Breathtaking COPD, TB, Sleep
t Profile: iiNet’s Michael Malone t e-Health Readiness t Training: In It Together t ACCC & the Pharmaceutical Code t Fair Game for Kids
September 2012 Major Sponsors
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CONTENTS
Major Sponsors
25 Cannabis, Health
FEATURES
and the Law
6 Michael Malone:
Internet Evangelist 8 Doctor Training: In it Together 16 Medicines Australia Code Review 22 Orthopaedics Travel Sheds New Light
NEWS & VIEWS 2 Editorial: Long Road
Dr Simon Lenton
26 Confidence in
Confidentiality? Mr Geoff Diver
27 NFPs Get Down
6
to Judgement 3 Letters:
18 Peel Health
Campus Update
32 COPD Online Course Dr Rob McEvoy
8
Dr Rob McEvoy
GUEST COLUMNS 10 Aged-Care Cuts the
in Pregnancy
16
Gut Symptoms Dr Nathan Francis
LIFESTYLE 42 Giving Kids a Fair Game Mr Peter McClelland
44 Kitchen Confidential:
Guillaume Brahimi 45 Wine Review: Barwick Estate
Ms Stephanie Fewster
Images Online
Prof Jeff Keelan PhD
41 Dysfunctional
21 Funny Side
17 PCEHR and Carers
20 Trustworthy
Dr Justin Waring
Dr Devind Bhullar
Can You Fire a Patient?
Dr Louise Schaper
35 Watch for TB
40 Nanotechnology
Ms Morag Smith
20 Future of e-Health
Dr Sina Keihani
39 Nutrition and CVD
Mr Stephen Kobelke
Dr Richard Riley
Problems
Dr Christiane Remke
15 Medico-Legal:
a Long Way to Go
Dr Anjana Thottungal
34 Common Respiratory
38 Support Group: LIFE
Final Blow
18 Hospital IT has
33 Transvaginal Ultrasound
36 Food Allergy in Children
19 Practice
Management Tip 23 Midland Health Campus Launch 24 SJOG Decades of Doctors 28 Doc of the Swan: Cheque Handover 37 Beneath the Drapes
A/Prof Andrew Gill
Dr Tim Gattorna
Johnson
Moral Dilemma
29 KEMH Ethics Committee
for Cardiac Implants
14 UWA’s Prof Paul
17 NHMRC Tightens Rules
Home Hospitals Dr Scott Blackwell
31 Remote Monitoring
12 Have You Heard
15 Interns and a
28 GPs Steer
CLINICAL FOCUS
Dr Bret Hart, A/Prof Julian Rait, Ms Sue Laing, Dr Alison Creagh
Mr Peter McClelland
to Business Ms Antonella Segre
Dr Martin Buck
22
46 Satire: Breath
of Fresh Air Ms Wendy Wardell
47 Funny Side 47 Car Plates Competition 48 Pirates of Penzance
Dr Moyez Jiwa
49 Competitions & Winners
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PUBLISHERS Ms Jenny Heyden - Director Dr Rob McEvoy - Director
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 ADVERTISING Mr Glenn Bradbury advertising@mforum.com.au (0403 282 510) EDITORIAL TEAM Managing Editor Ms Jan Hallam 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 Journalist Mr Peter McClelland journalist@mforum.com.au EDITORIAL ADVISORY PANEL Dr John Alvarez Dr Scott Blackwell Ms Michele Kosky Dr Joe Kosterich Dr Alistair Vickery Dr Olga Ward 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. Advertisers are responsible for ensuring that advertisements comply with Commonwealth, State and Territory laws. It is the responsibility of the advertiser to ensure that advertisements comply with the Trades Practices Act 1974 as amended. All advertisements are accepted for publication on condition that the advertiser indemnifies the publisher and its servants against all actions, suits, claims, loss and or damages resulting from anything published on behalf of the advertiser. EDITORIAL POLICY This publication protects and maintains its editorial independence from all sponsors or advertisers. GRAPHIC DESIGN 2 Thinking Hats
Editorial
The Long Road to Judgement The medical profession is part of the legalistic ‘blame game’ depicted in the media each day. The community seems to be switching away from being reasonably responsible for their own actions, to wriggling out of it or making someone suffer, by using a clever lawyer. Is this a good thing or bad? You can argue in both directions. The old system of Medical Board appointments seemed to attract doctors who were fair and of good standing and who applied common sense. Over time, there were complaints that appointments and investigations were politicised, too secretive and did not protect consumers enough. Things moved, in part, to the more judicial State Administrative Tribunal (SAT) where more serious complaints are considered more openly, often with media attention (e.g. Dr Woollard’s cases). However, many argue the legal system itself is in need of reform, that smart expensive lawyers can get you more ‘justice’, things move too slowly (we still await the Durani judgement), and often results appear out of tune with community expectations. The Mallard case highlights some of the broader issues. Much legal work, a lot of it pro bono because costs were prohibitive, went into freeing Andrew Mallard. John Quigley MLA was the subject of a complaint before his professional body in pushing for action (later dismissed). Former Crown Prosecutor Ken Bates had a SAT finding against him of 'unsatisfactory professional conduct' based on CCC findings around the prosecution and 12-year imprisonment of Mallard (rather than 'misconduct', which involves deliberate actions). He received a maximum $10,000 fine in contrast to a $270,000 payout when he earlier quit the DPP and the public service. On face value, the Legal Professional Complaints Committee seems as busy as the Medical Board on the SAT website (http://www.austlii.edu.au/cgi-bin/ sinodisp/au/cases/wa/WASAT/2011/). Within the new legal framework, the Medical Board’s slip is showing. In May 2011, a Medical Board application was denied due to a legal
technicality influenced by legislative changeover to SAT. In October 2011, an application by the Medical Board to prosecute a matter was struck out on appeal to the Supreme Court, which gave as its reason abuse of power arising from unreasonable delay (18 years). In April this year, SAT dismissed the Medical Board’s claims of carelessness and incompetence involving six surgical patients of one doctor, while at the same time the Medical Board voluntarily withdrew other allegations due to lack of evidence. In May this year, on appeal, SAT overturned a decision of the WA Medical Board to fine and reprimand a doctor and instead imposed the earlier recommendation of the Board’s own Professional Standards Committee, to caution the doctor. In contrast, there are successful and complex cases but the work involved in getting a judgement seems huge, expensive (for plaintiff and defendant), and full of technical hurdles. Why then does the Medical Board prefer to inform doctors well after the event, when appointing doctors to investigating panels? A resounding 85% of the 313 GPs and Specialists who had formed an opinion when we surveyed them (July edition), said all doctors should be given the opportunity to comment on WA panel appointments. When we asked AHPRA to comment, they said police checks, health and conduct checks would satisfy selection. How nominations occur and what influences State Health Ministers remain a mystery to us. We suggested to AHPRA that it would be in the public interest, for example, if a doctor had the opportunity to inform the Medical Board when a colleague who nominated as a panellist strongly believed that women would lie about sexual harassment to incriminate a doctor. The alternative was the embarrassment of having it pointed out by the defendant’s lawyer at a SAT hearing. There are many other potential scenarios related to gender bias, religious persuasions, political appointments, and the list goes on. Conservative doctors are not going to stick their necks out without good reason. O
By Dr Rob McEvoy
Write the Cartoon Caption and Win Write the speech bubble to the cartoon on the below and be in the running for a prize.The best entry will appear in the November issue of
the magazine. Enter by September 30 to be in the running. Head to the Medical Forum website at www.medicalhub.com.au.
July's Winner Ms Nicole O'Brien, from Joondalup, is the winner with her entry: "I could use a drink, but it's dry July."
I could use a drink, but it's dry July.
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Letters to the Editor
Upstream message lost?
intellectual and …material resources to bring to bear on these problems using an agreed … approach.” In the review, he estimated that since the 1980s, resourcing Community Health Services, including Child Development Services, fell 29%.
Dear Editor, What a rich diversity of topics around child health in August’s Medical Forum. Diversity is said to be strength but there’s a fine line between diversity and division. Judge Reynolds promotes division by suggesting, “mental health funding should not be linked to crime reduction.” This is the opposite to criminologist Graycar’s suggestion on ABC Radio National’s Ockham’s Razor (still accessible from their website). He urges agencies to blur their boundaries and be flexible with budgeting. He cites child abuse as an example requiring a public health approach as espoused by Peter Winterton. STIs would also be easier to tackle if Sexual Health Education was mandated. But this is not the core business of the Education Department. Peter Newman refers to cities designed to facilitate children to play safely as promoted by Griffin Longley. However, health benefits are not the prime consideration of Planning Departments.
He made 172 recommendations to rectify the situation and to reconfigure the service to meet the future needs of the State. No recommendation was implemented. The consequences are being felt now as reflected in the E-poll on child health and with Michelle Scott noting that WA has the highest percentage of developmentally vulnerable children when they start school. Ironically, Geoff Emery suggests the way forward – except that he paddled (or scrambled) in the wrong direction. It is upstream where efforts need to focus and, having become so critical, threats to child (and therefore future) health, warrant being an election issue. Dr Bret Hart, Glen Forrest
Indemnity and PCEHR Dear Editor,
Prof D’Arcy Holman recognised the need for agencies to work together over 20 years ago in his review of Community & Child Health Services. He recommended the establishment of 20-30 Regional Human Services Areas to “identify cross-boundary issues, and to pool
Following extensive consultation and collaboration with DoHA, NEHTA and interested doctors’ groups to ensure several medico-legal concerns were appropriately addressed before the commencement date,
MDA National has given its qualified support for the PCEHR. These discussions have resulted in more positive outcomes for doctors than initially proposed, with significant improvements to the Healthcare Provider Organisations (HPO) contract, which doctors wishing to participate in the PCEHR need to sign to register. The recent removal of the ‘unilateral indemnity clause’ and modifications to the ‘intellectual property clause’ in the HPO contract means participating doctors will shoulder less legal liability and can feel more secure about being involved. DoHA’s responsiveness to the concerns raised by the industry has resulted in a more practical system and facilitated positive change with the HPO contract. However, while this is a pleasing outcome, it is concerning that general practices will become ineligible for the eHealth Practice Incentive Program (ePIP) if they choose not to participate in the PCEHR. Furthermore, the PCEHR's capability for patients to add to, delete or deliberately withhold aspects of their medical conditions or treatments from the PCEHR could lead to patient harm. This could arise from incompatible medicines being prescribed by different doctors, unaware of the other's treatment, or from conflicting treatment regimes. So we will continue to advocate for further improvements. We will provide updates via our website at www.mdanational.com.au. A/Prof Julian Rait, MDA National President
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Smith Coffey Group, 20 Nicholson Rd, Subiaco, WA 6008 Telephone: 08 9388 2833 email: smith.coffey@smithcoffey.com.au web: www.smithcoffey.com.au medicalforum
3
Letters to the Editor
Donor registry open Dear Editor, I would like to inform your readers about the voluntary register for people involved in donor-assisted conception. The Department of Health provides this service for donorconceived adults who wish to find out about their origins, for donors of genetic material who wish to know about any child born as a result of their donation, and for parents of donorconceived children under 18 years of age. Some doctors may have donated genetic material when they were medical students and wondered about any children born as a result of their donation. Or some of their patients may be donor-conceived adults; parents of donor-conceived children or have donated genetic material in the past. The voluntary register enables donors, donor-conceived adults and parents of donor-conceived children to potentially access information via secure processes, subject to other parties’ preferences. People who were involved in donor-assisted conception when donations were anonymous (before 1 December 2004) are particularly encouraged to join the voluntary register. However, the Department of Health is aware that records of donation outcomes may no longer exist in some instances. Information about a person is entered on the
voluntary register only if the person completes a signed and witnessed registration form. They may provide non-identifying and/or identifying information depending on their preferences. Registrants may also indicate if they do not want to be contacted by another party. Relevant non-identifying information is provided to the registrant if a ‘match’ is made. Identifying information about a person can only be released after both parties have had counselling with an approved counsellor to discuss implications, and they have both provided written consent to proceed. Services are conducted in a sensitive and discreet manner. The personal wishes and the privacy of each person are respected. For information on how to register, see www.voluntaryregister.health.wa.gov.au Ms Sue Laing, Senior Policy Officer, Reproductive Technology Unit, WA Department of Health
Update on contraceptive use Dear Editor, This is to notify the readers of Medical Forum that there have been a number of changes to the evidence on contraceptive use in the last couple of years. For example,
many readers will know that the use of most antibiotics does not interfere with the effectiveness of the combined pill (the only significant drug interaction is with liver enzyme inducing medications). Some of the other changes include: t "EWJDF PO NJHSBJOF XJUI BVSB BOE combined contraceptive pills and rings t )PSNPOBM FNFSHFODZ DPOUSBDFQUJPO should still be given as soon as possible after unprotected sex, but is now considered very effective up to four days later, and has some effect up to five days later t 5IFSF JT B TMJHIU SFMBYBUJPO JO MFWFM PG contraindication of women with a high BMI and combined pills and rings t 5IFSF JT B MFTTFOJOH JO UIF MFWFM PG contraindication of women with chronic liver disease and hormonal methods t 4JNJMBSMZ XJUI DVSSFOU WFOPVT thromboembolism for using progestogen only methods For fuller information on these and other changes, see The Clinical Guidance section of the UK Faculty of Sexual and Reproductive Health, found at: www.fsrh.org/ and the just released third edition of Contraception: an Australian clinical practice handbook, available from FPWA library. The new edition is $60. Dr Alison Creagh, Medical Educator, FPWA Sexual Health Services
STI e-LEARNING RESOURCE FOR GPs Any patient in your waiting room could have a Sexually Transmitted Infection (STI) and not know it. Edith Cowan University (ECU) and the Department of Health, WA have developed a free online education program for general practitioners, nurses and other health professionals, designed to improve both knowledge and skills in managing sexually transmitted infections. The program has been approved by the RACGP QI & CPD program for 40 category 1 points. Explore the learning program at http://sti.ecu.edu.au or for further information email sirch@ecu.edu.au
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4
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Spotlight
Evangelist of the Internet As head of the second biggest ISP in Australia, Michael Malone relishes the world of fast-speed internet but says it needs creative forward-thinking. medicine and tech problems it’s often a process of elimination.�
A suggestion that the internet might be regarded as a cold, remote and anonymous social platform brings a predictably voluble response from iiNet co-founder Michael Malone. Australia’s second largest Internet Service Provider (ISP) has come a long way from its 1993 beginnings in a suburban garage in Perth. The essence of iiNet is all about keeping customers happy and improving communication. And the world of medicine stands to benefit as well. “I think it’s a ludicrous assessment to think of the internet as a degraded form of social interaction. It’s all about allowing people to reach out and communicate with each other in a convenient and low-cost manner,� Michael said. “Sure, there’s a generational aspect. My grandparents would have found the telephone cold and impersonal and not nearly as good as sitting down for a cup of tea. Now we have people, particularly Gen Y, breaking up relationships on the strength of a text message.�
It’s not good enough to roll out the fibre and think about finding applications for it later on.
The twin peaks of concern regarding the Personally Controlled Electronic Health Record (PCEHR) are accuracy and confidentiality. Here in Australia there’s a great disparity in the use of electronic records in GP clinics compared with hospitals. The latter is very much at the bottom end of the usage scale. In terms of pre-planning, Singapore provides an exemplary model. “These two issues – accuracy and privacy – have to be foundational, not something you patch in afterwards as an electronic solution. The Federal government needs to have clear objectives with the rollout of this (PCEHR). Aiming for all patient records to be stored digitally and securely is all well and good, but there has to be a close focus on how it’s going to work and why it’s important. Singapore is a good example. They came up with precise national policy objectives linking technology with disease control. They had real concerns in the wake of the Asian bird flu in 2010-11, so they rolled out fibre connections to every bus 6
“It’s a miracle that the internet works at all. We’ve got a network that was built for voice, the copper’s about 35 years old and we’re pushing it to the limits. There are so many parts that can break.�
Q iiNet co-founder Michael Malone
shelter and billboard. If there’s a concern regarding a potential epidemic they can warn people about it.� “We can use the NBN to facilitate similar outcomes. It’s not good enough to roll out the fibre and think about finding applications for it later on. I know some people might say, ‘Big Brother’s alive and well’ but I’d suggest that ‘Big Brother’s never gone away.’ I admire what they’re doing in Singapore.� Michael Malone has been described as an ‘Evangelist for the Internet’ and spouts slogans such as, ‘Get Connected’. It’s essential infrastructure in the 21st Century but, as we all know, it’s not infallible. “The technology underpinning all this is not completely reliable. For example, about 2% of our customers will have a fault and when that happens it’s usually tech-related. I’d draw parallels with medicine here. You visit the doctor and say, ‘I’ve got these symptoms’ and often the doctor can’t give you a conclusive diagnosis but based on experience she might say, ‘well, it sounds as though it could be this?’. With both
THE MAKE-UP OF IINET t JJ/FU FNQMPZT TUBGG BOE UIF company recruits many from the hospitality and tourism sectors t PG JJ/FU TUBGG JT DPOUBDU DBMM centres. t *U IBT BMNPTU NJMMJPO DVTUPNFST t *U BOTXFST DBMMT B EBZ t 5FMTUSB JJ/FU 0QUVT 51( NBLF up more than 88% of ISP market in Australia.
Technology is always in pursuit of the ‘new’ and sometimes it bumps up against a brick wall as demonstrated recently when iiNet won a landmark case in the High Court involving illegal internet downloads. Judge Cowdroy made two interesting points: it was the first copyright case against an ISP to proceed to court and the first trial to be ‘tweeted’. The case dragged on for four years and, in the end, David triumphed over Goliath. It was yet another reminder that technology consistently outpaces public opinion and regulatory frameworks.
I wouldn’t want a doctor operating on me via Broadband or even providing important medical advice down a DSL line. “It’s something that every CEO should experience just to see how the legal system works. In hindsight, we should have picked up the phone and spoken with our lawyers a lot earlier.� The IT sector never stands still and everyone’s talking about the faster fibre of NBN with speeds of one gigabit per second. And that, according to the iiNet evangelist, can’t happen soon enough. “What we’re most excited about is ubiquity and reliability. With NBN everyone’s going to have access, whereas now a sizeable percentage of the community can’t get fixed-line Broadband at all. It’s a network designed to carry data and it has been shoehorned into doing a job for which it was never designed.� “I wouldn’t want a doctor operating on me via Broadband or even providing important medical advice down a DSL line.� O
By Mr Peter McClelland ED. Michael Malone was last interviewed in 2007 – visit www.medicalhub.com.au and search "Malone"
medicalforum
Feature
Q Prof Patrick McGonigle supervises medical students Jonathon Chia and Leesa Equid.
Medical Students Get a Taste of the Future Hard work and determination has seen the Brightwater IPE program become a success story for everyone involved. Last month, the federal AMA released a sobering survey that found the medical workforce in aged care was ageing and cutting back visits, and that younger health professionals were not filling the gap. While that news is grim, an InterProfessional Education (IPE) progam involving Brightwater Care Group, medical students from UWA and allied health students from Curtin University offers some hope for the future. Head of the UWA Medical School Prof Fiona Lake said that the program had developed over its 21/2 years to Q Prof Fiona Lake become a valuable experience for all of the students, but it’s taken the combined commitment of Fiona and Brightwater CEO Dr Penny Flett to steer the program through its teething problems and funding 8
issues with help from Health Workforce Australia along the way. “I’m passionate about ensuring students graduate with the broadest understanding of the health system they work within. And while IPE may be the buzz word in universities, I didn’t want an orchestrated experience for students, it had to be authentic and something that could promote change at the clinical setting,” Fiona said. For Penny, the IPE program at Brightwater Madeley is dear to her heart.
disciplines learn to understand what their own and others’ skills are so they can all work well together. I learnt my medicine 40 years ago and it wasn’t until I got into geriatrics that I began to appreciate the skills and the value of other health professionals.
People have viewed that the medical profession are leaders in the delivery of care and now it’s changing to understand how we work with the other disciplines as a matrix.
“Many students don’t get a lot of exposure to environments outside the hospitaltraining setting. Knowing that a great deal of their time in the future will be taken up with people who are older and who have chronic disease, it is really important to give them some exposure and experience of that before they qualify.”
If we don’t work together on these complex cases, the person in the middle of all this is not going to get the best outcome.”
“Also the workforce issues are going to be really challenging and because of the complexity of chronic disease and ageing, it’s important that students from all the
“They were much more attuned to a tertiary hospital setting and didn’t quite know what to do in a setting where the problems were
Fiona said that it took medical students some time to get their head around what was required during the Brightwater rotation.
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deciding the cause of the pain and whether she needed urgent imaging or if it was all right to wait awhile.” “I found this very challenging as I am usually supervised and even then the Registrar on the general medical team makes the diagnosis. I saw many residents for various complaints that this unsupervised exposure made me more confident of making clinical Q OT student Danica Hendry, left, and Physio student Kahli Masini with a resident. decisions and of my own capabilities at assessing patients.” Jonathan also found the team more chronic; where the problems were not structure rewarding and useful. so much diagnostic as trying to work out the issues they could do something about.” “Each day, we had a meeting with the IPE “I don’t think we’re that sophisticated looking after patients in that chronic care setting. You need a different approach and you need a depth of understanding of what patients want and a depth of understanding of medication. It took us a little while to get that balance but now all of the students feel they are doing something that relates to their profession as well as linking in with the other students as a team.“
Knowing that a great deal of their time in the future will be taken up with people who are older … I believe it is really important to give them some exposure … before they qualify. Sixth year medical student Jonathan Chia was initially uncertain about the type of learning he’d be getting at his recent rotation at Brightwater. “I assumed it would be geriatrics all over again (dealing with dementia/doing lots of MMSEs/falls risk assessments/incontinence screening), I also did not understand the concept of IPE at the time, and wondered why there would be allied health students there with us. However, I tried not to jump to any conclusions.”
team to discuss resident issues, similar to multi-disciplinary team meetings I had attended in the past. Working as a team most definitely helped me to address more issues than having no team at all. I learnt a great deal about the role of the physiotherapist and occupational therapist, and how these allied health professionals had some knowledge of disease which could be beneficial to my role.” “Aged care is more complex than I initially thought and it requires one to think more widely about causes for different symptoms. It was a very good experience for me and I think it puts me above my peers who have not had such rotations.” Prof Lake said that inter-professional care would be a core part of training in the future. “There’s a change in thinking. People have viewed that the medical profession are leaders in the delivery of care and now it’s changing a bit to understand how we work with the other disciplines as a matrix. It’s about being able to step back and say ‘I’m not the important person here … somebody else is. We as a group have decided that this is what’s most important for the patient’.”
“However, it is definitely not about developing a multi-skilled generic health professional. It’s about honing up your skills and also learning about everyone else’s.” And as for the residents, Penny Flett says they love it. “We were a bit worried initially because it is the residents’ home and students coming in could have been quite intrusive. We worked closely with both universities and we limited the numbers Q Penny Flett and the residents think it’s terrific.” “They’ve got people who are interested in them, who have the time to spend with them and for some, their function in various ways has significantly improved because the students have worked together to sort out a program for them.” “The students initiate this themselves. We haven’t said to them ‘look that person needs more of this or more of that’ they’ve sat down and thought out what the issues might be; they’ve worked up a program; they’ve had it supervised and approved and then got on with it. And then they’ve handed it over to the next set of students who have continued it.” “The benefits for residents, apart from the social aspects and the relationships they’ve developed, the actual clinical outcomes have improved. Everybody has been on a winning streak.” O
By Ms Jan Hallam
STATE OF AN AGEING NATION t JO QFPQMF JO UIF OFYU ZFBST JT going to be aged. t .PSF UIBO IBMG PG QFPQMF JO IPTQJUBMT on any one day is elderly. t î PG SFTJEFOUJBM BHFE DBSF BOE NPTU of community aged care is provided by NFP sector.
“On my first day, I met up with Prof Patrick McGonigle (the GP there) who gave me and fellow medical student Leesa Equid a comprehensive orientation and spoke to us about what was expected of us. It seemed quite daunting as we were to work unsupervised and we had not done that before."
t "." TVSWFZ GPVOE UIBU KVTU of surveyed doctors who attended residential aged care facilities were under the age of 40. t 5IF BWFSBHF OVNCFS PG NPOUIMZ GP visits to residential aged care facilities fell to 6.14 in 2012 from 8.36 visits in 2008 – a 27% decline.
“On the first day, I was called to see a resident with a background of osteoporosis and chronic lower back pain who had started complaining of acute lower back pain after trying to open a heavy door. I was faced with the task of assessing her and
t 5IF BWFSBHF OVNCFS PG QBUJFOUT doctors saw in a visit rose to 5.36 from 4.77. Q Graduate nurse Jasvir Chahal with resident.
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Guest Column
Aged-Care Cuts the Final Blow CEO of Aged & Community Services WA, Mr Stephen Kobelke, explains why the sector is fighting mad and why 3368 beds are needed right now.
O
ver the past 18 months nearly every Local Government authority in WA has been workshopping their provisions for a fast ageing population and then developing a plan for ageing. When it comes to age-care provision they almost all have reached the same conclusion – they do not have the residential aged-care facilities that will be needed and that the home-care provisions in their area will be severely stretched.
The answer to residential aged care at first glance seems very easy to them, they decide that they will throw in free land and expedite planning and then stand back for the rush of providers wanting to get hold of this sensational deal. This is what happened in one of the largest councils in the metropolitan area this year, and the ‘rush’ was two expressions of interest. Both parties have subsequently pulled out due to the uncertainty of Federal funding. The State Government through Royalties for Regions has even gone one step further for the bush: it is throwing in $20m of aged
care capital grants into their Southern Inland Health Initiative, plus the local authority throws in the land. It will still take a missionbased organisation to take up this offer. You see, the Rudd/Gillard Governments lost control of residential aged care in WA in 2007 when, for the first time in history, the annual allocation of bed licenses was unsubscribed by aged-care providers in WA. This under subscription has continued every year since and we now stand 3368 aged care beds short, which is the equivalent of five Fiona Stanley Hospitals. Other States started undersubscribing beds in 2009, showing the wider collapse of the aged-care system. To build a single bed with ensuite aged-care room in WA without land currently costs $240,000, while the Federal Government provides the equivalent of $114,000 to do this. So there you have the first reason why the system has collapsed. It’s totally unviable to build, so add to that the severe workforce shortage for the sector and chronic underfunding for operations and you have the chemistry for an unsustainable aged-care industry. The Federal Government has failed to act
in the face of the mining resources boom in WA. Prime Minister Gillard unveiled her Governments response to the Productivity Commission’s Caring for Older Australians report in April this year. The Living Longer, Living Better aged-care reform package is aimed at setting the future direction for aged care in Australia. However, many of the provisions in the reform do not come into place until mid2014 and even then it is unclear whether this will stimulate the WA aged-care sector. On top of this, in June this year, only weeks before the start of the new financial year, the Government slashed aged-care funding by $480 million and provided no annual funding indexation for 2012-13. Aged-care providers are committed to ensuring that older West Australians receive the very best services, both in their own homes and in residential care. They are proud of the job they do and proud of their outstanding workforce and the care that is given. The Federal Government’s decision really affects their ability to remain viable across this vast State. O
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11
Have You Heard?
Facebook promotion clamp down
AHPRA expense It’s arrived, like the banks, online registration through AHPRA. Click on the reminder email and you are there – go through your paces, tick the boxes, and get your credit card out. It will take you less time than a walk to the ATM and you can print out your tax invoice. Certainly efficient. Should be cheap? For a registration that’s “Limited (Public Interest – Occasional Practice)”, which is the old farts looking after the rels with an occasional script, it is $262, 150% increase.
Any medical entity with a Facebook page must now regard content as advertising. A complaint against the official Smirnoff Vodka Facebook page prompted this decision from the Advertising Standards Board – Facebook was a marketing communication tool if used “to draw the attention of a segment of the public to a product in a manner calculated to promote or oppose that product”. Facebook now becomes subject to regulations relating to standards in advertising and marketing, as well as liability under consumer protection laws for misleading conduct. This includes anything placed there by people accessing the site. Scrutiny to remove obscene material now extends to inaccuracies (that need to be corrected) and a real no-no is paying someone to say things on your Facebook page.
e-Generation gap Now that the Federal Government has funded the development of the PCEHR and set ePIP and telehealth MBS requirements, it appears support offices are appearing everywhere. Of course, rural need for access to services is the big drawcard, so Rural Health West is leading the way. Medicare Locals have money too, as does AAPM. Everyone is coming up with lists
of local resources as part of the ePIP, when centralisation and coordination seems needed to prevent waste and simplify things for the end-user i.e. doctors with needy patients. In case someone didn’t notice, there is a generational thing happening here too!
Boom-time WA While retail SMEs are shutting down in regional areas, the mining boom continues, so strongly that five of the country's top 10 richest towns are said to be in WA. Dampier is first, with 22% of its residents earning >$4000 pw, followed by Karratha (18.9%), Port Hedland (17.6%) and City Beach (16.1%). The highest median income towns are in postcode 6710 (that’s Onslow and four other Australia Post delivery areas we’ve never heard of), at >$2,000 a week. Next in line are Newman, Bullfinch, Tom Price and Hamersley ($1915-$1824 pw median incomes). In NSW its Kirribilli and Milsons Point ($1311 pw). Another measure of wealth is Australia's 934,000 unoccupied private dwellings.
Cystic fibrosis PXS Australian company Pharmaxis (ASX:PXS) announced a PBS listing for Bronchitol (a spray-dried form of mannitol delivered in a specially designed inhaler) for the treatment of the 3000 or so Australians with cystic fibrosis. Announced to the market on June 25 and again by recent press release, the treatment has been shown to improve
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lung function and infection rates. The big markets still to be cracked are North America and Europe, currently with only permission to market Bronchitol in the EU. The company has received Federal Government grants to develop the drug and manufacture it at their Sydney plant, and PBS listing should not involve a big spend. The share price has shown little movement since the announcement (see graph).
are advertised as available on the day. Two of the five doctors consulting are Dr Vasantha Preetham and her daughter Amitha. They hope to introduce health promotion, chronic disease management and suchlike as demand increases. GP afterhours services in the area are currently through the AH clinic at Swan District Hospital.
Flying the flag North Metropolitan Area Health Service (NMAHS) has launched a Reconciliation Action Plan to deal with inequity over Aboriginal employment, learning opportunities and health service delivery. It takes in Charlies, KEMH, Osborne Park, and Swan Kalamunda Health Service. Aboriginal and Torres Strait Islander flags are flying alongside the Australian and WA flags at Charlies to mark the commitment. The press release said NMAHS covers 3000sq km and falls entirely on Noongar land. See www. nmahs.health.wa.gov.au/pdf/RAP_Plan.pdf
Superclinic Midland running GP Super Clinic at the Midland Railway Workshop is up and running with six GPs consulting (3 FTEs). Hours are only 8.30am to 6pm weekdays, with the intention to increase to 8am to 10pm, seven days, over the next year. GP services are bulk billed. Appointments
the relevant letter is stuck on a Dictaphone somewhere in limbo-land. The doctor said that staff were apologetic and offered to listen to letters dictated on that day and type it up.
System overload We know the hospital system is under the pump, but a reader of Medical Forum has tipped us off to the load on admin staff. More specifically, the ENT Clinic at SCGH is struggling to keep up with the paperwork. One doctor reported that the typing of patients’ notes was up to three months behind schedule. Her patient was seen early July and
BYO ball and chain Some Not-For-Profits have taken Her Majesty’s Pleasure literally in their latest fundraiser at the Fremantle prison. The Liver Foundation of WA, Cystic Fibrosis WA and Rotary International are holding their annual Convicts for a Cause shindig complete with a Royal Medieval Wedding. Partygoers can opt to be locked up at the old prison and must post $500 in bail to be released. The past two events raised a total of $74,000 – this year’s aim is $100,000. Mark November 20 in your diary. Tickets $30, convicts $30 to sign up (only $470 left to raise). Ring Shoma Mittra for info on 0433 558 125. www.convictsforacause.org.au
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13
News & Views
Educating for the Future UWA Vice-Chancellor, Prof Paul Johnson is well positioned to respond to the rapidly changing landscape of tertiary institutions and social change. Paul Johnson’s academic focus on social and economic demographics is a neat fit with many of the issues affecting health care in his newly adopted home town of Perth. Appointed in 2011 and commencing his tenure this year, the UWA Vice-Chancellor ranges widely in a discussion embracing an ageing population, medical professorships and the training of young doctors. UWA’s new Vice-Chancellor has an impressive background – he studied at Oxford University and the London School of Economics (LSE) in the area of historical patterns of social policy and market dynamics with a particular interest in the material costs of an ageing population. “My research interests are certainly relevant and topical. And they’re tinged with the recognition of the power of the market to allocate resources. My early research looked at the costs of an ageing population. Part of what makes us a society is how we support the needs of others and there comes a point for everyone – whether it’s illness, disability or old age – when we’re incapable of looking after ourselves,� Prof Johnson said. “I think the current debate on a National Disability Insurance Scheme reflects the fact that we have important obligations to people with disabilities. The market doesn’t always accommodate those needs particularly well and that’s when government should step in. And the ageing population is a pretty simple equation. The number of hours we’re working is contracting – we’ve now got, on average, 40 years of work supporting 20 years of retirement – so we’re going to have to allocate a larger portion of our income to support ourselves in the future.�
I suspect these future doctors are going to be working much more in multi-disciplinary teams and a local GP will have much greater access to information. UWA has a reputation as one of the world’s pre-eminent research universities and is positioned firmly as a member of the Group of Eight (Go8) coalition of leading Australian universities and last month was listed in the top 100 universities in the world for the first time. An important part of the Go8 brief is to contribute to the debate on social, economic, 14
UWA 2011 MBBS COHORT t GFNBMFT %PNFTUJD and 13 International students. t NBMFT %PNFTUJD BOE 12 International students. t PG TUVEFOUT XJMM HSBEVBUF access to information from organisations such as genetic testing facilities. This will enable new and different clinical interventions and we encourage our young doctors to embrace these possibilities.� Q Prof Paul Johnson
cultural and environmental issues. That’s a neat fit for a university situated within one of the few regional economies in the developed world exhibiting sustained growth. “UWA’s global reputation is driven by its research performance and, at the moment, we’re positioned quite nicely in medical research. We’ve got a similar ranking in the broad field of chemistry and it’s important to attract world-class researchers. Just like worldclass athletes, they’re few and far between. We’ve got a wonderful history – we publish more indexed scientific papers than all the other local universities combined.� There’s no doubt that high-profile medical professorships add to the research prestige and academic ‘clout’ of a tertiary institution. Indeed, many would argue that UWA punches well above its weight, particularly given its geographical isolation. “Medical professorships within universities are always complex. Almost all these people hold multiple positions – clinical appointments in hospitals, teaching and research at universities and often commitments at a research institute as well. At UWA these are highly competitive posts ranging from the laboratory bench to clinical practice. This ensures that the training of our medical students has a strong correlation with clinical practice and is also well attuned to rapid developments in medical science.� UWA has embraced the trend towards reshaping the medical degree to reflect the rapidly evolving nature of medical practice with medicine now a postgraduate course at UWA. “This new structure allows the student to look beyond tightly drawn boundaries. I suspect these future doctors are going to be working much more in multi-disciplinary teams and a local GP will have much greater
For a Vice-Chancellor with proven academic expertise in social demographics, Paul Johnson is well-placed to crunch the numbers on medical students, clinical placements and the prospect of Curtin University emerging as the third medical school in Perth. “We need to do some very careful planning around medical workforce needs. For example, we know there’s going to be a severe shortage of nurses and that the baby-boomers are entering retirement. The population in WA will double by 2050 and it takes the best part of a decade to transform a medical student into a fully qualified doctor. Here in WA, we’re a little under the national average for doctors per head of population.�
We need to do some very careful planning around medical workforce needs.
“In 2000 UWA graduated 108 doctors and, by 2015, that figure will have increased to 234. Add to that another 100 from Notre Dame and things look a little more positive. However, a real challenge is going to be clinical placements because let’s say we add another 100 students a year, that means another 100 new intern positions need to be found. That’s equivalent to the number of current positions at SCGH, Joondalup, Swan Districts, Geraldton and Osborne Park combined. “You can’t just create placements. You need the requisite patient numbers for a start and sufficient clinical turnover. We’ve had two intensive-care unit placements lose accreditation this year because of insufficient clinical throughput, so we’re pretty finely balanced. All this needs to be thought through very carefully.� O
By Mr Peter McClelland medicalforum
Medico-legal
Can you â€˜ďŹ re’ a patient? Avant senior solicitor in Perth, Ms Morag Smith, looks at the doctor-patient relationship from the doctor’s perspective, and how to extricate yourself when dissatisfaction reigns.
A
n article published in the United States in 2011 suggests that US paediatricians are increasingly turning patients away who refuse to vaccinate their children.(1) While the frustration of doctors faced with these situations is understandable, actions such as these raise questions about the legal and ethical obligations owed to these patients. Can you validly end the doctor-patient relationship if a patient refuses to vaccinate their child or if they persistently refuse to follow your advice about health-care matters? It is well known that patients have the right to determine what is or is not done to their own body and they have the right to withhold consent to medical treatment, even though the refusal could result in a worsening of their condition or even death. An important risk management strategy would involve documenting in detail the explanation given to the patient about the diagnosis, the treatment options, and the prognosis if they choose not to follow your
advice as well as the risks and benefits of the treatment and any alternative therapies. It is important to explain the reason for your treatment advice and give the patient the opportunity to express their concerns. In appropriate cases, provide written information to patients about the proposed treatment and give them time to make an informed decision. While you may disagree with the patient’s ultimate decision, it is important to respect his or her choice and not prejudice your care of the patient because you believe that their behaviour has contributed to their condition.(2) A patient’s well-informed decision not to follow a treatment recommendation should be distinguished from the patient who consistently refuses to comply with treatment programs or asks you to do something that your religious belief precludes you from doing. With the exception of an emergency or where termination of the therapeutic relationship may be in breach of discrimination laws, doctors are not compelled to continue to treat a private patient if the relationship has become untenable or if a conflict of interest arises.
How to end the doctor-patient relationship When ending a therapeutic relationship it is important to: t $PNNVOJDBUF PQFOMZ XJUI UIF QBUJFOU *G appropriate, a verbal discussion should take place. t 4FOE B MFUUFS UIBU DMFBSMZ DPNNVOJDBUFT your decision and highlights the importance of any ongoing care. t (JWF B SFBTPOBCMF EFBEMJOF UP GJOE B OFX doctor and in the meantime reassure the patient that you will provide care until they find a new doctor. t 'BDJMJUBUF B UJNFMZ USBOTGFS PG SFDPSET t /PUJGZ ZPVS TUBGG BOE TQFDJBMJTUT JOWPMWFE in the care of the patient that you are no longer involved. Most importantly, contact your MDO for advice on managing the difficult process of ending the doctor-patient relationship. O References (1) Pediatricians’ Experience with and Response to Parental Vaccine Safety Concerns and Vaccine Refusers: A survey of Connecticut Pediatricians, Leib and Ors Public Health Rep. 2011: 126 (suppl 2) 13-23 (2) Medical Board of Australia’s: Good Medical Practice: A Code of Conduct for Doctors in Australia para 2.4.2
Issues Facing the Health Workforce Surge in the Intern Places The 20% surge in intern training places, largely brought about by Notre Dame graduates, is being met in a number of ways. The actual jump is 128 in 2007-08 to 280 in 2011-12. With 280 medical graduates starting internships in WA hospitals in February, it means all graduates from WA medical schools got a spot. They are based at Perth’s tertiary hospitals with rotations through other metro hospitals, as well as Country Health Services (83 training spots), community clinics and private hospitals. State Health has put $12.5m into extra training and supervision, and more simulation. When Fiona Stanley, Albany Health Campus and the PMH replacement come on stream, new doors will open. WACHS got $27m over four years to increase junior doctor regional positions, with $8.5m from Royalties for Regions to cover travel and accommodation. There are also 19 specialist training positions in rural WA and interns and post graduate doctors were located at Albany, Broome, Bunbury, Geraldton, Kalgoorlie-Boulder and Port Hedland. The Rural Practice Pathway was established to provide a full year of employment and training for RMOs as well as ongoing specialist training. medicalforum
Regional Development Minister Brendon Grylls said each major regional hospital has been funded to increase Director of Clinical Training and Medical Education Officer positions and WACHS had established a Postgraduate Medical Education Unit to co-ordinate junior doctors’ education, training and support. Other collaborators are Rural Health West, WAGPET, the Rural Clinical School, the Postgraduate Medical Council of WA, and the AMA Doctors in Training.
A moral dilemma However, all things are relative. At the annual congress of Australian medical students in Perth, student leaders were criticising the Q Dr Neale Fong projected shortage of hospital training places. On the discussion panel was Dr Neale Fong who is working on the Curtin Medical School bid. He raised a moral dilemma. In March he was on a trip to Zambia where he met Dr Joseph Kasonde, the country’s health minister. Dr Kasonde was lamenting the loss of 700 of the 1400 doctors the system
trains each year to overseas hospitals. “Just how much of an issue is that when grads from relatively impoverished countries like Zambia go away and fill the workforce needs in other places?� Dr Fong told Medical Forum later. “I’m not saying that these graduates from Zambia are coming to Australia, and I’m not anti-international medical graduates either because they do provide some flavour and expertise to our workforce, but it is now becoming a real moral issue when you have, in African countries in particular, some of the highest infant mortality rates in the world and where there are huge needs for medical doctors.� Neale says the national health strategic framework recommends focusing on achieving a minimum level of selfsufficiency in health work supply while acknowledging that it is part of a global market. “They’ve modelled it at 50%, which would mean that by 2025 Australia would need 9300 more doctors. That report was endorsed in 2006 and we’re still nowhere near that figure.� “If you actually believe in these scenarios, we will need an additional 1175 grads a year.� O
15
Medical Marketplace
New Medicines Australia Code Review Educational events, research, generics, PBS listing and doctor sponsorship are all in the mix for the industry code review, now due by the ACCC. Boehringer Ingelheim and Pfizer complained to Medicines Australia, and Novartis was fined $100,000 for breaches of the voluntary advertising code around its COPD drug indacaterol. Dobbing by other pharma companies is the way this system mainly works. Apparently inaccurate advertising portrayal of the product to doctors was the issue in this case and the complainants wanted Novartis to issue a corrective letter but the committee decided otherwise. Medicine Australia’s proposed 17th edition of their Code of Conduct is coming up for review by the ACCC. In 2007, it insisted there was transparency through website posting of company event sponsorship. Now, a flurry of late submissions to the ACCC is reportedly calling for even greater transparency. (The Generic Medicines Industry Association (GMiA) has a separate Code.) The submission by Choice (Australian Consumers Association), authored by prominent campaigner Dr Ken Harvey from the School of Public Health, La Trobe University, gives a good run down of some of the important issues.
Disclosure Medicines Australia now require member companies to submit aggregate amounts of all payments made to healthcare professionals for advisory boards and consultancy arrangements; attendance and speaking at medical conferences and educational events; and sponsorships for consumer organisations including the value of non-monetary support.
Limitations of industry self-regulation
However, Choice wants full disclosure of payments made to individual healthcare professionals, such as sponsorship to attend educational events or to do research. It says Medicines Australia is dragging its feet, and suggestions of tabloid media witch-hunts of doctors is not of enough importance compared to the need for transparency.
Sanctions A Medicines Australia average fine is $50,000 with $200,000 the maximum for a severe breach of their Code. In contrast, GSK was recently fined $3 billion by the US Justice Department, and settlements for criminal and civil penalties from the US pharmaceutical industry reached $15 billion over the past five years. Choice suggests fines do little to change unethical behaviour and that jail sentences are needed for the company executives responsible, or increased fines.
Monitoring Code effectiveness Medicines Australia produces useful annual reports but the data is in PDF format, as is company information posted on their website, with enough variation between submitting companies to make a copy and paste very difficult for analysis purposes. Choice also wants this fixed.
This submission says procrastination on important issues illustrates how self-regulation fails through not having consumer or health professional reps on committees, or allowing the views of progressive pharmaceutical companies to prevail. Non-members can act improperly without sanction. What is needed is one code, one efficient complaint (and monitoring) system and one set of effective sanctions applicable to all therapeutic claims and promotional activities, regardless of the industry sector, media or target. As well, key stakeholders, including consumers, consumer associations, the government and other community groups needed to be on the Medicines Australia panels.
Limitations of ACCC Imposed ACCC “conditions” only go some way and government strengthening of selfregulation is needed e.g. external stakeholders involved; code compliance is a condition of marketing approval. Other topics raised by submissions, and of particular interest to doctors, were the product familiarisation programs, disease and treatment awareness programs for direct-to-consumer promotion, and patient support programs. See http://medicinesaustralia.com.au/ code-of-conduct/education-events-reports/ member-company-reports/ http://www.accc.gov.au O
By Dr Rob McEvoy
Eyes Win! For Melanoma Armed with good eyesight and the Glasgow seven-point checklist, primary care doctors can equal or beat the Molemate system. These findings, published in the BMJ, were a surprise to UWA Winthrop Professor of General Practice Prof Jon Emery, who was involved in this trial and an earlier one. “This is not what was expected. Compared to previous reports of routine practice, people in the trial who used the seven-point check list performed better. This is first test comparing human eye with the machine’s capability,” he said. Jon was involved in developing the algorithm used in the Molemate’s SIAscope, which measures the amount of haemoglobin, melanin and collagen in the skin surface 16
(to a depth of 2mm), to identify melanoma patterns – how light scatters or bounces and how this varies for different wavelengths. They tested the device on 500 people in Perth. Differentiating melanoma from other pigmented skin lesions is the challenge and when, in this most recent trial, the machine was pitched against clinical acumen and vision in about 1300 patients in 15 practices around Cambridge, England, they found no difference in the appropriateness of referral or diagnostic capability. In fact, the Molemate resulted in an overabundance of false positives (benign lesions). Although Aussies joke about the lack of sunshine in the UK, the incidence of melanoma has quadrupled over the past 40 years. With early detection being the key – stage 1, 95% five-year survival, compared with stage 4, 10-20% – accurate reassurance for
GP and patient, or rapid referral of suspicious lesions is everyone’s goal. The GPs in this study thought the device improved their diagnostic accuracy when it did not. Back to the drawing board. O
GLASGOW SEVEN-POINT CHECKLIST Major features t $IBOHF JO TJ[F t *SSFHVMBS TIBQF t *SSFHVMBS DPMPVS Minor features t %JBNFUFS NN t *OGMBNNBUJPO t 0P[JOH t $IBOHF JO TFOTBUJPO medicalforum
Guest Column
PCEHR and Recognising Carers Carers WA’s Ms Stephanie Fewster questions if PCEHRs assist GPs and other health providers to identify and support family members in a caring role.
I
n Australia, about one in eight people provide care for a family member or friend who has a chronic illness, disability, mental illness or an age related disability. In WA, this means an estimated 252,100 people are ‘carers’.
Carers WA, was initially optimistic about the potential for PCEHRs to raise the profile of carers with health professionals.
The family carer is often the only constant in a person’s care across multiple health settings. They provide valuable information relevant to clinical assessment, and, if the person requires ongoing care at home, it is most often a family carer who provides or organises it.
Unfortunately, the current format for entering information on PCEHRs does not appear to prompt family members in a caring role to self-identify. Neither does it facilitate the identification of carers by GPs or other health staff. Even when an individual carer has identified the need to be listed on the PCEHR of the person they care for, barriers exist that will discourage family carers from attempting to have their carer status recorded.
However, if the carer is not identified by health professionals and does not self-identify, they can be excluded from decisions about treatment and discharge planning. This outcome not only reduces the ability of carers to provide care, it also means that they themselves are less likely to access the health and other supports that they themselves require. For these reasons, the national carer network, including
The current software supporting PCEHRs fails to mirror the complexity of family situations, including the fact that a carer may not have legal authority such as guardianship, or being next of kin. This often happens in the case where an adult child is supporting ageing parents. Next of kin could be one or both of the partners in the couple, but where is the space to record the details of the person who is providing care?
In the PCEHR, a person can name their carer as their ‘emergency contact’ but this does not necessarily alert medical staff to the fact that this person has a carer who needs to be identified as such and should be included as a partner in care. The situation becomes even more complex when the person receiving care does not have the capacity to manage their own health record and does not have the capacity to nominate their carer to manage their health record. These and many other problems relating to the status of carers and guardians are currently being considered by DOHA and NeHTA. Meanwhile, Carers WA believes that the potential of PCEHRs to encourage selfidentification by family carers, to facilitate their caring role and to have their own health needs considered by GPs and other health providers, could be achieved through additional consultation with families and with more consideration given to state and national legislation on carer recognition. O References available on request.
NHMRC tightens rules The country’s biggest funder of medical research, the National Health and Medical Research Council (NHMRC), strengthened its disclosure policies ensure there is clarity and transparency in the declaration of interests. The new policy, effective from August 1, requires potential members of guideline committees to work through a check-list to help them complete the disclosure of relevant interests. In the past, committees were required to identify, document and manage potential competing interests. A competing interest declaration must be completed by each member of the group. The principles in the new policy provide guidance to ensure that there is clarity and transparency in the declaration of any interests, a balance of perspectives, and guidance on disclosing and managing interests. A spokesperson from the NHMRC said the new policy recognised that many experts, who brought experience and ideas to guideline development, would also often have interests. He said these interests must be transparent and appropriately managed to maintain the integrity of all guidelines seeking NHMRC endorsement. The change is in line with national and international standards, and are aimed at improving the transparency of health and medical research and developing evidence-based health advice.
For a free consultation with a trained nurse please ask your patients to call 1300 787 055 or visit continenceandyou.org.au
Any relevant interests are made public on the NHMRC website and in the final published guidelines. www.NHMRC.gov.au O
medicalforum
17
Mobile Technology
Clinicians are Getting App Happy Clinical apps are becoming big business, but don’t let the technology fool you. A good app is a useful app. When it comes to developing an application for tablet or mobile phone, it has never been easier and, consequently, there is a bewildering array of apps just waiting for you to download. But how useful are they? According to A/ Prof David Glance, the director UWA’s Centre for Software Practice, who has helped developed clinical apps for the Health Department among others, there are some simple rules. “Clinical applications need to follow the same principals as for any application on the mobile platform – they need to be engaging, pleasurable to use and they need to do something useful otherwise people will just have a quick look at them and then never use them again.” So David says an app needs to solve a problem and inherent in that, it needs
to demonstrate that it can be solved better using a mobile platform, but most importantly it needs clinical expertise. “Sometimes there are unrealistic expectations of what an app can do. Sometimes clinicians think that making an app transforms something that wasn’t really useful, into something useful. I have people coming in saying I’ve got this great idea for an app and there’s absolutely no rationale to put it on a mobile platform because it’s too complicated.” David has worked on a range of clinical applications, for instance a pathology manual for the Royal College of Pathologists of Australasia and also on an app for diagnostic imaging pathways for RPH. “Both of those applications took a lot of time in terms of compiling content. As a first version they are quite good, but apps need maintenance for their continued usefulness.” David says his current work is focusing on the e-health platform to give providers and clinicians a way of communicating with each other and sharing records. “Eventually, if the PCEHR ever materialises, we’ll integrate with that, but the thing that’s really been missing is the interface between clinicians and consumers. So what we’re trying
to do is to develop mobile ways for consumers to not only be able to record information onto their own records but also integrate with information from the health record.” “We’re working with Flinders University on a self-managed chronic disease care plan process. Once a care plan has been developed with the clinician, the idea is to put that on a mobile platform – for an iPhone, iPad or android device.” The cost of a useful app reflects the amount of work and complexity of the content involved. David says a basic app could be about $15,000 and upwards of $100,000 or even $500,000. And when it comes to that question that has grown men sparring – Apple v Android – the answer is really the maths. Apple still dominates the mobile market but new versions such as Samsung Galaxy are starting to make inroads. “In terms of the health market, Apple is still dominant,” David said. “The iPad, in particular as a clinical platform, is ideal. It’s non-intrusive in terms of doctor-patient interaction and with voice input and camera and other ways of interacting and recording data, it’s going to become more significant.” O
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Checks & Balances in the Practice Many practitioners put a lot of trust in their staff and practice manager. It only takes one ‘bad egg’ for serious problems to occur in your practice. Therefore, it is of paramount importance to ensure that there are checks and balances in place to deal with your financial trail. You must ensure you have robust systems to avoid any type of fraudulent behaviour by any of your staff. One simple task that is a great example is payments from your patients: you must have a system of tracking EFTPOS payments from your patient through the EFTPOS settlement, right to your practice management program’s banking. Then you need to ensure the payment actually arrives at the bank, so this too needs to be tracked by reconciling your bank statement with your MYOB/Quickbooks etc. Your practice management program should be capable of printing audit trails or reports that show deleted payments or account adjustments and these reports need to be routinely run and checked. This task, and many others, are taken for granted because they form the absolute basics in a practice. DO NOT let these tasks go unaudited in your practice.
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New WA Committee Announced The WA committee for 2012-13 comprises Jane Reid, Dot Melkus, Sue Start, Kathy McGeorge, Fiona Wong, Narelle Supanz and Karin Tatnell.
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Guest Columns
The Future is Now for e-Health Sharing information is the key to solving problems in the health system, says Dr Louise Schaper, CEO of Health Informatics Society of Australia.
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alking technology, computers and alien acronyms can alienate some healthcare professionals who don't see the relevance to their 'real job' of looking after people. However, the time has come that regardless of your personal use of technology, if you are in the business of healthcare, then you are in the business of e-health. About 98% of GPs have a desktop computer system for entering clinical notes on patients. In allied-health land, the statistics aren’t as readily available, but an educated guess is that 98% of allied health professionals do not have a computer system for capturing clinical data. This imbalance means that GPs have a “super-highway to nowhere” (to quote WMA president Dr Mukesh Haikerwal), where there is a chronic inability to adequately share health information with others in the healthcare team. The use of technology as a tool to create, store and share health information and the use of technology as a tool in the direct
provision of care is not ‘the way of the future’ – it is an essential tool and an integral part of healthcare as we continue to strive for best quality, safe, evidence-based care. Health informatics focuses on information, people and systems. I describe health informatics as an understanding of how health information is used; how individuals engage with technology and use technology in the best way possible to help make informed clinical decisions. There are experts who specialise in health informatics and you will see a rise in roles such as ‘Chief Health Informatics Officer’ over the coming years. The legitimacy of this profession and the high pace of growth in the field has given cause for the US to create a clinical specialty for doctors to specialise in health informatics. At no time before has the need for this knowledge and ability in health informatics been as pertinent for Australian healthcare professionals as it is now. Healthcare professionals are the front line of health reform and e-health is front and centre of health reform.
As of the July 1, all Australians are able to register for a Personally Controlled Electronic Health Record (PCEHR). In this model, the patient decides on who can access and contribute to their PCEHR. In the coming months an online portal will be available to healthcare professionals, ‘plug-ins’ to your desktop systems are on the horizon and over time the functionality and content of the online health record will grow. During the first month of registration, just over 4000 people registered to have a PCEHR. However, the PCEHR isn’t the only game in town. There are significant e-health innovations where the focus is on better management of healthcare information, through technology, to deliver better, more efficient care. O ED: The transformation of healthcare will be the focus of discussion at the upcoming HITWA Conference (Health, Information, Technology) to be held in Perth on October 19. See www. hisa.org.au/hitwa. Health Informatics Society of Australia (HISA) is one of the organisers of the conference.
Creating a Trustworthy Image Online It's easy to gauge trustworthiness face-to-face but online consultations are another matter. Dr Moyez Jiwa argues the case for the stethoscope. hronic and complex medical conditions are increasing and access to doctors is becoming more difficult. Waiting lists for routine GP appointments abound and sometimes that means weeks rather than days! Increasing the number of doctors is one remedy and so is a reconsideration of how we see a doctor.
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More research is needed and we’ve started the ball rolling.
In the late 1990s in the UK there was a furore when telephone consultations were proposed. My practice was one of the first to recognise that telephone conversations were both safe and mutually beneficial. So, if in 2012 we can book a holiday online, order theatre tickets and buy a wallet from Korea with the click of a button, why can’t we have a medical consultation via the internet?
We decided to find out. A random sample of individuals (the majority were women aged over 40) were shown a series of images of a ‘doctor’ sitting at a desk with different items of medical equipment. Result? The man wearing the stethoscope was considered to be more than twice as likely to be honest, trustworthy, ethical and genuine. This positive regard predictably increased when other medical items were added to the image.
I’m hearing echoes of the UK telephone debate – it’s not safe, it’s not secure, it will lead to litigation or worse. Is that true? 20
One of the central questions is how effectively will an online consultation be able to recreate the face-to-face experience? In the latter, all five senses are engaged. We know that humans are conditioned to respond to visual, auditory, tactile and olfactory cues. So, online medicine – have stethoscope will travel?
items, the presence of the stethoscope appears to be of paramount importance. Perhaps this admittedly limited study has merely reinforced what we already know – stethoscopes are worn by doctors and doctors are trustworthy. However, at the very least our study demonstrates that the presence of specific items is strongly correlated with perceived trustworthiness. Mutual trust is a critically important element in a therapeutic relationship. An online consultation, lacking the full scope of sensory cues, makes different demands on rapport between doctor and patient. When you’ve got one hand on a mouse, the artful draping of a stethoscope mightn’t be a bad idea. O ED: Dr Jiwa is Chair of Health Innovation at Curtin University.
Notwithstanding the relative trustworthiness ‘ratings’ of individual medicalforum
Feature
Orthopaedics Travel Sheds New Light Orthopaedic surgeon Prof Piers Yates is back from a discovery tour of orthopaedics centres and as cost constraints begin to bite, his reflections gain in importance. The prestigious American, British, Canadian (ABC) Travelling Fellowship, with a proud history stretching back to 1947, promotes collaboration between participating nations to ‘further the art and science of orthopaedics’. Dr Piers Yates, Professor of Orthopaedics at UWA and Unit Head at Fremantle Hospital, was awarded a fellowship. He has just returned with some interesting insights into the international orthopaedic world, having started his travels in London and visited 15 clinical sites before finishing at the American Orthopaedic Association conference in Washington DC. “Six weeks away from our families and a busy orthopaedic practice is a significant commitment, but the fellowship is highly beneficial. It’s a way of stimulating an established consultant practice, reflecting on career paths and bringing back valuable ideas and contacts to WA,” Piers said.
implant choice and one of the concerns often voiced about the US system is that approximately 80% of orthopaedic care is carried out by low volume surgeons in small hospitals with variable collegiate back-up and quality control. That may explain why the revision rate for joint replacement in the US is much higher than here. “Understandably, one of the hot topics for discussion is how we measure performance and maintain standards. The existing joint registries in Australia and the UK are one way we achieve this goal and the large centres in the US are clearly keen to adopt this.” He said there is virtually no teaching of musculoskeletal medicine to US undergraduates but the closer relationship between residents and their mentors during their 4-6 years of orthopaedic training had huge advantages.
Rochester, Minnesota, one of the most prestigious and largest hospitals in the USA, with a huge campus, 30,000 employees and a turnover of US$7b every year. He presented to some famous names there. “Minneapolis was next, where I met some of my heroes in trauma surgery. Research there is highly clinically focused and closely aligned to the work I do back here in Perth. We visited one elective unit where the patients were discharged to a Hilton hotel rather than keeping them in hospital!” In Chicago he visited five different centres. “They reflected the variation in health care across the private, university and public systems. Rush was the ultimate private unit with flash facilities and even flasher surgeons. Cook County was the public hospital made famous in ER and in the books of Michael Crichton.”
He added that large orthopaedic units run very differently in North America compared with Australia, with an efficient business model and a clear profit imperative. “If the private units don’t make money they lose their best doctors and they close. Three aspects are critically important – quality measurement, advertising and competitiveness. ‘Coding’ is central to recouping costs from government and insurance companies and accuracy is paramount because it’s the basis for research data collection, surgeon appraisal and payment. Research both defines and promotes an orthopaedic unit. A high profile attracts large grants from both the National Institute of Health and private endowments.” “A culture of philanthropy is very strong over there and it’s something we don’t have. For example, $500,000 gets your name on a building and individual donations in excess of $150m are not uncommon!”
Q Minneapolis orthopods in action: a navigated pelvic tumour resection using intraoperative CT scanner.
London, Ontario, started his travel routine for North American sites – demonstrate UWA’s research, visit their research facility or go into Q Prof Piers Yates, ABC Travelling Fellowship recipient. theatre, and then socialise in the evenings with Piers said there is no marked technical chasm faculty people and other clinicians. between North America and Australia in orthopaedics but there are some significant differences and lessons to be learned. “We have some different approaches to
“Ontario had the best surgical simulators I’ve ever seen and definitely something we could look at, as exposure to clinical training becomes more restricted in Australia.” Then it was off to the Mayo Clinic in
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“The University of Iowa was one of the most academic centres we visited and we learnt about clubfoot, cartilage injury and joint replacement follow-up. They look after one of the ‘big ten’ college football teams and have superb facilities. There’s big money attached to top-level sport and this flows to the medical units.” Then on to Nashville and the Campbell clinic in Memphis, home of the premier orthopaedics text, Campbell's Operative Orthopaedics, where he was pleased to note that, like everywhere else, its compilation involved reams of disorganised papers on the floor. medicalforum
News & Views
Work on Midland begins Noisy protesters didn’t dampen the WA Health Minister spirits as he launched the Midland Health Campus project. The unit at St Louis, Missouri, was next to impress him due to their work in cementing and spinal surgery, then the Cleveland Clinic in Ohio where innovation in patientdriven care compels its best clinicians to take up managerial roles for which they are amply rewarded. “Across town is the university at Case Western Reserve, which has access to the unique Hamann Todd collection of human skeletons in the Natural History museum. They’ve got several thousand individuals with medical histories – a wealth of information for implant design and disease study.” “The final clinical stop was Pittsburgh with the energetic Freddie Fu. He’s a real ‘celebrity surgeon’ who looks after top athletes from
The cost of health care in the US is 18% of GDP and completely unsustainable. There’s recognition that this cost needs to be reduced while still addressing the issue of improving coverage across the whole population. around the world. The medical centre turns over $10.5 billion a year and the facilities are incredible. Constance Chu showed us why she is the #1 rated research orthopaedic doctor in the USA.” Piers’ offers his perspective on the politics of health care in the USA. “The Obama Health Care Bill is causing enormous polarisation within the medical community. The cost of health care in the US is 18% of GDP and completely unsustainable. There’s recognition that this cost needs to be reduced while still addressing the issue of improving coverage across the whole population.”
A dozen placard-carrying protesters bailed up the WA Health Minister Dr Kim Hames as he entered the construction site of the Midland Health Campus for the official foundation laying ceremony last month, noisily criticising him for privatising the public health system. But the minister was unabashed and upbeat when he addressed the gathering of St John of God Health Care and Catholic Church guests who were there to witness the minister and the project partners – SJOGH, the Federal Government (represented by Health Minister Tanya Plibersek), the WA Government and construction giant Brookfield Multiplex – turn the first sod. “It means they love the government,” Dr Hames told the audience. “The unions involved with SJOGH and Brookfield Multiplex are happy with the project to be in private hands, so it must mean the protestors think the government would do a better job.” “But when they see what a fantastic hospital this is going to be and the standard of facilities that will be available free to the public, we’re sure they’ll change their minds.” The $360m project will include a 307bed public hospital and a private 60-bed hospital and is due to be completed in 2015. However, the SJOGH administrators will not allow patients (public or private) to undergo certain procedures such as terminations, contraception or sterilisations at the Midland health campus because of the organisation’s Catholic ethos. Dr Hames was not perturbed by this apparent conflict of interest. “The numbers for these procedures is relatively small. We estimate about 200
patients out of 29,000 would demand these services and these patients would first be seen by GPs and then treated at KEMH.” “However, the government will fund the building of a facility adjacent to the new Midland hospital that can handle these issues, which will be contracted out to a private service provider.” Ms Plibersek told the gathering that the Commonwealth was contributing $180m to the price tag with the State Government providing the remaining $180m. Dr Hames said that awarding the service provision to SJOGH Health Care would save the public purse $1.3b in costs. After the function, Ms Plibersek told media that the decision to privatise the hospital services was made by the State Government. While State Labor did not endorse privatisation of the health system, she said the new hospital at Midland would give people living in and around Midland ready access to chemotherapy, high-dependency care, coronary care and a dedicated pediatric ward for the first time. When the hospital is complete, the Swan District Hospital will close its doors. O
By Ms Jan Hallam
He draws parallels with Australia, saying we face similar problems with the funding of health care, maintenance of standards, and leadership in academic orthopaedics. The Fellowship promotes both leadership and communication centred on these issues. “I would also like to thank UWA and my colleagues at Fremantle Hospital and Murdoch Orthopaedic Clinic for supporting me in this once-in-a-lifetime opportunity,” he said. O
By Mr Peter McClelland Q From left: SJOGH head Dr Michael Stanford, Federal Health Minister Ms Tanya Plibersek, Brookfield Multiplex executive Mr Chris Palandri and WA Health Minister Dr Kim Hames trowel in hand at the Midland Health Campus site.
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Looking Back
“Jail Risk for
Medical Professionals
Careless with
Tax Returns”
Gems from the Past The sisters of St John of God have had an unbroken connection to doctors in WA since they first arrived in 1895. Historian Sr Eurgenia Brennan and a team of researchers drew together this story in a book, Decades of Doctors, which was published last month.
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Q Sr Eugenia Brennan and Prof Michael Quinlan
And it was a big month for SJOGH, with the foundations being laid for the Midland Health Campus and the launch of this book which will be distributed free to all visiting doctors associated with St John of God Health Care through its hospital and pathology divisions. In a time when the group is looking to the future, Sr Brennan was keen to document the work of past doctors, piecing together fragmented information about the early days but also taking oral histories from doctors who are now retired. Prof Michael Quinlan, who retired last year as Trustee of SJOG Health Care after decades of service, certainly had much to contribute to the book and to the group. His family association stretches back to the beginning with his great uncle, who was the sisters’ first doctor. His personal connection began as a young boy in the 1940s, sitting outside the Subiaco hospital waiting for his father, obstetrician Dr Daniel Quinlan. In 1968 Michael commenced practice as a General Physician at St John of God Subiaco as well as Sir Charles Gairdner Hospital and Royal Perth Hospital. He believes the book is a very important part of acknowledging the trailblazers of the past. “Everything as far as I’m concerned is based on tradition and history. It sets you apart and gives you a philosophical underpinning. It’s where your whole ethical stance about delivering health care comes from. The sisters have always had such tremendous faith and farsightedness. It’s amazing that the whole organisation has evolved into what it is. But it will always have as its prime goal the care of the sick and the disadvantaged.” O ED: For more information or contributions to the SJOGH historical record, contact info@sjog.org.au. medicalforum
Guest Column
Cannabis, Health and the Law Cannabis may be something of a political football but GPs are really on the frontline, says Prof Simon Lenton.
Research has shown that neither criminal nor civil penalties have had much impact on the cannabis use of the vast majority of those apprehended, or on rates of use in the community generally. But a conviction can have major adverse social impacts on individuals, and is expensive in terms of criminal justice resources. Despite the steady downturn in cannabis use in WA and nationally (see graph), and evidence that attitudes to cannabis in WA were becoming more negative rather than ‘softer’, the Barnett government, when it came into power in January, 2009, set about implementing its pledge to overturn the previous Labor government’s Cannabis Infringement Notice (CIN) scheme. Under the CIN scheme, which commenced in 2004, cannabis use remained illegal. Adults in possession of 30g or less of cannabis, who cultivated not more than two non-hydroponic cannabis plants, or in possession of a used smoking implement could face fines of between $100 and $200 per offence. The person could pay this within 28 days, attend a cannabis education session, or have their driver’s licence suspended. In August last year, the Barnett government’s Cannabis Intervention Requirement (CIR) scheme replaced CIN. It provides for a cannabis caution for first offences for adults and third offences for juveniles in possession of 10g or less of cannabis if the person completes a Cannabis Intervention Session (CIS) within 28 days. If they don’t, they receive a criminal conviction. The CIS addresses adverse health and social consequences of use; cannabis laws; and effective strategies to reduce cannabis use. Any cultivation of cannabis results in a criminal charge, and selling smoking paraphernalia is banned. While it is positive that an evidencebased cannabis intervention is available, the law and health interventions tied to it will always be ineffective in addressing the majority of cannabis-related harm in the community because only about 3% of cannabis users have contact with police in medicalforum
any one year. Furthermore, these comprise only about 10% of people with a cannabis use disorder. Assistance and information are available to cannabis users on the Drug Aware website http://www.drugaware.com.au/ and through the National Cannabis Prevention and Information Centre http://ncpic.org. au/. Yet many people who use cannabis, and who may have associated problems, will present to their GP.
What GPs can do
years. Although producing subjective effects similar to cannabis, they are structurally dissimilar to delta9-THC and can contain one or more of a large number of different synthetic cannabinoids, most notably the JWH group (e.g., JWH-018). Products containing synthetic cannabinoids are often sold online and through adult shops under a variety of brand names – Kronic being most popular – though most Australian jurisdictions prohibited them in late 2011. The Australian TGA added groups of these chemicals to the Federal Poisons Standard in May 2012, effectively banning most known at that time. It is likely that new compounds will continue to be released in an attempt to avoid these legal restrictions.
GPs have an important role to play. They can routinely include questions about cannabis along with inquiring about alcohol and tobacco use and other health behaviours. Simply raising the possibility that other presenting health problems may be the result of cannabis use can often be enough to prompt a change in behaviour. Being open and non-judgmental, and supporting ! # ! disclosure, as with ! alcohol or tobacco, is # " appropriate.
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here is no doubt that cannabis use can be harmful but the question remains as to what is the best legal and regulatory structure to manage use of the drug and the associated harm. In the past two decades, reforms in several countries have moved away from the criminal justice approach.
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Interventions should focus on cannabis users known to be most at risk. These include young people ##" ! who use cannabis frequently, and older users who are Q From National Drug Strategy Household Surveys dependent. Note that cannabis use increased in the 2010 survey (see graph) Testing by the WA ChemCentre has found – the first increase since the mid-1990s – considerable variation in the chemical which appears to be caused by persistent contents of products sold in WA and noted use by some baby boomers in their late 50s. that other psychoactive agents were often present. With quality control and potency Providing ‘self-help’ materials often works, unknown, users report a varied range of and there is an option to refer patients to a side effects with tachycardia and anxiety clinical psychologist under a Mental Health most common, though help seeking appears Care Plan. Parents should be reminded rare. So there is a dearth of information that prevention of cannabis use and most about short and long-term health effects. O other problems among young people is
maximised when they feel connected to their family, school and community.
Synthetic cannabinoids – an emerging issue Products containing plant material sprayed with synthetic cannabinoids and sold as a legal alternative to cannabis were first observed in Europe in 2004 and increased use has become apparent in Australia, New Zealand and North America in the past two
Declaration: Simon Lenton is professor and Deputy Director at the National Drug Research Institute at Curtin University. He advised the previous WA Labor government on design of the CIN scheme. His clinical psychology practice sees people with cannabis and other drug problems.
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Guest Column
Is it Time to Reform Confidentiality? Health advocate Geoff Diver's 18-year-old daughter took her own life after leaving a psychiatric unit, so he offers unique insights.
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atient confidentiality is a concept as old as the Hippocratic Oath itself. But then again, so is slavery, denying women civil and human rights, and eating the hearts of those you killed in battle so that you might gain their courage. Longevity of a concept ought not automatically imply its legitimacy.
A lot has changed in society, in medicine and in mental health since the concept of patient confidentiality was developed and there is risk of it ossifying while the rest of the world moves on. The risk extends to potentially higher death rates among patients.
I feel it is only legitimate for practitioners to claim patient/ practitioner trust as a rationale for patient confidentiality if they themselves are willing to commit to the long haul. For example, one of its main rationales is to allow a trusting, therapeutic relationship to develop between patient and practitioner. However, I would counter this with the phenomenon of the past 30 years of the mobile practitioner. Doctors may want to cling on to the concept of a trusting relationship yet the reality is they don’t always stay on a case until the patient recovers. In the case of those I cared for, public sector mental health and social workers exercised their right and took better jobs as they arose. At one stage my daughter saw five people for consecutive appointments as each worker came and went. Not only did the turnover block progress, it actually generated a negative effect where my daughter, perhaps rightly, claimed that “they just didn’t care” about her.
So a point for practitioners to think about is reciprocal respect. Think about how willing you are to stick with a mental health role before you take it on. I feel it is only legitimate for practitioners to claim patient/practitioner trust as a rationale for patient confidentiality if they themselves are willing to commit to the long haul. Moving on to medicine, one of the biggest changes seen is the use of computerised medical records. Information fits better in a computerised system if it is codified, someone (usually non-medical) has to enter the data, which can be remotely and anonymously accessed in many cases. Various studies have shown that between data entry people, computer people, medical people on- and off-site, a patient’s record can sometimes be seen by more than 100 people while still being ‘confidential’. We may need to redefine what ‘confidential’ means, and from whom are we shielding the information.
and carers wanting to know everything about their loved ones. While I can see from where both of these viewpoints arose, I am disturbed that they dominate the debate to the expense of the voice of the patient. Taking human rights and recovery oriented treatment as our philosophical reference point, I would like to argue to all but the patients ‘This is not about you’.
I hope we can seize the momentum of the reform agenda, and put a new and relevant interpretation of patient confidentiality into practice in the 21st century.
Some time ago I was asked to review the concept of patient confidentiality in mental health as part of this reform agenda. As part of this task I gathered a mass of medical, scientific, ethical and legal literature. One thing which struck me from the medical and ethical literature was that it was nearly all written from the perspective of the practitioner, or the carer. Virtually none of the literature was researched and written after consulting the patient.
For practitioners it’s about trying to work out what the patient actually sees as important information. For families, as difficult as it may seem, you don’t really need to know everything. This is especially the case with so-called ‘lifestyle choices’ the patients make. Illicit drug use and sexuality issues are the two which loom large with potential for patient/family clashes. Trust me, having been there, you really do not benefit from knowing more and more about how your kids spend their time. So my call is for patient confidentiality to be placed at the head of the queue as we go through the reform process. Let’s get out there and ask the patients themselves what they feel about all this. The fragments which make it into the literature indicate that knowing what they think is important, as opposed to what we guess they think is important, is insightful and constructive. I hope we can seize the momentum of the reform agenda, and put a new and relevant interpretation of patient confidentiality into practice in the 21st century. O
What was more alarming was that this absence of a patient perspective wasn’t seen as alarming. While I recognise it as a huge simplification, the literature seemed to read as practitioners covering their bums, or families
ED: Geoff Diver is a mental health advocate and activist based in WA. Geoff has no medical training but draws on his lived experience as a mental health carer for some of his family members.
Mental health is changing. In WA we have now got a Minister for Mental Health and a Mental Health Commission, and the legislation is being revised to place a greater emphasis on a patient’s human rights and recovery. It is a dynamic time of change and, in my view, an excellent time to redefine what patient confidentiality for the mentally ill means and how we might better articulate it.
ATO is Taking Aim at Expense Claims The Australian Tax Office says that expense claims are on its radar and it will be using technology to seek and fine. It’s using data-matching techniques aimed to pinpoint individuals claiming incorrect or fraudulent refunds for over-claims and 26
deliberate fraud. It will also be scrutinising work-related expenses for occupations with high levels of claims, people getting caught up in tax avoidance schemes and omitted income, including dividends and interest, capital gains, and foreign sources of income.
A statement from the ATO says that it is looking in to individuals with a net worth of between $5 million and $30 million – there are about 70,000 people in this category around Australia, doctors included. O medicalforum
Guest Column
NFPs Get Down to Business Ms Antonella Segre, the Chief Executive of ConnectGroups, explains what an injection of funds and new professionalism will mean to the community.
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he state government’s $605m injection into the NFP sector may have been unprecedented but it came after some serious lobbying by the social services sector over quite some time. It gave an immediate 15% injection of funds to about 300 organisations with the promise of a further 10% in 2013. There were no strings attached as to how the funds would be spent, but it was expected that they would be passed on to staff as salary increases. It is generally acknowledged that those working in the NFP sector were earning 30% less than those in a comparable position in the public sector and there was a high attrition rate of staff and low attraction rate. But the cash injection also acknowledged that those who accessed services needed consistency and continuity from those at the coal face. There is no suggestion that these wage increases have negatively impacted on the sector’s ability to deliver services or ably meet emerging needs.
Since 2010 ConnectGroups has focused on its peak body activities, raising the profile of self-help and support groups within government agencies and across the community. It is vital that the community is aware of the services support groups provide people as they recover from health and mental health-related illness. It has also developed strategies to engage and inform health providers to the benefits of support groups in the care of their patients. A flexible framework, Towards Good Practice Standards, was developed in collaboration with agencies such as the Cancer Council WA. It addresses the important issues such as accountability, liability, governance and safety – areas which, in the past, have deterred health practitioners from encouraging their patients to participate in support groups. This process has also led to positive engagement with GPs and localised health services such as the South Metropolitan Health Service. Last year, the work of ConnectGroups was recognised by the Mental Health
Commission. It recognised that support groups, regardless of their core focus, worked on the belief that a ‘healthy mind’ is fundamental to all recovery and that those who ran those groups had skills that should be valued. Just recently we have been invited by the Department of Premier and Cabinet to participate in a working group looking at Self-Directed Services. Now, on September 5, ConnectGroups will launch two initiatives funded by the Mental Health Commission aimed at development and training. The Pay It Forward Plan will offer one-off grants of between $500 and $15,000 for self-help and support groups. While the SHSG Care Plan is a pilot program in partnership with TAFE WA which will see the delivery of six core units that will go towards a Certificate IV in Community Services (Self-help and Support Group Facilitation). These are the first steps that will add credibility to the role support groups play in the lives of those affected by adverse circumstances. O
(52264) Vocational Graduate Diploma of Women’s Health again on offer for WA GPs The KEMH and AMA invite you to enjoy built-in flexibility, CPD rewards, and up-to-date content make the course value for money. Fine tune your knowledge and build useful clinical contacts. Participants can access the information in part or in whole (i.e. full Diploma). There are only 40 places – kept low to safeguard interactive learning – so enquire early. The course is designed by educational gurus at King Edward Memorial Hospital.
THE 2013 DIPLOMA’S THREE THEMES ARE:
Women’s Health Education for GPs and the VGDWH
1. Family Planning & Sexual Health - 12 February - 16 April 2013 2. Office Gynaecology - 14 May - 30 July 2013 3. Non-procedural Obstetrics - 13 August - 29 October 2013 Each theme is delivered over 10 evening sessions, with light refreshments beforehand. If you miss a session unexpectedly, you can watch via 'Moodle' webpage. We also provide 'Scopia' for those rural participants. Some GPs are keen to update on one theme only. They can, or they can attend selected evening sessions within a theme. Up-to-date information builds clinical confidence in women’s health, and participants learn of relevant services at KEMH and across WA.
Theme: Family Planning & Sexual Health så-ULTICULTURALåISSUESå åFEMALEåGENITALåMUTILATION så#ONTRACEPTIONånåHORMONALå åNON HORMONAL så34)S så-ANAGINGåANåUNPLANNEDåPREGNANCYå åTERMINATIONSåATå+%-( så%ATINGåDISORDERSå åWEIGHTåLOSS så6ULVALåDISEASEå åVAGINALåDISCHARGE så3EXUALåPARTNERSHIPåPROBLEMS
GP Paulien de Boer. “As a graduate from out of state, the Diploma enabled me to gain an awareness of all the women’s health and information services in WA… and make some very useful contacts.”
COURSE DETAILS
så#HILDå åADOLESCENTåGYNAECOLOGY så3EXUALåASSAULT åDOMESTICåVIOLENCEå åCHILDåPROTECTION
Glen Forrest GP Liz Wysocki overcame the daunting exam with eventual ease. “The lectures are of a very high quality, good notes and plenty of interaction and the obstetrics module is particularly useful to those of us attempting shared care.”
RTS A T S B FE 3 201
Tuesday evenings, 6.20-8.30pm. (Light refreshments 6pm). Agnes Walsh Lounge, KEMH. CPD points: 40 Category 1 per theme, 4 Category 2 per session (capped at 30 points) C Cost: $685 (incl GST) per theme (10 sessions) or $80 per session. Exam fee additional. Contacts: amy.chatterton@health.wa.gov.au
For those completing the Vocational Diploma, attendance at all three themes is required, with written and clinical assessments that include a Clinical Logbook of women’s health cases seen over six months.
medicalforum
27
Guest Column
GPs Still Steer Home Hospitals Dr Scott Blackwell outlines how Silver Chain is designing its Home Hospital service to keep GPs and funders happy and in touch.
W
hen Health Minister Kim Hames committed State Health funding to Silver Chain to improve the capacity of Community Health Services to manage more people with health problems in their own homes, he was no doubt leaning on his own 25 years’ experience as a GP.
General practice has long been the main stay of good clinical assessment and good clinical management in the WA community. Silver Chain Home Hospital emerged as the expression of the Minister’s commitment and from its inception recognised the need to augment, to complement both the assessment and management capacity of general practice. Assessment provided by Silver Chain Home Hospitals “Priority Assessment service� is designed to assess and treat acute but nonemergency problems at home and is ideal for residents of Aged Care and Disability facilities. Trained Assessment Nurses provide the clinical governance GP with results of clinical assessment supported by a range of onsite investigations (blood tests, ECG etc) and a management plan is developed through this collaboration. The patient’s own GP is kept informed throughout and is provided with a full report of the intervention the same day. GPs can
negotiate to take on the clinical governance role of their own patients and Silver Chain provides a 24/7 GP-based clinical governance team than makes sure there are no gaps. Priority Assessment is proving ideal for:t "TTFTTNFOU BOE USFBUNFOU PG JOGFDUJPOT requiring IV antibiotics t 1&( UVCF NBOBHFNFOU t *%$ BOE TVQSBQVCJD NBOBHFNFOU t "TTFTTNFOU BOE JOWFTUJHBUJPO PG %75 t "TTFTTNFOU PG IZESBUJPO BOE SFIZESBUJPO t 4VUVSJOH PG TJNQMF MBDFSBUJPOT t %FMFSJVN FTQFDJBMMZ JO UIF 3"$' TJUVBUJPO Management of clinical issues is a growing part of Silver Chain under the Home Hospital Program and 700 or more people are currently receiving these services. The partnership of GPs and Silver Chain to deliver hospital substitution care is important for best patient care. A range of acute conditions can be easily managed at home by the GP and Silver Chain, these include but not limited to :t $FMMVMJUJT t %75 BOE 1VMNPOBSZ &NCPMJTN t 4FWFSF 65*T t $PNNVOJUZ "DRVJSFE 1OFVNPOJB t )ZQFSFNFTJT BOE PUIFS DPOEJUJPOT requiring rehydration.
Short courses of treatment following specific protocols are provided for these patients who are then safely returned to their GP’s care for follow-up and ongoing management. Currently, 75-80% of these patients are referred from ED, but there are increasing referrals from GPs where the cycle of care begins with the GP. Referrals from all sources end in the community with the GP. Wound management is an area where Silver Chain has been a leader in service provision and remains a major part of Home Hospital’s clinical services. Post Acute Care provided to people returning to the community after an acute event rounds off the suite of Home Hospital Services. The majority of Silver Chain Home Hospital services are governed by the patient’s own GP. In the new acute services, Silver Chain has developed a governance team of GPs supported by relevant specialists. The final disposition for all patients for ongoing comprehensive care is their own GP. Increasingly, GPs are seeing Silver Chain Home Hospital as their hospital, and their patients appreciate the chance to have good care in the comfort of their own home. O ED: Dr Scott Blackwell is President of the Palliative Care Association of WA, VicePresident of Palliative Care Australia, and Lead clinician of the Primary Health Care Network of WA.
Doc of the Swan Helps Kids with Special Needs At a ceremony at the Royal Freshwater Bay Yacht Club a cheque for $7975.06, raised by Doc of the Swan this year, was handed over to the CEO of ConnectGroups, Ms Antonella Segre. The annual event is sponsored by Medical Forum magazine. This year, the money raised was to help three consumer support groups selected by ConnectGroups, with the health theme ‘children with special needs’. ConnectGroups also has responsibility to ensure the money is put to use effectively, as specified by the organising committee. If you would like to assist us in 2014 please contact editor@mforum.com.au O
Q Pictured from left: Basil and Jenny Twine (support boat crew), Chrissy Jordan (organising committee), Antonella Segre (ConnectGroups CEO), Ian Clark (RFBYC Commodore), and Dr Brian Galton-Fenzi (organising committee). 28
medicalforum
Guest Column
Ethics Committee's Supporting Role Neonatologist A/Prof Andrew Gill looks at how the Clinical Ethics Committee at KEMH and PMH helps clinicians work through the many dilemmas they face.
D
r Angela Alessandri and I convened the Clinical Ethics Committee (CES) in 2006, based on a similar and highly successful service at the John Hunter Hospital in NSW. We’ve now had six years supporting clinical teams, patients and their advocates and I think it’s safe to say that considerable initial suspicion has been dispelled.
Our main role is to give ethical input to the hospitals through education and provide an Acute Consultation Ethics Service whereby three or four members of the wider CES provide a highly responsive consultation, mostly within 24 hours, followed by a written response within 48 hours. The current membership (see table below) is a strong and diverse team combining individual skills, great commitment and extensive non-medical input. The CES embraces a distinctly discursive approach. The pluralistic nature of the committee is one of its strengths, ensuring each facet of a clinical issue can be fully explored. The entire process is open and completely optional, with no obligation for a clinician to refer to the CES and no expectation that a clinical team will follow its recommendations. In fact, we deliberately discuss a range of options and the relative strengths and weaknesses of each one. The final decision always rests with the clinical team and the patient. We don’t usurp the responsibility of the clinical team for direct patient management. We don’t offer a legal opinion, although the legal aspects of each case are taken into consideration and where a formal legal opinion is required the input of
the State Solicitors Office is recommended. The CES currently receives about one acute referral a month, mostly involving the direct management of a patient. In a predominantly paediatric environment, many of the issues revolve around a conflict of perceived best interest. More broadly, referrals have required discussions on the merits of withholding information on pending Department of Child Protection apprehension, the availability of public infertility treatment and what obligations there are regarding a child brought to WA from overseas for medical treatment by an NGO. How are the issues resolved? In many cases, just convening an ethics consultation
TABLE 1: ETHICS COMMITTEE MEMBERS Reverend Robert Anderson ................Head, Dept of Pastoral Care Services, PMH/KEMH. Dr. Angela Alessandri .........................Clinical Director Paediatric Haematology/Oncology. Co-convener. Mr. Glen Duffield .................................Deputy Principal, Dept of Education WA A/Prof Andrew Gill .............................Neonatologist, Co-convener. Mr. Ian Gollow .....................................Paediatric Surgeon Ms. Belinda Jennings ..........................Perinatal Loss Service, KEMH A/Prof Brenda McGivern ...................Lawyer, Law School UWA Prof Stephan Millett .............................Director, Centre for Applied Ethics, Curtin University Prof Leanne Monterosso ....................Chair of Nursing, Notre Dame Reverend Dr Joseph Parkinson .........Director, L J Goody Bioethics Centre Dr. Mark Salmon ..................................Director of Medical Services, PMH/KEMH Mr Maurice Spillane ...........................State Administrative Tribunal WA Chairman medicalforum
helps resolve the problem as the bringing of parties together and providing tangible support to a clinician and parents is highly beneficial. Often a clear path has already been formulated but the clinical team and/ or parents are seeking external validation. This concept of sharing the burdens and, in some cases, sharing the blame of complex medical decisions is a recurrent theme. In some consultations, clarifying facts have helped achieve resolution while others have become exercises in conflict resolution. A rephrasing of arguments, focussing on values or discovering common ground often proves useful. Institutional Ethics Committees are becoming more common within Australian and New Zealand hospitals. As their role becomes more clearly defined, a growing relationship between the committees and the courts has developed. The courts generally look favourably on the role of the CES and regard it as ‘due process’. The two organisations play very different, yet somewhat complementary roles, in resolving medical issues. In contrast with a legal approach, ‘Ethics’ is an inexact process; nonetheless, it is aspirational in nature and always seeks to find the best path. We would be very open to facilitating Clinical Ethics Services in other WA institutions. O
29
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medicalforum
CLINICAL UPDATE
New remote monitoring for implanted cardiac device W
Dr Tim Gattorna, Cardiologist & Electrophysiologist, Western Cardiology. Tel 9346 9300
ith an ageing population and expanding indications for cardiac device therapy the number of cardiovascular implantable electronic devices (CIEDs) is estimated to increase dramatically. Traditionally, interrogation of CIEDs to receive the telemetric signal requires a “wand” to be placed over the device during face-to-face contact. This labour intensive approach places a burden on both the health system and the patient, particularly those who are isolated, and limits the detection of problems that occur between scheduled attendances. Recent technological advances allow remote monitoring (RM), which is the measurement of device function, performance and other patient-related information via transmitted electromagnetic signals. This RM capability is available in all types of CIED, including pacemakers, loop recorders, defibrillators and cardiac resynchronisation therapy. RM allows device data transmission, via a home transmitter, to a central (internetbased) secure server/secure website, either automatically at pre-programmed times or manually. The landline phone or mobile telecommunications (usually global system for mobile communications) transmit to the network the device information that can then be accessed and analysed by the treating physician who then responds appropriately. (Currently, the reprogramming of devices remotely has not been implemented, mainly due to safety considerations.) Earlier remote monitoring systems required patient-activated transmissions on a scheduled day. Automatic RM, in contrast,
NO NEED TO SHOUT I have always had a severe hearing loss and struggled in everyday situations, even with hearing aids. At 36, I decided to get a ‘bionic ear’ from the ESIA Implant Centre. The day my implant was switched on was life changing. It was incredible to hear new sounds. Of course I didn’t know what half of them were, and I had to spend a few weeks learning to adjust. Now, I can hear my daughters talking in the next room. My confidence has skyrocketed and work is reaping the rewards - especially as I can now use the phone. I have only one regret - that I didn’t do it sooner. Brett Paton.
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allows continuous daily surveillance of device function and employs device-triggered transmissions for rapid problem notification. Device triggered events selected by the physician can include specific arrhythmias (e.g. atrial or ventricular arrhythmias), device activities, or acute deviations from established trends (e.g. battery depletion, impedances out of range). Recent multi-centre trials demonstrated RM-enhanced problem discovery of both clinically silent as well as symptomatic events, despite less frequent hospital evaluations. This suggests that RM offers improved patient safety and quality of care, compared to traditional calendar-based follow-ups, through earlier detection of technical and medical events and a reduction in resource intense patient consultations. The legal considerations of RM include
appropriate written informed consent stating the purpose and limitations of RM, such as: it does not replace an emergency service; whether alert events outside office hours can be dealt with; and authority to transmit personal data to third parties, such as device companies. The lack of appropriate physician reimbursement despite the available evidence is a concern in many countries, including Australia, which is limiting its use. The responsibility for establishing such policies, in the face of such convincing evidence and cost-effective delivery of health care, is now shifting back to the policy makers.
Declaration: Western Cardiology contributes towards the publishing costs of this clinical update. Author – no competing interests.
I can hear whispers since my cochlear implant. Brett Paton, 40.
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consultation through to long term hearing management. To learn more, call (08) 6380 4944 or visit www.esiaimplants.com.au and click on the Professionals tab.
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31
CLINICAL UPDATE
COPD Online – for practice nurses C OPD Online is a web-based interactive learning module by The Australian Lung Foundation pitched at primary care nurses (although doctors will appreciate the update as well). It covers diagnosis and management of patients with COPD. We test drive the module, 18 months in the making, and designed with primary care practice nurses in mind.
First, why primary care nurses? They help manage chronic disease, often do practice spirometry, and assist patients with selfcare. The training offered by the module, estimated at eight hours in total, is self-paced so participants can bookmark and return to where they left off. Looking at the common barriers: t "DDFTT o JT FBTZ TFF www.lungfoundation.com au>� professional resources�>�COPD nurse training on-line� t $PTU o JT QFS QFSTPO XJUI CVML EJTDPVOUT and some training scholarships available. t $1% QPJOUT o FOEPSTFE CZ UIF 3$/" and APNA with seven or eight points on completion. t 5JNF o QBSUJDJQBOUT IBWF B ZFBS UP DPNQMFUF but two months is recommended. The course is comprehensive, which might seem a lot for someone wanting the basics. There are case studies and videos, downloadable assessment tools and patient handouts as well as quizzes to test knowledge.
Most of what is presented focuses on the patient and what will happen between nurse and patient as this knowledge is applied. The participant is locked out of future modules so they build on knowledge as they go through the 10 modules, presented in a logical sequence. Making the training concise and hands-on is tricky but it achieves it pretty well, and although it does not aim to teach spirometry, it provides some theoretical background (see separate critique). The assessment at the end of each module is practice quizzes and the real assessment comes at the end of the training where 80% is the pass mark on Assessment 1 (30 questions) and Assessment 2 (a case study with eight questions). Five weeks was enough for the 50 nurses to complete it during the pilot phase and course designers now recommend two months. However, access is provided for 12 months so nurses can continue to use this as a professional resource and download patient resources as they require. The Toolbox contains all the resources, many as PDFs.
Suggestions for improvement t 5IF QBUJFOU handouts could be better – language and presentation need some work with a friendlier, more interactive and encouraging style for patients. t $PNNPO DMJOJDBM scenarios are presented but need to be more at the forefront. Q It might seem like information overload but you can grab what you need. Common patient scenarios are covered.
t 3FHJTUSBUJPO OFFET streamlining – it requires
FACTS: COPD IN AUSTRALIA t " TJNQMF MVOH GVODUJPO UFTU GSPN a GP can diagnose COPD. t $JHBSFUUF TNPLJOH CSJOHT PVU $01% particularly in those with an inherited tendency, as does exposure to pollutants and irritants – women more so. t "GGFDUT NJMMJPO "VTUSBMJBOT XJUI 1.2m moderate to severe (Stages II – IV) i.e. symptoms affecting everyday life, with >50% loss of lung capacity. Half these people are unaware they have COPD. t &WFSZ EBZ $01% QBUJFOUT occupy hospital beds (average 7.5 day stay). Health-care system costs of $900m p.a. (half in hospitals). t &BSMZ EJBHOPTJT BOE NBOBHFNFOU BSF said to slow disease progression, reduce mortality and keep people out of hospital. t 1VMNPOBSZ SFIBCJMJUBUJPO SFEVDFT breathlessness, fatigue, anxiety and depression, and enhances feelings of self-control. See www.lungfoundation.com.au and toll free support hotline 1800 654 301.
filling in an order form as a downloaded PDF from their website! The developers are hosting the training elsewhere and then provide username and password. O
By Dr Rob McEvoy
SPIROMETRY COMPONENT REVIEW We asked Dr Sally Young PhD Respiratory Scientist from ProHealth Training to critique this component. Her comments included these points. In summary: “Overall an informative, well presented and logical boardbrush review of the role of spirometry in the assistance of the diagnosis of COPD (Part 2: Spirometry)�. Sally pointed to some errors and omissions regarding the 32
performance of spirometry: t 5P DPNQBSF B QBUJFOU UP SFGFSFODF values you need only age, gender, height and ethnicity. t "QQBSFOU DPOGVTJPO BCPVU UIF difference between technical acceptability of the F-V curve (blow technique assessment) and repeatability (consistent technique with a set of technically acceptable curves). A spirometry operator is required to perform both these assessments.
t 7JEFP JT 0, BT B CSJFG CSPBE CSVTI demonstration of spirometry but never advise a subject to ‘try not to cough’ which can affect validity of FEV1 and FVC through a less forced blow. t $PNCJOJOH TQJSPNFUSZ WJEFP XJUI the test results is a good idea but may be more useful if (a) COPD alone (no response to bronchodilator), and (b) COPD + asthma (response to bronchodilator of >12% and ≼200mL increase in FEV1 or FVC) scenarios are presented. medicalforum
Using Transvaginal Ultrasound for Uterine Pathology T
ransvaginal ultrasound, first 2D and now 3D, has revolutionised gynaecology as a non-invasive and accurate way to image the uterus and endometrium. We can see what can or cannot be palpated, to optimise management. Doctors from obstetrics, gynaecology, primary care, and fertility backgrounds refer for similar problems but with different requirements. GPs give emphasis to accurate diagnosis, to explain the patient’s symptoms. Gynaecologists seek more information regarding known pathology, to plan further management – hence more complex clinical questions and specialised tests. Fertility specialists are more focused on uterine pathologies that prevent pregnancy. Common benign uterine pathologies are:
By Dr Anjana Thottungal, Perth Obstetrics & Gynaecology Ultrasound, Mercy Medical Centre
Fibroids Leiomyomas (fibroids) are usually associated with menorrhagia, dysmenorrhea and pelvic pressure symptoms. Submucosal fibroids may also reduce fertility and increase the risk of miscarriage. Transvaginal scan gives a typical appearance; smooth in outline with a thin layer of connective tissue separating it from the normal myometrium. Preoperative 3D ultrasound (US) demonstrates the cavity and myometrium in the coronal plane, important information in planning surgery (Figure 1).
Adenomyosis Adenomyosis – the benign presence of ectopic endometrial glands and stroma within the myometrium – causes diffuse uterine enlargement and often menorrhagia, dysmenorrhoea and chronic pelvic pain. Typical features on ultrasound are: t Moderate symmetrical uterine enlargement. t .VMUJQMF NZPNFUSJBM TIBEPXJOH ASBJO JO UIF GPSFTU BQQFBSBODF t 4NBMM NZPNFUSJBM DZTUT NN t %JTSVQUJPO PG UIF NZPNFUSJBM FOEPNFUSJBM CPSEFS t *SSFHVMBS UIJDLFOFE KVODUJPOBM [POF FWJEFOU PO % 64
Q Fig 1: 3D image showing multiple subserous fibroids, none encroaching on the endometrial cavity, although the endometrial echo deviates to the right side.
About 50% of women with adenomyosis have co-existent fibroids.
Endometrial polyps
(a)
(b)
Benign endometrial polyps, found in ~30% women, are often asymptomatic but can be associated with abnormal uterine bleeding, abdominal pain and dysmenorrhoea. On transvaginal US, polyps are small hyper-echogenic, well-defined masses within the endometrial cavity. Doppler ultrasound can visualise feeding vessels (pedicle artery sign), which improves the detection rate with a sensitivity of 95% and specificity of 80%. Saline infusion sonography may also improve detection and help define polyp position and size, which is useful in planning surgery.
Congenital uterine anomalies These are associated with infertility, recurrent miscarriage, malpresentations and preterm labour. 3-D ultrasound examination is fundamental when distinguishing between arcuate, septate and bicornuate uteri (Figures 2 a & b) and is typically performed in conjunction with traditional 2D transvaginal scan using a probe that has both 2-D and 3-D capabilities. This enables us to go over the images in any scan plane desired, including those unobtainable on standard 2D imaging (Figure 3). Q
Q Fig 2: (a) 3D surface rendered coronal image showing the normal outer contour of a uterus identified as arcuate (i.e. the fundal indentation was an obtuse angle at the central point < 1.5cm deep). (b) Normal outer contour, partial septate uterus, differentiated from an arcuate uterus because the fundal indentation is an acute angle at the central point >1.5 cm deep (Troiano and McCarthyâ&#x20AC;&#x2122;s formula). Q Fig 3: Endometrial echo of the subseptate uterus on HD live surface rendering, clearly demonstrating the encroachment of the partial septum into the upper uterine cavity.
Mercy Hospital Mount Lawley, Thirlmere Road, Mount Lawley 6050 Ĺ&#x17E; 3DK Ĺ&#x17E; %@W Ĺ&#x17E; $L@HK GNROHS@K LDQBXB@QD BNL @T medicalforum
33
CLINICAL UPDATE
Common respiratory problems T
By Dr Sina Keihani, Respiratory and Sleep Disorders Physician, Leeming. Tel 6161 7647
hese short practical points, based on my experience, may prove useful and are by no means exhaustive.
Chronic cough
concerns around sole use of a long-acting beta agonist in asthma.)
A CXR and spirometry (preferably full lung function) are mandatory. If the patient is on an ACE-I, consider ceasing. The onset of cough in relation to medication commencement is highly variable and cough cessation can take up to three months. Reflux often contributes and can be ‘silent’. Cough from any cause can induce reflux and set up a vicious cycle. Inadequate dose and duration of prescribed PPI is relatively common – I give two months of b.d. dosing. It is often said that with a normal CXR and spirometry in non-smokers, 90% will have either GORD, Upper Airway Cough Syndrome (UACS; formerly 'postnasal drip'), asthma, or combinations of these. While cough as a sole manifestation of asthma is uncommon, a trial with bronchodilators in suspected cough variant asthma is warranted and should help within two weeks (with full resolution taking up to two months). Occasionally, inhaled medications worsen cough variant asthma, and response to a one-week course of systemic steroid can be helpful. For UACS, if intranasal steroids are not helping, try an antihistamine-sympathomimetic combination +/- five days’ oral steroid.
COPD ‘Irreversible’ airflow limitation does not mean ‘untreatable’. Early diagnosis is the key. A
Pulmonary rehabilitation and addressing the very common co-morbidity of anxiety and depression cannot be overemphasised. Remember to treat the condition not the disease.
Obstructive sleep apnoea The Berlin Questionnaire is a handy simple tool to assess who may be at risk and need polysomnography. Remember to consider a sleep study in those with difficult-to-treat HT, history/high risk for IHD and diabetics (over 50% have OSA). What test? For patients at high risk for OSA a portable sleep study is an acceptable test, however, the quality of devices used can vary a lot. The lab-based test remains the ‘gold standard’. Community promoted 'sleep studies' with a 2 or 3-channel basic readout are unreliable at ‘ruling out’ sleep apnoea (sensitivity <60%) and especially as the results are often not manually analysed, which is very important.
Q Nasal EPAP: stick-on valve system allows unobstructed inspiration but increased airway resistance during expiration aims to keep the airways open.
gamut of recent studies show early treatment results in slowed decline of lung function, reduced exacerbations, improved quality of life and probably improved mortality.
Besides CPAP we now have nasal EPAP (see photo) with proven efficacy for mildmoderate OSA in particular and is a welltolerated treatment option.
A new choice in bronchodilator (indacaterol) is available for COPD (not asthma) but is not clearly superior to existing equivalent therapies. (Remember
Author competing interests: No relevant disclosures.
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CLINICAL UPDATE
Watch for TB T
Dr Justin Waring, Respiratory Physician RPH & Medical Director, WA Tuberculosis Control Program. Tel 9222 8500.
uberculosis (TB) remains an unusual diagnosis in WA, but is becoming more common. In 2011 there were 124 cases notified compared with 63 cases 10 years ago (an increase in rate from 3.3 to 5.2/10(5) population; very low in a global context e.g. UK = 13.6, India = 185, South Africa = 981(2)). Because TB is uncommon and also usually an indolent disease, it can be missed, leading to delayed diagnosis and excess morbidity.
How to avoid missing TB Nearly all TB notifications occur in people born outside Australia (88% in 2009), and 50% of these have immigrated less than three years ago(1). The risk of an individual having TB is closely correlated with the rate of TB in their country of birth, with TB most common in people from India, Vietnam, Philippines and China. This is not a failure of immigration screening, which is highly effective in identifying active pulmonary TB before migration. Rather, most TB cases are reactivation of latent TB infection after migration, undetectable by symptom review or chest x-ray then. Most TB is pulmonary (~60%)(1), presenting with low grade chronic cough, fever and weight loss. A cough lasting more than three weeks in a person of the right demographic should be a trigger to investigate for TB. Patients are mostly young healthy adults without a reason for reactivation such as immunosuppressive co-morbidity. The presentation of TB is usually sub-acute and the diagnosis should not be discounted in an apparently well, ambulatory patient.
Tests for TB The key to diagnosis, and the test to order first, is microbiological. This is usually early morning sputum samples on three consecutive days for acid fast bacilli (AFB). Any site of clinical disease that is sampled (lymph node aspirate, pleural fluid, urine, other biopsy) should be sent for AFB culture. If a patient cannot produce sputum and has a chest x-ray suspicious of TB, induced sputum can be collected at the TB clinic (see below), at short notice. Chest x-ray is a good screening test for pulmonary TB, as a normal x-ray is rare in a symptomatic patient with pulmonary TB. However, x-ray changes are non-specific, both in respect to diagnosing TB or whether TB is active or dormant. CT scan is of no additional use in the diagnosis of TB. The QuantiFERON TB-GOLD assay is not a test for active TB, and should not be used in clinical settings when investigating a symptomatic patient. Like the tuberculin skin (Mantoux) test, it is a test for latent TB infection, and does not distinguish between this and active disease. It can also be falsely negative in active TB.
Management â&#x20AC;&#x201C; the TB Clinic Patients can be treated by any doctor with expertise in TB, under the case management of the TB clinic from where the nurse ensures treatment adherence and contact tracing. TB medications are free to all patients, even if prescribed by a doctor outside the clinic. A new TB patient should not be sent to ED unless medically indicated â&#x20AC;&#x201C; they are rarely that sick. The TB clinic can assess patients and start treatment no later than the next working day. Even infectious patients need only stay at home until this happens, without being hospitalised for infection control. The TB clinic is a purpose-built facility: Anita Clayton Centre, Suite 1 / 311 Wellington Street, Perth. T: 9222 8500, E: accadmin@health.wa.gov.au, W: www.health.wa.gov.au/acc/ References (1) Tuberculosis Notifications in Australia, 2008 and 2009. Commun Dis Intell 2012;36(1):82â&#x20AC;&#x201C;94. (2) Global tuberculosis control: WHO report 2011. www.who.int/tb/publications/global_report/2011/ gtbr11_full.pdf
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PIVET MEDICAL CENTRE Specialists in Reproductive Medicine & Gynaecological Services
FERTILITY NEWS
Medical Director Dr John Yovich
Optimising Sperm Recovery from Azoospermic Men +LVWRULFDOO\ 3,9(7 KDV EHHQ LQ WKH IRUHIURQW RI GHYHORSPHQWV WR Ă&#x20AC;QG solutions for the male aspect of infertility â&#x20AC;&#x201C; publishing extensively on a range of methods in the 1980â&#x20AC;&#x2122;s including the use of Pentoxifylline for severe oligospermia (Yovich et al, Fertil Steril 1988) and then the successful application of sperm surgically collected directly from the epididymis combined with micro-injection into the oocyte (Jequier et al, Fertil Steril 1990). Over the subsequent 20 years, there has been a worldwide application of developments involving testicular and epididymal sperm retrieval techniques. The retrieved sperm are selected by various laboratory techniques prior to intracytoplasmic injection (ICSI), sometimes after Pentoxifylline enhancement. PIVET has shown that microsurgically retrieved sperm is best for many reasons: 1. Enables epididymal sperm recovery in obstructive cases which optimises cumulative pregnancy rates (Stanger et al ANZJOG 2010) 2. Enables focussed techniques of testicular sperm recovery from nonobstructive cases (Jequier, Male Infertility 2011) 3. Enables large numbers of sperm to be recovered improving fertilisation results and embryo quality 4. Ensures minimal trauma to epididymis, vas and testicular structures with uncontaminated sperm samples and micro-surgical closure of ductules 5. Enables cryopreservation of typically 12-15 straws of sperm thus avoiding repetitive collections
Dr Artef Saba undertaking MESA (microsurgical epididymal sperm aspiration) from a man 11yrs post vasectomy and subsequent failed reversal â&#x20AC;&#x201C; 16 straws recovered. Wife already pregnant after using 1 straw!
6. Enables controlled IVF/ICSI arrangements for men who cannot easily be present at the time of egg recovery e.g. FIFO and overseas workers 7. Can be combined with microsurgical vasectomy reversal in suitable cases At PIVET 6 Consultants are fully competent in microsurgical open sperm recovery techniques and participate in ongoing research in this area. The procedures are performed in PIVETâ&#x20AC;&#x2122;s Day Care Theatre.
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35
CLINICAL UPDATE
Food allergy and intolerance in children A
Dr Christiane Remke, Paediatric Allergist. Tel 94423950.
dverse reactions to various foods is a common clinical problem in paediatrics. When a parent describes food â&#x20AC;&#x153;allergyâ&#x20AC;? in their child they usually mean adverse food reaction of any type. In medical terms, food hypersensitivity can be immunemediated (allergy) or be caused by other pathways (food intolerance).
Immune-mediated food allergy
FACTS: AUTHOR SUMMARY
IgE-mediated The prevalence of these allergies has increased (by 350% between 1994 and 2005(1)) and is in most cases is caused by seven foods: peanut / treenuts, egg, cowâ&#x20AC;&#x2122;s milk, soy, fish, shellfish and wheat.
t 5BLJOH B EFUBJMFE IJTUPSZ JT QBSBNPVOU in allergic reactions, as a positive SPT/ RAST alone does not mean â&#x20AC;&#x153;allergyâ&#x20AC;?
Reactions occur within two hours of contact or ingestion, sometimes at very low doses, and can cause urticaria, angiooedema, facial swelling and vomiting, but also respiratory distress (wheeze, cough, tongue swelling) and cardiovascular compromise (hypotension) and may lead to collapse in the case of anaphylaxis.
t /PO *H& NFEJBUFE GPPE BMMFSHZ DBO present with a wide range of symptoms, with SPT/RAST not diagnostically useful.
Taking a detailed history is most important for making the diagnosis, which can then be confirmed by Skin Prick Testing (SPT) and/or specific IgE testing (RAST) to the suspected food. These tests show immune sensitisation to the offending food, which does not automatically translate into allergic reaction but indicates an increased likelihood of an adverse reaction (but not the severity of reaction). Patients need to avoid the offending food, be equipped with an adrenaline autoinjector and trained in the management of anaphylaxis if they had an anaphylactic reaction or are at particular risk of developing one (such as asthmatics, teenagers, or patients with nutallergies). Further information can be found at www.allergy.org.au. Non-IgE-mediated These are most common in the first few years of life. Onset of symptoms is typically 12-48 hours after ingestion and comprises of eczema, diarrhoea, and abdominal pain, as well as gastro-oesophageal reflux and irritability in babies. Other conditions described in this category include: t 'PPE QSPUFJO JOEVDFE QSPDUPDPMJUJT o causes rectal bleeding in babies and is usually due to dairy exposure. t '1*&4 GPPE QSPUFJO JOEVDFE enterocolitis) â&#x20AC;&#x201C; causes severe vomiting, diarrhoea and possibly hypotension 1-3 hours post ingestion and is most often caused by dairy, soy, rice or chicken. t &PTJOPQIJMJD PFTPQIBHJUJT o DBVTFT EJGGJDVMUZ feeding, dysphagia, vomiting, food refusal and impaction hours after ingestion and can be caused by various foods. 36
t *NNFEJBUF POTFU TZNQUPNT NFBOT IgE-mediated food allergy and carries a risk of anaphylaxis. Adrenaline autoinjector must be provided for all children with anaphylaxis.
t 'PPE JOUPMFSBODFT BSF EJBHOPTFE PO history and elimination diet along with a symptom diary â&#x20AC;&#x201C; specific dietary advice is required.
Diagnosis of these conditions is reliant on history as laboratory tests such as SPT and RAST are inaccurate. A diet diary and elimination diets can be useful. Patients need to avoid the offending food and be offered a safe alternative.
Follow-up and outcome â&#x20AC;&#x201C; immune reactions Most children still â&#x20AC;&#x2DC;grow out ofâ&#x20AC;&#x2122; milk and egg allergy as well as many of the non-IgE mediated food allergies, however more and more allergies tend to be persisting. Review by a Paediatric Allergist is helpful, including for the interpretation of test results and a clinical food challenge when circumstances are appropriate (always done under medical supervision because of associated risk).
Food Intolerances These also occur in babies and children. Lactose intolerance is the most common and symptoms such as diarrhoea, flatulence and abdominal pain are caused by difficulty in digesting lactose, which can be transient (e.g. post infections) or a permanent genetic condition. Diagnosis is made by elimination diet or through demonstration of faecal reducing substances in babies or hydrogen breath test in older children. Food intolerances can also be caused by a variety of natural food chemicals (salicylates, amines and glutamate such as MSG) as well as additives such as flavourings and colours. Susceptibility is different amongst individuals and the exact mechanisms are unclear, hence there is no clear diagnostic test.
t $IJMESFO XJUI LOPXO GPPE BMMFSHJFT PS intolerances must avoid the offending food and be offered a safe alternative.
An elimination diet followed by a food or additive challenge is required to confirm the diagnosis and a Paediatric Allergist and/or dietician can help in finding the most suitable dietary options for these children. Friendly Food (Murdoch books) is a helpful resource. Onset of symptoms is usually several hours post exposure and often varies with the dose consumed. Symptoms include irritability, eczema and loose stools in babies, behavioural changes such as hyperactivity and mood swings in older children, as well as headaches and gastro-intestinal symptoms. Hyperactivity in children has been demonstrated to be caused by specific food additives in several studies (2) (3) and it is worth pursuing dietary changes in affected children. Most food intolerances are transient in nature and a trial-and-error approach can be used to follow-up. This can be done by the parent / carer at home as these reactions do not carry the risk of IgE-mediated reactions. References (1) Liew et al: Anaphylaxis fatalities and admissions in Australia. JACI 2009 (2) Bateman et al: The effects of a DBPC artificial food colourings and benzoate preservative challenge on hyperactivity in a general population sample of preschool children. Arch Dis Child 2004 (3) McCAnn et al: Food additives and hyperactive behaviour. Lancet, Nov 2007 Other references available on request.
Author competing interests: No relevant disclosures.
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Introducing
BENEATHthe Drapes X Dr Elizabeth (Liz) Marles is the new President-elect of the RACGP. A practising GP in Hornsby, NSW, Liz will take the reins from Prof Claire Jackson. X Professors John Burnett, Steven Webb, Fiona Wood and A/Prof David Nolan received Practitioner Fellowships and Drs Keith Giles and Andrew Woo and A/Profs Jon Pfaff and Natalie Ward were awarded Postdoctoral Fellowships from the RPH Medical Research Foundation. C/Prof Richard Herrmann also received a Research grant. X Joel Chan the former Manager of Fundraising and Public Affairs at Alzheimer’s Australia WA has taken on a PR role at Armadale Hospital. X Australia’s first Chief Scientist, Perth-born Professor Ralph Slayter AC has died at the age of 83. He began his career as an agricultural scientist at CSIRO in 1951. X SJOG Subiaco Neurologist Prof Bill Carroll was recently named Western Australian of the Year in the Business and Professions award category. The award recognises his contribution to research into Multiple Sclerosis (MS). X After leaving Silver Chain last year, Mr Nick Harvey has resurfaced as General Manager Marketing & Communications at RFDS (Western Operations). X Ms Gizelle Lau is the new RACGP examination officer who will assist examinees, particularly IMGs completing the fellowship. X Dr Jenny Deague is the first Director of Cardiology at Joondalup Health Campus and is also heading up the Junior Doctor Program. The latter position is linked with a joint Associate Professorship at UWA. X Prof Moyez Jiwa has received a $20,000 HCF/RACGP grant to run a pilot study into educational intervention to support GPs during the treatment of breast cancer patients. X The WA Department of Health’s Health Information Network has awarded Kinetic IT a $15m contract to provide an End User Computing (EUC) environment to support its existing and new applications and business initiatives. X Dr Anita Bourke was thrown a party by her SCGH colleagues to celebrate her 30th anniversary at the hospital. Over the years she’s worked with her husband, her sister, her brother and brother-in-law and now her son, who is a medical registrar. Anita was the first dual-qualified Radiologist and Nuclear Physician in WA. medicalforum
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37
Support Group
Lung Information & Friendship for Everyone LIFE support group began in 1992 (previously LISA, or Lung Impaired Support Association) amongst people with various respiratory diseases who wanted to know more about their conditions. There is now a network of support groups in WA. Monthly meetings moved from member’s houses to SCGH’s Department of Respiratory Medicine with the help of Dr Martin Phillips. LIFE now operates from the Lung Institute of WA (LIWA), which has Prof Philip Thompson and Prof Lou Landau on the board, and is involved in research and clinical trials out of SCGH. The group hopes WA doctors mention them to relevant patients.
IN BRIEF: LIFE SUPPORT GROUP Background: For people with chronic lung conditions, their carers, families and supporters. Provides information by phone, mail and email, regular gatherings with speaker, newsletter (Breath of LIFE), and social events.
Q Ms Edna Brown and Ms Jenni Ibrahim
Meetings: SCGH first Weds each month. Wheel-chair, electric scooter and wheeled walker access. Oxygen users welcome.
Ms Edna Brown and Ms Jenni Ibrahim
Members: Currently ~90, Cost $22 a year Budget: Subscriptions & medical institutions; $800 p.a. Contact Info: Hours 9.30am-8.30pm; People: Edna Brown, 9309 9610 and Jenni Ibrahim, 9382 4678. Address: LIFE, c/- LIWA Ground Floor E block, Sir Charles Gairdner Hospital, Perth 6009.
Additional Support The Australian Lung Foundation (based in Brisbane on toll-free 1800 654 301, www.lungfoundation.org.au/) knows of these additional WA support groups, often comprised of patients in local areas: Beechboro
The Altone Improvers
Bentley
Bentley Bronchiatrix
Bunbury
South West Impaired Lung Support Group
Email: life@liwa.uwa.edu.au Website: www.liwa.uwa.edu.au/
Esperance
Esperance Easy Breathers
Perth
Huffers & Puffers (Chronic Air Flow Limitation Support Group)
Rockingham Rockingham Lung Support Group
Founding members Edna and Jenni organise speakers (specialists, nurses and allied health). “We get to hear wonderful speakers, and their researchers get to meet the people who have lung disease so they can put a person to the condition,” Jenni said. “Everyone ought to know the support group is around in case they want fellowship and information – people who understand what it’s like to have a bad day breathing, to be very tired all the time, to be on oxygen and be conscious of people looking at you. And then there’s the information about lung health and how to live well and keep a good attitude to life.” “It’s not that we’re all psychological wrecks or anything like that. Being with others who share our journey with lung disease can make life feel more normal. We don’t sit around grizzling. We are all living with lung disease, with self-management. You can’t manage what you don’t understand,” she said. O
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CLINICAL UPDATE
Nutrition and cardiovascular risk and disease C
By Dr Devind Bhullar, Cardiologist-in-charge Cardiovascular Invasive Laboratories, SCGH. Tel 0411792975
ardiovascular disease is the greatest cause of morbidity and mortality in Australia (22% of the disease burden(1)), and of death world-wide, except in sub-Saharan Africa(2). The INTERHEART study demonstrates that diet and lifestyle factors account for 90-94% of the risk of myocardial infarction(3). In addition to the well recognised cardiovascular risk factors of hypertension, dyslipidaemia, diabetes and smoking, we can now add: metabolic syndrome, obesity, depression, sedentary lifestyle, sleep disorders, vitamin D deficiency, homocysteinaemia and chronic inflammation. Despite standard medical measures, cardiovascular risk factors such as obesity, diabetes and a sedentary lifestyle, seem to be increasing in prevalence(4). Optimal human wellbeing is like a tree. Just as trees need roots to absorb water, trunks to transport both water and nutrients to the leaves, and leaves to convert sunlight into chlorophyll, so too, a human being requires a combination of approaches to optimally fulfil their needs. In reality, is this easy to fulfil? Yes, if we help patients understand and become more involved in their treatment plan. While everyone agrees prevention through good lifestyle and nutrition is better than cure, once someone displays cardiovascular risks, a synergistic nutritional approach to their treatment plan improves patient outcomes.
Omega-3 Fatty Acids Omega-3 fatty acids, mostly found in fatty fish, have appeared increasingly as a nutritional element involved in patient treatment plans, due to studies showing they decrease arrhythmias, decrease triglyceride levels and reduce inflammation(5). The GISSI-Prevenzione study(6) demonstrated in post-myocardial infarct patents given omega3 fatty acids, a reduction in total mortality of 28% and a reduction in sudden death of 47%. The National Heart Foundation recommends 500mg daily of combined EPA (eicosapentaenoic acid and docosahexaenoic acid) for all Australian adults(7).
Vitamin D “Slip! Slop! Slap!” was initiated to prevent skin cancer but may have contributed to an estimated 30% (at least) of Australian adults being Vitamin D deficient(8). Vitamin D is fat-soluble, derived from cholesterol, and is converted by sunlight to its active form, 1,25 dihydroxycholecalciferol. Vitamin D deficiency is associated with hypertension and increased cardiovascular risk(9). Measuring vitamin D levels and appropriate replacement therapy may help to reduce the risk of cardiovascular and other diseases, improve mood and hence reduce cardiac stress. In Perth summer, exposure to 6 minutes of midday sun on the head, neck and arms medicalforum
generates approximately 1000IU of active vitamin D. In Perth winter, approximately 25 minutes of midday sun exposure is required to produce the same amount of vitamin D. The sun exposure required and the amount of vitamin D produced by it varies greatly according to skin type. Sun exposure to increase vitamin D levels needs to be considered carefully, including the risk of sun-related skin disorders.
Salt Hold the salt! Decreasing our daily salt intake from 10g to 7g (3/4 teaspoon) has been demonstrated to decrease the risk of cardiovascular disease by 25% and decreases the risk of dying from cardiovascular disease by 20%(10).
Coenzyme Q10 Coenzyme Q10 is a necessary cofactor for ATP production in the mitochondrial respiratory chain, the fuel to the powerhouse of the human cell. HMGCoA reductase inhibitors are widely used in the management of cardiovascular disease and hyperlipidaemia. People with heart failure or who use HMGCoA reductase inhibitors have been demonstrated to have lower Co-enzyme Q10 levels. Statin-induced myalgia may be improved with the co-administration of Coenzyme Q10(11). Caution should be used in patients on warfarin, as coenzyme Q10 may decrease INR levels(12).
“Breathe in, breathe out” If we physically show patients how profoundly and immediately slow, controlled, deep breathing benefits their heart rate – before and after deep breathing – patients will be more willing to incorporate nutritional and lifestyle habits into their treatment plans.
problems. In addition to conventional medical therapy, there are many nutritional, dietary and lifestyle measures that may assist in the management of our patients’ cardiovascular risk. References (1) The shifting burden of cardiovascular disease in Australia, Access Economics and National Health Foundation, 2005. (2) Circulation 2002;106:1602-5. (3) Lancet 2004;364:937-52.
“We must not see any person as an abstraction. Instead, we must see in every person a universe with its own secrets, with its own treasures, with its own source of anguish, and with some measure of triumph”. Elie Wiesel from The Nazi Doctors and The Nuremberg Code. Optimal patient care requires us to manage all of a patient’s health and wellbeing
(4) Australian Bureau of Statistics. Causes of death 2006. (5) Circulation 1998;97:1029-36. (6) Circulation 2002;105:1897-1903. (7) Heart Foundation Position Statement on Fish, fish oil, n-3 polyunsaturated fatty acids and cardiovascular health, 2008. (8) AusDiab study, Clin Endocrinol 2012;77:26-35. (9) Arch Int Med 2007;167:1159-65. (10) BMJ 2007;334:859-60. (11) Lancet 1989;2:1097-8. (12) Lancet 1994;334:1372-3.
39
CLINICAL UPDATE
Exploiting nanotechnology for therapeutics in pregnancy T
By Prof Jeff Keelan PhD* Head of Laboratories, School of Women’s & Infants’ Health, UWA
herapeutic administration in pregnancy poses unique problems: pharmaceutical companies avoid drug trials in pregnant women due to concerns about safety and litigation, which means prescribing is frequently ‘off label’; medications that treat some illnesses and disorders in pregnancy carry significant fetal and maternal risks and we lack targeted treatments for relatively frequent fetal or placental disorders.
Currently, a drug given to the mother usually reaches all her major organs, including the placenta, where the barrier to fetal drug exposure is incomplete and varies according to gestational age and the structure of the drug. Recent advances in nanotechnology may deliver therapeutic solutions through the selective targeting of maternal, placental or fetal tissues while avoiding unwanted exposure of non-target tissue.
Advantages of nanotherapeutics Drug delivery via nanoparticles offers enormous advantages. Nano-sized drug carriers, typically the size of a virus (5-250 nm diameter), are loaded with one or more drugs that are released upon entering the cell. Nanoparticles can be optimised in terms of their chemical composition, size, uptake properties, plasma half-life/clearance and immunogenicity. They can be tailored to deliver drugs that would otherwise be ineffective when given via conventional routes. They can carry drug cocktails that exert multiple modes of action, and can reduce the dose of a drug by ensuring more efficient delivery.
40
Most excitingly, nanoparticles can be functionalised to target specific cell types or tissues, those that would benefit from the therapy.
Targeted options The placenta, primarily an organ of uptake and exchange with unfettered access to substances circulating in maternal blood, offers an excellent therapeutic target as well as a potential conduit for fetal drug administration. In the past year, several groups have used different approaches to generate nanoparticles that target and deliver their cargoes to the unique cells (trophoblast) of the placenta. Some nanocarriers traverse the placenta to reach the fetal circulation. Targeting strategies, combined with the flexibility inherent in nanoparticle construction, open the door for therapeutics that could be given maternally to improve placental function, or alternatively used to correct a fetal genetic defect without affecting maternal organs. Examples of such nanoparticle-delivered therapeutics include growth factors to enhance placental growth,
antioxidants to combat oxidative stress, or modified nucleotides to alter gene expression. Alternatively, drugs delivered via nanocarriers that avoid placental binding and uptake could be given to the mother to treat (for example) hypertension, mental illness or cancer without running the risk of inadvertent fetal exposure.
How far advanced? Nano-sized delivery systems for use in pregnancy are close to development. Already nanoparticle drug preparations have been approved for treatment of a variety of conditions and are on the market, and their numbers are predicted to grow rapidly over the next decade. The next few years should see this technology exploited in preclinical and clinical trials in pregnancy. ED. *Prof Keelan is a keynote speakers, along with Prof Robyn North and Prof Jan Dickinson, at the upcoming seminar by the Women & Infants Research Foundation “Predicting the Outcome of Pregnancy’ (see below).
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Guest Column
Dysfunctional Gut Symptoms Dr Nathan Francis explores an approach to otherwise unexplained gut problems.
P
rimary care doctors often encounter patients with unexplained gut symptoms. In fact, about 15% of the population suffer chronic symptoms (i.e. lasting at least three months). Traditionally, the patient is diagnosed as “IBS” after normal endoscopies, biopsies and laboratory investigations. Management is symptomatic. I attended a Nutrition in Medicine Conference (May 2012, Melbourne) that explored possibilities, which may interest others.
Research by Dr Jane Muir and others at Monash University Eastern Health Clinical School, has identified rapidly fermentable short chain carbohydrates as inducers of gut symptoms, labelled as FODMAPs (Fermentable Oligo- Di- Mono-saccharides, And Polyol). A diet low in these carbohydrates (e.g. sorbitol is one well-known polyol) can improve symptoms in up to 74% of IBS patients. Dr Muir’s group says that restriction of FODMAPs should be recommended as first-line therapy in constipation and diarrhoea predominant IBS patients. Tests around FODMAP sensitivity are now available in Perth. A group of patients report gluten intolerance despite all tests for coeliac disease being normal. Demand for gluten-free foods has risen. Dr Muir’s group suggests that a proportion are reacting to the FODMAP content of many gluten-containing grains. Gastroenterologist Prof Peter Gibson from the Alfred Hospital explained the GIT-brain connection as being partly responsible for dysfunction in IBS. The enteric nervous system becomes visceral hypersensitive from the exaggerated motility responses, leading to a perception of pain, discomfort and awareness. He says possible factors are genetic, GI infection, stress effects, microflora, food hypersensitivity, and drugs (especially antibiotics). Prof Gerard Holtman, Director of Gastroenterology and Hepatology for Queensland Health, considers IBS as primarily a disorder of the enteric sensory nervous system. Studies have shown an altered rectal sensation in IBS patients, as well as the presence of a post-infectious dysbiosis, raised cytokine release from an inflammatory response to allergens or infection, a psychiatric co-morbidity and an increased incidence in monozygotic twins (i.e. possible genetic link). He also quoted a metaanalysis of four trials confirming insufficient evidence of the efficacy of psychological interventions, although he advises a symptom-driven approach with CBT for any co-morbid psychiatric condition. There is a further dimension. Dr Rob Lobday from the Allergy Unit at Prince Alfred Hospital has looked at the non-nutrient component of foods e.g. salicylates, glutamates and amines. Every meal is a potential chemical assault for the susceptible individual complaining of migraine, angioedema and even IBS. Adverse food reactions can be an interplay of food allergy (IgE-mediated or eosinophilic reactions, or food protein induced enteropathy), and non-immunological food intolerance. Elimination diets followed by challenges remain diagnostic in the absence of accurate tests (www.sswahs.nsw.gov.au/rpa/allergy/). My personal management of IBS, is to exclude serious pathology with a good history followed by appropriate investigations. If the latter are negative, a trial of a low FODMAP diet follows. Difficult cases are managed on merit: a small bowel study especially in the presence of an elevated CRP or iron deficiency (inflammatory disease); a trial correction of hypochlorhydria; checking pancreatic elastase for pancreatic enzyme deficiency; or correction of suspected dysbiosis. O ED. References available on request. For more information on FODMAPs: www.med.monash.edu.au/ehcs/research/index.html medicalforum
You can now prescribe exercise! As part of our commitment to health of Western Australia the team at Obesity Surgery WA, is now offering exercise programmes at no cost. To enrol, we need a referral to our practice for exercise. Everyone gets a health review to check their suitability and will get a personal plan or get to join one of our group sessions. The service is open to anyone who needs a little help to get fitter, even if they are not considering surgery. < Mr Harsha Chandraratna Surgeon Jo Climo > Clinical Nurse & Exercise Co-ordinator
Obesity Surgery WA (08) 9332 0066 SUBIACO
MURDOCH 41
Charity Campaigner
Q Dr John van Bockxmeer (second from left) at Strelley Community in the Pilbara.
Recycled Sports Gear Gives Kids a Fair Game Encouraging disadvantaged children to get involved in sport and lead healthier lives drives young intensive care resident Dr John van Bockxmeer. John van Bockxmeer, an intensive care resident at SCGH, is the face behind Fair Game, a charity that collects pre-loved sporting equipment and redistributes it to Aboriginal and migrant communities. Last year, more than 1400 sporting items were recycled and put to good use in communities in the Kimberley, Pilbara and the Goldfields. John has seen firsthand how sport and fitness can change lives and encourage better health outcomes among disadvantaged groups. “I saw so many preventable lifestyle-related illnesses and realised that we could access these under-serviced sectors using Fair Game as a vehicle for health promotion and community development.” Fair Game has since morphed in a number of directions. John has initiated an indigenous yoga program that’s culturally relevant and delivered in local dialects 42
throughout WA. He’s also trained migrants involved in sporting programs in first aid and works with mental health patients at the Richmond Trust. “Fair Game has evolved rapidly, ever since we realised that the sporting equipment actually inspired an improved approach to health and fitness. We’ve got a unique delivery because we integrate our messages within the program. For example, before a game of football, we’ll smear the ball with sticky goo and afterwards we’ll put their hands under a UV light. The message is, ‘wash your hands!’ The end result is reduced communicable and respiratory illnesses.”
Fair Game has evolved rapidly, ever since we realised that the sporting equipment actually inspired an improved approach to health and fitness.
“There’s a three-pronged approach: recycling sporting equipment, participation activities and community programs – we have got some extremely passionate allied professionals working with us, from physiotherapists to school teachers.” When this 27-year-old medico is not putting old cricket bats and soccer balls to healthy use he’s usually throwing himself at work. “I’ve always tried to have a great deal of variety in my life. I’m heading towards a twinpronged specialty in Emergency Medicine and General Practice which certainly isn’t a standard career pathway. I did an Arts/ Medicine double degree which was a little unusual, too, and I also went to the UK to study urban planning. But Fair Game is my main passion at the moment and the catalyst occurred when I was working at the Port Hedland Health Campus,” John said. John has formed some interesting views about medicine, from his chosen career path to a wider overarching desire to advocate within the international health arena.
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Q Dr John van Bockxmeer and Dr Ashvin Isaac collecting sporting gear at SCGH. “I love the continuity of care as a GP and I’m also attracted to the acute environment in ED. And, with the latter, there’s that adrenaline buzz and the team environment. There’s also an opportunity to make a big difference because 70% of the hospital population comes through ED.”
We’ve got a really good health system compared with a lot of other countries and I think we forget that sometimes.
“I’ve done a lot of travel in developing nations such as East Timor and the idea of working in those areas is very appealing. We’ve got a really good health system compared with a lot of other countries and I think we forget that sometimes.”
of doctors coming through the system and the promise of more if and when the Curtin Medical School’s up and running, the issue of intern placements is becoming increasingly contentious.
There’s no doubt that the workload of young doctors at tertiary hospitals can be taxing. In fact, Medical Forum spoke with John as he pulled into his driveway after a tough ED night-shift. With an increasing number
Q John working in a hospital in East Timor.
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“The long hours are variable and it very much depends on the workplace. I’ve deliberately chosen critical rotations because I think it’s important for doctors to take control of their own learning and professional development. And that’s more so than ever now with so many young doctors in the system. We’re getting watered-down rotations and the experiences of two interns at the same hospital can be entirely different.” “There are a lot of ‘job share’ creations, especially at RPH and SCGH where surgical terms are normally oneperson positions. They’re being split into two, sometimes with a morning and evening shift but in
some rotations there are still extremely long hours for junior doctors.” Tired or not, an ED can be a highly stressful working environment with poor outcomes combined with sad and very human stories. “Working in intensive care at a tertiary hospital you do see some absolutely horrific cases. I haven’t developed my coping strategies to the point I’d like and I go home and reflect on some of the cases. I think it’s important in ED not to switch off my emotions because you need to be in tune with how a patient might be feeling. It is very stressful sometimes and I do get upset. But it’s important to maintain that sense of humanity.” “I think the way we express how we’re feeling is to talk about the case with our colleagues. We’ll say something like, ‘I feel so sorry for her and her family… it’s a difficult situation for them.’ In other words, we don’t talk about our feelings in a direct way. Maybe that’s something we should be doing.” O
By Mr Peter McClelland ED: To find out more about Fair Game, email john@fairgamewa.org.
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Kitchen Confidential
Great chefs are trained by great chefs, who was your greatest inspiration? Joel Robuchon. Once you've trained with him you know you have trained with the best. It gets into your blood and stays there for the rest of your cooking life. You had a stellar career in France, what was your most treasured moment? Living with my grandparents in Paris. It was bitter-sweet as I was so young, working so hard – the hours were brutal. My grandparents would wait up until I got home, sometimes at 2am, and give me dinner and talk to me about my day. They knew I needed a lot of support and love and I was forever grateful to them for doing that. What does the French culinary culture offer the world? What is its great strengths? Technique – there are no short-cuts and good produce is everything. What lured you to Australia? I wanted a change – it was either USA, New Zealand or Australia. My parents knew Wolfie Pizem and he was so welcoming. I came for a few weeks to check it out and I knew immediately that I wanted to live and work in Australia. What inspires you about the food culture here? The produce is great and you have all these different cuisines spilling into each other. I love the lifestyle. It is less formal than Paris – I'd say less intense – food is like a religion in France – here, it’s sport! Some restaurants are doing it tough right now, while you are expanding. What gives you the confidence to establish a restaurant here in WA at Burswood Entertainment Complex? I have not expanded until I felt I and my team were ready. I'm a worker – if you come to my restaurants, I'm there in the kitchen. Confidence comes with experience and I've been doing this for a long time now. There’s a real buzz in Perth dining circles about French cuisine at the moment and in particular the bistro style of restaurant. Why do you think that is?
10 minutes with... Guillaume Brahimi
I'm not sure why the buzz – I just hope the buzz will get louder and stronger when I open!
French chef Guillaume Brahimi is a regular on our TV sets, now he’s set to open open his signature bistro at the Burswood complex this month, we’ll be seeing a whole lot more of him.
What other West Australian produce excites you?
I notice in the menus at your Sydney and Melbourne restaurants you feature scallops from Rottnest Island and truffles from Manjimup. What is it about these two that impresses you? The flavour, texture – the people that farm them are world class. I'm genuinely excited to be opening in Perth. I think as a city and lifestyle it’s pretty difficult to top.
The wine – when I have a few days off, I'm going to head South and visit the wineries. On my list is Leeuwin Estate and Cullen Wines. What can Perth diners expect at Bistro Guillaume?
GB: Near Versailles.
Good honest food that's big on flavour in a stylish setting. Bistro Guillaume in Melbourne has a great energy – it’s relaxed in that people have a good time, but the service and food are precise.
Who did the cooking when you were growing up?
What is the one dish on the menu that reminds you most of France?
My mother! My father was not interested. Maman is a great cook – when she comes to visit us in Australia, I always ask her to cook. I think everyone loves their mother's cooking – it’s comforting.
My Roast Chicken with Paris Mash
Where did you grow up?
What did she teach you that you still draw inspiration from today? Mum would never rush anything – and she always cleaned as she cooked. What is your most abiding food memory of childhood?
When you close your eyes, what do you smell? My new baby son Loïc. Is there a better smell than a baby? What would be your last meal? Easy – Wagyu beef with Paris Mash accompanied by a worldclass Burgundy.
On Sunday, Mum would cook cous cous dishes. I still dream about them. When did you decide that food and cooking were your future?
By Ms Jan Hallam
I didn’t like school. I struggled academically probably because of undiagnosed dyslexia. But when I cooked I felt sure of myself. I left school at 14. I don’t regret that but there's no way my children will be doing that. 44
medicalforum
Wine Review
Barwick BIG IS BEAUTIFUL AT
Q Dr Martin Buck 2011 White Label Sauvignon Blanc Semillon
Barwick Estate is a large operation with 200ha of their own vines located in the premium areas of Margaret River, Pemberton and the Blackwood River. Established in 1997, Barwick Estate produces more than 120,000 cases of wine annually and exports widely. The vineyard philosophy is to maintain a healthy vineyard environment with minimum environmental impact and to encourage bio-diversity. Current winemaker Nigel Ludlow has been based in Margaret River since 2007 having worked as “fly-in winemaker” in many overseas locations. Barwick Estate has four wine ranges with the Black Label and Collectables using premium singlevineyard or selected parcels of fruit. White Label wines are wines blended from all vineyards in the stable.
This is almost a 50/50 blend of the two varieties from select vineyards. It’s a lively blend with plenty of lime, passionfruit, capsicum and herbs with a clean palate. Blending a small portion of barrel-fermented wine adds complexity to a tropical palate. A good wine for seafood dishes. 2011 Black Label Sauvignon Blanc With premium Margaret River fruit and some barrel fermentation makes this wine stand out from the usual varietal from across the Tasman. There are aromas of cut grass, green beans and spice with hints of oak. The palate is well balanced, complex and with a touch of sweetness. A wine well suited to Asian dishes. The 2011 White Label Shiraz This current release wine is still young and developing with its fruit/tannin balance needing to settle further. It’s a big wine with 14.2% alcohol and aged in French and American oak. It will benefit from a little age. 2009 Black Label Cabernet Sauvignon If you prefer your Margaret River wine to be a Cabernet then this is a cracker. It was well-credentialed at the Decanter Awards. It has a fabulous nose of mint, plums, cassis and oak and a faultless palate of well-integrated tannins with big fruit, chocolate and spices. Nicely aged in French oak and ready to drink now but best consumed sitting down with a solid 15% alcohol. Perfect for red meat dishes. 2008 Collectables Blackwood Valley Cabernet Sauvignon Just when I thought life couldn’t get better, this Cabernet arrived in my glass. It’s a typical cool-climate Cabernet with all the punch of great Bordeaux. It’s been matured for 18 months in French barriques and weighs in with 14.5% alcohol. This is a limited-release wine with shouldering aromas of plums, blackberries and sweaty leather. Great fruit and oak integration complemented by spice and cassis. The wine highlights the quality fruit of the Blackwood Valley and was my favourite in the portfolio.
WIN a Doctor’s Dozen! What’s Dr Martin Buck’s favourite wine in the Barwick portfolio? Answer:
...................................................................................................................
ENTER HERE!... or you can enter online at www.MedicalHub.com.au! 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, September 30, 2012. 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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Please send more information on Barwick Estate offers for Medical Forum readers.
45
Satire
Just a Breath of Fresh Air Resident Medical Forum satirist Wendy Wardell ponders the complexities of the human condition without running out of puff. Breathing – the most basic of biological processes and the secondbest thing most living people do, next to having a pulse. Yet what starts with a simple smack on the arse when we’re born needs an entire medical specialty to help us get it right for the rest of our lives.
acrid internal organs or possession by the Demon of Poor Personal Hygiene.
And what happens when good breath goes bad? In the wrong lungs, air can become an offensive weapon.
If you think you might find it hard to sleep snuggled up in the business end of a wind turbine, why on earth would you even consider hitting the hay with a snorer? Possibly a man's inability to breathe freely through the nose and mouth bestows compensatory abilities on his ears that have flow-on benefits in other areas of the relationship. (This is purely conjecture, in case you thought I might have checked the science behind this.)
Take, for instance, halitosis – the ability to stun prey at 10 metres without lifting a finger. It's just air that's been inhaled, run past a few alveoli and exhaled again. Where and how does it acquire the foetid bouquet of a teenaged boy's gym bag, with upnotes of a Delhi dumpster on a hot night? The sufferer may be unaware of his problem, thinking it’s quite normal for people’s eyes to water uncontrollably when in conversation at a party, or the milk in their cereal bowl to curdle at the first spoonful. When reality hits, it’s a mortal blow to self-image, implying
Snoring is an even worse affliction, similarly inflicted on innocent others. This has to be the single greatest cause of unhappiness in the bedroom other than finding the wrong person occupying it. Even a partner who does a nightly crocodile death-roll with the duvet pales into insignificance next to a chronic sleep apnoeac.
But as evolutionary adaptations go, it's like a tortoise growing an aerofoil. No one is going to be in the mood for boudoir hijinks if they have been driven to the very edge of reason 327 times during the night.
THE Ultimate
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The standard advice to snorers' longsuffering bed partners was to ‘roll them over’. Where to? The centre lane of the freeway? My mother was once told she should sew cotton reels onto the back of my father's pyjamas. Quite honestly, she could have welded an entire overlocker on there and it wouldn't have made any difference to a nightly nasal chorus that triggered landslides on distant islands and motivated primitive tribes to make sacrifices to the angry volcano god. Not unreasonably, living with this, cast my mother into a bad mood, which spanned the best part of seven decades. Of course, we also have to consider the environment. Can the earth afford the pollution of 14 billion carbon dioxide-exuding human lungs? It would be tempting to legislate that certain people should breathe less (be afraid, Canberra, be very afraid) but it’s an idea that’s unlikely to fly. Maybe we just have to hope that respiratory physicians can work out a way of getting trees to pant a bit harder.
cure FOR SNORING
medicalforum
funnyside e Q Q Snail Male
Q Q Raising the bar
Paddy's racing snail was coming last all the time so he decided that he would take his shell off before the next race. Mick sees him after the race and asks how his snail did this time. Paddy says "terrible....if anything it made him a little more sluggish!"
Two guys are sitting on a bar stool. One starts to insult the other. He screams, “I slept with your mother!” The bar goes quiet as everyone listens to see what the other man will do. The first again yells, “I SLEPT WITH YOUR MOTHER!” The other says, “Go home, Dad, you’re drunk.”
Q Q The Space Race When NASA first started sending up astronauts, they quickly discovered that ballpoint pens would not work in zero gravity. To combat the problem, NASA scientists spent a decade and $12 billion to develop a pen that writes in zero gravity, upside down, underwater, on almost any surface including glass and at temperatures ranging from below freezing to 300C. The Russians used a pencil.
Q Q Dilemmas of diagnosis A woman rushed to see her doctor, looking very much worried and all strung out. She rattles off: “Doctor, take a look at me. When I woke up this morning, I looked at myself in the mirror and saw my hair all wiry and frazzled up, my skin was all wrinkled and pasty, my eyes were bloodshot and bugging out, and I had this corpselike look on my face! What's WRONG with me, Doctor!?” The doctor looks her over for a couple of minutes, then calmly says: “Well, I can tell you that there’s nothing wrong with your eyesight.”
Q Q What do you call a monkey in a minefield? A Baboom!
Q Q One-liners from
Billy Connolly
"My parents used to take me to the pet department and tell me it was a zoo." "So, have you heard about the oyster that went to a disco and pulled a mussel?" "Never trust a man, who when left alone with a tea cosy... Doesn't try it on." "What always staggers me is that when people blow their noses, they always look into their hankies to see what came out. What do they expect to find?" "Who discovered we could get milk from cows, and what did he THINK he was doing at the time?"
Q Q Taxing Times If an accountant's wife cannot sleep, what does she say? "Darling, could you tell me about your work."
What is the definition of "accountant"? Someone who solves a problem you didn’t know you had in a way you don’t understand. How do you know when an accountant is on holiday? He doesn't wear a tie and comes in after 8am! Why did God invent economists? So accountants could have someone to laugh at. What's the difference between an accountant and a lawyer? The accountant knows he is boring. What does an accountant say when you ask him the time? It's 9.18am and 12 seconds; no wait - 13 seconds, no wait - 14 seconds, no wait... Why did the accountant stare at his glass of orange juice for three hours? Because on the label it said ‘Concentrate’.
Q Q In the Boss’s Corner A junior manager, a senior manager and their boss were on their way to a lunch meeting. In the taxi, they found a lamp. The boss rubbed it, and a genie appeared. ''I'll grant you one wish each,'' the genie said. Grabbing the lamp from his boss, the eager senior manager shouted, ''I want to be on a fast boat in the Bahamas with no worries.'' And, poof, he was gone. The junior manager couldn't keep quiet. He shouted, ''I want to be in California, with beautiful girls, food and cocktails.'' And, poof, he was gone. Finally, it was the boss's turn. ''I want those idiots back in the office after lunch.''
TOO FUNNY TO STAY IN THE CARPark Some people where their heart on their sleeve, some put it on the back of their car! Some snappers got happy with their mobile phones and sent us these examples of numberplate tagging.
Do you know who these docs are? We’d love to hear from you, and we’d also love to publish some more car-plate humour, just drop us an email at editor@mforum.com.au. And don’t forget, photographers, the theme for October’s picture spread is “And … Action!”. Send your photos to editor@mforum.com.au by September 13.
medicalforum
47
Musical Theatre
The Very Model of a
Modern Operetta Gilbert & Sullivan’s Pirates of Penzance gets a boy-band makeover.
“We get people going ‘Oh My God, I really didn’t want to come and see this but I really loved it’. That’s partly down to our approach but it’s mostly to do with the fact that Gilbert and Sullivan were so witty and satirical and clever. They used to love poking fun at the government and the upper classes – people in positions of authority and power – and we all still enjoy that.”
How to invigorate a 130-yearold musical satire about pirates, wenches and hapless naval officers? Easy! Cast handsome young men into every role, throw a skirt over a couple of them and ask them to sing very high. That’s what producerdirector Sasha Regan did in a small 50-seater theatre in South London with Gilbert & Sullivan’s Pirates of Penzance several years ago and now she has an international hit on her hands. Perth is set to enjoy this romp next month but don’t go thinking you’ll see a send-up, not one note or word is changed from the original. Sasha explained how it all came about. “I run a tiny 50-60 seater black box theatre off the West End on South London and it’s an environment where you can experiment without the commercial pressures of staging big shows,” Sasha said. “When the idea of doing Gilbert & Sullivan came up we wanted to do something fresh so we looked at the concept of an all-male cast.” “But they’re not in drag. We’ve taken the approach of a school production, so they’re young boys playing dress-ups and audiences really appreciate the fact that we didn’t mess around with the text. I was a bit wary about the Gilbert & Sullivan 48
Society, who are traditionalists, coming to see our show and not liking it. But they have absolutely loved it and embraced it because we haven’t changed the score and it sounds stunning.” It’s not only lovers of G&S who have taken to Pirates. Not long after the season ended in her own theatre, came gigs on the West End playing to thousands and soon they will be heading to Australia for a national tour. “People will have a lot of fun at the show. The pirates run through the auditorium and sing all over the place. When they sing falsetto, you close your eyes and you wouldn’t know it was an all-male cast. It sounds absolutely beautiful. And we have really strong choreography, which is something traditional G&S don’t do and that has refreshed the production.”
“I think Gilbert and Sullivan would enjoy what we’ve done. The comedy is already there and the boys are playing the humour absolutely straight, which of course just makes it funnier and funnier.” “I think they would love the fact that we have a managed to grow a new audience for their work after more than 100 years. They’d be very chuffed about that.” O
By Ms Jan Hallam
WIN See the Competitions page for your chance to win tickets to see Pirates of Penzance.
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Competitions
Entering Medical Forum’s COMPETITIONS has never been easier! Simply visit www.medicalhub.com.au and click on the ‘Competitions’ link (below the magazine cover on the left).
Ballet: Pinocchio Soon-to-depart artistic director of the West Australian Ballet, Ivan Cavallari, presents his own choreography of this classic story of the puppet who becomes a real boy and son to the master wood-carver Geppetto. And what a swan song it will be. Charming, heartwarming and totally entertaining, this ballet will enthral young and old alike and the sets by Edoardo Sanchi will make it a night to remember. His Majesty’s Theatre, season starts September 15
Theatre: Boy Gets Girl Journalist Theresa goes on a blind date with computer nerd Tony and while there were no sparks it was a pleasant enough experience but not pleasant enough to repeat. But rather being the end of the story, it’s just the beginning in this tight, taut thriller. This great cast including Alison van Reeken, Steve Turner and Myles Pollard will have you on the edge of your seat. Heath Ledger Theatre, season starts September 15
Some of the opera world’s most prized gems are to be found in this great Puccini opera. Nothing beats it for high drama as the fleckless American naval officer Pinkerton abandons the exquisite Butterfly, heartbroken and pregnant, and it contains some of the most beautiful music in the repertoire. Soprano Kelly Kaduce is in the title role for WA Opera. His Majesty’s Theatre, season starts October 23
This film is a heavy hitter – it’s won the Camera d’Or at Cannes and the Sundance grand jury prize and it has a slip of a girl as its hero. Six-year-old Hushpuppy (Quvenzhané Wallis) goes in search of her mother when faced with the declining health of her father and a world that looks as if it’s coming to an end. In Cinemas September 13
COMPETITION WINNERS From the July issue
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Mundaring Truffle Festival: Dr Narelle Vujcich, Dr Simon Carrivick, Dr David Day, Dr Carolyn Bracken, Dr Sue Bant, Dr Melanie Chen, Dr Jack Faigenbaum, Dr Kon Kozack & Dr Michel Hung
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J U LY 2 0 1 2
Movie: Beasts of the Southern Wild
The very happy wine winner of the Churchview Doctor’s Dozen is Dr Ben Clark. The infectious diseases physician is most definitely a ‘red’ man and loves the rich, robust wines from South-West WA. And pretty soon he’ll have a very good reason to open a bottle or two. Ben intends to leap out of a perfectly good aeroplane courtesy of a 40th birthday present. Thank goodness for parachutes and screw-caps. The latter are so much easier to remove when your hands are shaking.
MEDICAL F ORUM
Opera: Madam Butterfly
A Wing and a Prayer with Churchview
Major Sponso
rs
This Girl Laughs, This Girl Cries, This Girl Does Nothing – theatre: Dr Stephen Sun Ice Age 4 - family movie tickets: Dr David Chew, Dr Avril Chong, Dr Eric Khong, Dr Kevin Kwan & Dr Yohana Kurniawan Judith Lucy - Nothing Fancy – theatre: Dr Barry Leonard The Mousetrap – theatre: Dr Jean Foster Nutcracker on Ice – theatre: Dr Janina Anderst, Dr Greg Glazov & Dr Sarah Kurian
Musical Theatre: Pirates of Penzance This much-loved Gilbert & Sullivan operetta gets a radical makeover at the hands of British theatre director Sasha Regan for an all-male hilarious romp on the high seas. Nothing is lost of the G&S magic and a lot is added as this new twist to an old tale brings out some special chemistry of its own. Young lovers Mabel and Frederic are at the centre of this romp, as pirates and Her Majesty’s navy come to feather-duster blows. Regal Theatre, season starts October 24
medicalforum
The Sapphires – movie: Dr Angeline Teo, Dr Stephen Rodrigues, Ms Helen McCann, Dr Karen Prosser, Dr Elena Monaco, Dr Hilary Clayton, Dr Nicky Endacott, Dr Shih-Ern Yao, Dr Alan Prosser & Dr Max Kamien Racing Gloves: Dr Derek Chen
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Medical Forum CLASSIFIEDS PRACTICE FOR SALE GIRRAWHEEN Girrawheen Surgery For Sale (Building & Practice). Well established computerised solo practice, purpose built, can accommodate up to 3 doctors Adjacent shop is available for H[SDQVLRQ FXUUHQWO\ UHQW WR D pathology company). 6HFXUH FRPSOH[ /DUJH SDWLHQW EDVH HDVLO\ H[SDQG Genuine buyer only. Please contact Joseph on 0403 270 430 or Email: nmjpham@arach.net.au.
FOR LEASE APPLECROSS Applecross Medical Group is a major medical facility in the southern suburbs. Current tenants include GP clinic, pharmacy, dentist, physiotherapy, fertility clinic and pathology. Both the GP clinic and pharmacy provide a 7 day service. 7KH KLJK SURÂżOH ORFDWLRQ FRUQHU of Canning Hwy and Riseley Street Applecross), provides high visibility to tenants in this facility. A long term lease is available in this IDFLOLW\ WKH VSDFH DYDLODEOH LV P with the current layout including 4 consulting rooms, procedure room and reception area. Would suit specialist group, radiology or allied health group. Contact John Dawson â&#x20AC;&#x201C; 9284 2333 or 0408 872 633 NEDLANDS Hollywood Medical Centre 1HZ IXOO\ IXUQLVKHG P FRQVXOWLQJ VXLWHV RQ QG Ă&#x20AC;RRU DYDLODEOH IRU lease. Phone: 0401 289 276 MURDOCH Murdoch Specialist Centre, brand new stylish large rooms. Please email you interest to admin@sleepmed.com.au NEDLANDS +ROO\ZRRG 0HGLFDO &HQWUH Âą IXOO\ IXUQLVKHG FRQVXOWLQJ VXLWHV RQ ÂżUVW Ă&#x20AC;RRU DYDLODEOH IRU OHDVH Secretarial support available if required.Phone 0414 780 751 BEACONSFIELD Opportunity to lease newly renovated rear building adjacent to medical practice. $SSUR[ VTP WRWDO ZKLFK LQFOXGHV 3 consulting rooms, reception area and bathroom. In prime location on South Street, ZLWK FORVH SUR[LPLW\ WR 6W -RKQ RI God Murdoch, Fiona Stanley Hospital & Fremantle Hospital. Contact E-Mae Lim 0423 282 762 / 9335 9884
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Greater Bunbury Medical Centre Are you ready for a lifestyle change for the better? State of the art non-corporate Medical Centre opens early 2013. GPs, Allied Health staff and Specialists wanted. Employment, contract or tenancies available now various sizes. Contact: 9791 8133 Jill Riggall, Project Manager MARGARET RIVER Long established accredited family practice seeks GP or trainee to replace retiring Doc. Anaesthetics, Obstetric and surgical scope available but not essential. Some afterhours commitment - not onerous. 3KRQH 6DOO\ 9757 2733 for more info.
BUSSELTON GP required by privately owned accredited general practice in Western Australiaâ&#x20AC;&#x2122;s most desired rural location. Well-equipped treatment and procedure room, staffed by two full time registered nurses. Obstetrics, anaesthetics and hospital inpatient opportunities are available. Easy 1 in 7 on call roster. Contact Jill Pontague on 9752 1133 or email jill@busseltondoctors.com.au ALBANY VR GP required to join our 4 Doctor, busy, friendly family orientated practice. Full time or Part time a special interest in Womenâ&#x20AC;&#x2122;s Health would be a bonus. We are Accredited, and an Accredited Teaching Practice, fully computerised, full nurse support DQG DQ H[SHULHQFHG $GPLQ 7HDP with Healthscope Laboratory on site. 0L[HG ELOOLQJ Phone Gaye - Practice Manager 9841 6711 Email: gaye@hillsidefp.com.au BINDOON Fulltime GP required for friendly, progressive rural practice only 60 minutes from central Perth. No after hours or weekends. Accommodation provided in 5 bedroom house with pool. â&#x20AC;&#x2DC; 60-65% of billings dependant on H[SHULHQFH Phone: 9576 1222
URBAN POSITIONS VACANT BICTON Bicton Medical Clinic VR GP required for PT or FT position. 1RQ FRUSRUDWH FOLQLF ZLWK PL[HG billing. Would suit Dr with long term view. In a stable friendly family GP clinic. )RU FRQÂżGHQWLDO HQTXLULHV SOHDVH contact Dr Sam Messina. Mob: 0417 948 551 Email: smess@iinet.net.au Web: www.bictonmedical.com.au KINROSS GPs required. F/T or P/T in busy accredited family practice. For further details please contact Janet or Jackie on 9305 5999 or Email:kinrossmedical@eftel.net.au JOONDALUP Edith Cowan University, Student Health Services. Part time VR GP - Tuesday and Thursdays available from August Interest in Womenâ&#x20AC;&#x2122;s and Student Health. Attractive well equipped purpose built medical centre, accredited, H[FHOOHQW ZRUN HQYLURQPHQW 5HJLVWHUHG 1XUVH VXSSRUW Ă&#x20AC;H[LEOH work arrangements. ECU Joondalup Campus Medical Centre is located in a district of workforce shortage. For information: Dr Robert Chandler Phone 08 6304 5618 Email: r.chandler@ecu.edu.au
LANDSDALE Rare opportunity for a FT GP to join the team at Kingsway Medical Centre. DWS Location. 7KH FHQWUH KDV DQ H[LVWLQJ SDWLHQW base and offers Full time nursing support and onsite pathology. For more information on this opportunity contact: Amanda 0419 045 997 Email: Amanda.piercy@ipnet.com.au
DUNCRAIG Duncraig Medical Centre requires a female GP. )OH[LEOH KRXUV H[FHOOHQW remuneration. Modern, predominantly private billing practice with full time Practice Nurse. Fully computerised. Please contact Michael on 0403 927 934 or Email: Dr Dianne Prior: dianne@duncraigmedicalcentre.com.au GWELUP Gwelup Medical Centre is a busy, accredited, privately billing, non corp, general practice. We require a PT VR GP. ([FHOOHQW UHPXQHUDWLRQ Fully computerised. Great nursing support and pathology on site. Well-equipped procedure room. Enthusiastic, friendly staff. UWA associated teaching practice. Ph Dr Patrick Mc Gonigle 9244 8588 OUTER METRO PRACTICE BEELIAR Full time/Part time VR/NON VR GP required to join our privately owned, fully computerised non-corporate family practice. Fully supportive including Practice Nurse and friendly working environment. Contact Dr Jagadish on 0413 879 023 Email: jags.krishnan@gmail.com Or Caroline â&#x20AC;&#x201C; Practice Manager 0427 342 488 / caroline@theheights.com.au SOUTHERN RIVER Full Time/Part Time GPâ&#x20AC;&#x2122;s required. Modern, friendly, computerised, GP Area of Need/DWS Nursing and Allied health Support Occupational health, Travel clinic and Pathology collection centre Contact: (08) 9490 2900 Email: srmc@westnet.com.au NORTH BEACH VR GP wanted for a small beachside VXUJHU\ FORVH WR JUHDW VXUÂżQJ beaches and restaurant strip. Fully computerised practice, accredited, practice nurse, on site pathology and psychologist. Hours negotiable. Please phone Helen or David 9447 1233
OCTOBER 2012 - next deadline 12md Friday 14th September - Tel 9203 5222 or jen@mforum.com.au
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Medical Forum CLASSIFIEDS GOOSEBERRY HILL Part-time GP, Pref. VR, required for our busy, accredited family practice in Gooseberry Hill. We are fully computerised with H[FHOOHQW DGPLQLVWUDWLRQ DQG QXUVLQJ support. Please contact Peter on 9257 1121 Email: RI¿FH#KLOOVIDPLO\PHGLFDO FRP DX
BULLCREEK Come and join us in our New General Practice located SOR. Non-Corporate Practice. We require Full-time or Part-time GP’s for our Surgery. The surgery is Computerised, Private and Bulkbilling. Practice Nurse available part-time. Please contact the Practice ManagerAnnette on 9332 5556
Are you looking to buy a medical practice? As WA’s only specialised medical business broker we have helped many buyers find medical practices that match their experience.
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85% Supplement your income: Are you working towards the RACGP? – we have access to provider number for After Hours work. Are you an Overseas Trained Doctor with permanent residency and working toward RACGP? - we have access to provider number for After Hours work.
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Equipment Provided - WADMS is a Doctors’ cooperative e Essential qualifications: U General medical registration. U Minimum of two years post-graduate experience. U Accident and Emergency, Paediatrics & some GP experience.
UÊFee for service (low commission). UÊn ÀÊà vÌÃ]Ê`>ÞÊ ÀÊ } Ì° UÊÓ{ ÀÊ iÊÛ Ã Ì }ÊÃiÀÛ Við UÊ VViÃÃÊÌ Ê*À Û `iÀÊ Õ LiÀð
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Contact: Jenny Heyden RN Tel: 9203 5222 Mobile: 0403 350 810 Email: jen@mforum.com.au
76
Generous relocation packages available at a progressive rural practice 2 hours from Perth. Collie in WA. is not in the dusty hot North of WA but the only serious mining town in the South West close to Perth. Aside from procedural opportunities, great location and a progressive practice with all the usual modern practice requirements, there is some serious money for relocation and retention available. SIHI is offering very generous payments for GPs willing to commit to the town. There are limited numbers of relocation packages, so first in best dressed! Ideal opportunity for a GP registrar with procedural skills, either finishing or about to finish training. We are an accredited training practice and so there is excellent teaching opportunities and support. We have recently expanded the practice for the anticipated growth in the region so there is loads of opportunity for progressive new Drs. For more information, contact Angela 08 9734 4111.
OCTOBER 2012 - next deadline 12md Friday 14th September - Tel 9203 5222 or jen@mforum.com.au
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