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May 2013

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The Jessups’ Story

Dream home, dream retirement in Mandurah After living in Warwick for 40 years, David and Rhonda Jessup decided to move south to Mandurah to enjoy a relaxed retirement. They had spent a lot of time in the area with regular trips to their beach shack – and decided to replace that shack with their dream home. “We were able to subdivide our holiday property, so we decided to move away from Perth and take advantage of living by the ocean,” said David. “There was a house being built by Webb & BrownNeaves close to our beach house. The design seemed to fit everything we wanted and, as we watched the building process, we were impressed with the quality and workmanship that went into the house. It was from that point that we decided to build our dream home, and we chose Webb & Brown-Neaves to make that dream possible.” David and Rhonda worked closely with Webb & BrownNeaves to create a home that reflected their home’s unique position. “We’re actually on an island within the canals and inlets, which has influenced our choice of colours and furnishings both inside and outside. Our style of home allows us to enjoy a beautiful ocean view of Avalon Bay, with living areas on the top floors. It has a feeling of peace and tranquillity, which we love.”

The Jessups found the building process to be an easy one. “Building with Webb & Brown-Neaves, we found everyone was very helpful, particularly our pre-start consultant, interior designer and building supervisor. Our sales consultant Kim Gartrell was also very helpful and suggested and followed up on initial changes that we wished to make. If ever we decided to build again, we would have no hesitation in choosing Webb & Brown-Neaves.” “We love everything about our home. The layout, the colours, the lifestyle it has given us on the beach, and the quality home that has been built. Our decision to build this home has to be one of the best decisions in our 44 years of marriage.”

Top tips from the Jessups > Do your homework and have a clear budget in mind. > Look at display homes to find a builder who offers attention to detail, good workmanship and has good work ethics. > Build with people who are happy to spend time with you, answer questions and offer advice in all areas of the building trade.

Fo more stories on how other West Australian families For have built a home that truly defines them, download your ha free ‘Your life. Your home. Your style.’ magazine. fre

Download at wbhomes.com.au/yourstyle or call Steve Connelly on 6365 2945 for your free copy.


Contents

Major Sponsors Heenan Lam Skin Pathology

FEATURES

GUEST COLUMNS

8 Nathan Sharpe: Life

after the Final Siren 12 Staying On: Choosing Rural Medicine 14 The Pain of Change: Chronic Pain Management 24 Doctor in Uniform

NEWS & VIEWS 2 Letters:

• Midland Health Campus Concerns: Dr Olga Ward, Dr Maria Garefelakis and Dr Steve Blackwell • SJOG Response, Dr Allan Pelkowitz • Anti-Catholic/Christophobic Opportunism?, Dr Catherine Hurworth • Crushing Weight of Bureaucracy, Dr Don Prendergast • Confidentially Speaking, Prof Max Kamien

6 Editorial: Doctoring

is About Caring 11 Have You Heard? 18 Shenton House Opening 20 KOPE: Dealing with Kids Pain 21 Healthway Research Dr Rob McEvoy

22 ICT at Fiona

Stanley Hospital 23 ePrescribing and Duty of Care 26 Caring for the Mental Health Carer Mr Peter McClelland

29 Dr George Jelinek:

19 Management of

WA’s Work Injured Needs Reform

8

Little Time to Listen

Ms Lyn Mahboub

34 Smoking in Those

With Mental Illness Ms Joyce Vidot

CLINICAL FOCUS Biopsy for Melanoma C/Prof Peter Heenan

36 Angina with Normal

Coronary Arteries

12

Dr Eric Whitford

37 Serious Painful

Eye Conditions Dr Boon Ham

39 The Impact of HPV

Vaccination on Cervical Neoplasia Dr Paul Cohen

41 Support Group:

MIFWA

41 Practice Tip 43 Joint Injections:

Trigger Fingers and Thumbs

14

Dr Mike Eaton

LIFESTYLE 44 A Diamond as

Big as Kal 45 WA Medical Art Society 46 Kitchen Confidential

Shannon Wilson, Terrace Hotel

47 Wine Review:

Windance Estate

Ms Jan Hallam

48 Vika Bull Sings

32 Hyperbaric Medicine

Etta James

Mr Peter McClelland

Working Outside Clinical Guidelines 34 Beneath the Drapes 35 Medical Marketplace

28 Many Questions,

7 Sentinel Node

Doctor Heal Thyself 30 Nursing in the Future

33 MedicoLegal Q&A:

Dr John Salmon and Dr Stephanie Davies

49 Local Answers to

24

Poverty 50 Heavenly Music, Wicked Sounds 50 Expanding the Mind 51 The Funny Side 52 Competitions

T S TH E N E X U M ! IS M ’t N O D DRUM FOR DOCTORS ils medicalforum

r deta See P18 fo

1


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 Thinking Hats 2

Letters to the Editor

Midland Health Campus concerns Dear Editor, Medical Forum and Dr Marc Rumpus have managed to raise my concerns, so I can only echo the sentiments published (Pass the Parcel – Midland Health Campus, April edition). I caught an interview with Health Minister Dr Kim Hames that fascinated me – he stated that although these services (IUCD, vasectomy, lap steri, STOP) would not be available under SJOG administration, that “local GPs and KEMH would be able to provide the services instead”. Well, we are the local GPs who provide the services and I can tell you that if the patient needs a GA, we don’t have an alternative hospital in which to admit the patient. I’m sure that KEMH will be totally thrilled at having their already lengthy waiting lists increased – a tertiary referral centre doing simple, secondary referral procedures. I hope they have a vasectomy ward in the funding arrangements. It’s all very well to tell the GPs to do these under local in their own practice, and I can indeed do this, but not all men are willing to have a painful needle in the scrotum, and when they sit up to have a look (is it the same as the sheep, doc?) they have a tendency to faint and fall off the bed. We usually don’t have enough assistance, equipment or privacy in the average GP surgery for vasectomy to be really viable and men often want at least a little sedation, which raises issues of reversal, recovery and resuscitation. Likewise, we do put in IUCDs in the surgery, but I distinctly remember the last difficult patient for whom I put one in under GA, cervix rock hard, retroverted uterus and a pinpoint OS that had to be dilated with a nasolacrimal duct dilator because of scarring after a cone procedure. This wouldn’t have been at all possible in the GP surgery – and was the reason for using a GA, but not a reason for a referral to KEMH for the registrar list. Regardless of how well-resourced GPs may be to perform these procedures in their surgery, the problem is really that a public patient in a public hospital being funded by the public and secular sector is being refused a procedure on the basis of the administration of the hospital being Roman Catholic in ethos. Having the contract to pay the staff shouldn’t translate into restricting the services that can be offered by the doctors to their patients. I will happily concede that contraceptive procedures can be restricted by the private wing that will act as a Catholic hospital, but I don’t think this should extend to what is effectively being marketed as the replacement for a very functional but crowded and busy public hospital. Evidently the public purse is paying the piper, but not calling the tune here. I would love to hear what the AMA thinks.

Dear Editor, In response to the recent commentary (Pass the Parcel – Midland Health Campus, April edition), questions do indeed still remain. How exactly will the state government ensure that the range of reproductive services remains available within the health campus so that consumers, especially women, have access to a timely and convenient service? Will alternative referral pathways be easily negotiated by consumers and their referring doctors? There is no debate that adverse outcomes are associated with short inter-pregnancy interval and unintended pregnancy. Why can’t women wait until their postnatal visit? Many couples resume sexual activity before six weeks and ovulation frequently returns before six weeks in women who aren’t fully breastfeeding, hence contraceptive counselling needs to be provided much earlier than this. What about a three-week postnatal visit? Even with appropriate referrals, the necessity for another visit can be a barrier. Postpartum contraceptive methods are commonly offered to those at high risk of early repeat pregnancy in public maternity units and administered before they leave the unit. Tocce et al (2012) demonstrated that adolescents who had immediate post-partum placement of contraceptive implants had high continuation rates at one year after delivery and significantly decreased ‘rapid repeat pregnancy’ compared with control participants. Guiahi et al (2011) looked at the impact of a policy change that occurred in a US hospital in 2007. The practice of immediate “medically indicated” postpartum depot medroxyprogesterone (DMPA) came to the attention of the institution’s administration and was subsequently discouraged. Women were then instructed to delay initiation of DMPA until their six-week postpartum visit or obtain DMPA injections at an outside institution. The authors found that women who received immediate postpartum DMPA were significantly less likely to have a repeat pregnancy at their institution within one year of their delivery. Family Planning WA requests reassurance from the Midland Health Campus that consumers will continue to be offered information about all contraceptive options and have seamless access to their contraceptive of choice. Dr Maria Garefalakis, Medical Director, and Mr Steve Blackwell, CEO, FPWA Sexual Health Services References on request St John of God Health Care Response and more letters continue on P4

Dr Olga Ward, VMP procedural GP

Scan the QR to tell us what you think or email editor@mforum.com.au medicalforum


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3


Letters to the Editor

Sjog Response Thank you for the opportunity to respond to the sincere queries about St John of God Health Care’s plans for managing reproductive services at St John of God Midland Public Hospital. Before taking up medical administration, I was a GP in New Zealand for 15 years and I fully understand the frustration that arises when solutions are perceived to be imposed unilaterally on primary care. One of the main reasons I was appointed to the position of Director of Medical Services some three years before the opening of the hospital is precisely to engage early with local doctors to discuss areas that might change when the new hospital opens and to work out new options for patient care that might arise. This will also ensure that, by the time we open in late 2015, all local doctors will be fully aware of where in Midland various services will be provided, so they can continue to provide a good referral service to their patients. Together with Perth Central and East Medicare Local, I am hoping to discuss with local GPs agreements over pathways to care that might assist with speedier outpatient and inpatient elective care in all areas of the hospital and will talk about how this might work, what already exists and what can be improved. The purpose of these activities is to work out how and where these services will be provided in the public hospital system. This dialogue is already under way and is best conducted in face-to-face meetings among clinicians. Over the next couple of years, St John of God Midland Public Hospital will work closely with all the doctors in the area and particularly GPs to improve care for the local population. Doctors should be further reassured that North Metropolitan Health Service will continue to manage the provision of those reproductive services we will not provide as well as a number of other health services to ensure all patients receive the best possible care. Dr Allan Pelkowitz, Director of Medical Services, Midland Health Campus

Anti-Catholic/ Christophobic opportunism? Dear Editor, My clinical experience is quite different to that of Dr Marcus Rumpus in dealing with the fertility of young women (Pass the Parcel – Midland Health Campus, April edition). Having school-age children myself, I have seen ‘neglected’ children of all socioeconomic backgrounds; ‘planning’ a child 4

does not always ensure it is ‘wanted’; and most ‘unplanned’ pregnancies are not unwanted. Let me give a few real clinical scenarios: 1. Mrs H came to see me for assistance in conceiving another child. She and her husband had four children. The youngest was almost a teenager when they conceived again, ‘unplanned’. Timing was bad. He had just been made redundant. He was stressed at the prospect of a baby. They went to their GP, who suggested she ‘for the best’ terminate the pregnancy, and handed Mrs H the referral. Mrs H wasn’t keen; she wanted her child. With no one supporting her choice, she felt obligated to have the TOP. Outcome: She later sued the GP for not giving her other options; not to mention the grief and guilt she carries, and the impact on her marriage and family. 2. Mr and Mrs B, after successful fertility treatment, go for the 12-week scan, expecting good news. The ultrasonologist, void of emotion, tells them they have a ‘high risk’ pregnancy and rattles off the next steps to investigate the foetus. They explain this is a wanted pregnancy, and they do not plan to terminate it. The doctor’s reaction implies they are irresponsible not to even contemplate the options. Their baby is born healthy. 3. Mrs Y has discovered that WHO has categorised the OCP as a class 1 carcinogen. She also is concerned about the abortifacient effects of the OCP, as she is a devout Catholic. At her six week check-up, her GP had given her a script for the OCP, reassuring her of its safety and efficacy; but she had done her own research. Her GP had not informed her of any of these issues which are very relevant to her. Her GP had ridiculed her questions about natural family planning and not been able to offer any information. With the “contentious clinical scenarios” you have put together, the overall theme is that of the ‘unwanted’ pregnancy, and how the young fertile female can be ‘at risk’ of it. This tendentious condition is poorly defined, if not quite offensive and paternalistic? There seems to be angst in the medical profession to suppress the fertility of as many young women as possible, presuming, of course, that all young women (even if they say they are not) must be sexually active these days. From this paradigm of Pills and TOPs, has the ‘parcel’ actually been unwrapped to understand why Catholics (and they are not alone) are against contraception and abortion? Probably not, yet I hope it’s based on philanthropy, not on assumptions and antiCatholic/Christophobic opportunism? The above scenarios help to illustrate that actually some people value life even if it’s a tough and inconvenient decision. The SJOG policies are based on respect and value for the unborn children that present at ED with distressed mothers; offering them real options. No doctor should expect a woman to want a TOP, even if she is distressed. The dilemma for her is usually that she wants her child but she is afraid of not having support. At least with a culture of life, SJOG will offer real

help to women who do want their unplanned pregnancies. Dr Catherine Hurworth, consultant to Restorative FertilityCare, Helena Valley

Bureaucracy rip-off Dear Editor, I would like to clarify the reported statements attributed to me in the April magazine (Doctors Never Had It So Good? April edition) regarding allied health. I have always maintained that funding of chronic disease management – and general practice generally – has been sacrificed at the expense of the funding of bureaucracy. The level of bureaucracy in this digital age is unnecessary. We don’t need bureaucrats to tell us how to utilise specialists; diagnostic services; or allied health. We need allied health in general practice but we should be able to access them directly. Having a government entity to manage my clinical use of allied health even if it is through a Medicare Local seems unnecessary. The rip-off is in the funding of bureaucracy at the expense of allied health. We have a multi-layered bureaucracy that costs millions and then we are asked to swallow demands to be more cost effective and drive economic models of care. That is appalling. Dr Don Prendergast, Midland

Confidentially Speaking Dear Editor, Before the advent of the Privacy Act, GPs would fax warnings about doctor shoppers doing the rounds to other GPs in their locality. After the Privacy Act this was deemed to be illegal. Repeated Coroners’ reports have shown that this has contributed to the deaths of many doctor shoppers. But Dr Liz Tompkins’ letter about the Albany Hospital’s failure to notify a GP of a patient’s death because it breaches confidentiality (Medical Forum, April), puts a whole new slant on dying with your privacy intact. Prof Max Kamien, City Beach

We want to hear what you think. Send in your letters by May 10 to editor@mforum.com.au medicalforum


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Editorial

Doctoring is About Caring

L

et’s be honest. Future changes in health will be driven by unsustainable costs, no matter which political party runs the show. World-wide trends are drivers, as well as local factors – relative prosperity in Western Australia means more people have more to protect. This is worrying because doctors have become more income focused as the profession has gradually shifted from thinking of itself as a vocation to a business. And the rapid pace of change has not only reduced our workplace attention spans, it has led to some crazy health decisions built on political cycles, and lowered the years that medical leaders can give us without burnout. How do we find exceptional leaders who do things effectively for the greater good and stay around long enough to take others on their journey? How do we maintain caring for others as the dominant focus? The truth is many doctors fashion their working lives around these ideals – they look at patients, reassure them and touch them. Others try to apply the ideals in leadership roles – they see beyond the statistics to

The desire to fix things remains the main ethos of most people in medicine but it’s an ethos under threat. personal care. It’s when you enter the political arena that things can go downhill. The political and commercial careers of individuals and the income of doctors can take precedence. The heart and altruism can go out of what we do. We become another faction and get treated as such, whether we are successful in getting what we want or not. In this edition, we are delighted to highlight the altruism of doctors. Those who want to more effectively help those with chronic disability; who see how a health dollar spent overseas relieves more fundamental needs; or who see ways to improve our public health system. The desire to fix things remains the main ethos of most people in medicine but it’s an ethos under threat. ‘Doctors – The Care Factor!’ is the theme of the next Doctors Drum breakfast, designed to explore this. And talking of caring, there is no doubt

that primary care is at a cross roads. Good primary care saves health dollars, as does moving care from hospitals to the community. Shepherding GPs is possible (witness, 82% bulk billing) and delivery of care through a better coordinated model (watch this space, Medicare Locals) and one that involves patient registration with a GP (intention, Medical Home model) both hold promise. What we don’t have is a system that encourages the cream to rise to the top and acknowledges those GPs who excel, so patients can easily select them on merit. Word-of-mouth can operate while patient opt-in remains. Revalidation is process-heavy and devised by bureaucrats out of CPD’s failure. Plus we have people in the RACGP who seem fixed on the generalist model, an attitude that will stifle innovation and seems blind to the reality that nearly half GPs say subspecialisation is a necessary trend. Money or power does not naturally flow from altruism, but that is no reason to diminish it. We remain advocates for our patients. l

By Dr Rob McEvoy

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Sentinel Node Biopsy For Melanoma S

entinel lymph node (SLN) biopsy followed by complete lymphadenectomy (CLND) for melanoma patients with positive SLN has received widespread acceptance on the basis of its perceived prognostic value and its purported beneficial effect on survival. The influential multicentre selective lymphadenectomy trial (MSLT-1) report in 2006 emphasised a significant advantage in disease-free survival for the biopsy group versus the observation group. It also concluded that SLN biopsy has prognostic value in patients with intermediate thickness (1.2 – 3.5 mm) melanoma and identifies patients with nodal metastases whose survival can be prolonged by immediate CLND (5 year survival rates 72% vs 52%). The analysis of melanoma specific survival, the primary aim of the study, showed no survival benefit for the procedure. The rationale for SLN biopsy is based on the theory that metastatic cells spread in an orderly step-wise fashion from the primary site via lymphatics to the regional lymph nodes, where the cells remain latent before spreading to distant sites, also known as the incubator hypothesis. Alternatively, the marker hypothesis states that primary melanomas metastasise simultaneously via lymphatic and haematogenous routes. If the incubator hypothesis is correct, a marked benefit in survival from SLN biopsy and CLND would be expected. The absence of any significant difference in overall survival (a surrogate for distant metastasis) between the observation and SLN biopsy groups favours the marker hypothesis. The 2006 MSLT-1 report has been criticised on the basis that, although the study was well planned to achieve its primary aim (i.e. melanoma – specific survival), the subgroup analysis which provided the basis for the claim that survival of SNB positive patients can be prolonged by immediate CLND was inappropriate and prone to error. This comparison did not make appropriate allowance for false positives (i.e. SLN +ve which did not progress and cause the death of the patient) and false negatives (i.e. SLN -ve cases in which the patient died due to systemic metastases)

and, therefore, was unbalanced. An alternative interpretation by other researchers used the randomisation and available numbers in the MSLT-1 report to calculate a theoretical risk ratio that compares the survival of sentinel node +ve patients in the biopsy and observation groups. This “theoretical” analysis showed a nonsignificant benefit in favour of immediate CLND in SN+ve patients. The MSLT-1 report highlighted a significant advantage in disease free survival (DFS) for the biopsy group vs the observation group (78% vs 73%). DFS in this context means no evidence of lymph node or other locoregional metastases. It is not surprising that patients who have had CLND have a lower rate of lymph node metastasis because the regional lymph nodes were removed and therefore could not develop subsequent nodal metastases. The absence of any overall survival advantage, furthermore, indicates that both groups have the same rate of systemic metastases.

By Clin Prof Peter Heenan, Consultant Dermatopathologist Peter Heenan graduated MBBS (UWA), and completed his pathology training at the Radcliffe Infirmary, Oxford, where he developed a special interest in skin pathology. After returning to Perth he joined the Department of Pathology, UWA, as Senior Lecturer, later as Associate Professor. Peter established Cutaneous Pathology, the first private skin pathology service in WA, in 1987, combining teaching and research with a comprehensive diagnostic service. He has contributed to the WHO Histological Typing of Skin Tumours, the UICC TNM clinical staging of melanoma, the ACN Guidelines for the Management of Melanoma and was the first director of the WA Melanoma Advisory Service. Peter is a past President of the Australian Dermatopathology Society, past Vice President of the International Society of Dermatopathology and is currently a Clinical Professor of Pathology, UWA.

For individual patients, a negative SLN is no assurance that they remain free of disease in the long term, while a positive SLN does not invariably lead to death from systemic disease. The apparently high rate of prognostic false positivity in SLN means that, for individual patients, prognostication on the basis of SLN positivity is likely to be inaccurate. A more recent study (2010) in UK showed that prognosis could be better predicted if clinicians used combined clinical and pathological data from the pathology report in a model rather than by using the SNB status. l

Conclusions From Alternative Interpretations of MSLT-1 • Result of MSLT-1 primary analysis (melanoma specific survival) – no survival benefit. • Subgroup analysis in the MSLT-1 report is substantially biased. • Immediate CLND for SLN +ve does not prolong survival. • SLN status has no demonstrable prognostic significance for the individual patient.

Heenan Lam Skin Pathology Part of Perth Medical Laboratories P/L (APA): Independent, Pathologist Owned and Operated. Contact Phone: 93863500 • Fax: 93863511 • 26 Leura St Nedlands WA 6005 medicalforum

www.heenanlamskinpathology.com.au

7


Spotlight

The Final Siren Nathan Sharpe recently brought his international rugby career to a close. He’s now in his mid-30s and retirement from the world stage looms large. More than 80,000 fans packed into the Stade de France in Paris for Nathan Sharpe’s first run-on as a Wallaby in 2002. In the ensuing 11 years there’ve been highs and lows, including that nailbiting World Cup loss to England in 2003. The tallest man in the lineout reflects on a stellar career and, just as importantly, looks forward to what comes next. “In some ways I feel I’m starting all over again but I’m excited about the next stage of my life. There’s still so much to do! I do miss the team environment and that’s hardly surprising because I was closely involved with a group of really good players. My overriding feeling running on as a Wallaby was not to be the weakest link in the chain. I didn’t want to let my mates down in a high-pressure environment,” Nathan said. “There are some moments, such as the World Cup loss, that are tinged with a bit of sadness. We ended up on the wrong side of the scoreboard against England and you don’t get more than one bite at a cherry that size.” Nathan has made the move to the mining sector, specifically heavy machinery and labour hire, primarily based in Brisbane but returning to Perth to see his family. “Everything is pretty bullish in Queensland at the moment and coal is obviously a driving factor in that. I’m finding it quite difficult to juggle all my commitments and I haven’t got my work-life balance quite right yet. There’s very much a team focus within the mining industry and that’s helped me to make the transition from a playing career.”

You don’t get more than one bite at a cherry that size! “I’m affiliated with a few corporate organisations in an ambassadorial role and I’d like to develop my public speaking profile. Rugby at an international level helped me develop those skills and I’m comfortable moving from a high-level executive environment to an underground shift-change.” The physical transition from elite professional sport to the workaday existence most of us know so well appears to have progressed smoothly for Nathan. “The last scan I had they told me I had the knees of a 20 year-old so I was happy with that! I’m feeling pretty good at the moment, 8

n Nathan Sharpe

but I guess I’ll have to wait and see if it catches up with me in a few years.” Nonetheless, Nathan stood head and shoulders above the rest – literally! He topped the tape at two metres exactly (nearly 6’7’’ in the old language) and was the ‘go-to’ man in the lineouts. When you’re descending from a great height with a rugby ball held above your head there’s bound to be a problem or two. “Rolled ankles, lateral ligament strains and, with taller guys, there’s a real risk of shoulder injuries due to your arms acting as long levers above your head. My injury list was interesting, but nothing too serious. I’ve had a shoulder reconstruction, knee arthroscope, bicep reattachment, lacerations – including one on my eyeball, front teeth knocked out and a couple of hernias. I guess it might catch up with me in a few years.” Clearly, a productive relationship with medical staff was imperative. “I built up a good relationship with Dr Mike Cadogan at the Western Force and he’s still a close mate. In the course of a professional career you spend a bit of time with the medical people and they have links with the specialists so it’s important to develop a sense of trust between players and support staff.” The issue of performance-enhancing drugs in sport is contentious. Rugby Union seems to have emerged pretty well, so far. “I certainly didn’t see any sign of it when I was playing and we were tested randomly, both post-game and at training. There’d be about four or five players chosen and you’d

Career Highlights • Wallabies 2002-12, 116 Caps • Super Rugby Brisbane Reds 1999-2005, 70 Caps • Western Force 2006-12, 92 Caps Western Force Team Doctors; Dr Mike Cadogan and Dr Gary Couanis

always hope it wouldn’t be you because inevitably you’d have just been to the toilet. Then you’d just have to sit and wait to deliver a sample.” Most international rugby players have got tall tales and true tucked away in their kit bag. So, does Nathan have a biography waiting in the wings? “No, if I was going to write one I’d want to do it truthfully and I don’t see the point in potentially ruining relationships. The truth can be a bit harsh at times so you end up skimming over some things. I’ve had a wonderful career and I wouldn’t want to bring it to a close by being contentious just for the sake of it.” And a last word on the ‘final siren’ from the most capped Wallaby forward of all time? “I’m lucky that I’ve had some control over my retirement. I’ve been able to retire to something rather than from rugby. Not everyone gets to do that. It’s so important to make the most of the professional networks within the sport and to enjoy the game while you’re there. When it’s all over it happens very quickly!” l

By Mr Peter McClelland medicalforum


medicalforum

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Have You Heard? No step down to retirement Come July 1, 281 doctors with limited registration (Public Interest – Occasional Practice) will no longer be able to write scripts or referrals for friends or family. AHPRA is abolishing this category. These semi-retired doctors will be no longer. The task will fall to other doctors, maybe the 181 docs with limited registration working in supervised practice or doing postgraduate training! With 37% of LPIOP docs in WA 65 years or younger, and 83% male, the already overstretched profession is going to feel the difference! In comparison, Queensland has twice the number of doctors as WA, but only half the LPIOP doctors.

The latest is that if you call in your termite pest controller to treat the house the year before conception, it may double the CBT risk. We are not sure what happens in other States but investigations in WA uncovered household over-treatments with carcinogenic organochlorine pesticides, leading to them being banned. The common thread through all this might be DNA damage/protection.

Wise words heeded

Education online RACGP is in partnership with HealthCert, a Singaporean company that has delivered skin cancer courses through Queensland Uni since 2006 and office procedure courses through Monash Uni since 2010. Their new product is GP Clinical Update (see www.gpclinicalupdate.com.au), a slickly presented educational product that covers six areas – respiratory, diabetes, ovarian cancer, dermatology, cardiovascular and mental health. RACGP members pay $295 (non-members $395) and to gain 40 Category 1 CPD points, participants review six online video lectures, attend a face-toface one-day course (10 events, with May 4 in Perth), and do a course evaluation and 30 online multiple choice questions. Sponsors are Pharmaceutical companies LEO Pharma and Servier, JLM Accutek Healthcare (medical devices), and medical defence insurer MDA National.

Pain lobby targets government The pain “industry” (see www. painaustralia.org.au) is keen to see chronic pain listed as a chronic disease as part of federal government strategy, especially with the upcoming election. Painaustralia has sent a press release saying that 40% of early retirements (280,000 Australians aged 45-64) are due to back problems and arthritis, which equals chronic pain. It’s costing the country and effective treatment and management of chronic pain could keep more people working and paying taxes longer (saving $13.7m in 2013, increasing thereafter). A new nexus between health, economics and welfare is needed, according to study author and health economist Professor Schofield. Is she right?

Paediatrician acquitted of insider trading

Telethon trickle feed As they get published in scientific journals, West Australians are being treated to findings from Telethon Institute for Child Health’s part in the Australian Study of Childhood Brain Tumours (AUSCBT), a national NHMRC-funded casecontrol study between 2006-11, which investigates the interplay of genetic, dietary and environmental risk factors for CBT (about 350 cases). So far, findings include that preconception maternal folate supplements halve the risk of CBT, there is no association with maternal or paternal smoking (no press release on this one!), and preconception maternal or paternal exposure to diesel fumes increases risk. medicalforum

As an update to last month’ story, Fremantle Hospital paediatrician Flemming Nielsen has been acquitted of 11 charges of insider trading, with a hung jury on the remaining two charges, which ASIC has dropped. The case involved shares purchased in Vision Systems in 2006, which we do not think is related to the Medical Vision Australia that has been in the news lately over a dropped class action around imported breast implants.

Kids in lockdown at adult prisons and those facing court have hit the headlines again. The President of the Children’s Court, Judge Denis Reynolds, foreshadowed some of these flashpoints in Medical Forum (August edition) and in the case of the mental health of young offenders, Government has listened. Back then he poured cold water on the plan to have a special Mental Health Court saying it would be better to spend that money to increase mental health services. The Government has now announced that juvenile offenders with mental health issues – an estimated 250 a year – would have access to a team of professionals including psychologists and specialist nurses, to provide assessments for the court and support the children.

Peel Health Campus There were a few dropped jaws when it was ‘revealed’ by Health Minister Dr Kim Hames on April 8 that Ramsay Health Care would take over the operation of the Peel Health Campus from Health Solutions WA. Surprising on two counts – firstly, it seems Dr Hames jumped the gun before Ramsay, an ASX-listed company, had told the Exchange it had entered an agreement with HSWA. And, secondly, the swipe he took at former chairman of HSWA, Mr Jon Fogarty. Both put the Minister in some choppy seas. As the news cycle wore on that day, Ramsay made an official statement about the agreement, subject to state approvals and the transfer of operating licences. By late afternoon the story accommodated Singapore-based Mr Fogarty who said he was disappointed that news of “a great development for the people of Peel … has been given a negative slant with a slur on me’’. In the age of the instant journalism the episode reminds us that ‘loose lips can sink ships’ or at least let in a little water. l 11


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Staying On: Choosing Rural Medicine Rural medicine in North West WA is rewarding but it’s not for the faint-hearted. Karratha is the fastest growing town in Australia with plenty of clinical challenges. An early baptism of fire for Des and Gareth Taverner as young doctors in South Africa stood them in good stead for careers in WA rural medicine. A sixmonth contract in Broome in 2007 has morphed into a long-term commitment to the Pilbara region. There’s no traffic gridlock on the way to work, but when they get there it’s not all fun and games. Medical Forum caught up with the two Karratha-based doctors while they were in Perth pushing the barrow for rural medicine. Des was a guest speaker at Notre Dame highlighting the positives of being a rural doctor and Gareth sits on the Prevocational Education and Training Committee (PETC) set up to facilitate the transition from interns and junior doctors to locally trained rural GPs. “It’s the best job I could wish for but I’d be lying if I pretended there aren’t days when I feel like handing in my resignation. The Health Department is a large organisation and it can be a clumsy beast. There are so many levels of bureaucracy spread over a vast State. The work is challenging and interesting but some days I end up so totally exhausted I don’t want to see another human being. There are tough moments and living near Cable Beach doesn’t always compensate for that, but overall I’m happy,” Gareth said.

My last shift in ED was a bloodbath! – Des Taverner Des and Gareth moved from Broome to Karratha in 2010. They both work as procedural VMPs at the 32-bed Nickol Bay Hospital. Des is also closely involved with the Rural Clinical School in Karratha and Gareth has sessions at Onslow and Roebourne Hospitals and Roebourne Regional Prison. Both of them have witnessed the profound social transformation of an increasing population linked with the mining boom and its FIFO workforce. “We’ve been up in the North-West for more than six years now and, when we first got here, there weren’t many doctors who’d been here much longer than that. We certainly heard some horror stories about just how bad it was and a lot of that was linked to staffing levels. When we first arrived in Broome there were eight salaried doctors covering Nickol Bay, Roebourne 12

and Onslow Hospitals and now, with FIFO locums, we’ve got anything up to 20. It’s busy but when we look back we wonder how we coped,” Des said. “It’s quite difficult to estimate the impact of the FIFO population on the health system. Karratha had around 21,000 people at the last census [2011] and, with the mining boom, there’d have to be an additional 10,000. So just on numbers alone there’s a social impact, particularly on young families, and we’re seeing that in Emergency Departments every day. Mental health is another area of real concern and Access To Allied Psychological Services (ATAPS) is increasingly overburdened.” Gareth suggests the medical sector could perhaps use the mining sector’s approach to meeting service demands in remote rural locations. “It would be much better to fly a specialist in and out than not have anyone here at all,” he said. Their training and early experiences as junior doctors in South Africa gave them broad exposure to a range of clinical situations. Some were positive and others highly confronting. “The level of work we dealt with was often pretty complex and that develops your clinical skills. You come across a lot of trauma and I did a lot of pre-hospital medicine out on the road that was very intimidating. Des and I talk about going back for a short stint to get that broad procedural experience but we’re realistic, too. It’s a violent society and that gets to you after a while,” Gareth said. A personal anecdote from Des tells the story of an ED shift that proved to be a defining moment. “Both of us have had experience in large cities. After training in Pretoria, we worked in Durban and Pietermaritzburg. I vividly remember my last shift in ED on New Year’s Eve. It was a bloodbath! I heard the fireworks going off at midnight and 15 minutes later the ward was full of firecracker injuries. Not long after that the stabbings and gunshot wounds started coming in and we had to allocate one consulting room for patients coming through the door DOA. I was 25 years-old and I said, ‘never again!’.” Gareth and Des remain committed to procedural medicine, albeit in different areas. “I find anaesthetics particularly rewarding. In fact, I was on that training program

n Karratha GPs Des and Gareth Taverner with son Nathaniel

before I migrated to Australia and I’m continuing to focus on that specialisation using remote clinical education, which is pretty sophisticated these days. One thing I’d like to see is an upgrade to the hospitals so we can treat people here rather than overburden the RFDS. Aboriginal people are very close to their country and when you put them on a plane to Perth you might as well be sending them to Uzbekistan,” Gareth said. Des has a foot in a number of different camps and loves the diversity that is an integral part of rural medicine. “I get the chance to do a lot of networking because I work with the Aboriginal Medical Service, at Nickol Bay and in private practice. The clinical aspect with women’s health and childbirth combined with my teaching is very satisfying. I’ve got just the right balance and I couldn’t see that happening in the city.”

It’s the best job I could wish for but some days I feel like handing in my resignation. – Gareth Taverner Gareth and Des lived and worked in the UK and, in one respect, it would’ve been easier for them to stay and practice medicine there. “The weather’s not great and it seemed that everyone we spoke to was packing for Australia! However, the UK accepts the South African medical degree and medicalforum


that would have made it easier. The AMC accepts the UK qualification so, in my opinion, there should be the same recognition. I put that argument to the AMC, they said no and we had to sit the exams,” Des said. Gareth takes a pragmatic line on this issue and also comments on the occasionally vexed issue of IMGs. “We don’t begrudge the Australian medical community protecting their patch and the advantage of doing the exams is that it puts us on parity. If there’s a perceived problem with our expertise, then take it up with the AMC. The skill level of overseas doctors does vary and sometimes it’s difficult bringing them up to the required standard. We’ve got a lot of sympathy for the IMGs who struggle and very little sympathy for some who, perhaps, shouldn’t actually be here. As a colleague in Broome said, ‘there are doctors who do medicine to get out of their country’. It’s used as a platform to emigrate.” Both Des and Gareth are very happy to have made their home in Karratha. “It’s an interesting combination of first and third-world medicine. You can get a CT scan in 10 minutes but the Top End of Australia still has massive medical need and some marginalised communities are really struggling. We feel we’re contributing and would recommend it to anyone. You have to leave the coastline to do this kind of work.” l

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Feature

The Pain of Change Chronic pain management is a litmus test for how much the profession can adapt to better manage chronic disease and promote self-care. For about 10 years, evidence has been growing that 80-85% of those with chronic pain do not have anatomical pathology you can diagnose accurately and fix with surgery or some other physical intervention. Spinal pain is our finest example. The best available imaging, more often than not, throws up false positives to confuse us, leaving no test-and-treat model to follow. The majority of patients battle on while a small group with addictive and dependent behaviours pester us for more. What can doctors do to be effective? Not more of the same. Medical Forum talked to some of the innovators who are open to changing what they do. It appears that offering chronic pain patients more tailor-made programs backed by a team of experts gets results – a bio-psychosocial or functional approach. Of course, doctors will need to manage fear of making things worse by skilfully triaging patients to find the minority with radiculopathy or compression problems. And if government is funding change, a biopsychosocial approach done poorly is no doubt seen as a financial black hole. Despite these misgivings, more positive stories are emerging that provide the anecdotes for forming clinical opinions.

Dr Richard Yin helps

patients with chronic pain and musculoskeletal problems. He has done so for many years, using his training in both n Dr Richard Yin manipulative physiotherapy and general practice to good advantage. He asks himself will adjuvant analgesia, facet joint injection, assistance with movement disorders, psychosocial help or other therapies, help? He believes coordinated non-fragmented care is the way to go, and GPs can develop the skill set in amongst their general practice, as he does. “As early as the 1990s, research was emerging as to the psychosocial determinants to disability in those with chronic low back pain. The notion of a biopsychosocial approach is not new, yet despite the huge body of evidence that supports a more integrated approach to these patients, there appears a huge discrepancy between accepted clinical theory and practice.” “Amongst many pain specialists, orthopaedic surgeons, neurosurgeons, and occupational physicians and within a medico-legal context, the emphasis continues to focus on a patho-anatomical model to explain the pain, or direct treatment, or assess disability, when there

Consumer Experience You hear it all the time – ‘You look fine, or you look really well’. You get the message from some doctors it’s all in your head when you should say it’s all in your nervous system.” – Katie Jones

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is overwhelming evidence that structural causes weakly predict pain and disability while psychosocial factors are consistently better predictors.” He said to assist these complex patients experts should follow the evidence. “Changes to pain clinics within public hospitals that reflect best practice are a welcome relief. These include the inclusion of psychological interventions such as cognitive behaviour, mindfulness practices, and structured exercises focusing on improving functionality,” he said, adding that the private sector needed to catch up, including occupational health and medicolegal practice. Otherwise doctors are potentially part of the problem. “When specialists, GPs, or physiotherapists solely focus on pathology and convey this to patients, they undermine the attempts by others trying to address some of the broader psychosocial issues that contribute to the pain.” “Surgeons that tell young patients that they have the back of an 80-year-old for example only support fear-avoidant behaviour which is strongly associated with chronic back pain and disability. Likewise, telling patients that there is nothing wrong with their MRI and that they just need to get back to work, hardly acknowledges the psychosocial dimensions that contribute to pain and disability.” He said health professionals know

Katie Jones knew her teenage symptoms were of ankylosing spondylitis because of her family history. Now aged 37, she has had to give away her work as an archaeologist to try and rehabilitate her body. Her pain is severe enough to claim a disability pension. She has just completed the LEAP (Lifestyle Education Activity Program) program at Shenton Park, run between the psych and physio departments, and she speaks highly of it. “LEAP has been fantastic – I’ve had a huge boost out of it. It was a lot of work but so worthwhile, and I would recommend it to anyone with complex or chronic pain.” “It’s been a long process where I have spoken to a lot of doctors, some helpful and some really unhelpful, then to people with pain and to physios. I began to understand that the mind and body are connected and it takes fitness and relaxation exercises, and a lot of approaches, to be able to manage life and cope with pain.” medicalforum


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that screening for psychosocial factors is important yet few do it. Changing behaviour in health professionals is as difficult as in patients, he suggested.

Dr David Holthouse

is a pain neurosurgeon with good reasons for adopting a more functional model of chronic pain.

n Dr David Holthouse

First, is his reputation. Any unsuccessful operation he does for pain is a blight on his reputation, so the disconnect often seen between imaging and chronic pain is especially important. “You can get people operated on because of a scan and they end up messed up because nobody took a deeper history or looked into the reasons for things,” he said. Second, his professional background assists him with a more holistic approach – a psychotherapy diploma and some general practice. Third, and probably most important, is his personal experiences. “I’ve had pain all my life so it makes it easy to relate to someone with pain. I see patients with far less pain than I and they are not functioning. The only difference between them and me is I know how to deal with my pain.” While at times he feels he deals with too many demanding patients, he falls back on the expertise of a string of different physiotherapists and clinical psychologists he knows. How does he broach the functional approach with patients?

Experiences with the medical profession have not all been positive. “I went to a pain specialist and had some cortisone injections that didn’t do a lot. When I went back to him about what medications and other approaches I could take, because I was struggling to cope and was overwhelmed with pain and quite badly depressed, he said, ‘If the cortisone doesn’t work there is nothing I can do with you. It’s a bit like a cultural thing, like giving birth where Italian women scream their head off and English women take a stiff upper lip. You just need to learn to have a stiff upper lip’. He sent me on my way and I was flabbergasted, appalled and upset because I do keep a stiff upper lip and don’t talk about my pain except to doctors. Most people around me don’t know about it. I just thought – are you saying I’m putting this on and being a sook?” Her best encounter has been the Shenton Park Pain Clinic’s LEAP program. “The thing that I liked, and which I haven’t really experienced before, is the medicalforum

“I tell them that the brain has software and hardware, which is connected. You can do an operation on the hardware but the brain can still recognise pain, which is how phantom limb pain occurs. You have to work on the brain, which is where the software interfaces with the physical thing you fix.” “You can usually predict which patients will listen to you but it’s worth giving them a go. Sometimes I’m extremely surprised, thinking people will not pull their finger out and then they do.” His parting comment was directed at narcotics, which he describes as “a doubleedged sword”. “They can cause central hypersensitisation. I’ve had patients on oxycontin that when I’ve taken them off it, their pain has gone. They get hyperalgesia from opioids. It’s a physical thing, not psychological. Adding in some pregabalin can have a profound effect. I see about one a month like this,” he said.

Dr Stephanie Davies has built

her reputation by replacing the pain specialist – and she’s one – with a team approach that aims to improve n Dr Stephanie Davies patient function, not just reduce their pain. It gets results, makes sense in her setting, and the team know each other well enough now to work together while physically apart, as a “virtual team”.

Non-structural pain makes up nearly all her workload and while clinical guidelines abound – Australia, New Zealand, and Europe – she said they tend to tell doctors what doesn’t work without emphasising what they can do. She has attempted to change that with STEPS (Self Training Educative Pain Sessions) over the last five years. It has reduced waitlists at Fremantle Hospital, more effectively helped chronic pain patients, and gradually changed patient and referring doctor attitudes. The team consists of pain specialists, clinical psychologists, occupational therapists and physiotherapists, working to overcome restrictions on patient function due to pain. “It’s crucial to get the patient to be part of the team. About 70-80% of people who go through STEPs end up ‘getting it’ so it’s much easier to build a team around them. They understand where they are heading and you usually get quite a lot of improvement. It’s a bit like a smorgasbord, there’s a range of possible activities but active management is the key and medical things are added in if they are useful, not harmful. Nowadays, we don’t believe that medicine can do everything.” She said results speak for themselves and the tide is turning. “Some GPs and specialists have changed their practice quite a lot and some have not. There’s a lot of published material but people don’t believe it until they see the patient in front of them. It’s a bit like needing the anecdote,” she said, adding Continued next page

multidisciplinary approach. In the past, I’ve seen different specialists and everyone is focused on their own patch. But with complex pain there are so many different things you need to know. At LEAP we had a range of people, all with very good skills, coming together – psychologist, physio, occupational therapist, anaesthetist, social worker, research scientist – and seeing the whole person and the whole problem.” She said she was impressed by their patient selection process – just eight motivated, focussed and positive people who were there to get the most out of it. How does she feel about the future? “I need to get on top of my pain so I can care for my husband. He developed multiple sclerosis two years ago. We both manage pretty well. I would consider going back to work and doing research from home but I’ve reconciled myself to not working as an archaeologist. My husband and I might be a bit more like 70-year-olds around the garden, but that’s just how it is!”

“There are some pretty big unknowns but I have a wonderful GP and now I’m part of the pain clinic at Shenton Park I feel much more comfortable in having that team supporting me.” What is her advice for family doctors with less experience? “A lot of people with pain are silent sufferers. You hear it all the time – ‘You look fine, or you look really well’. You get the message from some doctors it’s all in your head when you should say it’s all in your nervous system. It’s easy to lose hope, so if you don’t get someone who can suggest you look into different things you can feel very alone and hopeless.” “It’s important for GPs to tell patients you may not get rid of your pain but you can get control of your life again.” At the moment, meditation is her greatest ally. l

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The Pain of Change Continued from previous page

that once convinced, doctors become “advocates” for getting physios and clinical psychs involved. About 3000 patients have now traversed the STEPS program in Fremantle, so there are numerous anecdotes around to shift thinking in Perth’s southern suburbs. Referring doctors know that the team, not pain doctors, will lead patient triage. There’s been a change in what GPs expect when they refer and the STEPS program is now running in one of the northern Medicare Locals, with 270 patients already seen. Stephanie sees the need to both educate and resource doctors. She feels that breaking away from dependence on Medicare bulk billing and funding models will lead to more innovation and time allocated to the patient and liaising with the team.

Prof Peter O’Sullivan, a

physiotherapist researcher with expertise in the management of persistent musculoskeletal pain disorders, n Professor Peter O’Sullivan has developed ‘cognitive functional therapy’ for the management of disabling low back pain. He said there are a number of key things that set patients on the road to recovery. He said doctors must recognise how easy and predictive simple questionnaire screening is for identifying psychological risk factors. “If these factors are identified then that health professional can refer these patients to others who have the skills to deal

with these problems, rather than tell them to swim or do Pilates.” Second, we need to watch our language. “Health professionals who tell young patients they have the back of a 70-year-old or that their disc is worn out need to change their language as they often set a trajectory of fear, anxiety and avoidance. We know these physical findings don’t predict disability.” He said patients who do poorly appear fixated on structural damage and the need to be fixed, while those that do well realise pain is a feature of a sensitised nervous system and have behavioural strategies to manage it. Third is skilful triage of patients. “Pain is complicated and often the sorting is not done well, including sorting out if there is specific pathology or not. That’s really important because you don’t want to be pushing people to move if they have a prolapsed disc and radiating leg pain. That’s where the medical model works really well but it fails in the big group of people in a non-diagnostic basket or with non-specific findings such as a degenerate disc.” As to the initial triage, anyone with a multidimensional view was suitable, who could pick the patients with radiculopathy or stenosis. While imaging may help us to find the 15% we could make worse, there are pitfalls. “The problem with easy access to MRI scanning or the demand of patients to have one, is it picks up a whole lot of stuff which then creates a secondary problem by creating a diagnosis not built on thorough investigation. The amount of abnormal findings on people is huge and their predictive value is really poor but that’s generated a whole approach of trying to

Health professionals who tell young patients they have the back of a 70-year-old or that their disc is worn out need to change their language chase a structure, which might be sensitised but not damaged. That’s where people get caught in this horrible cycle of trying to chase symptoms.” “Orthopods and neurosurgeons triage well but it leaves a big group that end up shopping around because they often don’t get what they want in the pain management system.” He said this big group can get fragmented care, and they often need more because of poor coping strategies. “They end up dependent on what is another passive form of coping [medication] without actively managing their problems.” “Self-management is a huge part of what we teach, which is different to standard physio, which treats symptoms. We try and reinforce that pain may be scary but there is no need to panic. It might not mean you are damaged, it might mean you are sleep deprived or stressed out.” WA Health Network has started educational sessions for GPs and State Health and others have recently launched a website regarding chronic pain management to assist doctors and patients (http://painhealth.csse.uwa.edu.au /index.html). l

By Dr Rob McEvoy

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Joondalup Expansion You may have seen the March advert in The West Australian promoting oncology services with no waiting lists for radiotherapy, plus cardiology and sleep services, all at the fourstory Shenton House, Joondalup. The new building is owned by the Anglican Church and one tenant is GenesisCare, which operates an Australia-wide network of cancer and cardiovascular care centres – best known in WA through Heart Care WA (Mount Hospital), Perth Radiation Oncology (Wembley) and the contracting of radiation oncology to RPH and Bunbury Hospital.

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The basement now houses the State’s first linear accelerators north of the CBD and a sleep laboratory will be operational soon. The complex and Joondalup are going gangbusters, with Perth Radiological Clinic taking a floor, Heart Care WA relocating its Joondalup rooms there, and a 240-bay car park to handle the influx.

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n (L to R) Michael Davis (GM Genesis CancerCare WA), Phil Boyd (GM Heart Care WA), Dr Peter Purnell (cardiologist), Dr Raphael Chee (Director Cancer Services, Dr Scott Claxton (respiratory physician), and Justin Turpin (GenesisCare Shenton House practice manager)

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Guest Column

Management of WA’s Work Injured Needs Reform

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Pain minimisation, productivity and cost benefits – three compelling reasons for an overhaul of our workers’ compensaton system, says pain specialists Dr John Salmon and Dr Stephanie Davies.

he workers compensation system was devised to offer the best possible treatment to enable workers’ return to work and health as soon as possible. But too frequently the opposite occurs with substantially worse outcomes than treatment for the same injuries, which have occurred outside an insurance system. Work-injured people can become the victims of a feeding frenzy for radiological and interventional medical practitioners, insurance doctors and lawyers. The patients’ sensitised, disordered nervous systems go from bad to worse, excessive imaging of degenerative (normal for age) change and resultant surgeries can create symptomatic pathology where there was none. The majority of the protracted claimants never return to work, which has devastating effects on them and their families. There is a high prevalence of psychological dysfunction, and in some cases, drug and substance dependence. This is occurring in an environment of record high levels of employment, unmet demand for workers of all kinds and huge wages. There is clearly no financial incentive to remain off work. Employers should be concerned that they pay such huge premiums for worse outcomes in WA compared to workers’ compensation systems in almost any other jurisdiction in Australia. The current WA system is entrenched in the solo medical model, implacably defended by insurance claims managers and supported by some doctors. Current knowledge of neuroplasticity and capacity for sensitisation to develop in the nervous system of susceptible individuals (‘persistent pain as a disease’) and the complex interaction with the psychosocial environment (‘the biopsychosocial model’) has had a profound impact on our assessment and management of patients disabled by persistent pain. A recent confirmation of this formulation is a large new study from the Australian Centre for Post-Traumatic Mental Health, recently published in the Journal of Clinical Psychiatry confirmed that psychiatric symptoms are a greater contributor than the physical injury itself to disability one year medicalforum

after a serious car or workplace accident and that early intervention to address this aspect would result in significantly less disability. However, we have yet to see any insurance medical assessment that has included a psychosocial risk of chronicity measure such as the Orebro score, anxiety and depression questionnaire scores (such as the DASS 21), or screening tools for Neuropathic or Inflammatory contributory components. In the light of current knowledge it must be considered negligent to conduct an assessment of an injured worker without psychosocial risk assessment. Typically insurance reports are 10 or more pages of remarks about imaging and physical pathology when at least 50% of pathology (including severe grades) is asymptomatic.

… in WA these people are deprived of adequate multidisciplinary CBT-orientated pain treatment until they are in the terminal stages, years down the track, when they are practically unsalvageable. WorkCover WA statistics indicate that over $600m a year is spent on people with work injures in Western Australia. The majority is spent on about 3000 workers who suffered relatively minor musculoskeletal injuries but who remain off work because of persistent pain and fear of being active with pain. These are injured workers who have developed persistent pain enmeshed with psychological dysfunction; this dysfunction is escalated by a frequently highly adversarial workers compensation environment. But in WA these people are deprived of adequate multidisciplinary CBT-orientated pain treatment until they are in the terminal stages, years down the track, when they are practically unsalvageable. The only privately funded intensive multidisciplinary CBT program treatment for injured workers in WA had to close some years ago because of lack of funding support by insurers and WorkCover WA – despite documenting more than 60% return to work before claim settlement in protracted claimants (averaging more than

two years off work). We need, as a priority, a comparative cost and outcome study comparing WA with workers compensation systems in the Eastern states. Absorbing and implementing information from these other models is also likely to return a higher proportion of injured workers to the workforce. This is supported by evidencebased research. Recently WorkCover WA has begun compiling comprehensive return-to-workoutcome and related medical management data. WA’s existing workers’ compensation legislation (which differs significantly between the Australian states), empowers insurance claims managers to identify and dictate ‘reasonable’ medical management. However, the insurers’ imperative, like all commercial organisations, is profit and not necessarily prioritisation of healthy outcomes for injured workers and their employers. State Wide Pain Services (WA) has been reviewing the recent studies in Eastern States [the Concorde study in New South Wales and the Network study in Victoria (presented at recent World Pain Congress in Milan) ] which have demonstrated that systematic evaluation of psychosocial risk factors within days of the injury and early individualised CBT intervention integrated with appropriate medical management results in significantly improved work return outcomes and reduced costs (> 25%). Cost savings should be an irresistible argument even to insurers. However, in WA there appears to be a resistance to the broader integrated multi-disciplinary models which have become the foundation for evidencebased care for people with persistent pain in non-workers’ compensation cases in WA, and across Australia. In WA, individual pain specialists have called for changes over the past few years (or decade) to align clinical management with the Eastern States and embrace the biopsychosocial model and CBT-based interventions. It’s crucial that the dynamic changes between WorkCover WA, the insurers, health care professionals and the people with persistent pain following a work incident changes. l References on request 19


News & Views

KOPE for kids Arthritis and Osteoporosis WA is establishing a pilot education and self-management program for children and adolescents with persistent pain conditions. The Kids Overcoming Pain Education (KOPE) program is a series of one-day workshops catering for two age groups [8-12, 13-17] and their parents, with a half day follow-up workshop. Parents and children/adolescents will attend together at the start of the day and then split into two groups – one for children and one for parents. Both groups will be taught practical coping strategies based on cognitive-behavioural principles, a proven model for working with chronic pain. The groups will be conducted by a multi-disciplinary team comprising of a psychologist, occupational therapist and physiotherapist, all with extensive experience in cognitive-behavioural pain management and working with young people. Co-facilitating will be an adult and a young person who themselves suffer from persistent pain and who are able to manage their condition. The KOPE program, which is being funded by a grant from Telethon7 will be evaluated by an independent research study.

n CBT pain therapy for kids Arthritis WA

The group pilot programs – two for children and two for adolescents – will be conducted between July and November. Referrals and enrolments are sought from GPs, paediatricians, rheumatologists and other health professionals involved in treating children and adolescents with chronic pain.

Jane@easpain.com.au, ph: 0402 277 098 [cc psychologist Mary Roberts, mary.gold_roberts@hotmail.com], or phone Arthritis Foundation of WA on 9388 2199. l

Contact project leader Occupational Therapist Jane Muirhead:

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Research

Healthway Research A small renaissance in health promotion research will place the organisation in the spotlight from competing research applicants and the wider community. Nobody likes being told what to do, so Healthway has had its work cut out defining what is ‘healthy’ and then convincing the wider community. The medical profession is strongly represented on the current board, so how the wider community perceives the board’s deliberations becomes important to WA doctors. Healthway ED David Malone said the organisation takes its approach to any conflicts of interest seriously and as far as transparency and accountability are concerned, he says Healthway has been recognised by the Office of the Auditor General as a Best Practice Agency for the past three years. As an example of situations Healthway navigates, Prof Mike Daube sits on the Healthway Board as the ACOSH representative and also heads the Curtinbased Public Health Advocacy Institute. Legislation behind Healthway stipulates that of its budgeted spend, which is effectively a redistribution of taxes, 30% should be on sports (with a current 70:30 split between community and elite team/event sponsorship) and 15% on arts sponsorship. How much is spent on research is somewhat open to

ervatio m Cons Photo courte sy Tourism Western Australia: Coalsea

Board decisions, with around 13% of the total funding ($2.88m) going to research in 2010-11 and a further $2.6m spent on health promotion research a year later. Healthway says it prioritises research applicants who have a focus on primary prevention and strong links to practice and policy. Having health promotion practitioners or policy makers on the research team makes any application more competitive. Demonstrated links to a health agency that could implement research findings and assist in designing the research also creates priority. A plan to disseminate findings helps. Priority health issues for research are tobacco control, alcohol harm reduction, healthy nutrition promotion, promotion of physical activity/active living, promotion of positive mental health, and Aboriginal health. Grants are not given for laboratory research, clinical studies, research to improve health service provision or research on new causes of disease. To demonstrate the Healthway approach to research funding, it offered these examples: • Multidisciplinary studies of neighbourhood and urban environment design to encourage people to walk, cycle and be physically active, as well as influencing their mental health.

n Par

(Prof Fiona Bull, Centre for the Built Environment, UWA, Adj/Prof Billie GilesCorti, School of Population Health, UWA, and Assoc/Prof Lisa Wood, Centre for the Built Environment, UWA, and others). The research team included GIS experts, planners, architects and legal experts. • A small grant to Assoc/Prof Lisa Wood (UWA) looked at the features of children’s play areas that were most popular and most likely to make kids physically active. She worked with the City of Subiaco and Kings Park Authority to incorporate results into new play areas and influenced the design of the recently built naturescape play area in Kings Park. • Prevention of bullying in schools that led to teacher and parent resources, now endorsed by the Commonwealth Education Department. Healthway is currently funding research into cyber bullying and the best ways for schools/parents/kids to manage it. (Prof Donna Cross, ECU). • Families with a FIFO parent to discover ways to equip these families to deal better with the effects on child/parent relationships. (Assoc/ Prof Stacy Waters, ECU). l

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Technology

Futuristic IT is a Hospital Reality Now In April 2014, ‘the hospital of the future’ opens but as far as IT systems are concerned they are already being rolled out into WA hospitals. When Fiona Stanley Hospital opens, it will be one of the most sophisticated in the country but the team from the Health Department’s Health Information Network are not getting carried away with the potential of all that Information and Communication Technology (ICT) wizardry. “We could have the best technical system on the planet but if it doesn’t work for the health practitioners on the wards, then we haven’t succeeded. We are not an ICT development firm we’re about making hospitals work,” Dr Andy Robertson, acting Chief Information Officer said. “It’s no accident that a doctor was put in charge of ICT. Clinicians have a key role and doctors have a particular role because often they are the ones making the critical diagnostic and therapeutic decisions and IT systems are designed to support that.” So while Fiona Stanley may grab the headlines, ICT developments are healthsystem wide. “We are introducing new systems into hospitals now and training staff as we go. For instance, we have introduced the webPAS patient administration system into Fremantle Hospital, where we trained up a group of ‘superusers’ who have become the local authorities training other staff as they go. Other systems are also up and running at Fiona Stanley – both the laboratory information system and the picture archiving system are in place and people are becoming quite comfortable with those.”

“A lot of work is being done behind the scenes integrating and connecting systems. We’ve already upgraded our clinical management system, which is being rolled out to all hospitals. So these improved functionalities and stability will happen before the doors open on FSH.” However, Andy describes the move towards a digital hospital system and a totally electronic health record as a journey that will take 5-10 years as old systems are replaced. The aim at the end of the journey is to have an integrated health IT system that not only connects the hospital systems but also patients and the general practice 22

n Acting Chief Information Officer, Dr Andy Robertson

and private sectors. While it may not be all about FSH, the truth remains that there’s a lot of curiosity about its IT bells and whistles. So what can clinicians expect and how will it help their workload and their practice? Saving time is one thing. “The clinical portal will enable access (on screen and eventually on tablets and other mobile devices) to all of the patient’s history. Clinicians will be able to order tests, get results back, make internal referrals, write discharge summaries – all from their screen or tablet. That will speed things up enormously,” Andy said. “Doctors will not become computer operators – these systems will give them some practical tools to use. The reality is that doctors have to order tests. They are going to have to write it or do it on a screen. If they can do it on a screen, they will know that when they hit send it will go to where it needs to go (no sticking it in the internal mail and hope it will get there sometime).” “Similarly results of those tests will be sent back to the doctor’s screen immediately they are processed. No more chasing results. Being able to connect to a consultant’s booking system means everyone involved can plan their day efficiently, and the same goes for outpatient clinics.” Security is paramount with access restricted and discretionary. “I maybe chief information officer but I can’t access clinical data because I don’t need to see it. Each of the clinicians who need to see data for their day-to-day work has approval to access it within our intranet but it is very controlled and is based on an individual’s specific role. There is a dedicated team whose role it is to ensure the security of the

system but there will be challenges as we move to a more mobile system.” Andy says there’s another piece to the efficiency puzzle that’s not necessarily IT related but critical to its success. “We are doing a lot of work around work flows and processes to ensure we are being as efficient as we can. A system like webPas, for instance, means a patient doesn’t need to keep retelling their story, in fact as each clinician sees the patient, that story should get richer. With the patient’s history loaded into the clinical manager, you get a much better idea of how the patient is progressing.” You wouldn’t be human if you couldn’t be carried away with the potential of some of the ICT developments. For Andy, it’s the virtualised data and being able to develop adaptive systems. “If I were an ED doctor and I put my identity card into the terminal, it would load my personal screen with access to all the systems a doctor in emergency would need. Being able to develop a system tailormade for specific groups of practitioners (nurses, physios, whatever) and provide access to the exact services I need to do my job is pretty amazing. And the time saved means I can spend time with my patient knowing that the system is supporting me.” “These developments are partly linked to the national agenda for the PCEHR and mid-year we will be uploading discharge summaries directly into an electronic record and in time to their personal record. As electronic health records get better, GPs will get a better discharge and medication summaries and communication between the health sectors will improve dramatically.” l

By Ms Jan Hallam

medicalforum


News & Views

ePrescribing and Duty of Care Technology is making possibilities endless but when it comes to electronic alerts regarding patient script compliance, it’s time to slow the process down. Trying to predict human nature is difficult. And so it is with prescribed medications where patient compliance, doctor and pharmacy-shopping, and who takes responsibility for what have all come to the fore with Patient Controlled Electronic Health Record (PCEHR) and e-prescribing (eRx or Medisecure). The RACGP says e-scripts will be a safer option, and uploading scripts from desktop software to a centralised prescription exchange service provided jointly by eRx and Medisecure is good practice that does not require special patient consent. However, once this is done, the pharmacist has the ability to notify the prescribing doctor electronically if the prescription has been dispensed. Herein lies the problem. This dispense notification requires informed consent from the patient and puts the prescribing doctor in a new set of ‘duty of care’ scenarios, or worse still, liabilities if things go wrong. The RACGP has suggested that dispense notification not be installed by practices until things are sorted out. And with government looking to make PBS savings, doctors are nervously looking at what it might do with all the information. Medical Forum spoke to the RACGP’s Dr Mike Civil and Pharmacy Guild President Ms Lenette Mullen on these issues.

n Dr Mike Civil, RACGP

Dr Mike Civil said more information in the PCEHR would likely lead to better patient care, so we should be careful but not throw out the baby with the bathwater.

“The use of ePrescribing and the National Prescription and Dispense Repository (NPDR) may be a case in point. Basically, [both] mean that we will be able to have accurate information relating to medicines that have been prescribed and dispensed. Surely that can only be a good thing? But, is that always the case?” “If we know a script has been written and not dispensed, do we have a ‘duty of care’ or ‘clinical responsibility’ to ensure followup? While I have always held the view that the patient takes some responsibility for their health care, this adds another dimension to where that responsibility starts and finishes.” medicalforum

Yes, patients could choose not to follow advice, he suggested but the quality of that advice could shape whether the patient made an informed decision. As he put it: “Do patients really understand the consequences of not taking our advice, or not taking that particular prescribed medicine?” In most cases, nothing dramatic was likely to happen, at least in the short term, he said. While government may be interested in costly non-compliance for different medications and doctors, Mike was more interested in scenarios that carried high importance. “What if the medication prescribed was an antipsychotic for a patient suffering with paranoid psychosis? Suddenly the implications of not having a medication dispensed are greater. Who holds responsibility now if the patient’s condition deteriorates?” He said doctors who have good rapport with patients will better understand the patient’s ability to make informed decisions. While consent for the PCEHR might cover information relating to e-scripts, special consent was needed for dispense notifications, which was where things got complicated. “The RACGP has had discussions with MDOs. Do you have an obligation to follow up and encourage the patient to get a nondispensed medication filled, knowing that if you do not, it may, over time, have further ramifications? Should we receive dispense notifications for every medication or just some? It gets more and more complex.” MDOs, he said, just want doctors to get watertight patient consent. “It all becomes more time consuming for the busy GP, just as they are coming to grips with the PCEHR. My view is let’s get the PCEHR ‘shared health summaries’ and ‘event summaries’ flowing, and only then consider the dispense notifications associated with ePrescribing when we really appreciate the practicalities of using the PCEHR and how it fits into our normal daily routine.” Ms Mullen says the Guild has discussed only some of these issues but offered her perspective on the issues raised. n Ms Lenette Mullen, Pharmacy Guild

“I agree compliance is a problem. There

is the ability with the Guild-developed system [eRx connected to 3200 pharmacies] to report to the prescribing doctor when a prescription and repeats have been dispensed. This facility has recently been turned off over concerns from the medical profession about ‘duty of care’, so it is not currently available,” she said. Like Mike, she feels that the responsibility to have a prescription dispensed resides with the patient. “They may not have the finances, or may choose to get a second opinion or have some other reason for not getting the prescription dispensed. It is of benefit for the prescribing doctor to be aware of this. I have seen escalating dosages being prescribed as the GP was unaware the medication was not being taken, or not being taken sufficiently often.”

Suddenly the implications of not having a medication dispensed are greater. Who holds responsibility now if the patient’s condition deteriorates? – Dr Mike Civil She said patients often moved between pharmacists, or holidayed interstate, so a national system had advantages. “If the prescribing doctor was able to receive information on repeats being dispensed they would be better able to understand the patient’s compliance to the prescribed medication.” While she agreed that dispense notification had its place for patients with reduced levels of responsibility, other collaborations between the prescriber and dispenser offered better solutions. “There are other methods of assisting the patient. Dose administration aids, staged supply where the patient must present to the pharmacy regularly for a small number of doses as per care plan discussed by prescribing doctor, pharmacist, patient or carer, are all currently available.” Pharmacists are renowned for recognising incorrect dosages or medication clash and for bringing this to the attention of the prescribing doctor before dispensing. Lenette does not think ePrescribing will impact on this. l

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Feature

Doctor in Uniform Doctors are trained for frontline action when it comes to trauma and disease. Dr Andy Challen has taken the fight all the way to war zones in the Middle East. Dr Andy Challen’s working day at SCGH, where he’s training as an anaesthetist and emergency physician on the WA rotational training scheme, can be full of trauma and drama. But the medico, who has seen active duty as a Captain in the Australian Army in Iraq, Afghanistan and East Timor, brings special leadership and clinical skills to his civilian medicine. “It’s very much a matter of doing the job you’re trained to do. There’s a great sense of camaraderie and you don’t want your mates going into harm’s way without you being there too. I was 27 when I first went to Iraq as a doctor and that position of responsibility weighed quite heavily. But from a professional point of view the operational experience was extremely valuable,” Andy said. “I’ve brought that back to my practice of medicine in civilian life, particularly in relation to coordinating a crisis situation. Many of my colleagues with a similar level of training are quite envious of my clinical experience. I’ve done some procedures they’ve never seen before.” “I served as a full-time officer for seven years then became a reservist in 2010. I’m offered a deployment about once every two months and that can vary from a military exercise in New Guinea to active deployment in Afghanistan. My time in Timor as an aeromedical evacuation officer probably helped shape my career most of all. We were flying in Black Hawk and Iroquois helicopters taking military and civilians back to Dili. Timor has the highest birth-rate of

The regimental model was a big shock to the system… It was only when I went on operations in Iraq that I realised how important it was to have that structure and discipline. any country in the world so we saw a lot of neo-natal problems.” The link with developing countries goes back to Andy’s time as a medical student at UWA and the realisation that highly specific skills are needed to practice medicine in demanding and confronting environments.

n Timor Aeromedical Evacuation Team, Dr Andy Challen, kneeling.

“In second year, I did some aid work in a small clinic in Cambodia. They were poorly resourced and, in some cases, the personnel management could’ve been better. I realised that I needed to develop my management and logistic skills so I took up a Defence Force scholarship for the final two years of my medical training. Once I’d done my residency, I transferred to a full-time role with the military and was posted to a hospital unit in Sydney. My family and friends were very surprised because I was a bit of a longhaired surfing hippie.” “The regimental model was a big shock to the system. I struggled to understand it and some of the things they were asking me to do didn’t seem to have much purpose. It was only when I went on operations in Iraq that I realised how important it was to have that structure and discipline. In critical situations it allows a quick and efficient flow of information and resources.” “I was part of a Dutch-led resuscitation and surgical team in Afghanistan, treating both Coalition troops and civilians and also went out on armoured vehicle patrols in a forward resuscitative role. I think medicine is one of the better areas within the military because you do get a graded exposure to suffering and death. Nonetheless it’s still incredibly confronting when you see senseless loss of life, particularly when it involves women and children.” Andy points out that the act of providing medical assistance is something of a circuit breaker to some of the inherent stressors within the theatre of war.

Post Traumatic Stress Disorder and the Military The mental health of defence force personnel is increasingly in the spotlight after more than a decade of Middle East campaigns. n Dr Andy Challen As the Australian Government prepares to withdraw the last of our troops from Afghanistan by the end of the year, Dr Andy Challen reflects on some of the mental health challenges they face.

Q

Individuals react differently to these potentially traumatic situations. Some cope better than others. What are your observations?

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“There is significant individual variability in reaction to trauma, though there are well recognised risk factors for developing posttraumatic stress disorder: • Being female • Experiencing intense or long-lasting trauma • Having experienced other trauma earlier in life • Having other mental health problems, such as anxiety or depression • Lacking a good support system of family and friends • Having first-degree relatives with mental health problems, including PTSD • Having first-degree relatives with depression

• Having been abused or neglected as a child.”

Q

As a doctor in the field, how did you process the more shocking incidents?

“It was, at times, incredibly confronting to be faced with victims of traumatic circumstances. However, with increased experience and training it eased and the more support you are able to provide, the more empowered you feel. I certainly struggled with symptoms of acute stress reaction on returning from my first deployment and ironically found that being among fellow military service men and women helped me to deal with my reactions. The hardest incidents were those involving fellow Australians as these were people medicalforum


PTSD Services The Veterans and Veterans Family Counselling Service, Freecall: 1800 011 046 (24 hours) Centre: 7 Kintail Rd, Applecross; Tel: 6461 7800

n Dr Andy Challen, left, with a team at Tarin Kowt, Afghanistan

It’s horrendous to witness people deliberately inflicting suffering on others but being able to actually do something to alleviate it helps a lot. “I’m in a privileged position as a doctor. It’s horrendous to witness people deliberately inflicting suffering on others but being able to actually do something to alleviate it helps a lot. The military runs programs designed to address psychological stress, particularly on a first deployment. Padres and psychologists also provide immediate frontline counselling to deal with these traumatic exposures.” Recent news reports have highlighted increasing violence against non-combatant health workers. In a recent case, a young local woman who was a member of an anti-polio vaccine program was killed by the Taliban.

you knew and it is hard to be objective. Your personal grief and empathy can be overwhelming. There has been increased effort to better prepare Australian defence force medical personnel for the types of experiences they will face, based on past deployments. However defence force medical personnel remain one of the highest risk groups to experience stress reactions.”

Q

Is there still stigma attached the mental health issues within the ADF?

“This is a very difficult topic. There is obviously still stigma attached to mental health issues and this exists for multiple reasons. Firstly, the individuals attracted to the defence force are usually confident and dominant personalities. It is difficult for them to deal with feelings of insecurity, fear and

medicalforum

“Casualties do happen amongst medical staff. An Australian doctor was killed when a Sea King helicopter crashed in Indonesia in 2005 and I lost quite a few close friends in Iraq from other Coalition forces. Unlike local and international health workers, we do see ourselves as soldiers as well as medical practitioners. We are making a difference in Afghanistan. There are women’s health clinics, young girls are going to school and Afghan men are becoming medics and soldiers.” “The fact that vaccination programs are taking place is a huge thing. It’s easy to get caught up in the political positioning and lose sight of the fact that there is real hope for the future in Afghanistan. The men and women of the Australian Defence Force can take great pride in helping to achieve that.” Andy sings the praises of supportive medical communities and the wonderful diversity of medicine as a career. “I had some fabulous senior doctors supporting me on my military deployments.

failure. The individuals often withdraw from their work and their mates causing them to become isolated. Encouragingly, there are more and more individuals stepping forward and sharing their experiences with other soldiers, and this has helped normalise reactions to abnormally traumatising experiences. People like retired General John Cantwell writing on his experience dealing with these issues helps raise awareness, and increasingly people are being retrained and rehabilitated within the military organisation, which is helping people see that these reactions are not a terminal event from a social or professional perspective. This will continue to be an issue for the military.”

• Last year VVCS provided mental health treatment for more than 10,500 veterans and their family members, with over 60,000 group and individual sessions • For doctors: http://at-ease.dva.gov.au/veterans/ files/2013/01/Clinicians_Guide_to_ PTSD_Coach_Australia2.pdf

My Senior Medical Officer in Iraq was a Navy psychiatrist and he helped me see that our efforts were positive and worthwhile. In a similar vein, the local medical community has been generous with their mentoring and support and I feel part of the wider medical family in WA.” “As far as military and civilian medicine goes it’s a very exciting time to walk in both worlds. My real passion is retrieval medicine. Putting doctors on helicopters or in ambulances in a rapid response role is very common in the eastern states. In fact, South Australia does this really well. My military experience has shown me the value of placing critical care physicians into pre-hospital settings.” l

By Mr Peter McClelland

Q

There have been suggestions that some service personnel with mental health problems (PTSD) have been quietly ushered out the back door. Is this your experience? “This may have happened in the past or to individuals I have not been involved with. However, my experience was that the military, where possible, sought to retain and rehabilitate individuals and there was considerable personal and professional concern from the hierarchy in regards to these individuals. All the Commanding Officers I served under were incredibly compassionate individuals who took great personal interest in the cases of soldiers affected by stress reactions.” l

25


Mental Health

Caring for the Carer Makes Sense Family and community are important in the recovery of a person with mental illness and doctors can be more effective by being aware of support networks. It can be as simple as a logo popping up on Facebook or advice from a well-informed GP, but there’s no doubting the value of peer-support groups for families affected by mental illness.

The Consumer

It took Tracy Sulejmani, whose 22 yearold son Andrew suffers from schizophrenia, a few attempts before she found what she’d been looking for when the Families4Families (F4F) group logo popped up on Facebook. F4F, a service run by community advocacy organisation Mental Health Matters 2 (MHM2) has a specific focus on co-occurring issues. More common than not, these families are struggling with a mosaic of issues – mental illness, alcohol and drug abuse and often involvement with the criminal justice system. “It’s taken us a long time to arrive at this diagnosis for Andrew and, I have to be honest, there has been substance abuse and occasional brushes with the law. The support group focuses on a theme or has a guest presenter and the facilitation is wonderful. Recently someone was talking about legal advice their son had received to plead guilty rather than be tagged with the label, ‘mental illness.’ I burst out ‘Oh no, Andrew too!’ It’s reassuring to know others are going through similar problems.”

“These groups, and the courageous people in them, have given me the strength to say ‘yes, I have someone in my family with a mental illness’. That’s why I’m happy to put my name to this article. Someone might read it and be encouraged to ask for help.” Tracy sings the praises of her GP, but a combination of Tracy’s own personality and a paucity of information meant that it took longer to discover that her situation could be markedly improved. “I usually only see a doctor once every couple of years and I don’t ask for help easily. But I didn’t realise how lonely and worn down I was and there’s still a stigma attached to mental illness. It can be so isolating.” “We have a great GP but he wasn’t aware of these groups. The first response is usually medication and psychological counselling. Since going to Families4Families, I’m a better person for myself and for Andrew.”

The Counsellor

Charl van Wyk is a counsellor and facilitator at Cyrenian House, a not-for-profit organisation with extensive experience in the treatment n Charl Van Wyk of alcohol and drug dependency. “Families for Families is a joint project between MHM2 and Cyrenian with DoHA funding. The social and financial toll on families dealing with co-occurring issues is colossal. Why families have gone unrecognised as a key to

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recovery for so long I can’t imagine.” “I trained as a social worker in the UK a few decades ago, and even then mental health problems linked with alcohol and drugs weren’t treated separately. They’re all part of the same continuum. When I first came to Australia, the ‘silo’ approach to mental illness never made much sense to me.” As the name suggests the focus is very much on families. And the healing, suggests Charl, can take place in an oblique way. “The reason it works so well is that it’s incidental therapy. Stories are shared, there’s mutual respect and it’s completely nonjudgemental so people listen in a different way. Ironically, the minute you stop trying to ‘fix’ people they begin to change.” “The gender aspect is interesting. Fathers and husbands are there to support their wives but it’s apparent that men are much better at coming forward than they were 10 years ago. That’s important because family members need to look after themselves otherwise they risk becoming a patient themselves. The Mental Health Commission estimates that one psychiatric bed costs $1100 a day. These support groups are saving the government millions!” “I’d like to reinforce to GPs that we’re not here to challenge clinicians. It’s all about raising awareness, particularly the fact that a high proportion of these people are bumping up against the criminal justice system. The other aspect is the importance of a decent research base, which validates the actual need and analyses the efficacy of interventions.”

The Researcher

Angela Mendes is doing a Master’s degree in Counselling Psychology at Curtin University with a particular interest in co-occurring n Angela Mendes mental health issues. Her research focuses on the fortnightly F4F groups. “Family members might be struggling with everything from housing to unemployment. They’re inspirational people and, in many cases, so are the people they’re looking after. The success stories are amazing and some of them turn their lives around.” “The groups are always diverse, usually around 20 people with a gender and age mix encompassing mid-20s to late-60s. There are some people who’ve been chronic users and are now supporting others but the majority are family carers.” “I’m hearing stories regarding the occasional breakdown in communication medicalforum


between carers and clinicians. Doctors have the clinical knowledge and we need that advice and expertise but family members say they feel ‘shut out’ at times. Sure, there are privacy issues but we can’t underestimate the importance of family involvement in a person’s recovery.”

Support Groups

The Mental Illness Fellowship WA (MIFWA) embraces a ‘whole of family approach’. CEO Sandra Vidot and Recovery Coordinator Sharon Karas stress the n Sharon Karas importance of listening to people with ‘lived experience’ of co-occurring mental health problems. “We promote the fact that about half of our staff is either people who’ve recovered from a mental illness or are caring for someone who’s struggling with co-occurring issues. We run a range of programs, from a Parents Peer group to Tobacco Free training by people who’ve given up smoking. These people know what others are going through so it’s mutually beneficial,” Sandra said. “We’re working with a local community medical centre to lift its capacity to take on peer-support workers and inform them of the diversity of our services. There’s more support out there than some GPs realise and it can make their job easier.” Mike Seward, CEO of Arafmi Mental Health Carers WA says it makes sense to look after the carers. “Less than half the people in Australia with a mental health issue seek clinical help and more than n Mike Seward 75% of them are looked after within the family,” Mike said. “I used to be the CEO of a GP division in a previous life and I know doctors are timepoor. Arafmi encourages the involvement of peer-support in recovery and, hopefully, that means better outcomes. It might actually free up a bit of time for doctors because family members are doctors’ eyes and ears for things like medication side-effects and coping skills.” l

By Mr Peter McClelland

USEFUL LINKS: Arafmi www.arafmi.asn.au Cyrenian House www.cyrenianhouse.com MIFWA www.mifa.org.au Mental Health Matters 2 (Families4Families) www.mentalhealthmatters2.com

medicalforum

Youth mental health Youth is a critical time of development in terms of social and emotional wellbeing. Young people aged 16 to 24 have the highest occurrence of symptoms of mental health disorders and 75 per cent of all serious mental illness commences during this time. Young people with mental health problems also report a higher rate of drug and alcohol misuse in comparison to other young people. As a result they can often experience a greater likelihood of dropping out of school, losing their job, having conflict with family, being involved in the justice system and isolating themselves from friends. In saying this, evidence shows that young people are not readily accessing services to support their mental health and tend not to talk openly about mental health issues. However with the right support and timely information, young lives can get back on track. As Commissioner for Mental Health in Western Australia, I believe that improving services for children and young people is a matter of high priority. In December 2012 we produced a detailed guide of mental health services for young people in WA, which is available on our website at www.mentalhealth.wa.gov.au. GPs are often the first point of contact for people experiencing mental health problems. They play an increasingly vital role in the early identification of emerging mental health problems, assisting recovery and enabling social inclusion of young people, for example, by direct support and also referring young people and their families to appropriate services. The Mental Health Commission is continually increasing awareness of the importance of GPs within the community through regular updates on our website and in the Head2Head magazine. The magazine is not only an important way to keep up to date with what is happening in the mental health sector, but is also a great resource that features personal stories of recovery, friendships, relationships and offers ideas, contact details and tips on reaching out to others and looking after your own mental health. The latest edition is focused on youth and, together with the detailed list of mental health services for young people is available at www.mentalhealth.wa.gov.au. To order copies or submit a story, contact Communications@mentalhealth.wa.gov.au. Eddie Bartnik COMMISSIONER FOR MENTAL HEALTH

27


Guest Column

Many Questions, Little Time to Listen

Q

Recovery is what everyone involved in mental health is working towards – so it’s time to work together, says Richmond Fellowship adviser Ms Lyn Mahboub.

uestions are the answer. They lead the way to critical thinking about logic and assumptions. In mental health, some of the critical questions we might begin to ask are, ‘Why, in this day and age, is there such a mismatch between what people with mental health issues and their families are saying they want and what is on offer?’. ‘Why is it that something as simple as the notion of ‘recovery’ is so misunderstood?’ ‘Why are we pitting groups against each other and getting diverted into debates about ‘recovery versus the medical model?’, when, I would argue, we are largely, all seeking the same thing?’

It is not helpful to depict the medical model and recovery as in opposition to each other. To do so closes down opportunity for curiosity, dialogue, debate and critical thinking, and it sets us up for defence, resistance and possibly conflict. Further, it creates a false dichotomy, which brings with it all the attendant problems that come with such binary constructions such as: ‘if you believe in recovery, you don’t believe in medication and are you are anti-psychiatry’ and other such unhelpful generalisations. Instead, I prefer to start with common ground and explore just what we mean by ‘recovery’ and what it means for each individual. The common ground, I believe, is that as professionals, practitioners and workers

responding to mental health issues and crises, we are all trying to help people recover (whether we use that term or not). For many of us in the ‘Recovery Movement’ ‘recovery’ means access to a good life. Like anyone else in the world, we want somewhere safe to live, a job or some community involvement that is meaningful, and some connection or relationship that produces feelings of belonging. It also means being able to heal – and have help to heal – from some of the difficult things that have occurred to us. Essentially, we simply mean increased wellbeing. But the real question to ask is ‘How do our responses to, and treatments for, people’s reduced mental health and wellbeing aid them to recover and increase their wellbeing?’ and ‘What is the path to recovery for each individual’? I call for a harm reduction approach to mental health treatment and prescribing – sometimes called recovery oriented prescribing and treatment. We have seen this approach already in public health campaigns for seatbelt and sunscreen use, needle exchange, methadone maintenance and self-harm programs. Why not mental health recovery medication management? This would involve acknowledging some of the potential harms of some of our treatments and work toward minimising them. It requires a shift from thinking about taking medication to using medication to support personal recovery.

There is a growing recognition of ‘personal medicine’ and developing ‘power statements’ to aid recovery planning and treatment. For example, this power statement conveys the importance of a collaborative treatment: “My marriage is powerful personal medicine, and is the most important thing in my life. I don’t want paranoia or sexual side effects from medication to stress my marriage. You and I have to find a medication that supports me in my marriage so that my marriage can support my recovery”. Such an example honours the lived experience and recognises that ‘symptom’ elimination is not always the primary aim of mental health consumers. It recognises that there is always a tradeoff of some sort. Indeed many people are willing to find ways to live with certain discomforts in order not to lose all they hold dear. These power statements cut across such questions as ‘Is a medical or recoveryoriented explanation of ‘mental illness’ better?’. They direct our attention instead, to shared decision making and aiding people recover their lives while working on mastery over experiences /“symptoms” such as voices, anxiety and sadness. l ED: Ms Lyn Mahboub is also manager of Hearing Voices Network and a teacher at Curtin University. Her lived experience of recovery has aided her work. References available on request

Waiting for a knees-up There’s been a lot of trumpeting by WA Health about the positive results in the Australian Institute of Health and Welfare’s (AIHW) annual report on ED access and elective surgery targets for 2012. And we are all full bottles on how WA hospitals emerged the most efficient in both categories. ED stats showed WA was the only state to achieve a proportion greater than its 2012 emergency access target. Deeper into the report was the breakdown of median waiting times and admissions from elective surgery waiting lists and people waited longest for knee replacements (average of 114 days at the 50th percentile), followed by 103 days wait for septoplasty. The shorter wait of 15 days was for coronary artery bypass graft. Cataract extractions numbered 9728 for which there was an average of 40 days’ wait. 28

medicalforum


Life Choices

Doctor Heal Thyself Prof George Jelinek reassessed his lifestyle after he was diagnosed with multiple sclerosis and says it’s time for a new paradigm for treating disease. Prof George Jelinek was diagnosed with MS in 1999 and now, 13 years later, he doesn’t have a single symptom. The former UWA Professor of Emergency Medicine would like to pass on a new paradigm to his medical colleagues, one that focuses on an integrated approach to health, healing and well-being. Now based at the University of Melbourne and the Gawler Foundation, he travels the country spreading that message.

people realise that some medication can cause problems.”

statins should only be used when you can’t do anything about the risk factors.”

There’s no debating that the message regarding positive lifestyle changes has been around for a long time. George acknowledges that his audience doesn’t have to be persuaded to listen long and hard.

“I was listening to a podcast on the MJA website and someone was suggesting that anyone over the age of 50 should be on statins. The argument was that we’d reduce the cardiovascular event rate with a minimal increase in strokes or severe myositis. I thought it was a very odd approach to be weighing up the positive and negative sides of the ledger without addressing

“I don’t tend to focus too much on my own situation. I’m far more interested in those who attend the retreats I run and the thousands of people around the world who follow this approach. It’s an integrated package involving diet, stress reduction, exercise, adequate sun exposure and Omega 3 intake. GPs are ideally placed to be involved in this sort of care,” George said. “Our data shows that if people really apply themselves they can lead a normal life and not be affected by the usual problems associated with MS. If GPs and their patients get involved in some sort of ‘action plan’ and work together they can actively do something about this condition. Some doctors in the past have found treating MS patients quite depressing. People just got worse and there was nothing you could do about it. Doctors can now focus on a more positive course of action by monitoring Vitamin D levels, prescribing exercise and advising on improved diets. It’s a new paradigm.” According to George, the dichotomy

These days we reach for the drugs first and think of a different way of living as an alternative approach. between ‘traditional’ and ‘alternative’ needs to be redefined. “This approach offers the best of what’s available – traditional mainstream medicine involving pharmaceuticals plus approaches some people have sidelined as ‘alternative’. It has always struck me as a bit odd labelling exercise and stress reduction as ‘alternative’ or ‘complementary’. I think they’re the basis of good health and that, in many ways, drugs are the ‘alternative’ option. I think we’ve lost our way a bit, but the pendulum’s swinging back as medicalforum

n Prof George Jelinek playing in the band, Crocodiles’ at Steve’s Hotel and receiving the ACEM College Medal in 2003

“Conventional medicine does seem to be all about prescribing lap-banding, statins and anti-hypertensives. We’ve got to work out how to motivate people to look after their health properly. Sure, I’ve got a cohort of people with MS who are extremely motivated to do something about their situation. If they don’t, the outcomes can be pretty horrendous and these people are very willing to make lifestyle changes.” “I have trawled through the medical literature and located the different lifestyle factors that might make a difference to this illness. There’s a coherent science behind it but it’s never been put together. There’ll be one bit in a rehab article and another in an endocrinology journal. As a former editor of Emergency Medicine Australasia I can bring this material together.” Embracing an improved lifestyle is common sense, but confounding factors muddy the waters. “The pharmaceutical industry is enormous and it’s very easy for the medical profession to be seduced by their message.” “Sometimes our main form of education comes from people who’ve got a vested interest in selling their products and that can distort a more realistic perspective on optimal health. The approach these days seems to be if you’ve got risk factors linked with heart disease then you prescribe statins. It should be the other way around –

what’s causing the problem. I think that underestimates the capabilities of someone dealing with a serious illness.” There’s a spectrum within MS and some people respond to treatment really well and others are more resistant. The most important thing, George says, is commitment. “Everyone has their own individual response to this disease. But, in my experience, people who commit to this approach do pretty well. The cohort of doctors who’ve done the course is growing and they’ve had some of the best outcomes. Once they’ve seen the science behind it and how compelling the data is they tend to jump in and stick with it. I haven’t eaten meat or dairy products in 13 years and once you’ve broken the habit it’s pretty easy.” “GPs are on the frontline and I think the most important thing they can do is give MS patients some hope. A message of inexorable decline is very damaging, so it’s important to tell them that it’s actually possible to stay well.” l ED: Useful references: www.overcomingmultiplesclerosis; www.gawler.org

By Mr Peter McClelland 29


Nurse Training

Working with Nurses of the Future The heads of the three nursing schools share with Medical Forum their views on where they think their courses will take their graduates in a volatile medical landscape. Curtin University Prof Phill Della The Faculty of Nursing and Midwifery, which turns 40 next year, does a lot of research –taking clinical problems n Prof Phill Della and issues, finding the best way to care for them and then putting that into educational practice.” “A Curtin nurse will be a very good practical nurse but also one informed by the latest evidence from research. Our graduate program is 3½ years and in that extra six months students extend their critical thinking. A Curtin grad is going to question ‘is this the best practice’ based on the evidence.” “All health science students do a common first year and subsequently we find clinical placements where we can send naturally occurring groups of students – nurses, pharmacists, dietitians, physios – together. The best example of that is the student training ward at RPH where the students [UWA medical students join the group] go into the ward for six weeks and care for patients. They have to work as a team, and solve the problems as a team.” “We are researching and evaluating that program to ensure patients are comfortable and clinical and learning outcomes are met. There is growing acceptance of the team and case management approach.” As well as clinical placements, Phill, said the ‘care factor’ was an integral part of the program. “Yes, we have simulation suites with all the latest equipment but we also use patient volunteers, members of the community, who work with our student nurses. The feedback from students is that they get some of their best learning from those volunteers.” The future nurse, said Phill, would be looking for a solid career. “We need a clinical career structure so that our best clinical nurses are at the clinical bedside providing the best care. You don’t want to push them into management or education because you are going to lose that care factor.” 30

University of Notre Dame Prof Selma Alliex “The focus of our nursing education is the best possible balance between theory and practicum and our school has the n Prof Selma Alliex biggest amount of clinical practicum in the country. We start that from semester one but that doesn’t take away from the theoretical component of our course.” “Our core curriculum differentiates our students from other universities. Every student has to study ethical decisionmaking, theology and philosophy and I think that also helps students once they get into the clinical setting and see really complex issues. “The ND nursing degree began in 2000. At the time there was a perception that students weren’t educated to work with patients at the bedside. They had a lot of theoretical knowledge and that is a perception that in some quarters still exists.” “We do need nurses to be thinking nurses who will use the evidence in practice and we want them to do the research so they don’t compromise patient care. However, the first head of school deliberately designed a curriculum that would be balanced and we have changed very little because it still works very well.” Training the modern nurse has its dilemmas of clinical placement shortages similar to medicine. “A lot of universities are going down the path of hi-fidelity simulation and there is also talk of replacing clinical placement hours with simulation. We don’t actually have an issue here – we have enough practical and clinical exposure for our students that they don’t need hi-fidelity, they can actually talk to a real person to find out how to care for them.” “That’s why we haven’t steered away from reducing clinical hours. However, clinical placement is an issue and with the projected shortage of nursing it will have a big impact on the availability of places.”

Edith Cowan University Prof Di Twigg “We’re trying to prepare students for a lifelong career, so there’s an emphasis on critical thinking and their ability to analyse and make n Prof Di Twigg good decisions as well as the practical skills they need to function as a nurse. Compassion is also a core value and not just for the individual patient, but for the community as a whole.” “At ECU, we’re rolling out our virtual world – introducing simulation and other technologies together. Students are introduced to a virtual character, an elderly woman in this case, at the start of their training and they’ll experience this person and observe the things that happen to her and her family throughout the three years of their course.” “We’ve called her Barbara First and she will help students understand the impact of disease and health from a broader perspective.” “There are 52 beds available to us in a simulation suite built to the standards of Australian hospitals, which has given us a competitive edge. But we’re now trying to position the student by building a patient scenario so that before they go into a suite to practise a particular skill, they will feel like it’s a ward and they are being given a handover.” “The more we can do to make these simulations like a real clinical environment, the more confidence the students will be when they head into the real thing.” Research is also a strong focus. It has achieved the highest research ranking in the last Excellence in Research Australia report, one of only seven schools of nursing nationally to achieve a score of five. Di says that despite the grim predictions of nurse shortages over the next decade, the reality is that nurse graduates now are finding it tough to find jobs. “The GFC has made a lot of nurses put off retirement and there’s been no national strategy to manage that in the short term. We don’t want to lose these graduates.” l

By Ms Jan Hallam medicalforum


Nurse Training

Practice Nursing – the ‘Eyes and Ears” As more eyes turn to primary care to manage chronic disease, practice nursing has grown in number and stature. President of the WA Practice Nurses Association (WAPNA), Ms Rosemarie Winsor, says their membership is over 200, which represents about half of the practice nurses working in WA. WAPNA left the umbrella of the Australian Nurses Federation in 2002 and sees itself fulfilling a networking and education role for practice nurses. A practice nurse for nearly two decades, Rosmarie said she, personally, would like to see practice nursing in the university curriculum. “I’ve been a mentor for student nurses and I think more time could be spent training students about practice nursing. The students I have worked with were all quite amazed at the work that goes on in general practice. On some days it’s like a mini A&E. It’s always busy, especially with the growing emphasis on chronic disease management that takes a lot of time and room.” With growing responsibility has come growing support from doctors and the community. “To get good outcomes, a surgery needs to work as a team. I’ve got time, while say doing a dressing, to talk to the patient and they often say things they’ve forgotten to tell the doctor. It’s an extra pair of eyes and ears for GPs.” Rosemarie wants more political and policy

support for practice nursing and primary care in general. “The government needs to recognise, with appropriate payment, the time a practice nurse spends with a patient. They do it for health assessments but not for the many other things we do. Some surgeries are compromised because Medicare doesn’t adequately recognise our time or support doctors for what they have to do.” Last year she was in the final three in the annual Nursing and Midwifery Awards and, while thrilled personally, she believes it was a significant moment for recognizing the role of practice nursing within the health profession and wider community. Geraldton GP Dr Edwin Kruys believes his nurses are the eyes and the ears of the practice and do so much for the busy GPs. Although he said their n Dr Edwin Kruys contribution was invaluable, the system does not encourage teamwork. “For instance, my nurse does a blood pressure check on a patient in the treatment room or performs an INR for a patient on warfarin, those patients cannot be billed unless I physically come to a treatment room and confirm the results. A registered nurse is perfectly capable of doing things

n Ms Rosemarie Windsor (left) a finalist in the 2012 nursing awards

independently as long as we are working as a team, and Medicare is really restricting that.” “This mindset has to change. We are overloading our GPs with administrative tasks when we should be relieving our clinical doctors and nurses from the paperwork so they can see patients. It’s getting out of hand, and getting worse.” l

The ‘Privilege’ of Community Nursing Nurse training/ academia and community nursing have joined under an arrangement between Curtin University and Silver n Dr Keryln Carville, PhD Chain Nursing Association designed to teach and advance the discipline. Leading the charge is Dr Keryln Carville, PhD, who holds positions at both places, particularly Professor of Primary Health Care and Community Nursing at Curtin University. For Keryln it’s about fostering skill and knowledge. “There’s a quote from Florence Nightingale that always makes me stop and think. She said, ‘nurses in the community need to be cleverer than their hospital counterparts because they have nobody else but themselves to rely on’.” “She was so right. If you’re working in a hospital, you’re working as part of a team medicalforum

that is around you. In a community context you may be a part of a team not physically working together. You have to rely on your own clinical knowledge and skill a lot of the time.” “So the establishment of this stream and my position was to advance the community nursing specialisation and to address the knowledge and the skills required to fulfil that competently. The opportunity for community nurses to advance through a post-grad program to masters – and some may even aspire to a doctorate – that’s a wonderful thing because it builds nursing leadership, clinical expertise and recognition for the specialty.” With more patients discharged from hospital to care in their home, she said it was imperative there was continuity of care between the two that was of an advanced and recognised standard. She added it was a privilege to care for somebody in their home, or at a community clinic. “Patients in a hospital are guests in our environment but when you go into their home, they are quite empowered and rightly so. If a care plan doesn’t work, it’s because it doesn’t meet their needs. Working with

patients in the community is a partnership of care with them and their families.” Keryln was reticent to talk about recent industrial action that saw WA hospital nurses get a substantial pay increase. It wasn’t their major priority. She does believe in equity across all nursing sectors, and said we need to value nursing, no matter which vulnerable people in our community are cared for. “If we talk about the need for community nursing to be recognised as a specialisation then financial reimbursement is part of that, but it’s not the only part and perhaps not the most important in the eyes of most nurses.” The Silver Chain/Curtin partnership also has research in mind. The Cooperative Research Centre has nine research projects around wound care under way. She said wound healing and management were an important and large part of patient care, requiring both the art and science of nursing. “If we can prepare nurses well within this domain then that’s a large degree of skill and confidence they bring to their practice.” l

31


Feature

The Pressure is On The exciting potential of hyperbaric medicine will be explored in full when the new facility at Fiona Stanley Hospital opens its doors to patients. The new Department of Diving and Hyperbaric Medicine at Fiona Stanley Hospital (FSH) will be a far cry from its former home in an old converted laundry in Fremantle. But it won’t mean a complete break with the legacy and history of Alma St. Two small chambers, Sebastian and Rebecca, will make the move to FSH to sit alongside a new $4.6m hyperbaric installation. The postcode may be changing but one thing remains the same. Hyperbaric Medicine is much more than divers with the ‘Bends’. Dr Neil Banham and Ms Sue Thurston, Medical Director and Clinical Nurse Manager, respectively, head-up the WA Department. They’re integrally involved with the transition and gave Medical Forum a guided tour of the new facility.

Neil Banham began by pointing out

that approximately half the case-load in this highly specialised area of medicine is involved with the after-effects of radiation for head and neck cancers. “Most of our work centres on treating people after radiation treatment for oral and neck tumours, particularly when there are healing problems in the irradiated area. It’s even more critical when dental extractions are needed where we give patients 20 sessions breathing 100% oxygen at increased pressure [two-hour sessions, five days a week] and 10 sessions after the extractions. Another important area for us is diabetic patients with non-healing and necrotising infections,” Neil said.

n Hyperbaric Chamber Internal View

“There have been concerns by some doctors that Hyperbaric Oxygen Therapy (HBOT) might reactivate tumours but the evidence suggests exactly the opposite and that it actually inhibits tumour growth.” The new $4.6m chamber, constructed by specialist manufacturers Fink Engineering in Queensland, has three independent yet interconnected compartments. The first (and largest) chamber is capable of receiving a Royal Australian Navy Recompression Chamber (TRC) allowing a seamless transfer under pressurised conditions. “We have a close working relationship with the Navy – there’s a great deal of co-operation between our technical team and their facility. [The RAN chamber is located at the Stirling Naval Base, Garden Island and doesn’t treat civilian patients.] The chamber arrived last November and we’ll be doing training compressions initially, with the first patients scheduled for April 2014.” Two mono-place chambers from Alma St, Sebastian and Rebecca, will be heading to Fiona Stanley Hospital.

n Dr Neil Banham and Dr Sue Thurston 32

The former is a Seachrist Model 3200 Hyperbaric Chamber and the only one of its type in Australia. It can deliver oxygen at 100% concentration pressurised up to 3.0 atmospheres (ATA). There’s a two-way communication system between clinician

and patient; the latter can even watch TV or a DVD on an external screen. “The two single-person units will go across to FSH and we’re pleased about that because it will be quite sad to see the Fremantle unit close. Even though we were housed in an old laundry that was built a long time ago, the Hyperbaric Unit had a long-standing association with the hospital that goes back to 1989.” The perpetually delayed opening of the chamber at SJOG Subiaco is, according to its owners, Hyperbaric Health (HH), due to questions of commercial viability. The cessation of a Medicare number for non-diabetic hypoxic wounds [30% of HH case-load. See March, Have You Heard?] has thrown a spanner in the works. “The Subiaco situation exists because they’re relying on Medicare rebates. In the

The most important message is that hyperbaric medicine is particularly relevant for non-healing wounds, embolisms, gas gangrene and poorly healing skin grafts. – Dr Neil Banham medicalforum


Medicolegal

Working Outside Clinical Guidelines public system that’s not an issue and we treat and cover everything on the South Pacific Underwater Medicine Society (SPUMS) website. Everything on that list is approved and we treat some patients at no cost. If they’re privately insured, the hospital will recoup some money from the health fund and patients with Concession and Veteran’s Affairs cards just claim in the normal manner.”

Sue Thurston underlines the fact that, apart from the RAN chamber, there is only one other fully accredited HBOT unit in WA.

“There is a chamber in Broome that’s privately owned by the pearling industry. It treats commercial divers and doesn’t do any wound care. There are a few private organisations under the ‘Health and Wellness’ label with ‘bag-type’ equipment but they are only pressurised to 1.3 ATA and use 25% oxygen.” “This move is all part of making FSH a hub for specialist services and, from a hyperbaric point of view, we’re closely aligned with that. We treat critical care patients and we’ll be better able to manage those in one place rather than put them in an ambulance.” The Hyperbaric Medicine Unit runs regular courses for GPs enabling them to perform accredited Dive Medicals (AS 4005.1) Nonetheless, Neil is keen to let GPs know that there’s a lot more to HBOT than the ‘Bends’. “The Dive Medical is a three-day course and it allows doctors to register on the SPUMS website. The course costs $1000 and the next one is planned for November. It gives a basic grounding in diving medicine and allows GPs to make an informed assessment of a patient’s fitness to hold a Recreational Divers’ licence,” Neil said. “The most important message is that hyperbaric medicine is particularly relevant for non-healing wounds, embolisms, gas gangrene and poorly healing skin grafts. I think a lot of doctors still associate the chamber with diving-related conditions.” l

By Mr Peter McClelland

FACTS: The Chamber and CLINICIANS Direct Referrals: Hospitals, GPs and Specialists FSH Hyperbaric Chamber • 56 tonnes 14m x 3m x 4m • 2.4-6.0 atmospheres • Three independent/interconnected compartments • Seating capacity: 28 (12/8/8) GP Information: Dept of Diving and Hyperbaric Medicine 9431 2233 (Normal Hours) Emergency: Hyperbaric Physician (FH) 9431 3333 Decompression Sickness Cerebral Arterial Gas Embolism (CAGE) Assessment: Rapid onset of symptoms within 30 minutes of surfacing is likely to be either CAGE or neurological decompression sickness. Signs and symptoms are notoriously variable. The natural history of a CAGE resembles a transient ischaemic attack (TIA) South Pacific Underwater Medicine Society (SPUMS) www.spums.org.au

medicalforum

Q

“If a doctor responding to a patient’s problem appears to have acted outside recognised clinical guidelines, what counter-arguments support the view that treatment was both adequate and appropriate in the circumstances?”

A

Janet Harry, MedicoLegal Adviser, MDA National, answers the question for Medical Forum.

Appropriate patient care may involve treatment outside medically recognised clinical guidelines provided health professionals fulfil a common law duty to take reasonable care for the safety and wellbeing of their patients.

The legislated standard of care expected of health care professionals in WA is that he or she has not acted negligently, or below the standard expected of him or her. Section 5PB(1) of the Civil Liability Act 20021 provides that an act or omission of a health professional is not a negligent act or omission if it is in accordance with a practice that, at the time of the act or omission, is widely accepted by the health professional’s peers as competent professional practice. Matters taken into account when determining any breach of the doctor’s duty of care include whether the outcome was foreseeable, how close the plaintiff and defendant are, the degree of risk, whether the risk was likely to eventuate, the availability of resources and funds to take alleviating action, and any other conflicting responsibilities that a defendant may have. One example is ‘off label’ use of medication, which occurs in up to 40% of adult and 90% of paediatric patients according to the Medical Journal of Australia2. In a number of circumstances this practice can be appropriate such as research projects with proper approvals, and individual use in particular patient circumstances. Another example involves maternity care. The standards of care recognise that a doctor may follow a woman’s treatment decision that is outside recommended treatment guidelines, and provided she has made a fully informed decision, her choice should be respected3. In all situations where treatment outside clinical guidelines is contemplated, we recommend: • Consider the use and expected benefits carefully. • Discuss with senior colleagues and if necessary, ethics committees. • If for research, obtain all necessary approvals. • For an individual patient, ensure they give fully informed written consent. • Keep thorough records. • Contact your MDO beforehand, to discuss medico legal aspects and any implications for your cover. l References: 1. Civil Liability Act 2002 - SECT 5PB - Standard of care for health professionals 2. Medical Journal of Australia 2006 185 3. Royal Australian and New Zealand College of Obstetricians and Gynaecologists March 2011. “1.5 Women who have been fully informed regarding a recommended course of action, and the potential consequences of not pursuing such management, should have their decisions respected if they decline.” This article provided by MDA National Insurance Pty Ltd is intended as a guide only.

33


Guest Column

Smoking in Those with Mental Illness By Joyce Vidot, National Tobacco and Mental Illness Project. Tel 6365 2999

R

ates of smoking among those with mental illness are three times that of the general population; with some studies finding that up to 94% of people with mental illness are smokers. How we approach these people needs to be continually developed – with plenty of positive consequences, in our experience, when approached in a non-confronting and non-threatening way. Discussions around the subject are very useful; enlightening people with knowledge and helping to empower them. People can reduce their smoking and some can even kick the habit. Making plans with someone can take as little as a few seconds; like asking them to consider which cigarettes they do not really enjoy but smoke anyway, suggesting they allow themselves to not smoke them. These fragments of conversation with a smoker may remain in their minds and resurface when they are smoking cigarettes they are not enjoying. Perseverance is the key word. Medication can be reduced with cessation

provided it is monitored by a medical professional. Feedback from people who have quit is that they have greater mental clarity and develop the motivation to do other things and a sense of control returns into their lives. Barriers in overcoming tobacco addiction are many. They can be as little as the phone ringing, boredom, others smoking nearby (this includes staff) and people not believing in themselves. More serious barriers can be life-threatening diseases such as emphysema and lung cancer; although people should come to realise that even those with a life-threatening disease can address their tobacco use. All these barriers can be overcome as long as people believe there is support available, until they have the confidence to continue on their own. One of our participants who has not smoked for over a year, even though his partner still smokes, says “It’s a miracle Joyce”! Mental Illness Fellowship of WA’s

(MIFWA) Tobacco Free Program offers two-hour group sessions over ten weeks, to help like-minded people reduce their smoking. In the first hour participants are given information about tobacco, medication and emotions. In the last hour we help them make plans for the following week. We fax details to their general practitioner(s) and provide participants with Nicotine Replacement Therapy in the third week of attendance, and a weekly Smokelzer Test for carbon monoxide levels. MIFWA is happy for smokers who have mental illness to call us. We accept referrals from GPs and mail out literature to their surgeries. A wide range of services are on offer, including extra support in other areas of their lives for people who stop smoking. Contact Joyce Vidot 6365 2999 or 9250 2884 or see website: www.mifwa.org.au. References on request. l

Beneath the Drapes u Prof Bryant Stokes will be acting Director-General of Health until a permanent D-G is appointed in a few months. u Dr Michael Stanford has been appointed as Pro Chancellor of Curtin University’s council for a third three-year term. u Mr Peter Mott has resigned as CEO of SJOG Murdoch and has been appointed CEO of Hollywood Private Hospital, replacing Mr Kevin Cass-Ryall who takes on a more regional role for Ramsay Health Care. Mr Colin Young is acting CEO at Murdoch. u The inaugural Executive Director of the Office of Mental Health is Ms Nicole O’Keefe. The establishment of the office was a recommendation of the 2012 Stokes Review. She is an associate professor in Health Science at Curtin University. u RPH’s Dr David Khoo has been awarded the GPRA ambassador prize for the General Practice Student Network. u The CEO of Allion Legal Mr Brett Goodridge is the new chair of Lifeline WA. He replaces Mr Peter Mott. u Dr Robyn Lawrence, Executive Director of Sir Charles Gairdner and Osborne Park Hospitals, has been appointed to the board of aged and community care organisation, Amana Living. u Subiaco physician Dr Rob Gillett has been awarded the John Sands College Medal. The award recognises his contribution to the RACGP and his supervision of trainee physicians. u Prof Harvey Coates, Dr Alastair Mackendrick and Prof Marcus Atlas have all been awarded the Society Medal for Distinguished

34

Contribution at the Australian Society of Otolaryngology Head and Neck Surgery (ASOHNS) annual Scientific meeting in Perth. Dr Cameron Bracks and Dr Stuart Miller were awarded for Distinguished Service to ASOHNS. u Professor Lin Fritschi, from WAIMR, has received a $384,515 NHMRC grant for research into exposure to asthma and cancer causing agents in the workplace. Research is in partnership with Safe Work Australia, Cancer Council WA and Cancer Council Australia. u Medical Insurance Group Australia (MIGA) is acquiring medical indemnity insurance business Invivo. As part of the agreement, MIGA will manage claims on behalf of QBE for doctors who have been insured with QBE, via Invivo. On completion of the transaction, all new and renewal business will be underwritten by MIGA. u A $2.3m contract has been awarded to Carestream Health Australia to provide BreastScreen WA with a Picture Archiving Communications System. u The Health Corporate Network has declined all tenders for the provision of courier services for live donor kidneys for the Australian Paired Kidney Exchange [AKX] program. Couriers are required to provide a time critical door-to-door service 24 hours a day, MondayFriday, Australia wide. u Mr Robert Lister, formerly National e-Health Manager of Sonic Healthcare, has been appointed Manager of Information Technology at Best Practice Software.

medicalforum


Medical Marketforces

Prepare for the Big Squeeze

PIVET MEDICAL CENTRE

The health spend is under pressure with various health sectors jostling for priority while government is looking for more controls. Pharmaceutical companies are reporting a fall in marketing spend on GPs (particularly direct mail, advertising and sampling) as well as industry sponsored clinical trials in Australia. The more cynical suggest most of the pharmaceutical action occurs overseas and government has every right to put constraints on the PBS spend, leaving less in the pharmaceutical kitty for marketing and ‘research’. Both political parties will be looking for health cuts leading up to the election and one way is to save on drugs. The PBS outlayed $7b alone on atorvastatin (LipitorTM), which is now off patent. Ways to save include allowing others to prescribe (e.g. pharmacists, nurses), widening the time interval of repeat authorisations, e-Script systems that track compliance, moving to generics as patents expire, closer auditing of Home Medicines Reviews, and greater consumer payments (e.g. OTC listings). GSK has announced it is declaring sponsorship of individual doctors, consultancy on panels etc., ahead of the Medicine Australia Code redraft in two years’ time. Disclosure is expected to lessen the spend. It is hoped Information Technology (IT) will create efficiencies in our overstretched health system – this may be more from the administrators’ perspective. Many clinicians are saying they are yet to feel real benefits, except for some working in the high-tech specialties. We feature some of the Information Communication Technology (ICT) advances that Fiona Stanley Hospital is heralding (see P 22) but some older doctors see medicos and other health professionals as being largely responsible for content, which translates into more time in front of a screen and less time with patients. Primary care is being reshaped. Public hospitals are being asked to devolve management into the community with Medicare Locals to coordinate. GP services are a relatively small part of the health budget and the latest health workforce figures suggest we are in the middle of a GP shortage. Enter the cheaper Nurse Practitioner alternative. The federal AMA has a big fight on its hands. The federal government has responded to strong recent lobbying to fund an extra 116 intern training places (where the other 50 or so graduates end up is uncertain). There is ongoing haggling over how many medical graduates we need, when it may come down to how many we can afford. Training costs will also come under pressure, expect to see more mannequins replacing real patients. In WA, a lot of money has been put into rural training. Medical graduate salaries have done well, until recently, and in WA in particular. Other disciplines are catching up with Graduate Careers Australia listing dentistry, optometry, earth sciences, and engineering ahead of medicine in the median graduate starting salaries. Mind you, medical graduates enjoy the best employment prospects, with 98% in full-time work within four months of graduation (compared to 54% with Arts degrees). About 3500 medical students are due to graduate from Australia’s 20 medical schools in 2013 and attention is focused on their postgraduate training and community placement because the closer we match expertise with community need, the less hassle politically. l

Specialists in Reproductive Medicine & Gynaecological Services

Fertility News 

by Medical Director Dr John Yovich

The Swizzle Stick Effect … when all else fails The IVF story has developed so well over the 35 years since the first pregnancies, that it has become the preferred technique for a wide range of fertility issues. PIVET has been at the forefront of those developments and holds a very high position in the Australian (and world) league ladder so the majority of patients can now look forward to achieving a successful pregnancy from a single ovarian stimulation cycle when there are extra embryos available for cryopreservation. However, sometimes some cases repeatedly fail to implant their embryos. PIVET has pioneered a range of adjunctive methods, including Growth Hormone injections and DHEA trochéts to improve egg quality when this underlies the problem. We have also reported Dr Gayatri Borude proudly displaying her on the use of novel first infant Archie following a “swizzle stick” treatment on Mum, who had failed to implant hysteroscopic 23 embryos before this?! surgical techniques to correct subtle uterine configurational anomalies. These have been successful when this has been the underlying cause of implantation failure or recurrent miscarriage. However a highly novel method has also recently been explored to improve implantation disorder when no cause has been detected – a technique we have dubbed the “Swizzle Stick” procedure. Following some early overseas reports, our very own Dr Gayatri Borude “trialled” it on some cases of repetitive implantation failure, and struck success in her first few cases! The procedure involves creating a uterine “scratch” around day 21 of the preceding, or early within, the IVF or FET treatment cycle. This can be as simple as a Pipelle endometrial biopsy without requiring any anaesthesia, others may benefit from a more vigorous curette. Since then a major meta-analysis has been published from the University of Leister in the UK, pooling seven studies from various countries showing benefits in many similar cases (RBM Online, Dec 2012). It appears to work by stirring up the very cytokines involved in implantation, overriding those where the uterus has been blocking implantation when it wrongly suspects a suboptimal embryo.

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By Dr Rob McEvoy medicalforum

35


Clinical update

Angina with normal coronary arteries

Dr Eric Whitford, Cardiologist, Western Cardiology Tel: 9346 9300

A

! e s i c r e x E 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 36

MURDOCH

ngina classically occurs when there is a mismatch between myocardial oxygen demand and supply. Usually this is due to atherosclerotic stenosis in the coronary arteries. However we occasionally see patients with a typical history for angina pectoris who have completely normal looking coronary arteries at coronary angiography and no other obvious cause for their symptoms. Typically, these patients have effort-induced chest pain suggestive of angina but in some patients it occurs at rest. During spontaneous or provoked chest pain, some patients also have ST segment depression suggestive of myocardial ischaemia and/or stress-induced perfusion abnormalities on nuclear imaging. Despite efforts to work out the pathophysiology and to refine the criteria for both diagnosis and management of this condition, nothing is well defined. One of the problems is the heterogeneity of the patients that have been included in the studies published. Some had no risk factors and others had diseases like hypertension, hyperlipidaemia or diabetes, or had a history of exposure to drugs like nicotine that would increase the likelihood of occult coronary atherosclerosis and microvascular dysfunction. Macro-vascular or microKey Points vascular dysfunction may be present in some of these • Treatment is symptomatic and patients, but no ventricular other causes of chest pain need wall motion abnormalities to be excluded. suggesting ischemia have • Treatment of any cardiovascular been demonstrated in risk factors, including cessation of many patients during chest smoking, is indicated. pain, including patients • Despite symptoms, the prognosis with ischemic looking ST is excellent. changes at the time. Exaggerated visceral pain sensitivity is another possibility here, along with the possibility that this is associated with an altered CNS response to these visceral signals. Nitrates, calcium blockers, beta-blockers, oestrogen supplements, tricyclics, ACE inhibitors and aminophylline have all been trialled with variable success. Pain relief, however, tends not to be sustained and many patients end up on multiple drugs. Non-pharmacological approaches like exercise training, cognitive therapy, transcendental meditation and spinal cord stimulation have also been trialled with variable success. For patients who present like this I suggest a vasodilator stress, nuclear perfusion study if not already available. If that test is felt to be objectively positive for induced ischemia then it is reasonable to prescribe anti-ischaemic therapy. If the test is negative then cognitive therapy, an exercise program and perhaps medications like tricyclics should also be considered. Risk factors should be treated. The role of aspirin is controversial but risks probably outweigh benefits and this is especially true for women under 65 years. This diagnosis should only be considered if the pain is truly suggestive of angina and when other causes such as gastrooesophageal reflux and musculoskeletal pain have been excluded. The only good news here is that for most patients their prognosis is excellent. However the symptoms can significantly interfere with the patients’ quality of life as well as cause considerable ongoing anxiety in the patient, their families and their doctors. l Declaration: Western Cardiology contributes to Medical Forum’s production costs for this article.

medicalforum


Clinical update

Serious painful eye conditions E

By Dr Boon Ham, Ophthalmologist

ye pain is common, varies according to perception, and is described ‘in’ or around the eye as burning, aching, stabbing, throbbing, or foreign body sensation. Ocular pain comes from problems in the eye or around it, or is often referred from regional structures. Therefore, accurate history is important, although the patient’s description can mislead in localising the site of the problem.

Pain from superficial structures i.e. cornea, conjunctiva

Dry eye. Reduced tear production and imbalanced tear components result in superficial punctate keratopathy (tiny corneal erosions) that can be rather uncomfortable and at times painful. The formation of filaments can be particularly painful and require more than just topical lubricants. Cornea injury. (abrasions, chemical burns, thermal burns). A clear history of injury and positive fluorescein uptake confirms diagnosis. Management should be regular lubricants until the defect heals. Pain from spasm of the ciliary muscle can be relieved by cyclopentolate 1%. Episcleritis. Often mild discomfort with associated episcleral injection. It can be diffuse but more often sectorial and may recur. It is usually benign and selflimiting, requiring reassurance but the occasional low dose anti-inflammatory drops such as FML or Voltaren 1% n Episcleritis helps settle things if indicated. Scleritis. This is a granulomatous inflammation of sclera due to autoimmune dysregulation in someone genetically

predisposed. It may be secondary to trauma, infection or associated with systemic collagen disease. Symptoms of severe, boring pain; awakening patients at night. Eye is red, tender and photophobic and may be accompanied by decreased vision. There is no ocular discharge and the involved sclera has a bluish discoloration that may be localized or diffuse. Complications depend on anterior or posterior ocular involvement; and may include keratitis, uveitis, glaucoma, cataract, retinal swelling, scleral thinning/ perforation. Scleritis needs to be evaluated and treated to avoid uncommon visual loss.

Inflammation involving internal eye structures

Iritis. Inflammation of the iris and ciliary muscle may be isolated or part of a systemic disease e.g. ankylosing spondylitis, juvenile rheumatoid arthritis, sarcoidosis. It presents as a painful red eye, photophobia and blurred vision. Conjunctival vessels are dilated especially around the limbus (ciliary flush) and the pupil may be miosed or irregular

n Acute angle closure glaucoma

and minimally reactive due to posterior synechiae. Slitlamp findings are of keratic precipitates, anterior chamber cells and sometimes posterior synechiae (i.e. iris edge adherent to anterior lens capsule). Once confirmed, iritis needs to be treated with topical steroids and cycloplegics. Angle closure attacks. Acute angle closure glaucoma with its rapid rise in intraocular pressure results in severe pain, blurred vision/loss of vision, nausea and vomiting. The eye is red, cornea hazy (oedema), pupil is mid-dilated, and IOP is high (~50-70 mmHg); this ocular emergency needs to be managed in hospital. More often, there is a history of intermittent mild eye ache, slight blurred vision, perhaps haloes around lights and relatively symptom-free in between attacks; over time, peripheral anterior synechiae cause permanent raised IOP i.e. chronic angle–closure glaucoma. l Declaration: Perth Eye Centre P/L, managing the Eye Surgery Foundation, supports this clinical update through an independent educational grant to Medical Forum. Author – no competing interests.

n Iritis

Dr Ross Agnello Tel: 9448 9955 Dr Malcolm Burvill Tel: 9275 2522 Dr Ian Chan Tel: 9388 1828 Dr Steve Colley Tel: 9385 6665 Dr Dru Daniels Tel: 9381 3409 Dr Blasco D’Souza Tel: 9258 5999 Dr Graham Furness Tel: 9440 4033 Dr Annette Gebauer Tel: 9386 9922

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Clinical update

The impact of HPV vaccination on cervical neoplasia

By Dr Paul Cohen, Fellow in Gynaecologic Oncology, King Edward Memorial Hospital

P

reliminary results suggest an early impact of the HPV vaccine on vaccine-type disease but further evaluation is needed.Vaccination will not protect against preexisting HPV infection or those high risk HPV subtypes not targeted by the current vaccines, which means not all women will be protected. As the duration of protection is unknown, routine Pap screening according to Australian guidelines should continue (with the potential to modify guidelines in the future).

Vaccination program

Vaccine efficacy

In April 2007, Australia was first to introduce a national government-funded human papillomavirus (HPV) vaccination program. HPV is a sexually transmitted pathogen that causes anogenital disease in men and women. Persistent viral infection with high-risk HPV genotypes causes almost all cancers of the cervix. Two vaccines have been developed against HPV infection; the quadrivalent vaccine (Gardasil) that targets HPV types 6, 11, 16, and 18 and the bivalent vaccine (Cervarix) that targets HPV 16 and 18. Gardasil was licensed by the TGA in Australia for females aged 9-26 years and males aged 9-15 years. A 2011 report documents national coverage of 91.8% fully immunised at 12 months, and 92.6% at 24 months. From February 2013, boys aged 12-13 years are receiving the HPV vaccine at school and those aged 14-15 years will also receive the vaccine as part of a catch-up program until the end of the 2014 school year. HPV vaccines appear safe although rates of syncope and thromboembolism following vaccination have been reported to be higher than expected.

Excellent antibody responses have been reported after immunisation with both quadrivalent and bivalent vaccines. Two large randomised trials in 17,000 young women showed that among HPV-naïve populations, the efficacy of quadrivalent HPV vaccine for preventing CIN2-3 or invasive disease due to HPV types in the vaccine, was 97-100%. Amongst all study participants (with or without prior HPV infection), the efficacy of quadrivalent HPV vaccine for preventing CIN2-3 or invasive disease due to HPV types in the vaccine, was significantly lower at about 44% (mean follow-up three years). This reduced efficacy is attributed to the vast majority of trial participants being sexually active and many already infected with the HPV types included in the vaccine. This data emphasises the need to vaccinate individuals before the onset of sexual activity to gain the greatest benefit and maximise cost-effectiveness. The efficacy of the bivalent HPV vaccine (Cervarix) for preventing CIN2 or more severe disease was shown to be similar to the quadrivalent HPV vaccine in a large randomised trial in more than 18,000 young women aged 15-25. Four years after the commencement of the Australian HPV vaccination program, a substantial decrease in vaccine-targeted genotypes was evident (28.7% prevalence in the pre-vaccine group vs. 6.7% in the post-vaccine group) and this decrease in prevalence should, in time, translate into reductions in HPV-related lesions.

Cervical cancer Cervical cancer is the third most common female cancer worldwide (530,000 cases in 2008); the proportion of cervical cancers due to HPV infection was estimated to be 100%. HPV types 16 and 18 cause approximately 70% of cervical cancers and 50% of precancerous cervical lesions (intraepithelial neoplasia grade 2 and grade 3 – CIN2/3). In Australia, the incidence and mortality from cervical cancer have been declining for 30 years but the disease has not been eradicated. In 2005, there were 734 new cases and 221 deaths. The Australian National Cervical Screening Program screens just over two million women annually. In 2007, 28,188 histological abnormalities were detected, of which 13,709 were low grade and 14,479 were high grade. The financial impact on countries is enormous; in the USA, screening, followup and treatment of cervical cancer costs an estimated US$6 billion per year; in Australia, the screening programme costs $138m annually. medicalforum

Cost-effectiveness Modelling of the cost effectiveness of HPV vaccination has been done. One study suggested that vaccination of the entire 12-year-old female US population would annually prevent over 200,000 HPV infections, 100,000 abnormal cervical cytology examinations, and 3300 cases of cervical cancer (if screening continued as currently recommended). However, models of cost effectiveness are limited by uncertainty around duration of vaccine protection, the effect of herd immunity, level of vaccine uptake, and the prevalence of vaccine-specific HPV types circulating in age-specific populations – so findings need to be interpreted with caution.

Implications for cervical cancer screening Cervical cancer screening with cervical cytology has reduced the incidence and mortality of cervical cancer in developed countries by more than 70% over the past six decades. Cervical cancer screening continues to be of great importance since HPV immunisation will not prevent approximately 25 to 30% of cervical cancers in HPV-naïve females and does not protect females already infected with carcinogenic HPV types against the development of cancer. There is scope, however, to consider modifying the Australian guidelines with a large cohort of vaccinated young girls with a low precursor prevalence about to enter the screening program. Whilst vaccination will not protect against all high risk HPV types, these vaccinated young women are at a significantly lower risk of developing dysplasia, and options that might be considered include increasing the age of first screening, increasing the screening interval and the use of new technologies such as HPV testing. References available on request l

Author competing interests: No relevant disclosures.

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Support Group

Mental Illness Fellowship of WA

T

he Mental Illness Fellowship of WA (MIFWA) promotes an understanding of mental illness within the community and contributes to innovation and reform of the delivery of mental health services.

MIFWA and the Mental Illness Fellowship of Australia (MIFA) are working on a national awareness raising campaign focusing on the physical health of people with mental illness. People with mental illness have a life expectancy about 20 years less than that of the general population and are more than twice as

Membership: 250 Yearly Budget and Funding Source: $3.5m from mostly Mental Health Commission of WA and Families and Housing, Children & Indigenous Affairs, (FaHCSIA) Contact person: CEO Sandra Vidot Contact details: Address: 110 Edward St, Perth WA 6000. Mon-Fri, 9am-5pm. Ph: 9228 0200, Fax: 9228 0022, Mob: 0423 676 545. n The MIFWA stand at last year’s Blue Day for Mental Health Week.

likely to have diabetes, heart disease and strokes. This need to improve physical health outcomes for people with mental health issues is being recognised by many and was recently highlighted in the National Mental Health Commission’s first report. MIFWA is lobbying for improved co-ordination of care across the health and mental health sectors and better access to the Chronic Disease Scheme for mental health consumers.

Practice Tips Raising Fees and Cutting Costs? There are alternatives to raising fees and cutting costs to increase your profit in medical practice. Whilst this approach tends to be the main focus, it is worth considering other ideas in conjunction with traditional thinking. Many fixed costs cannot be changed, labour costs are governed by awards, and rebates paid to doctors have declined in real value over the years. It is worth considering non-Medicare income streams. Simple methods such as increasing patient consultations by a small amount a day can have a long-term, significant effect on the bottom line. Are your practitioners being used effectively? The true value of practitioners needs to be reflected in your fee structure. Staffing costs can be reduced by improving skills and efficiencies. The key expense items need to be identified and monitored. This can lead to strategies to reduce these key expenses. Both internal and external benchmarks are an effective way to assess practice and individual performance – “you can’t manage what you don’t measure”. So some simple analysis of your practice can lead to new insights and ideas for increasing the bottom line. Brett McPherson will give a comprehensive seminar on these points at AAPM’s next educational session on May 8. See www.aapm.org.au for more information.

Email: communications@mifwa.org.au www.mifwa.org.au

On May 16, MIFWA will host a Mental Health and Wellbeing Public Forum which will focus on diabetes and smoking and will be held during Schizophrenia Awareness Week (SAW). At this year’s SAW, MIFWA will also be working to reduce the stigma of mental illness and promote its support services, available to both people with mental illness and their carers/families. l

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MIFWA has 245 members, including people with mental illness, families and friends of people with mental illness, partner n MIFWA CEO organisations, Ms Sandra Vidot and supporters and local community members. It is also affliated with the national Mi Networks which links more than 100 mental health support services around Australia.

MIFWA at a Glance

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Transradial Approach for Coronary Angiography and Percutaneous Coronary Intervention The transfemoral approach has traditionally been the preferred access for coronary angiography and percutaneous coronary intervention but this approach is associated with a few limitations. These include postprocedural bed rest which may be poorly tolerated in patients with left ventricular failure, back pain or hip pain and vascular complications of haematoma, pseudoaneurysm, arterio-venous fistula, retroperitoneal bleeding, the need for blood transfusion and surgical arterial repair (1). The transradial approach where coronary arterial access is gained via cannulating the radial artery is associated with a reduction in serious access site complications compared to the transfemoral approach (1,2,3). Radial access is associated with a significant reduction in bleeding and was associated with up to a 75% reduction in bleeding complications (2). There is also the advantage of increased patient comfort, early mobilization and reduced length of hospital stay and cost (1,2). Post procedural blood transfusion is also reduced reflecting the reduced bleeding complications (1,2).

Anatomy The radial and ulnar arteries provide dual arterial supply to the hand which together form the deep and superficial palmar arches. The radial artery is thus n Fig 1: TR radial band: The TR radial not an end artery and in the band is used to compress the presence of a satisfactory ulnar arteriotomy site post procedure. supply to the hand, compression of the radial artery does not compromise circulation to the hand. The superficial course of the radial artery makes it compressible, thus bleeding is controllable. Radial artery cannulation can be considered in patients with a positive Allenâ&#x20AC;&#x2122;s test which tests for the presence of an adequate ulnar collateral (see figure 2). Radial access is contraindicated in the presence of a negative Allenâ&#x20AC;&#x2122;s test and in chronic renal failure patients with arterio-venous fistulas. Radial artery access may provide advantages in morbidly obese patients in which the femoral artery may

Table 1: Advantages and disadvantages of Transradial approach to coronary angiography and PCI Advantages

Disadvantages

Reduced bleeding

Steep learning curve

Early ambulation

Not routinely taught in fellowship training

Reduced length of stay and costs

Potentially limits catheter size

Improved patient comfort

Possible greater radiation exposure to operator

May avoid discontinuation of oral anticoagulation therapy

Long term consequences to radial artery unknown (e.g. for use as bypass graft or arterio-venous fistula)

By Dr Yuli Ten MBBS, FRACP, FCSANZ

n Fig 2: The Allen test. (left): The palm is rendered ischaemic by clenching and opening the hand during compression of the radial and ulnar arteries; (right): the test is positive (normal) if the palm discoloration returns to normal with 10 seconds of release of compression of the ulnar artery while radial artery compression is maintained.

be difficult to access and compress. Complex angioplasty may be performed through the radial approach. Potential complications of radial access include forearm haematoma, radial artery perforation, chronic regional pain syndrome, early and late radial artery occlusion and rarely compartment syndrome. Radial artery occlusion does not compromise the circulation to the hand in the presence of satisfactory ulnar collateral. In the RIVAL trial which compared transradial versus transfemoral access in STEMI subgroup of patients undergoing primary percutaneous coronary intervention, there was a 40% relative reduction in the risk of death, stroke, myocardial infarction or non-CABG related bleeding and 61% relative risk reduction in the risk of death (3). The transradial approach is a safe alternative to the transfemoral approach and is associated with reduced local access site complications and major bleeding. References: 1. Archbold RA, Robinson NM, Schilling RJ. Radial artery access for coronary angiography and percutaneous coronary intervention. BMJ 2004;329:443-6. 2. Rao SV, Cohen MG, Kandzari DE, et al. The Transradial Approach to Percutaneous Coronary Intervention Historical Perspective, Current Concepts and Future Directions. J Am Coll.Cardiol. 2010. 2010; 55;2187-2195. 3. Jolly S, Yusuf S, Cairns J, et al. Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): a randomised, parallel group, multicentre trial. The Lancet. 2011; 377(9775); 1409-1420. n

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In Practice

Joint injections – trigger fingers and thumbs

By Dr Michael Eaton, RDA (WA) President, Rural Locums

M

any of us do not have the luxury of referring patients for ultrasound-guided joint injections because we practise in impoverished or remote areas, or patients prefer us to do it. Moreover, they trust us to do joint injections safely and efficiently. Patient benefits are quick and much professional satisfaction comes from providing a simple and often highly effective treatment. This series aims to show how you can answer ‘Yes’ to the common question “But can’t you do this for me, doc?”.

Discovering a trigger finger or thumb means you have taken the patient’s hand temporarily. In modern GP practice such contact can seem strange but it has an ancient origin in traditional Chinese medicine where it formed the mainstay of diagnosis (after taking a comprehensive history, of course). Examination is needed to find the site of the nodule where you are going to gently inject some local anaesthetic and steroid around or into the tendon sheath but not into the tendon. Clean the area around the trigger nodule with your choice of cleaning solution. Then take your 3ml syringe, load it with an ampoule of 2ml Celestone Chronodose and 2ml of local anaesthetic and with a 25 or 26G needle at its tip, hold it just above the skin 2-3mm distal to the nodule and tilted away from the nodule at about 45º to the hand. Easier done than said (see photo).

feel back pressure, or see the swelling. Some articles advise that injecting near enough is good enough and injecting the sheath itself carries a small risk of longstanding perforation in the sheath, with herniation. Check that your patient is enjoying the analgesia you have just given and remove your needle quickly and apply the Bandaid you have ready. In general, an injection that works will improve triggering noticeably

n Swelling of a trigger thumb.

n Swelling of a trigger ring finger, at the crease.

within a day, and certainly within a week. If the injection is given early enough while the nodule is still tender the results are better than if given when the nodule is more fibrous and hardened. This may sound obvious but you need to recognise this difference when outlining the likelihood of success to your patient. A second injection may be needed for a good result, which can be given after 1-2 weeks. l

Introducing n Injecting a trigger thumb. Excellent result.

Then ask the patient to cough, and as they do, gently and quickly insert the needle into the palmar skin on the 45 degree angle and in line with the underlying tendon. Advance slowly until you feel the grittiness of the tendon sheath or the edge of the nodule. As you inject, feel with the index and middle fingers of the other hand for the fluid entering the space in or around the nodule and tendon sheath. If you feel resistance ask the patient to gently move their finger and observe that the needle does not move. If it does, you are in the tendon and injecting here will lead you to another place you won’t want to visit! At times I have felt the fluid thrill as it moves proximally (cranially) inside the sheath. Stop after 1-2ml, or when you medicalforum

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ail em u e .a as ple om s, d.c d a me lp rra leep e f s r re n@ Fo dmi a 43


Feature

A Diamond as as

Big Kal

Looking at Goldfields life through a camera lens has created a lasting memory for Dr Charley Nadin. It was nighttime when a young Dr Charley Nadin arrived in Kalgoorlie in 1983. He was just three days in Australia and had already discovered to his eternal discomfort, courtesy of a daytrip to Rottnest, that the sun burnt more fiercely than in his native Cornwell. As dawn broke, Charley, who had accepted an “adventure of a lifetime” – a post with the Royal Flying Doctor Service, was ready to take his first good look at the town that would be his home off and on for the next 25 years. “Kalgoorlie just blew me away – it was like a movie set, I thought I had arrived in Hollywood and I was in the middle of a Western, or maybe that should be an ‘Eastern’ given that Kal is at the centre of the Eastern Goldfields. Grand buildings lined wide, wide streets and there was this intense

n Bush grave 44

brightness and clarity of light. I thought of Poet Laureate John Betjeman’s description of the light in Australia as ‘like living in a diamond’. It was quite incredible.” So began a lifelong fascination with Kalgoorlie and the Eastern Goldfields, which he has painstakingly documented through the lens of his camera, another of his life’s passions, culminating late last year with the release in the Goldfields of his first photographic book, Fields of Gold, in the city where it all started. “I’ve been taking images in and around the Goldfields since 1983 but in the past 10-15 years, I started to concentrate on getting a collection of mainly architectural shots. I felt these amazing buildings in such a quirky place, 600km from the sea, were so undervalued yet so magnificent.” “The people who designed and built these buildings had such great vision. These guys said, ‘look we’re going to be here a long time so we are going to put up a beautiful hotel, in the best stone I can possibly find’. The whole place is full of buildings that ooze confidence and magnificence.” Charley describes his medical practice in the Goldfields as ‘Tours of Duty’. “Sometimes, medically, I felt I was on the front line. You can feel on your own ‘up there’. There is a hospital but you don’t have the support of the clever stuff in Perth. I spent 20 years in three jobs – RFDS, Public Health and then I spent the longest time there as a GP/ anaethetist up until 2007. My two girls were born there and my wife (a Boyup Brook farmer’s daughter who is a cardiothoracic trained nurse) and I built our lives there.” “I’ve always taken photographs. I’d wander around the town at 5am or the late evening to get the beautiful light. Some mornings with the sun on the walls, even the buildings looked like they were made from gold.” “Some of the best stories from my life and some of the best people I’ve met have been

during by time in the Eastern Goldfields. There are some incredible people working and living there.” Charley is planning a city launch of Fields of Gold next month to coincide with the 120th anniversary of Paddy Hannan finding gold near Kalgoorlie, setting off the Gold Rush. For details of the launch and to buy the book, go to www.charleynadin.com. l

By Ms Jan Hallam

Goldfields GP shortage Every boom puts resources of our mining centres under pressure. And the Goldfields is no exception, where there has been a serious shortage of GPs. Rural Health West has since November been working with a local KalgoorlieBoulder- Kambalda committee to try and attract doctors to the region both on a short and long-term basis. So far three new doctors have begun practice and 10 doctors are progressing through their applications, of which nine are being case managed by Rural Health West. If you are interested in working the City of Kalgoorlie-Boulder, please contact Rural Health Select on 6389 4500 or email recruit@ruralhealthselect.com.au.

medicalforum


n Cosmopolitian Hotel Kookynie

n Cornwall Hotel

n Eastern facades Maritana Street

medicalforum

Art Tour

Trip of a Lifetime The WA Medical Arts Society (WAMAS) is planning one of its most ambitious masterclass tours in its five-year history. Setting out on August 10, the band of creative medicos will paint and photograph their way for 15 days through some of the Murchison-Pilbara’s most stunning country with Karajini national park, Millstream and Mt Augustus some of the highlights. Dr Tony Taylor, convenor of WAMAS, said one of Australia’s best water colourists, Ross Paterson, would give tutorials each morning before the artists set out for a day’s painting or drawing, while professional photographer Dale Neill would support the photographers on the trip. “There is a lot of camping out under the Outback sky but we have a couple of nights staying in dongas at Mt Augusta and, on the way home, our farewell dinner and accommodation will be at the local motel in Dongara,” Tony said. “Artists are welcome to bring whatever materials they want – I love watercolours – and we’re packing generators so that photographers can recharge their equipment. That should leave us with enough power for some wonderful recounts in the evening as everyone is gathering around the campfire.” The tour is being organised by Tim Casey, of Casey Tours, who has experience in conducting art tours and his local knowledge will take artists to some magnificent spots along the way. There are graded walks to the gorges and participants will be notified in advance the level of fitness required for the different walks. Two chefs will accompany the tour and guides will help with the erection of the tents to leave plenty of free time for art, photography and good companionship. Tony said that he hoped an exhibition might be the result of the trip, but “that will be up to the artists and photographers.” There are spaces still available on the buses. The cost is $3600 for the 15 days, all inclusive of accommodation, meals and transport. For more information, email Tony at thuff@conceptual.net.au or phone 0418 945 047. l

45


Kitchen Confidential

Where did you grow up? Forrestfield, Perth.

Who was your first cooking influence? My mum. Have you always wanted to be a chef? Since I was about 15. It was just my mum and I living together and she didn’t get home from work till late at night so she left me recipes and I cooked dinner for us both. The Martins’ The Botanist, Sir Richard Branson … it all sounds very glamorous, which probably means a lot of hard work! What did you take away personally and professionally from your associations with these iconic people and restaurants? Yes definitely a lot of hard work and long hours. Personally, the Martin brothers Tom and Ed were great bosses whom I got on really great with. I enjoyed working for them and learnt a lot about the running of a business and giving the customers what they want. From Richard Branson I learnt about looking after your staff and how to keep them happy, so they in turn can keep the customers happy. You had a decade working in the UK, what was some of the professional highlights? Travelling to Richard Branson’s private island Necker in the Caribbean to work and his game resort Ulusaba in South Africa were special. Plus eating out at some of the best restaurants in the world. It sounded like a perfect life, what drew you back home? Ten years is a long time to be away from home and we are all getting older, so I wanted to come back to spend time with my family and friends. What changes to the Perth dining scene did you note after time away? Only 80% of restaurants now have Chicken parmigiana, chilli mussels and chicken Caesar salad on the menu instead of 100% of restaurants. Since arriving back in Perth you have been involved in the start-up of (at least) two establishments in Perth, what’s the thrill for you to start something from scratch? The Terrace Hotel is actually my fourth restaurant opening, it is a lot of hard work, but you get to put your own stamp on it and create it the way you want, which is very rewarding. The Terrace Hotel is a key part of the revitalisation of the CBD, what statement do you want to make with the food? Just good quality, local produce, cooked really fresh with my spin on it. The food could be described as modern British because I have spent so much time there. What do you think is your signature dish … the one thing you couldn’t leave off the menu?

10 minutes with... Shannon Wilson The Terrace Hotel is part of the transformation of St Georges Tce from a financial hub to a food mecca and executive chef Shannon Wilson is leading the way.

Whatever is on the menu, I don’t have a particular favourite. I get bored looking at the same food over and over, but everyone else seems to tell me it’s the lamb assiette – lamb done three ways, a rack of lamb, slow-cooked shoulder, shepherd’s pie and spinach puree. People don’t seem to like it if I take it off the menu. The kitchen at The Terrace Hotel seems never to sleep, when do you? What do like to you do when you’re not at work? When I’m not at work I like to keep fit and go to the gym. For fun I like to hang out with family and friends and play a little poker. I also like to have a quiet drink at a good bar that serves good wine and Scotch. I love my sport, in the winter it’s all about football and the mighty Geelong Cats. I hardly ever sleep. What would be your last meal? Probably a roast, I do love cooking and eating a good roast. l

By Ms Jan Hallam 46

medicalforum


Wine Review

Windance

A

ON A PL AT E

Windance 2012 Sauvignon Blanc Semillon This wine is an absolute cracker! Pale in the glass with just a hint of green. A flinty nose with hints of passionfruit reflects the smaller percentage of Semillon than is usual in a blend. Fresh fruit flavours with crisp acid and a hint of sweetness make this an excellent summer wine. A trophy and gold at the 2012 Qantas Wine Show. A must-try wine for lovers of this blend. 2011 Windance Reserve Chardonnay Here’s a trademark blend of the region. Its aromas are generous, savoury and rustic. There is loads of soft jammy fruit, and warm alcohol with blackcurrant, spicy and herbal flavours. It’s drinking well now and will do so for a few more years to come. I love this varietal blend for day-to-day drinking and it's ideal for a barbecue.

By Dr Martin Buck

Despite many wine travels to Margaret River I have not tried Windance Estate and after sampling what they have to offer I am quite disappointed in my lack of direction. The vineyard and cellar door are located just south of Yallingup in the northern part of the Margaret River wine region.

2010 Windance Cabernet Merlot The merlot has got some exciting fruit aromas of berry, plums and chocolate. At 14.8% alcohol there is some ripe fruit in this wine, as well as a little Margaret River leafiness. There is excellent balance and the tannins seem to fade into the fruit. It’s a very easy drinking wine.

2008 Windance Reserve Shiraz This wine is from the Windance cellar and is in limited supply. It has spent 14 months in American oak barriques and the colour is amazing – inky and impenetrable! This is a big wine with lively ripe raspberries and chocolate aromas with noticeable alcohol. It has a mature palate of plums, vanilla and fine tannins, which seems to go on and on. Certainly this wine has reached its peak and is terrific drinking.

Drew and Rosemary Brent-White planted their vineyard in 1998 on gently sloping, north-facing sheep paddocks. The sheep remain as a part of their sustainable land management and environmentally friendly viticultural practices. These wines represent some classic Margaret River styles and excellence in the vineyard and the winery.

2008 Reserve Cabernet Sauvignon Not to be outdone is this formidable signature wine from the region. There is again the typical eucalyptus leafiness on the nose as well as the powerful, savoury fruit. Both the cabernet and the shiraz have potential for further ageing potential but, for me, they are at their peak.

WIN a Doctor's Dozen! Which Windance wine stays in American oak barriques for 14 months? 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, May 31, 2013. 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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47


Music

Sing it

Loud! Vika Bull is coming to town to belt out the songs of American singer, Etta James. From soulful screamers to funky blues, At Last – The Etta James Story will have you dancing in the aisles. Etta James and Vika Bull both honed their power-house vocals in church. Five year-old Etta wowed the congregation of the St Paul Baptist Church, Los Angeles, in the early 1940s and Vika cut her singing teeth in a Tongan choir in the sparkling blue of the South Pacific. Etta’s life was bumpy and turbulent involving abuse, addiction, and stints in prison. ‘It’s all there in the music’ says Vika who’ll be charging through the Etta James song-book at the Regal Theatre this month.

“I grew up listening to my parents’ music, people like Mahalia Jackson, Elvis and Jim Reeves. My mum was very religious and my sister Linda and I had to get up in church and sing in front of the congregation. She was a great solo singer and taught us how to sing in harmony, so it’s no surprise Linda and I went the same way.” “Once I started playing in bands and heard Ruth Brown, Aretha Franklin and Etta James, I just fell in love with them. They were the big three for me!’ It can be pretty intimidating doing justice to an artist you’ve long admired, particularly if she happens to be an icon of American blues, funk and jazz.

“It’s a huge catalogue to get through, we do 23 songs and I have to memorise a script as well. The trumpet player, Tibor Gyapjas and I tell Etta’s story onstage. This really is a tribute to her life as much as her music. She was a wild gal and never lost her sense of humour. Her autobiography, Rage to Survive is very funny.” “I’ve never done any acting before so that’s completely new for me. It’s a bit scary. But the Essential R&B Band do an amazing job! They’re like a mini-orchestra and they do the harmonies as well.” Vika has had a long career in the music industry including singing with Linda and doing the backing vocals for Paul Kelly and the Black Sorrows. There’s plenty of energy in the Vika Bull voice, a perfect foil for the Etta James Story. “I really relate to her naughtiness. She lets things rip in spite of the fact that she started very young and had a tough time. She always put on a brave face, making out she was tough ‘so don’t mess with me’! In this industry you have to be resilient, you have to protect yourself or you won’t survive.” “I put that front up now and then and I’m sure some people think I’m a bit of a hard bitch. I’m not! It’s just that you get knocked a lot and you have to keep going.” So, will Perth audiences be seeing the real Etta James up there in the spotlight? “I don’t try to sing exactly like Etta, I can’t! I’m looking for an interpretation within the musical arrangements and I aim to get close to that Etta James sound. She does things with her voice that are impossible to copy. If you start mucking around with her classic songs everyone gets upset.” “I love Etta and her music because she lived through difficult times and never lost her voice. The show sold well in Melbourne and we’re looking forward to Perth. If you come to the performance you certainly won’t be bored!” l

By Mr Peter McClelland

COMPETITION **For your chance to win tickets to At Last: The Etta James Story (May 21-26, Regal Theatre, Subiaco, turn to the competitions page. 48

medicalforum


Charity

Empowering

s r e w s l a n c A o L to Poverty

Potholes, mountains and a dose of self-reflection confronted one Perth medico on a recent fundraising cycle through India for children in need. Occupational physician Dr Peter Connaughton has just spent some of his precious downtime with 11 other intrepid cyclists in West Bengal, pushing through 700km of rough roads, dodging traffic and sacred cows to raise money for the Child in Need Institute (CINI). “West Bengal is on the east coast of India on the border with Bangladesh and it has significant health and social challenges ranging from malnutrition and HIV to child labour and human trafficking,” Peter said. “There’s a firm belief that by empowering women, in particular, West Bengalis can address these issues within their own communities. We met formerly malnourished children who are now working for CINI with post-graduate qualifications in nutrition. It’s a highly successful inter-generational approach to breaking the cycle of poverty.” “And you have to ask yourself this question, how is a non-government organisation started by two people still growing 38 years later with about 1000 employees and 3000 volunteers?” One answer to that is CINI’s philosophy of developing knowledge, skills and self-reliance within communities in need. “About 90% of the CINI budget is funded from within India so they’re not reliant on overseas aid. In fact, their long-term goal is not to need overseas assistance.” The focus is on using resources available within the country – including their people, food and medications. At present, however, external financial support is essential to spread these successful programs to areas where there are still great unmet needs.

medicalforum

“The CINI model is to get development projects up and running, prove they work and then get public funding. They also have important health training roles with the Government of India and they work with other NGOs including UNICEF and Save the Children – so it’s a very co-operative model.” Peter wasn’t the only medico cycling through West Bengal. His sister, Dr Jennie Connaughton, who works in indigenous health and is a trainee surgeon from Sydney, were part of a larger peloton. “The age range was 21 to 69 and it was a pretty eclectic mix. We had an accountant, a lawyer, graphic designers and retirees all

doing battle with the roads and traffic. We ended up doing about 720km with the first seven days fairly flat going but the last day was in the foothills of the Himalayas. Part of that was a 1500m climb and I pushed my bike for 7km of the steepest bit.” “There was a mixture of bikes, most of us took our own and I used a touring bike with thicker tyres. A few used mountain bikes provided in India and they had a distinct advantage on the last day!” Peter found India a fascinating place – vibrant, colourful and noisy but it’s only since his return to Perth has he allowed himself a deeper reflection. “You find yourself asking, ‘how many televisions do you need and how many of our other challenges are just First World problems?’ There’s great abundance in our society and a lot of it we take for granted. We have a real opportunity here to share some of our good fortune with extraordinary results.” “We can learn a lot from the CINI model. There were some really good lessons regarding self-empowerment and cheaper, more effective health solutions. This isn’t all about doctors – we don’t have all the answers. Health workers providing advice, support and education are solving problems within these communities. You don’t need a fleet of expensive four-wheel drives to make a real difference.” l

www.ciniaustralia.org

By Mr Peter McClelland

49


Culture

The Master

Blaster

n Main Image: Children from the St Paul’s Chapel Choir. n Inset Image: Musical director at St Patrick’s Basilica, Fremantle, Dominic Perissinotto.

Dominic Perissinotto may have been at the helm of music at St Patrick’s Basilica in Fremantle for 15 years but the thrill of playing and mastering its massive pipe organ, which occupies the entire back of the church, never dims. “It’s the largest pipe organ in WA and one of Fremantle’s best-kept secrets. Visitors will often wander in and take a look at the altar and spot a small organ to the right, which we use for the choir. It looks all very nice but then they turn around and are blown away by this pipe organ on the back wall,” Dominic said. “I always think of the movie Spinal Tap and the band’s special speaker that goes to 11 … well my organ goes to 11 as well! There are four keyboards plus the pedals and it gives you incredible flexibility in the sounds you can produce.” The Melbourne-born and trained Dominic headed West after a two-year stint at the Royal College of Music in London to take up a combined position as director of music at St Patrick’s and to help set up the music program at Notre Dame University. When UND decided that music wasn’t its highest priority, Dominic decided to stay at St Patrick’s where his sacred music program, based

around the full-time adult choir and organ music, has developed a fine reputation. Medical Forum readers will also be familiar with Dominic’s own concert series, Pipe Organ Plus, which he started primarily to extend his own musicianship and to collaborate with other local musicians. “There are so many amazing musicians in Perth, it was really eye-opening for me coming from Melbourne to discover that some of the best musicians in the country live here. They are phenomenal.” “For the Pipe Organ Plus series, I try to work with different people all the time so there is immense variety for the audience. Each person or group brings something different to a concert and it’s a way for me to grow as a musician.” “St Pat’s has this amazing instrument and during the course of my regular work, it may not go to the Spinal Tap 11. The concerts are a way of letting people hear the organ in a different light and they give me an opportunity to play pieces I may not play in a service.” The second concert, Spirit, in the 2013

Pipe Organ Plus on May 19 features the St Paul’s Chapel Choir from John Septimus Roe Anglican Community School, directed by Jamil Osmond. On this occasion, St Patrick’s will ring out with two organs, Dominic on the large pipe organ and JSR school organist Jonathan Bradley on the smaller choral organ, playing and singing a program inspired by Louis Vierne’s Messe Solennelle with supporting works by Durufle, Elgar and Palestrina. l

By Ms Jan Hallam

COMPETITION ** For your chance to win tickets to Spirit on May 19, go to the competitions page for details.

It’s All In Your Mind Project, which aims not to produce artists but to help people unlock the creativity of their minds.

In January this year, a special exhibition of art work went on show at the UWA Undercroft. It was special because the work was created by participants of the Extraordinary Mind 50

Jan Cross, who established EMP in 2007, said she was not interested in creating an art school but to explore the potential of the adult mind and to retrain it to think as flexibly and creatively as we did when we were children. “Drawing is an effective medium because you can see the evidence of changes in thinking. You can see changes in the quality of lines, reflecting a changing focus,” Jan said.

“We have always thought our conscious mind does all the work but that’s not the case. In the case of insight, you have to get out of the way to let that part of the n Jan Cross mind work. What we learn at EMP is how to get that function of the mind working in real time.” For more information about the Extraordinary Mind Project and its courses see www. extraordinarymind.com.au. l

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funnyside

n n Vote Jacob 1 Trevor the farmer was in the fertilised egg business. He had several hundred pullets and eight roosters, whose job was to fertilise the eggs. The farmer kept records and any rooster that didn’t perform went into the soup pot and was replaced. That took an awful lot of his time so he bought a set of tiny bells and attached them to the roosters. Each bell had a different tone so Trevor could tell from a distance, which rooster was performing. Now he could sit on the porch and fill out an efficiency report simply by listening to the bells. The farmer’s favourite rooster was old Jacob, and a very fine specimen he was too. But on this particular morning Trevor noticed old Jacob’s bell hadn’t rung at all! Trevor went to investigate. The other roosters were chasing pullets, bells-aringing. The pullets, hearing the roosters coming, would run for cover. But to farmer Trevor’s amazement, Jacob had his bell in his beak so it couldn’t ring. He’d sneak up on a pullet, do his job and walk on to the next one. Trevor was so proud of Jacob, he entered him in the local show and Jacob became an overnight sensation. The judges not only awarded Jacob the No Bell Piece Prize but they also awarded him the Pullet Surprise as well. Clearly Jacob was a Pulletician in the making: Who else but a Pulletician could figure out how to win two of the most highly coveted awards on our planet by being the best at sneaking up on the populace and screwing them when they weren’t paying attention. Do you perhaps know of a Pulletician called Jacob?

n n Amazing Grace A woman invited some people to dinner. At the table, she turned to her six-year-old daughter and said, ‘Would you like to say grace.’ “I wouldn’t know what to say,” the girl replied. “Just say what you hear mummy say,” the woman answered. The daughter bowed her head and said, “Lord, why on earth did I invite all these people to dinner?”

medicalforum

n n Working in

Mysterious Ways

A couple had two little boys, aged eight and 10, who were extremely mischievous. They were always getting into trouble and their parents knew that if anything occurred in their town, their sons would get the blame. The boys’ mother heard that a clergyman in town had been successful in disciplining children, so she asked if he would speak with her boys. The clergyman agreed, and asked to see them individually. So, the mother sent her eight-year-old first. The clergyman, a huge man with a booming voice, sat the boy down and asked him sternly, “Where is God?” The boy’s mouth dropped open, but he made no response. The clergyman repeated the question. “Where is God?” Again, the boy remained silent. The clergyman raised his voice even more and bellowed. “Where is God?” The boy screamed and bolted from the room. He ran directly home and hid in the cupboard. When his older brother fished him out and asked, “What happened?” The younger brother, gasping for breath, replied, “We are in big trouble this time! God is missing and they think we did it!”

n n Simple Formula Three pilots crash in the Canadian forest, and the first guy goes off and comes back two hours later with a deer over his shoulder. His friends go “mate, how did you do that” and he responds “I see tracks, I follow tracks, I find deer.” So after two days the second guy goes off and comes back three hours later and has an elk over his shoulder, and his friends go “mate, how did you find that?” and he responds, “I see tracks, I follow tracks, I find elk.” So after another three days the third guy goes off and comes back one hour later and he is covered in cuts and bruises, so they ask, “mate, what the hell happened?” and he responds “I see tracks, I follow tracks, I get hit by train.”

n n How Bad Can it Get? A father passing by his son’s bedroom, was astonished to see the bed was nicely made, and everything was picked up. Then, he saw an envelope, propped up prominently on the pillow. It was addressed, ‘Dad.’ With trembling hands he opened the envelope and read the letter: “Dear, Dad. It is with great regret and sorrow that I’m writing you. I had to elope with my new girlfriend, because I wanted to avoid a scene with Mum and you. I’ve been finding real passion with Stacy, and she is so nice, but I knew you would not approve of her, because of all her piercings, tattoos, her tight motorcycle clothes, and because she is so much older than I am. But it’s not only the passion, Dad. She’s pregnant. Stacy said that we will be very happy. She owns a trailer in the bush, and has a stack of firewood for the whole winter. We share a dream of having many more children. Stacy has opened my eyes to the fact that marijuana doesn’t really hurt anyone. We’ll be growing it for ourselves, and trading it with the other people in the commune for all the cocaine and ecstasy we want. In the meantime, we’ll pray that science will find a cure for AIDS, so Stacy can get better. She sure deserves it! Don’t worry Dad, I’m 15, and I know how to take care of myself. Someday, I’m sure we’ll be back to visit, so you can get to know your many grandchildren. Love, your son, Joshua. PS. Dad, none of the above is true. I’m over at Jason’s house. I just wanted to remind you that there are worse things in life than the school report that’s on the kitchen table. Call when it is safe for me to come home!

n n Memo to Self When a woman says, “What?”, it’s not because she didn’t hear you. She’s giving you a chance to change what you said. 51


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).

Movie: In the House A 16-year-old boy insinuates himself into the house of a fellow student from his literature class and writes about it in essays for his French teacher. Faced with this gifted and unusual pupil, the teacher rediscovers his enthusiasm for his work, but the boy’s intrusion will unleash a series of uncontrollable events. It stars Fabrice Luchini, Ernst Umhauer and Kristin Scott Thomas. In Cinemas, June 23

Moon: The Australian Voices They received rave reviews from last year’s Edinburgh Fringe Festival and are fast-building a reputation as one of the best a cappella vocal groups in Australia. The Australian Voices are bringing their new show, Moon, on a regional tour of WA and Medical Forum readers have a chance to win tickets to their Mandurah performance on June 7. Moon features a first half of classic choral works by Rachmaninoff, Bruckner contemporary Australian composers. While the second half explores the sights and sounds of space in an original multimedia performance. June 7, Mandurah Performing Arts Centre, 7.30pm

Celebrating with Cosham

ken er had just ta Dr Lyn Minsk ad iP w of her ne possession ring te en by it ed and road test w in e al Fo ru m th e M ed ic case d ixe m a for competition ere is an Th . es in w of Cosham er ’s ab out beginn old saying The f. oo is living pr luck and Lyn to a al rti pa ite is qu Ballajura GP a rly la cu ine, parti drop of red w day rth bi th d case will 60 a s s – so the mixe merlot. There’ – yes, it’s Lyn’ th g already! in on m pp xt po s ne ap coming up ar the screw -c he n ca e W y. come in hand

Music: At Last – The Etta James Story The Australian lady of soul, Vika Bull, meets one of its legends in this musical/threatrical celebration of the music and life of Etta James. Bull and her star-studded band will belt out 23 of James’s classic hits, including At Last, Tell Mama and Something’s Got A Hold On Me while the tragic yet uplifting story of her life is retold by Bull and trumpeter Tibor Gyapjas. Regal Theatre, May 21. Season runs until May 26

Movie: Happiness Never Comes Alone Sacha likes his friends, his piano and partying. He spends his evenings playing in a jazz club where he seduces pretty girls. He is happy and free. No alarm clock, no wedding ring, no taxes. Charlotte has three children, two ex-husbands and a career to manage. She doesn’t have any space for romance in her life. Cue a perfect French romantic comedy. In cinemas, May 30

Music: Spirit The combined talents of organists Dominic Perissinotto and Jonathan Bradley and the St Paul’s Chapel Choir from John Septimus Roe Anglican School bring a gorgeous afternoon of sacred music at St Patrick’s Basilica in Fremantle. The centrepiece of the performance will be Louis Vierne’s Messe Solennelle and will also feature worked by Durufle, Elgar and Palestrina. St Patrick’s Basilica, May 19, 2.30pm

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anaeSthetiSt Wanted MT LAWLEY Dynamic specialist anaesthetist(s) required to replace retiring member. Share rooms with long established hospital based group. There will be no joining fee. Accreditation at Mercy Hospital is mandatory. Computerised billing system with excellent administrative/secretarial support. For further information please call Lorraine on (08) 9370 9733

board MeMber Wanted board MeMber Wanted Fremantle Women’s Health Centre seeks a female GP (VR) as a Board member. This is a voluntary position that would suit someone with expertise in women’s health medicine and an interest in the governance of a not-for-profit organisation. FWHC is a community facility providing medical and counselling services, health education and group activities. The Board currently has 8 members who are responsible for the governance and strategic direction of the organisation and meets monthly. For more information check www.fwhc.org.au or Contact Diane Snooks 9431 0500 / director@fwhc.org.au

For leaSe MIDLAND Consultant Psychiatrist - Private Practice We have a fully serviced new room in an established clinic in Midland. We would like to have a Consultant Psychiatrist join our practice. The rooms are fully serviced and reception will collect fees and process patients. The lease of the rooms is negotiable and very reasonable so we can attract a specialist into a high need area. www.cygnetclinic.com.au Phone: 9467 7676 Fax: 9463 6311 Email: admin@cygnetclinic.com.au

WeSt leederVille Specialists Consulting Suite (waiting room, office, consulting rooms) Onsite parking. Easy access to freeway. Phone: 9380 6457 JOONDALUP Modern sessional suites available in Joondalup CDB Secretarial support available if required. Phone 9300 3380 MURDOCH Murdoch Specialist Centre, brand new stylish large rooms. Please email you interest to admin@sleepmed.com.au ROCKINGHAM Sessional room for rent in specialist medical centre in central Rockingham. Choice of two rooms, medical or allied health with communal patient waiting room. Reception staff not available. Sessions are four hours and currently available a.m. and p.m. $120 plus GST per session for allied health room and $160 plus GST per session for medical consult room, negotiable. Contact Julie Neet, Practice Manager at julieneet@drbillpatton.com.au Telephone 9528 1511 (select option 0) Tuesday–Thursday mornings after 9.30am AVELEY Suitable for dental practice and/or allied health services (eg. Physiotherapy, Psychology, Podiatrist, Radiology etc). Medical centre located in the same building. Located in a fast growing community beside a shopping centre, close to secondary schools, primary schools, church and Child Care Centre. Contact: 0400 814 091 NEDLANDS Hollywood Medical Centre – 2 fully furnished consulting suites on first floor, available for lease Some secretarial support available if required. Phone 0414 780 751

For Sale or leaSe

MANDURAH SPECIALIST CENTRE Fully furnished consulting suites are now available on a sessional basis in the new Mandurah Specialist Centre. Reception support available if required. Phone: Graeme Dedman on 0413 065 009 Email: graemed@wacardiology.com.au

For Sale

WEST LEEDERVILLE Rare opportunity to secure a long term future in West Leederville. Property located on McCourt Street Subiaco – Available 1/5/2013 Well Presented premises – 113 m2 with ample off Street parking. All enquiries to Brad Potter – 9315 2599 / 0411 185 006

MIDLAND Specialist Centre. Attractive, purpose-built, with 2 selfcontained 64 sqm suites. Landscaped 737sqm corner block; on-site parking for 8. Well priced to sell. Phone: 0419 911 464 MEDICAL SUITE(S) 10 McCOURT STREET WEST LEEDERVILLE These well located 61sqm medical suite(s) with two car bays each are located opposite St John of God Hospital and ready for immediate occupation. GORDON TUCKER R/E 0408 093 731 gtrealestate@iinet.net.au

rural PoSitionS Vacant 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. Phone Sally 08 9757 2733 for more info ALBANY VR GP required to join our 4 Doctor, busy, friendly family practice. Full or Part time. We are Accredited, computerised, full nurse support, experienced Admin team. Excellent remuneration. Clinipath pathology on site. Phone Gaye - Practice Manager 9841 6711 Email: admin@hillsidefp.com.au

urban PoSitionS Vacant WEMBLEY DOWNS Urgently required P/T or F/T female GP to join this long established, non-corporate, private billing practice to replace a retired a doctor. Ring Dr Paddy: 9341 3399 Email: managerbmc@gmail.com WEST LEEDERVILLE - GREAT LIFESTYLE Part time VR GP invited to join long established West Leederville family practice. Computerised, accredited and noncorporate with an opportunity to 100% private bill if desired. Lots of leave flexibility with six female and one male colleague. Email: practicemanager@eftel.net.au or Jacky 9381 7111

FREMANTLE Fremantle Women’s Health Centre requires a female GP (VR) to provide medical services in the area of women’s health 1or 2 days pw. It is a computerised, private and bulk billing practice, with nursing support, scope for spending more time with patients, and provides recently increased remuneration plus superannuation and generous salary packaging. FWHC is a not-for-profit, community facility providing medical and counselling services, health education and group activities in a relaxed friendly setting. Phone: 9431 0500 or Email: Diane Snooks - director@fwhc.org.au or Dawn Needham clinical-manager@fwhc.org.au SOUTH PERTH VR GP required FT & PT Excellent River location in South Perth. Non-corporate, private billing, fully computerised. Friendly and efficient support staff. F/T registered nurse and onsite pathology. For more information contact Paris on 9367 1185. Email: bhabibi@bigpond.com ARMADALE Wanted VR/Non VR Female Doctors DWS/Aon Area Outer Metropolitan Perth Phone: Kerry 9498 1099 Email: sevilledrive@medicalcentral.com.au FREMANTLE General Practice in Fremantle requires VR GP FTor PT for privately owned family practice. Accredited, computerised with fulltime Nurse support available. 65% of billings. Phone: Practice Manager 9336 3665 INGLEWOOD GP VR required Part-time. Already heavily booked. Great mix of patients. Very busy private billing, non-corporate practice on the Inglewood / Bedford border. Part-time and hours to suit work-life balance. Full time nurse and pathology on site. We are friendly and generously staffed. We provide an excellent working environment, giving each other support. Phone Steve, Carl or our practice manager Denise on 9271 9311 or Email salisburymed@iinet.net.au BENTLEY GP VR needed for privately owned family orientated practice. 15mins from Perth CBD, AGPAL accredited, fully computerised using MD/ Pracsoft. Private billing. Supported by clinical and CDM nurses operating from purpose built practice. We offer 65% of billings. Contact Alison on 0401 047 063

JUNE 2013 - next deadline 12md Wednesday 15th May - Tel 9203 5222 or jen@mforum.com.au


medical forum HILLARYS Exciting Opportunity. Join us in our brand new General Practice located NOR. Non-corporate. We require a full-time or part-time GP for our practice. Hours to suit. No evening or weekend work required. The practice is fully computerised and well equipped. Private Billing and some bulk-billing Full-time Nursing support. Pathology on site. Please contact Practice Manager on 9448 4815 or Email: smc@westnet.com.au KARDINYA Kelso Medical Group requires P/T and/ or F/T GP This long established privately owned and managed mixed billing practice offers great opportunity for doctor with interest in CDM and minor surgical procedures. Located in Kardinya in newly refurbished premises with onsite pathology and allied health with growing patient base. Currently supported by 7 GP’s and 3 RN’s. www.kelsomg.com.au Please call 0419 959 246 for further information. JOONDALUP CANDLEWOOD MEDICAL CENTRE GP required to join our friendly team for After Hours work immediate start Weekdays 6 – 9pm and Saturday 12 - 5pm Very Attractive remuneration Privately owned, AGPAL accredited general practice Fully computerised Contact Michelle 08 9300 0219 MADDINGTON Maddington (DWS) is looking for a VR full-time GP. This privately owned and managed practice will offer up to75% billing to the right doctor. Various locations North, South and CBD also available. Please contact Phil on 0422 213 360 Email: phil27bc@gmail.com WINTHROP/MURDOCH Full time/Part time VR GPs needed to join Hatherley Medical Centre. No longer Corporate and reopening in March 2013 with very experienced GP. Had been open for over 20 yrs and become a successful 8 doctor practice. Services a large private billing underserviced area. Purpose built centre, well-equipped with on-site procedural room, large nursing station, pathology, physiotherapy, pharmacy and dental. Please call 0400 364 901 and get in early.

MT HAWTHORN Mt Hawthorn Medical Centre, a noncorporate accredited long established practice situated in a fast growing inner city suburb of Perth, seeks a part time or full time VR GP to join this highly desirable practice. Fully computerised, Nurse Assistant. Phone Rose 9444 1644 KWINANA VR GP Full Time or Part Time required for GP owned practice in an excellent location (centre of Kwinana). We are fully equipped and have excellent nursing and admin support. On site allied health, pharmacy and pathology. Mixed billing. Fully accredited. Contact practice manager Bili. Phone: 9419 2122 Email: chishamave@westnet.com.au WHITFORDS GP - F/T OR P/T. We are fully computerised, well equipped, accredited practice. Friendly practice Nurse and admin staff to support at all times, including Careplan/ Health Assessment Nurse. Medical Centre has on site pathology, pharmacy and physiotherapy. Please contact Jacqui, Practice Manager on 9307 4222 Email: jmarkouloop@iinet.net.au BAYSWATER Wanted General Practitioner (VR) F/T or P/T required within our friendly non corporate medical practice. We are a fully computerised, wellequipped, teaching, accredited general practice seeking an enthusiastic person to join our team with a view in assisting our growing patient load. We are a proudly independent practice which offers a friendly environment, flexible working hours, pleasant rooms, great staff, with wonderful patients. Email resume to: manager@walterrdegps.com.au or Fax: 9279 1390 MT LAWLEY Edith Cowan University, Student Health Services, Mt Lawley campus. Part time VR GP with an interest in Women’s and Student Health required. Well-equipped medical centre, accredited, excellent work environment, Registered Nurse support, flexible work arrangements. For information: Dr Robert Chandler Phone: 08 6304 5618 E-mail: r.chandler@ecu.edu.au BIBRA LAKE PT/FT VR GP with/without view to replace PT female Dr in a small privately owned 2 person accredited private billing practice in Bibra Lake. The practice is computerised, and has nursing and pathology support. For further information contact Ashley on 0417 181 070 Email: ashleyr@iinet.net.au

77

aGed care Medical Practitioners for Aged Care Service - Compassion – Efficiency Medical Practitioners for Aged Care (MPFAC) is seeking Medical Practitioners to join our expanding service to Residential Aged Care Facilities (RACF) throughout the Perth metro area. Our aim is to provide a compassionate and evidence based medical care to RACF. • MPFAC provides flexible work options • Remote log in to patient records and appointment scheduling • Nursing and Allied Health Care support • MPFAC methodology utilises the doctor’s time and resources more effectively • Efficient operational support ensures rewarding outcomes for doctor For more information or confidential interview please contact Rollo Witton – CEO Mobile 0417 921 632 Email: rollo@gpagedcare.com.au

DIANELLA Non Corporate practice requires F/T and P/T VR GP’s to join 6 female and 1 male doctor team. Our newly extended, long established, accredited, fully computerised practice is supported with 4 excellent nurses and 5 very friendly admin staff. Our practice is mostly private billing and we offer excellent remuneration. Please contact Practice Manager on 9276 3472 Email: dfmc@dianellamedical.com.au WEMBLEY GP wanted for long established private, accredited Wembley Practice. Sessions are negotiable but ideally Thurs/ Fri am or Mon to Fri pm or part thereof. Our practice is fully computerised using Med Director/Pracsoft. Practice Nurse on site, pathology and theatre. Adjacent services include Physiotherapist, Podiatrist, Psychologist and Dietician including diabetic educator. Please phone Pauline on 9381 9010 Email: wembleygp@westnet.com.au MIRRABOOKA Full time / Part time GP required for a very busy practice in Mirrabooka. VR prefered. 75% Private and Bulk Billing Applications can be made via Email: mds@mirrabookadoctors.com.au or calling 0400 814 091 THORNLIE FT/PT GP required for a friendly new rapidly growing medical centre. Computerised, non-corporate and no after hours required. Outer-Metro area 17km from Perth. Pay 65% of receipts. Contact Dr John Ku or Dr Sandra Lok on 9267 2888 or Email: thornliemedicalcentre@hotmail.com

Australian Skin Cancer Clinics Specialise in Skin Health in Western Australia • CANNINGTON • LEMMING (MURDOCH) Great opportunities for experienced GPs to join these two busy Australian Skin Cancer Clinics. • Flexible working hours to suit your lifestyle; • Great earning potential; • Modern well equipped clinic; • Professional administration and practice management staff; These are not DWS listed sites. For more information please contact Fiona James on 0447 006 846 or fiona.james@ipnet.com.au www.ausskinclinics.com.au/

APPLECROSS FT GP wanted. A rare opportunity to join Reynolds Rd 7 Day Medical Centre has just presented itself as a long term colleague moves out Day Medical of general practice. Commencing Jan or Feb 2013, don’t miss out on your chance to join this private billing, vibrant practice with immediate access to a full patient data base. Confidential enquiries to the practice manager 9364 6633. WANNEROO FT / PT Female GP required for noncorporate family practice delivering excellent healthcare to our local community in Wanneroo (Perth’s northern suburbs, approved DWS area). Our practice is fully computerised (Pracsoft and Medical Director), paperless and accredited. We have a wonderful reception team, professional Practice Managers, and full nursing support. Contact: Jody Saunders 0410 617 094 or Cheryl Barber 08-9405 1234 E-Mail CV to jsaunders.wthc@gmail.com or cbarber.wthc@gmail.com NEDLANDS Full time or sessions available for VR GP in brand new 2-doctor, non-corporate practice in shopping centre. Predominantly private billing, weekends optional. Close to UWA. Onsite practice nurse, pharmacy, physiotherapy, podiatry and dietitian in shopping centre. Please contact Vasanthi at 0402 440 966 Email: nedlandsdoctor@yahoo.com.au

JUNE 2013 - next deadline 12md Wednesday 15th May - Tel 9203 5222 or jen@mforum.com.au


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medical forum PalMYra

Palin Street Family Practice requires a full or part-time VR GP. We, at this privately owned fully serviced computerised practice enjoy a relaxed environment with space and gardens. Earn 65% of mixed billings. For further information call Lyn on 9319 1577 or Dr Paul Babich on 0401 265 881. WOODLANDS P/T or F/T VR GP wanted to join happy, non-corporate, mainly private billing practice. Good mix of patients, no weekends or afterhours. Great location, RN support. Would suit female GP. Contact help@thewoodsmedical.com.au or 9204 3900 BEACONSFIELD Well established, niche family friendly practice seeking VR Female GP to work flexible days and hours. Fully computerised and accredited. Good mix of private and bulk billing. Please contact Practice Manager Linda on 9335 9884 or Email: centralavenuemc@optusnet.com.au

CANNING VALE Seeking GP’s to work in a new purpose built practice in Canning Vale. Modern, Fully computerised and equipped with a Practice Nurse available. Also Pathology and Dental onsite. Please forward interest to ahgpcvale@gmail.com or Contact the Practice Manager on 0416 022 721 GREENWOOD Greenwood/Kingsley Family Practice In today’s market where there is an oversupply of GPs, are you feeling frustrated that you have to work exceedingly long hours and with little take home income? Are you pressurised to bulk-bill in order to stay afloat on today’s competitive GP market? Are you committed to offer quality personalised services to your patients? Are you to looking for likeminded GPs to work with? Come and have an obligation free confidential chat with us. Average gross billing $ 2500 to $ 3000 a day achievable for GPs who offer exceptional services to our clients. Contact Dr Chao 0402 201 311 or Email shenychao@hotmail.com Sorry we do not have DWS status.

FREMANTLE Part time or Full time (preferably VR) GPs wanted. ELLEN HEALTH is a doctor-owned and managed General Practice operating from two locations in port city of Fremantle. Well established patient base, offering a broad suite of services including nutrition and lifestyle, specialised pregnancy and midwifery care, community mental health nursing and skin clinic consultations. If you were to join our team we will offer you: • A growing database of Private Billing patients • A professional and dedicated support team • A lifestyle tailored to the location • Hours of work to suit our balanced lifestyle approach - Practice hours are Weekdays 8am-6pm, Saturday, 8am-4pm - No after hours, on-call or hospital work required at this time • High level of earnings Contact Practice Manager Bridie Hutton 0413 994 484 Email: bridie.hutton@ellenhealth.com.au

MANDURAH Mandurah coastal lifestyle 40 minutes from Perth. VR non VR doctor required short term or long term. No weekends or after hours. Good remuneration. Clinic has full time nurses, pathology, psychology, hearing centre, dermatologist and orthotics. Contact practice manager Elaine 9535 8700 Email: elaine@mandurahdoctors.com.au DUNCRAIG DUNCRAIG MEDICAL CENTRE requires a female GP. Flexible hours, excellent remuneration. Modern, predominantly private billing practice with full time Practice Nurses. Open 364 days: M-F 7.30am/9pm, Sat/ Sun/PH 8am/6pm. Fully computerised. Please contact Michael on 0403 927 934 Email: Dr Dianne Prior: dianne@ duncraigmedicalcentre.com.au

Reach every known practising doctor in WA through Medical Forum Classifieds...

Perth

INGLEWOOD / Mt LAWLEY GPs Required for Skin Checks Unique opportunity to join a busy noncorporate skin cancer practice. Friendly atmosphere with strong emphasis on quality and patient service. Urgent need for VR doctors to perform skin checks. No dermoscopy experience required. Flexibility to explore any area of skin cancer medicine of your choosing, from dermoscopy, biopsies, to surgical procedures. Fully computerised, with modern facilities and nurse support. Great peer support with continuing education and training. Suit VR doctors looking for reduced paperwork, flexible hours and above average income. Please contact admin@skincheckwa.com.au GOLDEN BAY PT female GP required. Fully computerised, DWS, private/ bulkbilling, Fully accredited, Practice Nurse, onsite pathology. Contact: Sheelagh 08 9537 3738 Email CV to: pracman@eftel.net.au

Become part of the Perth Bigger Picture! Long established and privately owned, Perth Medical centre is centrally located, accredited, fully computerised and privately billing. We have recently renovated so come and join our team and you will be busy from day one. We have an interesting and truly diverse mixture of clientele; young and old, blue and white collar, travellers and residents. You will have plenty of opportunity to develop an interest in whatever branch of practice you choose with the backup of a team of locally trained colleagues. We also have a team of RNs leading our chronic disease management program. We are a social group who support one another, are flexible with hours and believe in maintaining balance to avoid the rush hour, reduce your carbon foot print and keep fit; bus, train or cycle to work. Check us out www.perthmedicalcentre.com.au Interested? Call our practice manager Anne on (08) 9481 4342 or Dr Phil A/H 0411 108 883

CANNING VALE Part time VR doctor wanted to join very busy family practice. Fully computerised, excellent treatment room with full nursing support. Opportunity to extend hours in the near future. Email your resume to kate.westlake@canningvalemedical.com or telephone Neda 0414 641 963

Become a foundation doctor with Apollo Health. 3 positions remaining. Apollo is new healthcare group being established in Perth. We aim to push the boundaries of primary care through the provision of state of the art facilities offering a broad range of fully integrated healthcare services. Our first two sites open shortly in Armadale and Cannington. We offer the opportunity to be part of this exciting project and to help shape its future. We are particularly interested in hearing from individuals with ideas on how to do thing differently and do them better. We plan to encourage innovation and are always looking to improve. We have particular interest in doctors who wish to help us develop specific treatment modules in areas such as women’s health, walk-in urgent care, musculoskeletal and sports medicine, skin cancer treatment, chronic disease management, back pain, nutritional medicine and weight loss. We are offering certain incentives to our foundation doctors that will not be available in the future, acknowledging that it is a brave move to join something new.

If interested, we would love to hear from you. To arrange a confidential chat with our Medical Director please email: office@apollohealth.biz

JUNE 2013 - next deadline 12md Wednesday 15th May - Tel 9203 5222 or jen@mforum.com.au


opportunIty exIsts for high paying job in metro Gold Coast, Queensland. Golden priCe pibara Position is full opportunity time General Practice, complete toM on site

Finally planning to enrol medical forum

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The Australian Locum Medical Service provides General Practitioners an after-hours home visiting medical service to DO YOU HAVE A SPECIAL patients of over 700 PerthINTEREST GPs. IN

Price is a docs@medcall.com.au family focused, booming town set in emailTom your cv to: the heartland of the Pilbara close to the stunning dr tom Challenger 761 053 Karijini National0409 Park. Perfect lifestyle for families.

We offer: • $300k + package. private billing practice. fully computerised & accredited. As WA’s only specialised medical business To find out what your four bedroom home medical & pool with gardeningpractice team supplied. broker• we have sold many is worth , call: • full relocation,buyers 6 weeks practices to qualified onpaid ourleave. books. • practice available. u eYour ebusiness n nurse swill be l packaged a n and d marketed to ensure theshared on call. • Working 4.5 daysyou per achieve week with maximum price possible.

GPs for Gold Coast Q

Brad Potter on 0411 185 006

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confidentiality. Contact roger 0427 960 722

or Email: rb.tpmed@bigpond.com (no FRACGP needed) • If youYou have full will enjoy theregIstratIon benefit of our negotiating skills. • Would like to work as a Doctor in Private Practice on We’ll takeGold care ofCoast? all the paper work to Queensland’s, ensure a smooth transition.

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79

in that MBA course?

Make a difference in country WA

MULTICULTURAL AND REFUGEE HEALTH? As an Area of Workforce Shortage, non-VR Doctors working with us can Our busy per South Metro Multicultural Health Clinic The earn up to $10,000 week depending on the number of located patientsatseen. Bentley Centre provides a general practice service for culturally and Imagine these earnings and still fit in three rounds of golf per week. linguistically diverse patients. The clinic operates on Mondays and Wednesdays from 8.30am 4.30pm and are looking for General Flexible roster arrangements are –available andwe earnings are based Rural Health Select has vacancies for locums throughout to work on a sessional basis. on a fee-for-service Practitioners structure. Doctors working with us pay a variable Western Australia. We offer conditions, attractive remuneration, fully commission of friendly any feeswork billed, based upon their commitment. accredited clinic, nurse and interpreter support.

you canonhelp rural and remote For moreIfinformation joiningaour growing medical team, Please call Jenny Wells at the Canning Division contact Chad Stewart on (08) 9227 6658 or visit our on 9458 0505 for further information. community, contact us today! website: afterhoursmedical.com.au l Travel and accommodation covered l Administration support provided l Upskilling General Practitioner – StreetDoctor available l Locum subsidy available Perth Primary Care Network (PPCN) is a not-for-profit organisation in the primary health

further information please contact Rural Health Select Medical Forum For CLASSIFIEDS on T 08 6389 4500 | E locums@ruralhealthwest.com.au. www.thehealthlinc.com.au care industry. PPCN operates a mobile medical StreetDoctor service that takes primary healthcare to the marginalised populations of Perth. We are currently seeking a Vocationally Registered General Practitioner to join our committed team for two shifts per week. The two shifts that we are currently seeking to fill are on a Monday between 9am-3pm, and on a Tuesday between 12-3pm.

Do you like to be independent?BuRSWood Are you looking for a PeRtH country change? Then this is the job for you!!! General Practitioner – After Hours Clinics GP Opportunity Wanting higher remuneration and is not afraid of aGP. bit of hardtown work? has Do you enjoy travel? Are you lookingneeds for Paraburdoo Township a new The PPCN operates the Perth After Hours GP Clinic, located in East Perth and the Swans After Hours GP an alternative to General established busy bulk billing Clinic, located in Middle Swan. The Clinics are General Practice Centre’s offering medical services a population ofPractice? 2000, mostly Well young families. walk-in clinic looking for a full/part time directly public and to patients via the overflow from hospital emergency. We are currently › to the244m² Travel Medicine may be for you. • 7hrs consulting, 4.5 days per week. 07.HealthLinc_Advert_medical_90x80.indd 1 19/07/2011 10:00:12seeking AM› a VRRent: VR GP. GP to join our committed at our Perth Clinic on alternate Saturdays from 5.30pm $325/m² plus team outgoings and GST • Training Provided • Solo on-call but minimal call out, full hospital support. – 10.30pm, and at ourout Swans Clinic on Mondays from 6pm-10.30pm, and dressing up to three hours on › Fitted – waiting room, consulting rooms, room, Higher return than private billing clinics. • Good incentives • Huge on-call bonus and excellentNon income. full relocation Wednesday and Thursday These shifts may be filled by one GP or shifts may be separated.. x-ray roomnights. and reception corporate, RN support with onsite • Excellent available. team Computerised and accredited. 300k plus package. › positions Fullyoffer cabled pathology. these an attractive rate and a pleasant and professional working • Established national home network of pool traveland gardening team plus • 4 bedroom with › 5 secure bays available. environment. for morecar information please contact tracey Snowden, Human resources No patient base required. clinics providing excellent support subsidies, allows you to earn a great with lotshours. of Manager on 9376 9200 or to apply please send your resume to hr@ppcn.org.au DWS ncome available after • Sessionalhours hoursto join the family. for further information ppCn please visit our website at www.ppcn.org.au Contact MattonCampbell Phone Dr Ang 9472 9306 or email • Ongoing Education is encouraged sonseeker@gmail.com CPG Corporate Real Estate • Travel medicine/Tropical Medicine/ 0423 477 333 Occupational medicine Contact roger 0427 960 722 or Email: rb.tpmed@bigpond.com Werequire: are seeking a advantage. Senior Medical Officer to join our We GP – VR an Emergency Department at St John of God Hospital Murdoch. Team Player General Practice & Occupational Health Doctors Send resume to: We are seeking General Practice and Occupational Health Doctors Anaesthetic and Acute Medicine experience is preferred. A GP DECEASED ESTATE tony.gherardin@traveldoctor.com.au for opportunities to and support our metropolitan, regional rural clinics with anaesthetic procedural skills would be and ideal. or phone: 6461 7353 across Australia. Locations in Western Australia can include the Pilbara

West Perth Medical suites available

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MidlAnd - $598,000 (no GSt)

ss

MEDICAL PROPERTY FOR SALE

and regions, and interstate locations may range OurWheatbelt Emergency Department, located adjacent to thefrom

ing

FRemantLe Tasmania and Hospital Queensland to Victoria. We also regularly provide services moRLeY Fiona Stanley site, treats approximately 25,000 for Clients at their remote sites or offshore Youtime will enjoy the VR) Partfacilities. time Full (preferably patients per annum with significant acuity, andorplays a key Accredited practice in Morley seeking following benefits: GPs wanted. role and trainees in FT VR GP.in the training of medical students • Full time, time or short term locum eLLenpositions HeaLtH is a doctor-owned and Emergency Medicine. Attractive terms andpart conditions. • Mentoring, ongoing training and development managed General Practice operating Please contact Mrs Karen Meiers at • wish Exposure to all high aspects of general practice or occupational If you to practice quality patient care and continue from two locations in port city of cms100@iinet.net.au medicine with quality client consultations your own education in pleasant surroundings, Fremantle. you are • Opportunities advance into travel, diving andwork aviation encouraged to apply.toOpportunities for weekend andmedicine Well established patient base, offering WaRWIcK/GReenWood The role will encompass: salary sacrifice benefits enhance thea competitive broad suite ofsalary. services including Are you of working in a family bulk billing nutrition and lifestyle, specialised • tired General practice, and accident / emergency medicine For further information, please contact Director ofand Emergency Two consulting rooms, suit GP Practice and having to see patients • 2 Complete consulting rooms • self-contained Shared on call and other services to hospitals and/or multipurpose pregnancy midwifery care, any practitioners, partially leased. Medicine, Drand Andrew Jan on community 9366 1271mental or health nursing and every 5 health minutes? centres [rural remote locations] • Fenced 737sqm block on-site parking. Rustic charm with email andrew.jan@sjog.org.au • feeling Occupational Health medical assessments and General Practice Are Fenced you unappreciated? skin clinic consultations. enjoy flexible hours, • Quality construction & fitout construction and fit-out. units • a small, Acute injury treatment andBoth management Supplement We quality are friendly, private billing If you were to join our your team we less paperwork, & • Loads of parking income: have own reception and • Practice Health surveillance Family which provides thewaiting will offer Totheir apply, visit www.sjog.org.au/murdoch and you: Are you working • Employer liaison and consulting site work toilets, storage and interesting variety... full rooms, range of General Practice Services click on “Job Search” • Air conditioned towards the RACGP? • A growing database of Private room. Theneed: lovely treed gardens You as well aswill Mole Max dermoscopy andblend well – we have access to Billing • Partially tenanted patients with paved verandahs. provider number Equipment Provided is a Doctors’ cooperative procedure work. - WADMS • Eligibility for registration in Western Queensland orfor • AAustralia, professional andwork. dedicated After Hours and/or National registration Essential We havequalifications: aVictoria fully equipped, dedicated support team Are you an Overseas • medical A caring and quality commitment to providing general and •Procedure General registration. Room. Mike palmer 0403 621 899driven or 9274 5000 Trained • Awww.realestateplus.com.au lifestyle tailored the location practitioner health services and aDoctor desirewith to to continue •No Minimum ofoccupational two or years post-graduate after hours weekend work.experience. • Hours of work to suit our learning. • Accident and Emergency, Paediatrics & some GP experience. permanent residency Contact: Sheng 0402 201 311 balanced lifestyle approach andplease working toward To register your interest or for further information, contact • Fee for service (low commission).• Non VR access to VR rebates. RACGP? - we - Practice hours are Weekdays 8amourshifts, HR day Department on (08) 9242 0830 or • 8-9hr or night. have access to • Bonus incentives6pm, paid. Saturday, aScot 8am-4pm email or jobs@gemini.com.au • 24hr Homecareers@primehealth.com.au visiting services. provider number for • Interesting work environment. medic alFORUMwa We require Part-time VR GP for our - No after hours, or hospital Afteron-call Hours work. • Access to Provider numbers. friendly family oriented surgery. work required at this time We are an Accredited Non-Corporate • High level of earnings Contact Practice. Trudy Mailey at WADMS - 60% of Gross Billings The surgery is computerised; Private Contact Practice Manager and Bulkbilling practice. Bridie Hutton 0413 994 484 F: (08) 9481 0943 E: trudy.mailey@wadms.org.au 56 medic alFORUMwa Practice Nurse available part-time. www.wadms.org.au email: finance@ellenstreet.com Please contact – ID.6155) WADMS is AGPALPractice registeredManager (accredited Annette on 9479 4722.

85% take home,

54

(08) 9321 9133

Located in Maddington adjacent to Maddington Centro Shopping Centre ·

Opportunity to buy real estate – deceased estate

·

Modern brick and tile construction

·

Large block

·

Current practice not operating at full capacity - plenty of room for expansion

d te n a W s GP to pathologyprivately · One room leased : managed, new centre d in practice with option l a · Close tr to retirement village to buy in. us“Arcadia Waters”3 senior GP’s to support. A – ·

Practice currently fully accredited, computerised including Pathology centre, privately Psychologist and Chiropractorowned,

– retirees, Procedural not req but available. n · Demographics young o Visitingfamilies rights to and localindustrial hospital. Specialist i t workers and emergency department cover nearby. ca Facilities o with latest technology and equipment. L dand Experienced full time nurses to support. This property is a rare find would not n a be available except for le deceased estate. email details to practice Manager; So hurry to secure! y t elaine@leschmed.com.au or contact 9725 8471. es For more information please Lif contact Centex Commercial Rick Bantleman 0413 555 441

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JUNE 2013 - next deadline 12md Wednesday 15th May - Tel 9203 5222 or jen@mforum.com.au Produced right here


80

medical forum FOR SALE

HIDDEN VALLEY FOREST RETREAT

Venosan Diabetic Socks

The Magic of Silver for Sensitive Feet

Contemporary lodges built with luxury in mind

Four standalone architect-designed lodges with an on-site fitness centre nestle on 110 acres in the beautiful Margaret River wine region, with outline permission to build six more and a design for a 9 or 18-hole private golf course. The partially reticulated property boasts three vineyards, each producing wine grapes. Interested parties contact: Sally & John – Hidden Valley Forest Retreat – Tel: (+61 8) 9755 1066

www.yourhiddenvalley.com

Looking for a work life balance? GP Opportunities Available in WA

No Compression Silver Ion Therapy Contains the antimicrobial silver yarn Shieldex® which enhances a balanced foot climate. Tested and proven in controlling over twelve types of bacterial and fungal infections common on the feet and legs. •

Silver yarn - is permanent and cannot be washed out of the socks.

Keeps feet cooler in the summer and warmer in the winter

Comfort for The Patient

• Garden City Medical Centre • Kingsway Medical Centre • Mirrabooka Medical Centre • Noranda Medical Centre • Victoria Park Medical Group

Soft-Spun Cotton - Ultra soft cotton

Fully cushioned foot and fully cushioned sock

Comfortable for arthritic patients

IPN is a highly diverse and collaborative service provider. You will enjoy: • Clinical independence • Freedom & flexibility • Variable commercial terms to suit you • Modern, well equipped clinics Limited positions available. For a potential partnership with IPN, please contact esther.mortimer@ipnet.com.au or 0418 371 724.

Flat Seam Safety No noticeable seams due to hand-linked toe section. This reduces chaffing and blistering that could result in infection and skin ulceration.

All discussions will be confidential. www.ipn.com.au

!

LifestyLe and career

Beautiful BuNBuRY Specialist and allied health opportunities! A great opportunity for the right clinicians to own and operate their own practice or if preferred we can employ! We have a combination of single rooms with dedicated reception or individual tenancies available – come and have a look and choose for yourself! Opens late April/early May Project Manager: Jill Riggall 0437 516 850 jill.riggall@breckenhealth.com.au GP’s are encouraged to contact Dr Brenda Murrison 0418 921 073 brenda.murrison@breckenhealth.com.au

Non-restricting cuffs

tion.

– avoids restriction of circula-

Colours – available in Silver (essentially a white sock with Silver yarn) & Black.

Sizes – available in 3 sizes (Small, Medium & Large).

Your WA Consultant – Jenny Heyden RN Tel 9203 5544 or Mob 0403 350 810

JUNE 2013 - next deadline 12md Wednesday 15th May - Tel 9203 5222 or jen@mforum.com.au


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Medical Forum WA 05/13  

WA's Independent Monthly for Health Professionals Public Edition