): p. 275-299.

2. Bresee, C., J. Gotto, and M. Hyman-Rapaport, Chapter 53. Treatment of Depression, in Textbook of Psychopharmacology, 4th Edition, C.B. Schatzberg and N. A.F., Editors. 2009, American Psychiatric Publishing.

3. Rush, A.J., M.H. Trivendi, and S.R. Wisneiwski, Acute and Longer-Term Outcomes in Depressed Outpatients Requiring One or Several Treatment Steps: A STAR*D Report. American Journal of Psychiatry, 2006. 163: p. 1905-1917.

4. NIMH. In Second Try to Treat Depression, Cognitive Therapy Generally As Effective As Medication. Science Update 2007 [cited 2011 01/03/2011]; Available from: http://www.nimh. nih.gov/science-news/2007/in-second-try-to-treatdepression-cognitive-therapy-generally-as-effectiveas-medication.shtml.

5. Maes, M., et al., Lower serum zinc in major depression is a sensitive marker of treatment resistance and of the immune/inflammatory response in that illness. Biological Psychiatry, 1997.

42(5): p. 349-358.

6. Siwek, M., et al., Serum zinc level in depressed patients during zinc supplementation of imipramine treatment. Journal of Affective Disorders, 2010.

126(3): p. 447-452.

7. Poleszak, E., et al., Enhancement of antidepressant-like activity by joint administration of imipramine and magnesium in the forced swim test: Behavioral and pharmacokinetic studies in mice. Pharmacology Biochemistry and Behavior, 2005. 81(3): p. 524-529.

8. BinfarÈ, R.W., et al., Ascorbic acid administration produces an antidepressantlike effect: Evidence for the involvement of monoaminergic neurotransmission. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 2009. 33(3): p. 530-540.

9. Foley, L.S., et al., An examination of potential mechanisms for exercise as a treatment for depression: A pilot study. Mental Health and Physical Activity, 2008. 1(2): p. 69-73. n

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medicalforum

Guest Column

Mobile Work - No Easy Ride CEO psychologist Dr Jennifer Bowers outlines some unique mental stressors that a fly-in fly-out lifestyle brings to workers and who is at risk.

“Fly in-fly out. They call it FIFO. I’ve been on FIFO rosters for four years now and I can tell you, FIFO stands for something else when you get home. Fit in or f*** off.

Fact is, it’s hard being at work and hard coming home.” This comment from 37-yearold Andy is background to why in recent months the Australasian Centre for Rural and Remote Mental Health (ACRRMH) has been working with some mining and resource companies to develop integrated and sustainable mental health strategies.

We start by interviewing employees and managers and often have to break down the walls of male stoicism and the macho culture to establish communication and trust. It can take time but it’s worth it. It’s pretty clear from our interviews that long periods of separation from family and friends often lead to a loss of a sense of belonging and a corresponding sense of personal isolation.

“I missed my kids’ birthdays four years running and every time I missed one my wife got madder with me. She liked the money though. We’d always have a fight just before I flew out for my

vulnerable to the stresses of a FIFO lifestyle.

roster. I’d spend the next fortnight wondering if I had a marriage to go home to.”

Harsh surroundings, climatic extremes and long periods of intense concentration when a lapse can result in serious injury and/or death are not exactly ideal conditions in which to earn a living. Depression, anxiety, post-traumatic stress, social phobias and substance abuse are emerging

Harsh surroundings, climatic extremes and long periods of intense concentration are not exactly ideal conditions in which to earn a living. as significant features on the FIFO landscape.

Even though there’s not a lot of hard data available, some trends are emerging. For instance, the Centre is finding that mental health problems in the mining and resources sector are not confined to any particular age or socioeconomic groupings. Professional, skilled and unskilled, everyone is at risk - though men with young families, like Andy, seem particularly

There are some risk factors emerging too. People with a history of mental illness, people who react adversely to isolation and people with little or no experience of life outside cities seem to be at greater risk of developing mental health problems. On-site accommodation seems to play a part too: people who stay in a caravan park or single men’s quarters appear to be more predisposed to mental health disorders.

ACRRMH encourages GPs who work in communities that support the mining and resources sector to be on the look-out for mental health disorders in both mining employees and their families. There are social stigmas and connotations of weakness at play here and men, in particular, will often deny, ignore or deliberately conceal symptoms.

In addition to the usual care, treatment plans and referral mechanisms, there is a variety of other resources in rural and remote regions available to GPs. ACRRMH is happy to assist general practitioners with patients from the mining and resource sector by sharing resources, information and intervention strategies based on a “whole person, whole community” approach to wellbeing. l

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Doc of The Swan Charity sail to celebrate Dr Gordon Baron-Hay Major Placegetters: Gordon Baron-Hay Perpetual Trophy (Fastest Time): Sled owned by Tony Mitchell and skippered by Dr Jenny Downs Division A winner: Icefyre skippered by Dr Peter Packer (retired), with crew Ron Packer and Richard Timms Division B winner: Norsk skippered by Dr David Roberts, with crew Dr Douglas Meikle, Dr Rob McWilliam and Will Hammond

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Doc of The Swan 2011

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11 10 1. RPYC entrant Red Fever is owned by Dr Ian Hewitt from PMH and skippered by Dr Adrian Charles 2. Line honours winner Sled powers past spectator craft Nikomis, with guest of honour Pat Baron-Hay on board.

3. Gordon’s wife Patricia (second from right), enjoys a laugh with Jenny Heyden, Gillian Bush, Chrissie Jordan and Bette Baron-Hay, aboard the Nikomis spectator craft.

4. At Mulberry’s helm is Dr Alister McKendrick, with Gabriel Hammond and Dr Michael Joyce (and Liz Whan and Dr Hermann Meyer out of view).

5. W hitebait, with Dr Zlatan Golic at the helm, jostles with Dr Alister MacKendrick’s Mulberry at the start.

6. A happy crew: Peter Edmonds (owner), John Patterson, Tony Carano, Dr John Edwards, Dave Hutson, Michael Edmonds, Katarina Rakovska (barely visible) and Dr Peter Connor (skipper).

7. Division A winners: Icefyre with Mr Richard Timms, Mr Ron Packer and skipper Dr Peter Packer (retired) 8. Crews of Nirimba and Whitebait natter post race.

9. Bacchante with two unidentified crewman and Manfred Speicher, Steve Ward, and Dr Ed Fethers (skipper).

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10. Longstanding crew of Etchell yacht Z-ipi, Gordon’s old boat, are Gus McBriar, Anthony Vlachou and Dr Ric Bergesio, taking pride of place ahead of Red Fever.

11. Heading for home.

12. Division B winners: Dr Rob McWilliam (retired), Dr Douglas Meikle, Will Hammond and Dr David Roberts (skipper) on Norsk.

13. The crew of South Perth Yacht Club entrant Smoke on the Water - Dr Malcolm Thomson, Dr Jonah Desforges, Mr Simon Tiller, Miss Lisa Russell, Dr Mike Desforges (dentist) and Dr Krishna Epari (skipper).

14. Nereus with two unidentified crewman, Dr Jonathan Joyce, and Dr Adam Gajdatsy (skipper).

15. Boys in blue: Pallandrome crew are on a high (l to r) Jerome Allan, Dr Clem McCormick, Dr Matthew Allan and owner Peter Allan (with Drs John Kitchen and John Herron out of sight).

16. Lady Barbara is helmed by Dr Sally Edmonds, while owner David Campbell (left) and Ali McEvoy ham it up.

17. This Way Up crew Mr Paul Luke, Dr Kylie Waller, Dr Tony Ma, Dr Shih-ern Yao, Mr Brian Thurstan (at the helm) and Dr Steve Harding (with Dr Andy Gill out of sight).

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M A Y C ompetitions

Competitions ➧

To enter go to MedicalHub.com.au ➧ [Click on “Competitions” in the left menu] ➧ Theatre: Rising Water Win a double pass This will be the world premiere of WA’s favourite author Tim Winton’s first play. June 25-July17, State Theatre Centre of WA. bocsticketing.com.au

Competition Winners – March Cinema: Cane Toads; The Conquest 3D

Fermoy Estate Wines Doctor’s Dozen

Win a double pass A comic yet provocative account of Australia’s most notorious environmental blunder, which tracks the journey of the toad across the continent. It is Australia’s first digital 3D film. In Theatres from June 2. www. canetoadstheconquest.com

Orchestral: Verbitsky Conducts Tchaikovsky Win an A-reserve double pass Hear the music of the composer best known for his ballets including Swan Lake and The Nutcracker Suite, as WASO brings the romantic Tchaikovsky’s Symphony No. 4 to life. 7.30pm June 24 & 25. Bookings through WASO (9326 0000 or www.waso.com)

Dance Theatre: Helix Win a double pass Marrying together original choreography, cinematography and state-of-the-art medical imaging technology, Helix showcases dance styles from classical to contemporary to tap to gymnastic athleticism and more. June 8 to 11, Heath Ledger Theatre. bocsticketing.com.au or 9484 1133.

Comedy Theatre: A Germ of an Idea Win a double pass A dirty comedy by Monica Main who tackles bacteria to the max. She explores our obsessive relationship with germs through characters such as The Doctor, The Cleaner, and The Housewife. From June 7 to 25, 7pm Tues to Sat at the Blue Room Theatre. Bookings www.blueroom.org.au or 9227 7005.

Cabaret: Tom Burlinson Win a double pass Come fly with Tom Burlinson and a fabulous 16-piece big band as he salutes the masters of vocal swing: Frank Sinatra, Harry Connick Jr, Michael Bublé, Tony Bennett, and many more. June 6 His Majesty’s Theatre. bocsticketing.com.au

Leisure: Round of Golf Burswood Park Golf Course is offering a prize of 18 holes for two, with buggy thrown in (but you can walk if you prefer!).

Dr Bronwyn Stuckey is a consultant physician at the Department of Endocrinology and Diabetes at Sir Charles Gairdner Hospital. She said she enjoys reading Medical Forum over lunch and particularly likes information in areas inside and outside endocrinology.

Away from work, Bronwyn said her spare time is occupied with grandchildren, Labradors, music (both making and listening) and travel (preferably France). Though she said she leaves cooking to her husband, Martin.

When it comes to wine, Bronwyn said she mostly sticks to red.

“It’s supposed to be good for HDL cholesterol but I don’t think I drink enough to really make much of a difference,” she said.

She also has the occasional glass of white wine and said it is best enjoyed with oysters and crusty French bread. Bon appétit!

Catalpa – theatre: Dr Irina Kurowski & Dr John Thompson Love Letters – theatre: Dr Joanne Keaney & Dr Caroline Chin Just Go with It – movie: Dr Glenda Khoo, Dr Nicole Cole, Dr Yin Yin Wee, Dr Leanne Heredia, Mrs Dianne Ward, Dr Edna Sun & Dr Wei Chua

Prizes drawn at random. Competitions end 31/5/2011 38

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By Dr Louis Papaelias

On the Grapevine

Irvine Wines I was intrigued to receive a parcel of wines last month from Irvine Wines in the Barossa. This was because I had never tasted their famous Grand Merlot Wine. This wine has won a gold medal twice in the International Wine Challenge in 2008 as well as multiple silver and bronze at Mundus Vini and Decanter Magazine World Wine Awards. Perhaps it needed a seal of approval from overseas judges in order to gain recognition at home on Australian shores.

I for one hadn’t taken the Merlot variety too seriously. Sure enough I knew that it was behind some of the most famous (and expensive) wines in the Bordeaux district but in Australia the perception has been of a variety that was a good addition to cabernet sauvignon in order to round out the flavour. On its own it is usually sold as an easy drinking soft style of red.

Not too demanding on neither the palate nor the purse.

I can assure the reader that the 2004 Irvine Grand Merlot is in a completely different class altogether. This is a crackerjack wine, which at seven years of age is full of life and vigour. There are lashings of leather, plum tobacco and spice flavours beautifully integrated with a faint hint of pepperiness. It certainly reminded me of very good claret from the Pomerol/St Emilion region of Bordeaux. No doubt the international judges felt inclined the same way. It is a delightful drink and will last for years in a good cellar.

Irvine is not a new name in the Australian wine scene. A distant relative Hans Irvine established the Great Western sparkling wine cellars in 1888. He introduced the ondenc variety into Australian bubbly. Before formal identification it

was known as Irvine Dry White.

The current winemaker is Joanne Irvine who is mentored by her father James. Jim Irvine has worked in the wine industry for the last 59 years. As a winemaker and marketer he brings a wealth of experience. Having worked for Hardys, Normans, Krondorf and Lakewood he is very familiar with the vineyards and wines of South Australia. It is no accident that he chose a closely planted vineyard at Springhill high in the Eden Valley 400 metres above sea level with 9.43 hectares of vines about half of which are Merlot. The cool climate and low yields produce top quality fruit. Careful winemaking and prolonged maturation have resulted in a wine that truly does fit into the super premium category.

DOCTOR’S DOZEN COMPETITION

Q:

For how many years has Jim Irvine worked in the wine industry? ................................................................................................................................................

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, May 31, 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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The whites of Irvine’s are like the reds; not your average variety. I tasted a 2010 Pinot Gris, full flavoured and soft. A good food wine. I understand there are wines made from Savagnin (thought originally to be Albarino) and Petit Meslier (a variety little known outside the Champagne district of France).

Irvine is certainly worth a look. There is a real dedication to quality production of not-the-usual range of wines. And one last thing, don’t forget to let the reds breathe for an hour or two!

The 2008 Irvine Estate Merlot isn’t half bad either. Its soft rounded plumminess and spice make it very pleasant current drinking of above average quality. The 2008 Baroness is a further step up in quality. Here cabernet franc and cabernet sauvignon complement the Merlot. There is added depth of flavour with more berries and violets. A wine that blossoms in the glass. In fact all of the reds here opened up nicely after a couple of hours breathing.

WIN a Doctor’s Dozen! Courtesy of Medical Forum

Answer:

The 2006 Zinfandel came to me out of left field. I was expecting an over the top fruit monster but instead was charmed by an elegant, balanced wine of great sophistication. Lovely caressing cherries were all I could think of. Well worth seeking out

Enter here!... or you can enter online at www.MedicalHub.com.au!

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E-mail: ����������������������������������������������������������������������������������������������������������������������������������������������� Contact Tel:

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Please send more information on Irvine Wines offers for Medical Forum readers.

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Eating In Recipe

Barbecued King Prawns, Split and Marinated

Neil Perry from Burswood’s acclaimed Rockpool Bar & Grill shares a tasty recipe from his menu.

Photograph by Earl Carter

The marinade can be used for any seafood. If you feel like spoiling your friends, split a lobster in half for every two people, marinate and barbecue, taking care not to overcook. You need really large prawns for this dish so you can pull the flesh out easily once they are cooked.

Method - This recipe serves 8 as part of a shared banquet.

To make the marinade, place all the ingredients except the oil in a mortar and crush with a pestle to a course paste. Mix in the oil. Place the prawns in a large bowl and pour over the marinade. Allow to stand for one hour. Preheat the barbecue, making sure the bars are clean. Place the prawns on the barbecue for one minute, then turn over. After another minute, remove from the barbecue and pile onto a platter. Drizzle with oil and fresh lemon juice and give a generous grind of fresh pepper.

Marinade: Grated zest of 1 lemon 3 garlic cloves, peeled

Ingredients:

2 cm piece ginger, peeled and grated

16 extra-large green king prawns, shell on, cut lengthways down the middle.

1 tsp chilli flakes

Extra virgin olive oil

Sea salt

Juice of 1 lemon

100 ml extra virgin olive oil + extra to serve

Freshly ground pepper

1 tbs chopped oregano leaves 1 tbs chopped sage leaves 1 tbs chopped coriander leaves

By Dr John Quintner

A wonder-working physician

From near and from far those who were afflicted with pain flocked to Mesmer’s house in the rue Montmartre.

Early or late they awaited his coming, and when he at length appeared in the street the patients ran to meet him, hoping to touch his garments and thus come into contact with the healing emanations.

The Paris court idolised the wonderworking physician. Marie Antionette, the Duke of Bourbon, the Prince of Condé and Lafayette became his close friends. Other persons bearing the most famous names of the epoch were among his patients, and princesses besought the favour of being admitted to his presence.

From: Triumph over Pain by René Fülöp-Miller, 1938, p.31.

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