MedicalForumWA 0317 Public Edition

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Hidden Symptoms

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• Doctors’ Health Matters • Psychiatry Services Expand • Peter Greste on Resilience

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• Clinicals: Pain in ED; Stroke Imaging; Parenting; Allergy to RCM & More

March 2017

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EDITORIAL

Roll Out the Pork Barrel Division among health providers? Hardly news! However, its longevity and resilience is often the profession’s Achilles heel leaving individuals and whole sectors vulnerable to cynical politicking.

Take a well-documented piece of pork barrelling on pathology Accredited Collection Centres (ACCs) – climaxing right now as the new Minister Greg Hunt adjudicates before the proposed changes take place on June 1. If there is no change of heart, the government will regulate rental price where it had once given parties freedom to negotiate on market value.

Medical Forum sought comment via the PA website from its CEO, Ms Liesel Wett, without response. Perhaps, as far as PA is concerned, the job is done.

We also hoped to get Dr Wayne Smit’s views, who sold Perth Pathology before Christmas to Clinical Laboratories Australia.

He didn’t reply to our email either but he was quoted in the SMH in December as saying he was left with no choice but to sell his decade-old business after rent went from 5% of his costs to 20% “with more in the offing”.

There is no question that running a state-of the art pathology company requires enormous investment in equipment and there is equally an argument that such investment is prohibitive to the smaller independent pathology companies.

The SMH reported that Perth Pathology was one of six private pathology companies to have sold out or closed in the past two years.

Ms Wett suggested that if the Government did not follow through with its election promise, Australia would end up “with a duopoly, which would lead to increased prices and lower service standards".

MEDICAL FORUM

Primary Health Care recently issued its half yearly report to the ASX which showed it had suffered a 5% decline in earnings (36% pre-tax) of its mainstay medical centres put down to its changing recruitment and retention policies.

Its Pathology revenues grew by $22.6m, or 4.7%.

It was a huge concession for some pathology providers and a kick in the guts for independent GPs already reeling from the MBS rebate freeze.

Advertising Marketing Manager (0403 282 510) advertising@mforum.com.au

However, ACCs in practices owned by Primary and Sonic are not affected by the rent issue, so it’s hard to see that the rental issue would drive up prices and pathology companies may think darkly on her assertion about lower service standards.

However, it also said that since June last year it had embarked on a drive to secure more ACCs in response to the election announcement. It added 60 collection centres in the half year on a net basis and closed some underperforming centres.

The story so far…a 600,000-signature adverse petition on bulk billing collected

by Pathology Australia (PA) in the heat of a knife-edge election in May last year resulted in a behind-the-scenes deal for legislative change to reduce rents for ACCs in private general practices.

PUBLISHERS Ms Jenny Heyden - Director Dr Rob McEvoy - Director

Matching rhetoric with reality

EDITORIAL TEAM Managing Editor Ms Jan Hallam (0430 322 066) editor@mforum.com.au Medical Editor Dr Rob McEvoy (0411 380 937) rob@mforum.com.au

CEO Dr Gordon Harloe of Clinipath Pathology, a member of the Sonic Health Group, issued a statement to Medical Forum saying: “Clinipath Pathology supports general practice, and the Federal Government should provide appropriate funding for general practice and ensur[e] that all doctors can continue to deliver appropriate medical services to West Australians.”

GPs also have the influential support of the AMA on this issue.

Last edition we heard from some independent general practice owners who were prepared to go to battle on this issue, so crucial is it to the survival of hundreds of practices across Australia. The newly formed lobby group GP Alliance, with Canberra GP Dr John Deery and Perth Hills GP Dr Sean Stevens leading the charge, has its first meeting on March 4 in Sydney and the rental issue will be centre stage.

We rely on Governments to use their considerable power in a fair and just fashion and, as is demonstrated here, perhaps politicians don’t think that way. The Government was returned with the slimmest of margins and is struggling to make meaningful legislative headway. Independent general practice is at war with pathology. The Government has achieved little and created bad feeling with those bearing the brunt of its costcutting policies. Where is the social dividend?

Clinical Services Directory Editor Ms Jenny Heyden (0403 350 810) jen@mforum.com.au Journalist Mr Peter McClelland journalist@mforum.com.au

Supporting Clinical Editor Dr Joe Kosterich (0417 998 697) joe@mforum.com.au GRAPHIC DESIGN Thinking Hats hats@thinkinghats.net.au

MARCH 2017 | 1

CONTENTS MARCH 2017

16

10 FEATURES 10 Spotlight: Journalist Peter Greste 16 Psychiatric Services Spread Wings 20 Doctors Health – You Matter 24 Bright Young Things NEWS & VIEWS 1 Editorial: Roll Out the Pork Barrel

Jan Hallam 4 Letters to the Editor

New Thinking for Cost Spiral

Dr Linda Swan

Hope and Help is Out There

Ms Jill Rundle

Culpable Drivers: Change to Act

Dr Revle Bangor-Jones

Endocrine Discussions

Dr Serene Lim

Prof Tim Welborn 6 Govt Moves on Maldistribution 6 Curious Conversations

Dr Bijit Munshi 12 Have You Heard?

13 Beneath the Drapes 15 Thursday Island Dreaming:

Dr Wynand Breytenbach

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24

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MedicoLegal: Advanced Health Directives

Mr Enore Panetta 25 Practice Tips: Fraud

Lifestyle 44 Running for Life: Dr Cecil Walkley 38 Funny Side 40 Restaurant Spotlight: Yellow Pancake 41 Wine Review: Juniper Estate

Dr Craig Dummond MW

42 Doctor in the Arts: Dr Malcom Hay 43 WASO Concert Package 44 Doctor in the Surf 44 Funny Side 45 Competitions

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MEDICAL FORUM

clinicals

5

Rapid Microbiological Diagnosis Prof Miles H Beaman

27

Antisocial App Review Ms Karen Huggett

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Radiocontrast Media Reactions

By Dr Meilyn Hew

35

Principles in Stroke Imaging Drs Jolandi van Heerden & Manoj Tharakan

37

When Your History Becomes Their Destiny Dr Julia Feutrill

guest columns

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Power of Good Culture Prof William Hart

28

Drop Out and Drop Dead Dr Bret Hart

29

ED: Integrated Pain Management Dr Andrew Jan

31

How Does Your Garden Grow?

Dr Richard Yin

‘Serving the Community: Risk vs Reward’ Thursday, March 23 7.30am Royal Perth Yacht Club Generously supported by….

Visit www.doctorsdrum.com.au to reserve your place, see the panel, and more • Styled after the ABC’s entertaining Q&A with stimulating light-hearted discussion.

• Enjoy a delicious breakfast, courtesy of the two medical sponsors.

• Better understand another’s point-of-view.

• Independent MC Andrea Burns keeps it relaxing and relevant – away from any lay media.

Where will the audience lead us at this Doctors Drum?

• Is the work-life balance correct?

• Are doctors prone to burnout?

• Do we support doctors enough in at-risk situations?

• Are new graduates properly equipped?

• Is the medical profession attracting the right people?

INDEPENDENT ADVISORY PANEL for Medical Forum John Alvarez (Cardiothoracic Surgeon), Peter Bray (Vascular Surgeon), Chris Etherton-Beer (Geriatrician & Clinical Pharmacologist), Joe Cardaci (Nuclear & General Medicine), Alistair Vickery (General Practitioner: Academic), Philip Green (General Practitioner: Rural), Mark Hands (Cardiologist), Pip Brennan (Consumer Advocate), Olga Ward (General Practitioner: Procedural), Piers Yates (Orthopaedic Surgeon), Stephan Millett (Ethicist), Kenji So (Gastroenterologist) Astrid Arellano (Infectious Disease Physician) MEDICAL FORUM MARCH 2017 | 3

LETTERS To THE EDITOR New thinking for cost spiral

Hope and help is out there

Dear Editor,

Dear Editor,

I was interested to read the views of WA doctors on health trends (February). I’m often asked what I see as the biggest health challenge facing Australians. To be really succinct – it’s that we are going to run out of money.

Working with people who are experiencing alcohol and other drug related problems can be both challenging and rewarding.

I believe we have one of the best health systems in the world but we also have an ageing population, a growing prevalence of chronic disease, and the ever-increasing costs of new technologies.

Clinicians are at the heart of our healthcare system and they are dealing with all of these challenges on a daily basis. The health systems, both public and private, face significant technological change. In thinking about how best we offer care in 2017 and beyond, the patient’s outcomes must come first and this means we may need to move away from fee-for-service billing to a more outcomes and volume-based system.

Governments and private payers can't afford to continue to pay for health care in the way we have for the past 50 years. Health-care costs are increasing because Australians are going to hospital more often.

Every time we’re admitted, we are receiving more treatments and services than in the past, and the cost of treatments and services are also rising.

I can off figures from a Medibank Private perspective – since 2011, the number of hospital admissions per member has increased 19% and the average amount the insurer pays in benefits per admission has increased 10%. This has seen average hospital benefits paid per member increase by 31%.

Tackling these big and complex issues to ensure the sustainability of Australia’s health care system requires innovative and creative solutions. It also requires us to focus – not just on reducing waste and lowering costs – but on our ultimate goal of improving the health of individuals.

Dr Linda Swan, Chief Medical Officer, Medibank Private ........................................................................

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.

4 | MARCH 2017

Dr Amanda Stafford (New Hope for Alcoholics, February) is not alone in treating people affected by alcohol and other drugrelated problems. Specialist alcohol and other drug services exist throughout the state, employing dedicated staff passionate about prevention, treatment, rehabilitation and harm reduction.

Alcohol and other drug issues are primarily a health and social concern. While there are not enough community treatment services to meet demand, they currently provide more than 17,000 closed treatment sessions a year.

Alcohol and other drug dependence is a chronic and relapsing condition, requiring ongoing treatment and support. While these conditions may be challenging to treat, patients deserve the same level of care as other patients with chronic conditions.

WANADA supports medical treatments for Substance Use Disorders, provided they are well-evidenced, and that patients also receive psychosocial support needed to achieve long-term outcomes.

We therefore encourage doctors and medical staff to learn about the full range of treatment options available and to work with patients to find the best fit for them.

Alcohol and other drug work is not without hope. Empathy can go a long way to support people to achieve improved health and wellbeing.

Ms Jill Rundle, CEO, WA Network of Alcohol and other Drug Agencies ........................................................................

Culpable drivers: changes to the Act Dear Editor, On 10 March 10, 2017, changes to the Road Traffic Legislation

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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.

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will come into effect. These changes have implications for the taking of blood samples for forensic purposes, predominantly in Emergency Departments.

What is changing?

There will no longer be a need to assign culpability of the driver(s) at the time of the crash, and the time window for the taking of samples will be increased to 12 hours. The new legislation allows for a trained person other than a doctor or nurse to take the sample.

Why the change?

Many serious and fatal crashes are the result of driver impairment by alcohol and/or drugs. This amendment will make it easier for evidence to be collected from impaired drivers involved in such crashes.

Who will decide when it is appropriate to take a sample?

The responsible police officer will decide who requires a sample to be taken and will complete the necessary paperwork, as well as being responsible for taking possession of the sample after it has been taken.

What happens if the patient refuses to have the sample taken, or cannot give consent?

The patient cannot be forced to have a sample taken but a refusal will result in police action.

If the patient is unable to provide consent, e.g. patient unconscious, the police officer can authorise a prescribed sample taker to collect a sample from the driver in accordance with legislation. This must be provided in writing and signed by the police officer.

Where can I get more information about the amendment?

Information on the amendment can be found at: https://www.slp.wa.gov.au/legislation/ statutes.nsf/main_mrtitle_848_homepage.html Dr Revle Bangor-Jones, Medical Adviser, Office of the Chief Health Officer ........................................................................

Endocrine discussions Dear Editor, I was pleased to read Prof Tim Welborn's comment about adding T3 to T4 in hypothyroid continued on Page 6

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MEDICAL FORUM

Rapid Microbiological Diagnosis

Prof Miles H Beaman FRACP, FRCPA, FACTM

About the Author Infections are important causes of mortality worldwide. Survival in serious bacterial infections is dependent on using the correct antibiotic as soon as possible, requiring accurate early aetiological diagnosis.

Classical microbiology uses a sequential algorithmic approach which may delay appropriate therapy, that is, Gram stain (urgent results phoned within-an-hour to differentiate gram positive from gram negative, cocci from bacilli), culture (takes 24-48 hours for rapidly growing organisms, often with selection or disclosing substances in media i.e. lactose, methicillin/salt agar), which enables biochemical (i.e. catalase, oxidase reaction) or agglutination (Neisseria, streptococci) testing to indicate likely species or its likely sensitivity (i.e. nitrocefin). Methods are relatively slow.

Western Diagnostic Pathology (WDP) offers quicker molecular testing for: Sexually Transmitted Infections (Neisseria gonorrhoea, Chlamydia trachomatis, Mycoplasma genitalium, Ureaplasma species); respiratory virus (Influenza A and B, Respiratory Syncytial virus, Parainfluenza 1-3, Respiratory Adenovirus, human Metapneumovirus); and herpesvirus (HSV 1 and 2, Varicella).

For example, median turn-around-time (TAT) for respiratory virus testing decreased from 220 hours in a reference laboratory to less than 48 hours at WDP. To further improve TAT for rapid molecular diagnostic testing for bacterial infections, in 2010 WDP commenced

Take Home Points • Classical microbiology may take 4872 hours to yield useful results.

• WDP introduced molecular testing panels to speed up appropriate treatment: as well as those listed are tests for STIs and H. pylori including clarithromycin resistance markers.

• MBS restrictions require careful PCR panel selection, facilitated by a syndromic approach References available on request

a multiplex assay for atypical respiratory pathogens (Mycoplasma pneumoniae, Legionella pneumophila, Legionella longbeachae, Chlamydophila pneumoniae, Pneumocystis jiroveci, Bordetella pertussis and Bordetella parapertussis). This dramatically reduced the several weeks usually required for atypical respiratory serology to become diagnostic.

Clostridium difficile is a serious hospitalacquired infection that is becoming more common in the community and more virulent in some countries. Because Clostridium protocols can be slow (i.e. antigen test, followed by toxin testing and/or culture), in 2011 WDP introduced a Clostridium difficile toxin A/B PCR which gives a result within 24 hours.

Diarrhoeal disease is a major killer worldwide and results in enormous costs to health systems. In 2013, WDP introduced faecal multiplex PCR testing (Campylobacter species, Salmonella species, Shigella and Entero-invasive Escherichia Coli, Yersinia enterocolita, Aeromonas species, Giardia species, Cryptosporidium species, Entamoeba histolytica, Blastocystis species, and Dientamoeba species). The test is very specific, even though some of these organisms have a controversial role in enteric disease, which means the requesting doctor should correlate test results with the patient’s clinical status. This test panel is generally advised in adults or returned travellers, for acute and chronic diarrhoea.

We also offer multiplex PCR for enteric viruses (Norovirus, enteric Adenovirus and Rotavirus), usually tested in children or elderly adults without “red flag” symptoms (i.e. fever above 38°C or blood in the stool).

Recently PCR testing for Helicobacter pylori (a fastidious organism, often difficult to grow and keep viable) enables assessment of clarithromycin resistance (2142 C and G, 2143 G mutations) and can be performed on gastric biopsies and stool. Macrolides should be avoided in the presence of clarithromycin resistance, as failure rates are very high.

A cutting-edge technology introduced by WDP for diagnosis of bacterial infection is the MaldiTOF technique. The MARS Curiosity rover has this instrument on board to help in the search for extra-terrestrial life. This

Prof Beaman graduated from the UWA and trained in Clinical Microbiology and Infectious Diseases at Sir Charles Gairdner Hospital, making him the most experienced Infectious Disease Physician in WA. He completed a Post Doctoral Fellowship at Stanford University and then established the first Infectious Diseases Department in Western Australia at Fremantle Hospital.

He joined Western Diagnostic Pathology in 2002, where he is Medical Director and Deputy CEO. He is also a Clinical Professor at both the University of Western Australia and University of Notre Dame Australia.

method relies on the observation that whole organism protein mass spectra are sufficiently distinctive to allow taxonomic characterisation of genus, species and sometimes to strain level. This test will disclose in seconds the identity of an unknown bacterium. It has been incorporated into the WDP laboratory and has reduced most TATs by around 24 hours.

Because the Medicare Schedule only reimburses testing for three pathogens, it is important to choose the appropriate PCR panel for the patient’s symptoms.

A syndromic approach in ordering is recommended. Most PCR tests are run six times a week, and can give a rapid aetiological diagnosis.

Recommended Syndromic PCR Test Ordering • URTI, flu-like symptoms (fever, respiratory symptoms, myalgia/fatigue) – respiratory virus PCR (RES panel) • Cough, LRTI signs – atypical respiratory pathogen PCR (ATY) • Acute diarrhoea, infant or geriatric – enteric virus PCR (GAS) • Acute diarrhoea, infant or geriatric with fever above 38°C or blood in the stool – faecal multiplex PCR (FPM) • Acute diarrhoea, adult – faecal multiplex PCR (FPM) • Acute diarrhoea, recent antibiotic exposure – C. difficile toxin PCR (CDT) • Chronic diarrhoea – faecal multiplex PCR (FPM)

General Enquiries: Ph (08) 9317 099 Email: admin@wdp.com.au Website: www.wdp.com.au Results Enquiries: Ph 136 199 For a list of Collection Centres and Laboratories go to www.wdp.com.au

MEDICAL FORUM

MARCH 2017 | 5

LETTERS To THE EDITOR continued from Page 4 treatment as some patients are unable to activate T4 to T3 due to a genetic deficiency of deiodinase enzyme.

From my research, there are many more reasons why patients require additional T3.

• 20% of T4 is activated to T3 in the gut and patients with gut issues (inflammatory bowel disorders, IBS etc) often have hypothyroid symptoms. A large percentage of patients have poor bowel movements and it becomes very apparent when a detailed bowel history is taken.

Training and rural practice The new Federal Assistant Health Minister Dr David Gillespie met the National Medical Training Advisory Network (NMTAN) in Melbourne recently focusing on medical school places. The next day he was in Perth at Rural Health West announcing a new three-year $93m Rural Workforce Agency program.

Both were convened in the shadow of the findings of the 2016 AIHW Australia’s Future Health Workforce Report which predicted an oversupply of 7000 doctors in Australia by 2030.

• The deiodase D1 gene is down-regulated in times of stress. That would affect most of my patients.

• Vitamin B2 is required to convert T4 to T3. Low riboflavin levels are linked to higher alcohol intake. There is evidence suggesting that suboptimal riboflavin status (as determined by the functional biomarker EGRac) may be a widespread problem.

• The body converts T4 to Reverse T3 (instead of T3) to conserve energy e.g. when dieting. I often check Reverse T3 especially in those overweight who have had yoyo dieting patterns.

I find patients who have hypothyroid symptoms despite 'adequate' T4 treatment feel better (I monitor by their symptoms, not TSH) on a regime of 50mcg T4 a day and T3 twice to three times a day, the dose titrated to their symptoms. I also deal with all the other factors that support good thyroid function – alcohol and stress reduction, adequate vitamin D, iron, B12 and folate and the conversion to the activated forms by the MTHFR gene.

Dr Serene Lim, GP, Claremont

Dr David Gillespie

Dr Gillespie, himself a former regional gastroenterologist, is keen to “think about how we utilise the education and training pathways to attract and retain doctors to the regions”.

It’s an interesting statement given the Abbott government garrotted a successful prevocational GP rural program in 2015 but nonetheless it is crucial to redress the maldistribution particularly of the general practice workforce.

The statement was light on detail but the agency plan was part of a “suite of reforms” that included the creation of a National Rural Health Commissioner, reform of medical training and distribution, and development of the rural generalist pathway to upskill GPs in regions.

WA still depends on IMGs

Response Re: Correspondent’s response to my Unhappy hypothyroid letter (Feburary) My strong personal opinion about adding T3 to T4 therapy in a specified subset of hypothyroid patients still awaits evidence from a properly designed clinical trial. The other issues raised by your correspondent are speculative. In particular, measuring Reverse T3 has a limited role in conventional clinical practice.

Prof Tim Welborn, Nedlands ............................................................................................................

Correction In Dr Jenn Ha’s clinical column in the February issue on 3D printing in ENT subspecialties, her email address was incomplete.

It is drjennha@yahoo.com.au

But there is also a long way to go. We reported in October last year that WA still relies heavily on International Medical Graduates to work in rural and remote areas of the state. Up to 55% of our rural workforce is IMGs. That figure alone should give the minister pause when contemplating a national decision on GP training places based on an oversupply of doctors in the eastern states and anticipated new local data, which is expected to tell an even more compelling case. If the chopper is about to fall on training places, WA could be vulnerable to an acute shortage of doctors.

We welcome your letters and leads for stories.

Please keep them short.

Email: editor@mforum.com.au (include full address and phone number) by the 10th of each month. Letters, especially those over 300 words, may be edited for legal issues, space or clarity. You can also leave a message, completely anonymous if you like, at www.medicalhub.com.au.

CURIOUS CONVERSATIONS

With Passion and Commitment Fiona Stanley Hospital resident Dr Bijit Munshi declares a passion for the human factor in medicine.

One thing I’m really passionate about… is helping people in need.

Right now my focus is on climate change and refugee health.

If I could work overseas for a year…I’d go to Africa. My interests lie in surgery and trauma and there really is nowhere else where I can get that sheer diversity of clinical experience.

One aspect of my medical training I’d change… would be to include greater integration of technology and design. We need to collaborate with other professionals to initiate advances in our field. And I

6 | MARCH 2017

think this process should begin during medical school.

A mentor I really look up to is… the surgeon and author Atul Gawande. He’s always promoting the human side of medicine, and particularly end-of-life care.

The book I’m reading now is…When Breath Becomes Air by Paul Kalanithi. It’s about a young neurosurgeon confronted by his own mortality. It’s a powerful memoir that will evoke a deep response in everyone who reads it.

MEDICAL FORUM

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MEDICAL FORUM

MARCH 2017 | 7

Letters to the Editor

INCISIONS

Power of Good Culture As the doors open on the new Curtin Medical School, its Dean, Prof William Hart, asks what is the new culture and why.

I’ve just read Ric Charlesworth’s new book, World’s Best, in which he makes the point that developing a winning team culture is more important than hard training, individual skills or fine strategies. He reiterates the mantra that Culture trumps strategy or, as sometimes attributed to Peter Drucker: “Culture eats strategy for breakfast”.

Healthcare and health professional training, including medical school, is a team game. The day of the “rugged individualist” is over. We all need to collaborate. Learning to work as a successful healthcare team starts with working in teams at school – learning with, from and about each other.

So I’ve spent a long time pondering the best ways to inculcate this core value into medical education. In recently accrediting the new Curtin Medical School through to 2023, the Australian Medical Council made a point of commending us on our approach to interprofessional learning and collaboration. But even within the profession, working together to achieve a common goal requires building the right collaborative culture.

I’ve now helped establish two new medical

Leadership which facilitates collaboration among teams is most likely to result in a sustainable culture of success. schools (Monash Gippsland and Curtin).

Teamwork and collaboration are intrinsic to getting these projects off the ground.

Developing a winning organisational culture that will see a new school be sustainable is an important consideration.

What is the culture of the new faculty? What is the culture of the student body? How do the culture, values and behaviours of staff (the role models) influence the student body? This is part of the “hidden curriculum” and important in determining future clinician behaviours.

The recent Senate inquiry into the medical complaints process had a focus on behaviours associated with bullying and harassment. Such behaviours are clearly linked to organisational and professional culture. Most people state

that they cannot be tolerated, yet they remain fairly common, apparently. The committee recommended that bullying and harassment be addressed in the first instance at medical school and that the curriculum incorporate “compulsory education” on these issues.

There is a focus on leadership in medicine these days. In my opinion, leadership which facilitates collaboration among teams is most likely to result in a sustainable culture of success. What does this leadership look like in practice? It’s motivational communication. Not “rah, rah!”, but respectful, guiding and facilitative.

According to Ric Charlesworth: “Great teams share the load, cooperate fully, critique one another, set high standards and are encouraged to participate. They are able to disagree and still share a common goal and they work together to solve problems and repair damage caused by mistakes.” That’s the kind of team I’d like to be part of; or maybe even coach!

ED: 320 interns were appointed to city and country hospitals last month – 307 graduates from WA medical schools and 13 from interstate. Another 18 junior doctors including 14 IMGs started work at Ramsay Health Care campuses under a Commonwealth agreement.

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MEDICAL FORUM

MARCH 2017 | 9

Spotlight

BACK TO CONTENTS

Embrace the Unexpected... and Grow Journalist Peter Greste knows a lot more about the world and himself after being jailed in Egypt. He will share his experiences with WA rural doctors next month.

When Australian journalist Peter Greste flew to Cairo for a three-week stint with his Al Jazeera news team, he was forced to embrace the unexpected. In lateDecember 2013 Peter, Mohamed Fadel Fahmy and Baher Mohamed were arrested and charged with “damaging national security” and all were sentenced to imprisonment. On February 1, 2015, after a retrial, Peter was released and deported to Cyprus.

He believes there are some similarities in Embracing the Unexpected as a foreign correspondent and practising medicine in a rural setting (without the 400 days behind bars), which he will explore when he addresses Rural Health West’s annual conference on April 8 and 9.

“Certainly what happened to us in Egypt was utterly unexpected. There were more than a few people who thought that was a little naïve, but we really had no reason to think that we would find ourselves charged with terrorism. But embracing the unexpected has been on my calling-card for a while now,” Peter told Medical Forum.

Self-sufficiency required “I’ve spent the past 25 years of my life working at the edge of my comfort zone in places such as Latin America, Africa and the Middle East where getting things done can be pretty challenging. That’s why I have an affinity with rural doctors because, just like foreign correspondents, they often have to figure things out on their own without any support from professional colleagues.”

“And that can be difficult when you’re confronting serious problems on a daily basis and there’s no one else to turn to. There are occasions where you just have to improvise as you go along.”

While Peter certainly didn’t quite embrace his stint in an Egyptian prison, there were many who felt he exhibited a great deal of grace under fire.

Holding your nerve “Well, I don’t know how much ‘grace’ there was but we certainly felt under ‘fire’.

One of the things that I did learn was the importance of trying to project a sense of dignity throughout the entire episode. It really helped me maintain my bearings and portray, hopefully, an impression of confidence and professional authority.”

“It’s important to have a sense of poise and equilibrium because other people caught up in the same crisis may need to see that.”

10 | MARCH 2017

“There are some positives when you’re continually being placed in these situations.

You learn to think creatively and develop a sense of confidence – real or hastily constructed – that enables you go out and do what needs to be done. It’s the same for rural doctors, they have to deal with a medical problem and there’s no real choice. They just have to deal with it in the best way possible.”

“You do need a degree of self-reliance otherwise you won’t survive.”

Don’t underestimate yourself

happens is just down to dumb luck, both good and bad.”

“Sometimes you can just find yourself in the wrong place at the wrong time and it doesn’t turn out so well. It doesn’t mean you’ve stuffed things up and it doesn’t mean you’ve failed. I guess that’s just a round-about way of saying I was both lucky and unlucky.”

“We’re all far stronger than we realise. We all need to keep reminding ourselves of that.”

By Peter McClelland

“I know a lot of people ask themselves how they think they’d have coped in a similar situation to our experience in Egypt. Most of us would say that we’d have trouble coping with four days in prison, let alone 400. But most of us are far more resilient than we give ourselves credit for and have the capacity to cope with a crisis in ways we could never imagine. And, thankfully, most of us are never fully tested.”

“But certainly, you can’t go through an experience like ours without being changed in some way. I’ve got a few dings and knocks in the fender but I came out of it a far stronger person.”

“I’ve certainly got a much greater awareness of my own capacity.”

Find a network and use it The importance of close support mechanisms cannot be underestimated, says Peter.

“I’m very lucky to have a wonderful family.

They were central to the whole campaign to get me out of prison and I probably wouldn’t be here if it hadn’t been for them.

There seemed to be a sense that as people watched the entire process unfold that they were able to connect with my predicament through my parents.”

“There was a lot of respect for the way my family conducted themselves.”

“One of the important things that came out of all this for me is a much stronger sense of fatalism. One of the biggest mistakes we make in the West is an unflinching belief in our own agency.

We tend to think that we can be whatever we want to be, and that’s a fallacy.”

“A lot of stuff that MEDICAL FORUM

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Reducing debt, saving for your children’s private education, retirement, your next holiday, or a new car?

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It is important to have an adviser who understands the challenges facing medical professionals and who will work with you in developing strategies across wealth creation, investment portfolios, tax planning, “Sound financial superannuation, risk A strategic plan needs to be management management and specific to each individual estate planning. My is a lot more and tailored to your partner, Sam Pizzata, than simply circumstances. Importantly, minimising tax...” and I have been your plan needs to be delivering financial implemented effectively and solutions to medical professionals for reviewed on a regular basis to ensure it many years and we would be happy to evolves as your circumstances change. find solutions for you.

Developing optimised financial strategies will help deliver the best Understanding your priorities can financial outcome with minimal risk in save you money. For instance, direct the most cost and time investments in shares efficient way. and property, investment “Understanding funds, insurance bonds your priorities 3. Find the time or regular savings can save plans may be useful for Like good health, you money.” funding children’s future financial success requires education expenses. For dedication, time and effort. retirement savings and tax benefits, As professionals, we manage our work salary sacrificing to superannuation is well but when it comes to managing a useful strategy. our finances we often feel we lack the Whatever your stage of life, establishing time and discipline needed to achieve your priorities and planning for the our goals. But lack of time is not a future goes a long way towards good reason. In the same way that your patients rely on you for sound achieving your goals.

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MARCH 2017 | 11

HAVE YOU HEARD?

Time AHPRA changed its ways Doctors are concerned that reports to AHPRA against health professionals are too easily vexatious (whether colleagues or patients) and investigated for too long, which along with other behaviours, constitutes bullying. These issues were raised in testimony to a Senate Committee, set up following the high profile case of the Queensland neurosurgeon who returned to France. AHPRA received 3147 notifications about medical practitioners in 2015-16 (12% from other medical practitioners); 33% were fully investigated (the rest were closed on assessment); 3.2% of complaints led to a panel hearing and 3.5% to a tribunal hearing.

In 2014-15, 17 doctors (23% of complaints) felt compelled to contact the Ombudsman about AHPRA’s handling of notifications against them. AHPRA says its target is to complete each investigation within six months. One would have thought for an organisation that has been operating for five years and has sat through one inquiry where longevity of complaint handling was singled out as an issue, that a rundown of the age of outstanding complaints would be a simple, important response. Instead it came up with the median age of open notifications at 137 days (and mentioned a five-day reduction from the previous year). According to AHPRA it is working diligently to “bring those time frames within reasonable expectations.”

The College of Anaesthetists argued that justice delayed is justice denied. The College of Psychiatrists argued that timeliness of investigation is both vital and frequently absent. The Australian Dental Association (ADA) argued that practitioners not only invested time in defending complaints, they experienced shame, humiliation and psychological stress, particularly where the complaint was later deemed unfounded (two thirds of complaints). The Committee was not convinced that AHPRA's processes were adequate for the purpose of identifying complaints made vexatiously. “Alongside timeliness, the committee notes that the level

and style of communication with both notifiers and practitioners has been one of the key concerns raised about AHPRA's management of complaints. […] Many people have suggested there is a need for more change.”

With no appreciable action taken to resolve these matters, the Senate Committee’s findings were taken as an ineffectual whitewash.

Doctors on the hustings As far as our head count could determine there are three medical doctors standing for election at the March 11 state poll. Dr Alida Lancee and Dr Michael Watson are standing as independents in Premier Colin Barnett’s Legislative Assembly seat of Cottesloe.

Alida is running a high-profile campaign on end-of-life choices, while Michael is tackling bureaucratic culture in health and education.

Long-time Liberal MP Dr Graham Jacobs has been in the WA Parliament since 2005 and this year contests the new seat of Roe. Wellknown Kimberley health worker Dr Julie Owen is standing for the Legislative Council region of Mining & Pastoral.

New thinking on pain The Australian Pain Society’s annual scientific meeting is being held in Adelaide on April 9-12 and there will be a lot of rethinking problems, the new world order in drug use for chronic pain and the word neuromodulation crops up more than a few times in the program. The title of the meeting is Expanding Horizons.

WA is represented on the podium by A/Prof Juli Coffin (Notre Dame University) and UWA’s Dr Ivan Lin who are giving a joint plenary session on musculoskeletal pain in Aboriginal Australians. Juli is a Master of public health and tropical medicine and Ivan is a physiotherapist in Geraldton and researcher at the WA Centre for Rural Health.

No relief for post-surgery pain Putting opioids in the pain management spotlight, the team at SCGH is mounting a campaign encouraging GPs to reduce high opiate doses for patients needing elective hip

Hard facts or tipsy distraction?

Elections are always good times for the release of embarrassing reports. The Executive Officer of the McCusker Centre for Action on Alcohol and Youth released a report which reveals data of alcohol-related harms in the various electoral districts. It was certainly good for a headline and a quick search for how your district fared.

Of course, it doesn’t stop there. It can become a search on less scientific grounds that takes on darker social complexions which may drain some of the significance of the findings. The results, however, are literally, very sobering. Alcohol abuse is at serious levels whether you’re living in the “leafy suburbs” as reported in The West Australian, or strolling down a street in any one of the entertainment districts around the state. Check the report out on the McCusker website.

12 | MARCH 2017

BACK TO CONTENTS

or knee joint replacement surgery. Hospital pain specialist Dr Lindy Roberts told Medical Forum post-operative pain was becoming too difficult to manage as some patients had developed a high tolerance to the drugs and opioid-induced pain sensitivity. Surgeons may not undertake elective surgery unless the dosage drops given that the results for patients are not as good, with poorer function and an increased risk of complications such as infection and need for revision surgery.

“We are not going to leave GPs without assistance if they need it, and we have arranged for the SCGH pain clinic to provide advice over the phone if the GP is having trouble.”

Stubborn back pain Australian researchers are building a reputation for telling it how it is. This study, published in the BMJ, looked for consensus on the efficacy of non-steroidal antiinflammatory drugs (NSAIDs) for back pain.

A systematic review with meta-analysis of 35 kosher randomised placebo-controlled trials found that NSAIDs reduced pain and disability but not significantly more than placebo. In fact, six patients needed to be treated for one to achieve clinically important pain reduction, with the risk of gastrointestinal reactions 2.5 times higher during the median NSAID trial of 7 days. According to a report of an interview with researchers at the George Institute in Sydney, “Previous research has already demonstrated that paracetamol is ineffective and opioids are not much better […]. The findings are likely to impact on current clinical guidelines that continue to recommend paracetamol as a first-line analgesic, after NSAIDs, followed by opioids.” Ref: ‘Nonsteroidal anti-inflammatory drugs for spinal pain: a systematic review and meta-analysis’

Parent support waivers Public health physician Dr Bret Hart has written in this edition on the correlation between a child’s education and their longterm health outcomes (see p28). There is concern among some doctors that health care in the ante-natal and early childhood phases appears to be a victim of cost-cutting.

Given the news in December that the State Government has a new tender process, which saw the peak body Ngala lose some central contracts for parenting and children’s services, there is pause for thought. The Community Services Minister Paul Miles announced $5.6m in tenders to community groups in metro and regional WA, including Shire of Mundaring, Ngala, Communicare, Meerilinga and Anglicare. Ngala received extra funding for its 24-hour phone service.

It is to be seen whether Ngala’s loss costs the kids of WA.

Excellence comes at a price The Community Services Minister has been busy. Before the writs were issued for the March 11 poll, Paul Miles opened a $455,000 Centre for Parenting Excellence to encourage, no less, best practice in parenting services and to monitor parent support needs and service outcomes. A steering committee of 12 including CEOs of Ngala and Centrecare and Prof Stephen Zubrick from Telethon Kids MEDICAL FORUM

BACK TO CONTENTS

• Former RFDS executive Nick Harvey has been appointed CEO of St John of God Foundation.

• Peter Forbes, former CEO of MDA National, is the new chair of the Lions Eye Institute.

• Prof Julie Quinlivan has been appointed Director of the Professional Services Review (PSR).

• The work of three WA doctors was recognised in the Australian Day Honours list.

Geriatrician Prof Leon Flicker became an Officer (AO) of the Order of Australia, while rural GP proceduralist Dr Susan Downes and radiologist Prof Makhan Singh Khangure became members (AM).

Is Reality TV a mental health issue?

It might be that we are growing curmudgeonly here, but irritation starts around the time of the Australian tennis Open with the promos for such ‘real’ delights as MKR and hits crisis with the mass media saturation of shows such as The Bachelor, The Bachelorette, Married at First Sight and the latest, Bride and Prejudice. Up until this last steamy deposit they were but mild(ish) irritants until we learnt, at close quarters, that at least for the latter, people’s Facebook accounts were being trawled for any sign of ‘deviate’ relationships. The hunt was on for conflict, tension and drama. We heard from a source that she was approached on numerous occasions by the producers seeking out said conflict, tension and drama in her relationship with a foreign national. Were Mum and Dad happy? Yes! Were friends supportive?

Yes! Were they happy? Yes! Would they take yes for an answer … NO! Is this really healthy television? We don’t think so, but talking to Curtin academic Amanda Lambros some good can apparently come from it. She thinks these shows can raise awkward issues for couples and families unused to talking about such things and can open communication, which can only be a good thing. However, she added that people must remind themselves that these TV shows were numbers games and the last thing they were was reality. has been appointed. Could be good … could be half a million dollars of unaccountable funding. Who’s watching?

Commissioner to head bush The new Assistant Minister for Health, Dr David Gillespie, who is by the way a gastroenterologist by profession before becoming a Nationals MP in 2013 and a former director of training at Port Macquarie Hospital, is introducing legislation to create an independent National Rural Health Commissioner to advocate (and

hopefully adjudicate) for regional, rural and remote health. Dr Gillespie is enthusiastic to receive frank advice on regional and rural health reform so it is hoped that the first Commissioner will be someone who’s prepared to call a spade a shovel.

The Minister said the Commissioner’s first priority was the development of the medical generalist pathway – “giving consideration to the nursing, dental health, Indigenous health, mental health, midwifery and allied health needs in regional, rural and remote Australia”.

• Mt Lawley obstetrician and gynaecologist Dr Pierre Smith was named Doctor of the Year at SJG Mt Lawley Hospital’s annual awards night.

• Aegis Aged Care Group and Regis Aged Care have both signed contracts for significant aged care developments – Aegis, a $30m 133 bed facility in Canning Vale and Regis a 153 single bedroom complex at Port Coogee.

BY THE NUMBERS

$430,499 Medibank Private’s highest benefit paid for a single claim.

It was a for neonatal in NSW. Three neonatal cases in Queensland, were next with claims totalling more than $1.076m

2016 Financial Year Benefits paid Hospital benefit $2.48b Prosthesis benefit $488m Medical benefit $517m MPL total benefits $3.48b [excluding ancillaries] MPL total hospital admissions

• The Australian Digital Health Agency has announced its advisory committees. From WA, Stephen Wragg (WAPHA, Pharmacy Guild) and A/Prof Helen Slater (Curtin University Physiotherapy) are on the Clinical & Technical committee; Stephanie Newell (ADHA board member) is chair of the consumer committee; Robyn Daniels (lawyer WA Health) is on the privacy and security; Rob Bransby (retiring HBF CEO) is on audit and risk.

2013-2016 Up 9.7% Up 15.1% Down 1.3% Up 8.6% Up by3.8%

• Mr Russell Bricknell will be Baptistcare WA’s new CEO from April. Mr Wayne Belcher is the new CEO of Braemar Presbyterian Care.

• Telstra Health has been awarded a $10m WACHS contract to roll out a new community health information system based on its Communicare package.

• An award-winning miniaturised optical imaging probe known as the microscope in a needle and developed by UWA researchers led by Prof David Sampson and Prof Robert McLaughlin (formerly at UWA) has been licensed to Miniprobes (now run by Prof McLaughlin).

Source: Medibank Private Health Cost and Utilisation Report released January 24, 2017

MEDICAL FORUM

MARCH 2017 | 13

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PROFILE

Thursday Island Dreaming Narrogin GP Dr Wynand Breytenbach took up a posting on Thursday Island and so began an adventure that he and his wife will never forget.

Three years living in a tropical paradise gave Dr Wynand Breytenbach some rare insights into the vagaries of medicine and convinced him that stepping out of a comfort zone was a really good idea.

“Life on Thursday Island (TI), the capital of the Torres Strait group, is vastly different to the one most of us know on the Australian mainland. It’s the smallest inhabited island in the region, home to around 3500 people and only 3.5sq km,” he said.

“It gets hot at times but when you’re working in an air-conditioned hospital, your home is cool and there’s plenty of outdoor fun like fishing, diving and sundowners on the verandah, it makes for pretty enjoyable living.

That’s how my wife, Elmarie, and I spent three glorious years beginning in 2013.”

Diabetes hotspots The climate might be wonderful for lateafternoon sundowners but it’s not always conducive to promoting good health outcomes.

“When a nurse rings to tell you that a patient’s BSL is 26 and you say, ‘that’s not too bad’ you know you’ve been in the Torres for a while. Diabetes is rife and, coupled with an environment that basically acts as an incubator, the rate at which a patient can enter septic shock is astounding. It’s the full gamut, scrub typhus, melioidosis, necrotising fasciitis and septicaemia.”

“I’ve never seen so many diabetic foot ulcers and amputated digits. Mid-foot amputations and diabetic ulcer debridement is very different from my usual procedural GP practice.”

‘God will provide’ “Adding to the difficulties is the fact that the people are highly religious and this translates to wonderful family values but it also means that many of them are reluctant to take their prescription medicine. They make it quite clear that ‘God will look after me!’”

It was not all stitches and stethoscopes for Dr Wynand Breytenbach.

There was also fish to be caught.

But as Wynand suggests, he did some interesting health care providing himself.

“There’s no border control between the islands and PNG, mainly due to the fact that they’ve been trading with each other for centuries. A treaty exists stating that we’ll manage any life threatening diseases so when they come over in their dinghies with everything from Potts disease to spear wounds a TI doctor is exposed to an amazing range of ailments.”

“Two incidents spring to mind, one was a young female patient with severe abdominal pain. She had a palpable mass the size of a 20-week pregnancy, cystic on ultrasound.

After I removed it under a GA she was very grateful.”

“The other one involved a few mates and a late night. One of them fell asleep in some tall grass and the next day the others hopped into a four-wheel drive and went to look for him. They ended up driving over him and he needed bilateral intercostal drains and ventilation. The RFDS arrived 10 hours later and CT confirmed 23 rib fractures but no sign of cardiac or solid organ injury. I’ll never see a flail chest like that again!”

Medical services are top notch “I’d have to say that medical services in the Torres are of a high standard. Consultants and registrars of every major discipline visit regularly and patients are flown in from the outlying islands. Some are transferred to Cairns and all transport is by air – including the ambulance! It’s no surprise that the monthly travel budget is astronomical!”

Stepping out of the comfort zone and into a tropical paradise is all well and good, says Wynand, but some things never change.

“I’m sure everyone will be pleased to hear that bureaucracy is alive and well in Far North Queensland. I was sent to retrieve an acutely ill patient who rapidly deteriorated due to septic shock. He was hypotensive, GCS of 6/15 with acute renal failure.”

“I escorted him on RFDS to Cairns Base Hospital and handed him over to the ED physicians three hours later. Four months later, I received a letter from RFDS Queensland to let me know that I’d been granted ‘limited credentialling’ to render assistance on their aircraft between 1330 and 1730 on the day of the incident.”

Experience of a lifetime For any doctor thinking about shifting career gears, Wynand gives an unequivocal thumbsup.

“A highlight for me was delivering babies, and some of those belonged to colleagues. On one occasion my wife and I were asked to be godparents!”

“We became friends with many people – locals and visitors – had amazingly wonderful experiences and would recommend an adventure such as this to any colleague who feels a little trapped by their daily routine.”

By Peter McClelland Medical evacuations and dealing with the unexpected are routine on Thursday Island

MEDICAL FORUM

MARCH 2017 | 15

Feature

BACK TO CONTENTS

Inside WA’s Psychiatry Services With greater investment, mental health services in the state have become more focused on good policy and patient outcomes.

• Reducing seclusion & restraint Dr Nathan Gibson, as Chief Psychiatrist, is not part of either the Health Department or the Mental Health Commission. He is an independent statutory officer with a governance responsibility over any Mental Health Services within the WA community (Mental Health Act 2014).

His dual role, and that Dr Nathan Gibson of his team, is to assist clinicians reach particular standards and uphold the rights of people with mental illness. He provides advice and reports to the Minister for Mental Health.

The Towards Elimination of Restrictive Practice 11th National Forum will be held for the first time in WA on May 4-5, 2017.

The forum is jointly hosted by the Chief Psychiatrist (principle sponsor), Department of Health, Mental Health Commission and the WA Association for Mental Health (WAAMH).

What do we know of this topic as it applies to WA? Nathan said it was the Frenchmen Pinel and Pussin who removed iron shackles from the “insane” in Paris around 1800.

“It was earth-shattering stuff. Instead of bleeding and purging, hospital attendants spent time discussing with the patients.

Better outcomes ensued,” he said.

Restraint on restraints Yet 2007 was the year the last straightjacket was removed from Graylands Hospital.

“Why so long? Logic surely says we should just stop restraining or secluding people in mental health hospitals – it’s inhumane. The reality is significantly more complex.”

“When folk are unwell, a small number have strong delusional drives to aggression.

Clinical staff may exhaust all talking or other less-restrictive options, and, to prevent acute harm to the patient or others, they use seclusion and restraint. These clinicians are ethical, highly trained professionals (and humane), not gaolers.”

“These challenging clinical situations do not disappear by magically incanting, ‘Stop seclusion and restraint!’.”

But he said some of the evidence around restraint and seclusion is food for thought: • Up to 70% of those admitted to a psychiatric hospital have previously experienced serious trauma (emotional, physical, or sexual).

• Despite preventing harm, seclusion and restraint are often emotionally and physically traumatic for both the patient and staff.

16 | MARCH 2017

• What happens when mental health services don’t use it: services often reduce their staff lost-time due to injuries (counterintuitive, but true); most services do not increase staffing; and there are demonstrable higher levels of therapeutic engagement.

morning. If someone needs urgent contact there is also the Kids Helpline 1800 55 1800 or Lifeline 13 11 14. In WA we also have the 24/7 Mental Health Emergency Response Line (MHERL) at 1300 555 788. Of course clients can self-present to an Emergency Department at any time.”

“Close to home, WA has seen about a 70% reduction in seclusion rates in mental health units over the past seven years. Services are using strategies involving high level communication skills, the use of ‘chill-out’ rooms, patient-led processes, and programs such as Safewards, to name a few.”

“The intake criteria for the hYEPP component of headspace are specific and these tend to be more acute clients at ultra-high risk of psychosis or with a first episode psychosis.”

“It remains challenging but we have an ethical responsibility to work towards eliminating restrictive practice.”

• Teens with problems Dr Gordon Shymko is the leading clinician in youth/ early episode psychosis and works with the Rockingham Kwinana Mental Health Services in the public state system for the Early Episode Dr Gordon Shymko Psychosis (EEP) services. These also run out of Bentley Mental Health and Fremantle Mental Health and referrals can be made directly to these services.

However, he has a strong focus on HeadSpace, commonwealth-funded until 2019. HeadSpace services cover mental health, physical health, work and study support and alcohol and other drug services.

There are HeadSpace centres in rural areas and urban Perth. It’s Youth Early Psychosis Program (hYEPP) is a specialty program operational since early 2015, of which he is the Clinical Director.

“One of the general principles of HeadSpace centres is that they are a consortium of services that co-locate to provide a 'one stop shop' for the young person.”

Access for all HeadSpace and public sector services are free and people can self-refer, so that both obvious barriers are overcome. Generally lower acuity referrals go to HeadSpace.

“By lower acuity I would include anxiety, depression, stress, school issues, relationship issues, alcohol and drug use, sexual health, etc.”

“There is always some way of receiving support. The after-hours contact for HeadSpace [eheadspace] can be accessed daily from 9am until the early hours of the

Overall hYEPP is a program that runs for up to five years for 12 to 25 year olds who are either: • Experiencing their first episode of psychosis; or • Are at ultra-high risk of developing psychosis; who have a family history of psychosis; have a decline in functionality; and/or have transient psychotic symptoms.

Timely access improves outcomes “The hYEPP services are North and East Metropolitan based and situated in three HeadSpace sites, a 'hub' in Joondalup with two 'spokes' in Osborne Park and Midland.

These services are non-government and are managed by Black Swan Health and Youth Focus.”

The range of services offered within the hYEPP framework includes home-based assessment and care, multidisciplinary care coordination and medical management, psychological interventions, group programs, family programs, youth participation and peer support. All workers within HeadSpace and hYEPP are trained to deal with drug and alcohol-related issues.

“The ages between 15 and 24 are a crucial time in the development of a young person and this coincides with the peak onset of serious mental illness, including a first episode of psychosis.”

“Psychosis is significant public health issue and has been made all the worse by the near endemic utilisation of substances particularly stimulant-based substances such as methamphetamine.”

“Evidence shows that early intervention can change the course of the illness, generating greater personal, social and economic benefits than intervention at any other time in their lifespan. However it can also take long periods of time and patience before one sees significant shifts in alcohol and drug use behaviours.”

• Keep Care Clinically Relevant In 2015, formation of the Mental Health Clinical Reference Group (MHCRG) was designed to provide the Health Department with broad-based expert clinical opinion and MEDICAL FORUM

policy advice around statewide mental health services. The 16-member group draws on people from a range or clinical disciplines (including doctors, nurses and the allied health professions), care settings (rural and metropolitan, inpatient and community) and areas of practice (such as youth mental health, forensics and older adults).

Dr Bradleigh.

Hayhow is chair of the Clinical Reference Group and clearly wants to ensure that psychiatrists like himself get involved so that any polices are clinically relevant and can be Dr Bradleigh Hayhow appropriately implemented.

His involvement with the group was initially peripheral as a representative of the South Metropolitan Health Service.

“I still spend most of my time working as a frontline clinician but it has certainly been a privilege to work with such a talented group of clinical leaders and such a receptive group of policy-makers.”

Policy and implementation “Each member is empowered to consult broadly within their own professional networks. Obviously the view of clinicians is that clinical perspectives matter, especially in relation to policy feasibility and implementation at the clinical coalface; after all, policy is only as successful as its implementation.”

In this way clinically astute advice reaches the Health Department and working clinicians get involved in the strategic management of their services. This duality of function is built-in to the group's terms of reference.

“It is really this bilateral capacity that makes the group so valuable. This is to the great mutual benefit not only of policy-makers and clinicians, but more importantly to the patients.”

No doubt his special interests in neuropsychiatry and adult eating disorders provide some personal insights.

MEDICAL FORUM

Links have been established with the Mental Health Commission (MHC) and the independent Office of the Chief Psychiatrist (OCP). This liaison with the OCP has been particularly useful and exciting with the implementation of the new Mental Health Act. “Mental Health has become diverse so building workable relationships in this workspace are important – public sector clinicians remain key players in the delivery of good mental health care to Western Australians.”

• Treating Older Patients One of the struggles Dr Helen McGowan faces in her role as Clinical Director of the Older Adult Mental Health Program (OAMHP) for North Metropolitan Health Service has nothing to do with funding or lack of resources. While every health service can do with more of both, she believes many older people are held back from effective mental health treatment by their thinking and the thinking of those around them.

Many older people, their families even their medical practitioners fall into the ageist trap that reinforces a therapeutic nihilism and she thinks that view needs to be challenged.

“We can’t cure dementia but we’re very good at alleviating distress for patients and their families. We get great results for older people who suffer from anxiety, depression or psychosis. I think sometimes the nihilism associated with treating dementia spills over into a pessimistic view of likely outcomes for other mental health conditions in the elderly,” Helen said.

Therapeutic nihilism “There is an ageist view that goes something like this: “If I had peripheral vascular disease and needed an amputation, and my wife died last year, I’d be depressed too…but there’s not much anyone is able to do about this’.”

psychiatrists. The program runs outpatient clinics, community in-reach services, and inpatient services at three sites – at Shenton Park, Joondalup and Osborne Park with 56 inpatient beds across Osborne Park and Shenton Park and eight hospital-in-the-home beds and sees about 800 people a year and an additional 400 elderly people when consulted by other specialty staff at SCGH).

Helen said about 50% of referrals related to Behavioural and Psychological Symptoms of Dementia (BPSD) and of that group, 60% came from residential aged care and the rest from the community.

The other half of referrals were for functional Dr Helen McGowan psychiatric illnesses associated with people getting older often triggered by a deterioration or change in their physical health or psycho-social circumstances. There are also those with a range of neuro-psychiatric issues that commonly present in the older population, such as Parkinson’s disease Referral process is detailed on the website (see p19) and Helen says the triage officers working business hours are adept at streamlining urgent cases which can often been seen within two days and other referrals between one to two weeks.

Helen stresses communication channels between the program and the referring GP are always open. If a GP has a question, a phone call can often answer it.

“I would counter that with the evidence which shows a lot of people in exactly these types of situations come through these scenarios well with good treatment care and support and regain a good quality of life. The OAMHP has the specialist skills and the resources that can help.”

“We operate very much on a consultation model. We’re not here to take over, we’re here to support patients, families and their GPs with specialty skills that can add value and improve quality of life. If circumstances allow, we prefer not to prescribe psychotropic medications but rather advise the GP on what medications and actions are needed so the GP remains case manager where possible. If risks escalate, that’s when we will

The OAMHP works in multidisciplinary teams that are clinically led by subspecialty trained

continued on Page 19

MARCH 2017 | 17

Intentionally left blank to comply with Medicines Australia Code

FEATURE continued from Page 17

Smoke Advice from GPs is Powerful Wembley Downs GP Dr Howard Yip is taking part in the Cancer Council’s Make Smoking History campaign because he believes GPs can help turn the tide.

Dr Howard Yip

“In the week leading up to Christmas, I had to tell three of my patients that a mass was found in their lungs likely to have been caused by their tobacco smoking,” he said.

“Delivering bad news to a patient never gets easier and it’s even harder when you know that the bad news could have been prevented. Despite years of successful Quit smoking campaigns in Australia, smoking continues to cause the greatest burden of disease nationally.”

Howard said the most recent data shows that tobacco smoking was not only killing over 1600 West Australians a year but it was also causing 52 hospitalisations each day.

“This is why I’m supporting Cancer Council WA with their new Make Smoking History campaign, From Every Quitter, which features testimonials from 12 West Australian current

Inside WA’s Psychiatry Services

and former smokers appealing to people who smoke to support their loved ones who are attempting to quit by not smoking around them. As part of this campaign I feature in a video with a personal message for GPs.” He urges GPs not to underestimate their influence to motivate a patient to quit smoking.

“Research indicates that advice from a GP can double a patient’s chance of quitting.

Even spending just two or three minutes can make a big difference,” he said.

do more assertive management with the aim of handing over to GP as soon as possible,” she said.

Collaborations will help Helen says OAMHP is developing a relationship with Dementia Advisory Service (DAS) a commonwealth initiative which is run nationally by Hammond Care. It is anticipated that DAS will be another pathway for patients and family if dementia behaviours become difficult to manage.

• Brief advice to quit;

“We are trying hard to develop a ‘no wrong door approach’ which is why we are working on this collaboration. This is a complex space with a lot of different service providers and it can be confusing for doctors and their patients and families – we’re hoping to simply the process a bit. If you refer to either OAMHP or DAS for people who have BPSD, those referrals will be followed up appropriately.”

• Assessing a patient's readiness to quit;

http://www.nmahsmh.health.wa.gov.au/ services/oamhs.cfm

ED: See www.makesmokinghistory.org.au/gps

Breakout Box Interventions to encourage smoking cessation can include:

• Offering counselling and pharmacotherapy; • Providing self-help material and • Referral to intensive quit programs such as the Quitline or the My QuitBuddy app.

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Feature

BACK TO CONTENTS

Lifelines for Doctors The Colleagues of First Contact has morphed into Doctors’ Health Advisory Service – an organisation determined to improve the physical and mental wellbeing of doctors.

The Doctors’ Health Advisory Service of WA (DHAS WA) has recently begun its expanded service after last year’s decision by the Medical Board of Australia (MBA) to allocate $2m annual funding nationally to address the growing needs of the profession for an independent doctors’ health program.

As part of the MBA funding requirements, DHAS WA has become a formal association with a formal service agreement with the Board.

Back in April last year, the MBA partnered with the AMA, which has historically funded doctors’ health services, to administer the states’ doctor health programs at arm’s length from the MBA and AHPRA.

Dr David Oldham

This distance from regulatory bodies is seen as essential for the

success of any program, a fact that DHAS WA medical director (and deputy chair) Dr David Oldham, said was strengthened in WA by the legislated exemption to mandatory reporting.

New age of service DHAS WA has been operating in one guise or another since the 1980s and has operated a 24/7 advice line for doctors and medical students staffed by a panel of volunteer GPs. This confidential service continues along with a raft of new services – including education and training for doctors who treat other doctors; establishing dedicated health networks among colleges, universities and medical organisations; and education and promotion resources for self-care.

It has released an extensive Doctors Health Resource list which draws on existing resources and welcomes additions (see opposite).

DHAS WA’s organisational structure enhances its focus. Alongside David are Chair Prof Geoff Riley, Secretary and psychiatrist adviser Dr Eileen Tay, Treasurer; paediatrician and Notre

Dame professor of clinical governance and professionalism, Dr Angela Alessandri; 2014 medical graduate Dr Rosalind Forward; GP registrar Dr Sarah Newman and cardiothoracic surgeon Dr Nikki Stamp.

Dr Elizabeth Connor is manager.

Independent and confidential “DHAS WA has always been, and remains, a wholly independent entity,” David said.

While the AMA has a contract to provide administration support to the service, it is not involved in its decisions. However, input from all quarters is welcome from a planned reference group which will include representatives from various colleges, the AMA, doctors-in-training and rural doctor groups, which will advise on issues specific to their memberships.

At the time of writing, a blog from an Australian hospital physician, documenting his despair at the suicide of a colleague, went viral on national and international medical blog and news sites. (Search “Something’s rotten inside the medical profession”).

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MEDICAL FORUM

Feature

Grim home truths The anonymous author begins: In the year it has taken for me to finish my medical residency as a junior doctor, two of my colleagues have killed themselves. I’ve read articles that refer to suicide amongst doctors as the profession’s ‘grubby little secret’, but I’d rather call it exactly how it is: the profession’s shameful and disgusting open secret.

Medical training has long had its culture rooted in ideals of suffering. Not so much for the patients — which is often sadly a given, but for the doctors training inside it.

Every generation always looks down on the generation training after it — no one ever had it as hard as them, and thus deserve to suffer just as much, if not more.

This dubious school of thought has long been acknowledged as standard practice. To be a good doctor, you must work harder, stay later, know more, and never falter. Weakness in medicine is a failing, and if you admit to struggling, the unspoken opinion (or often spoken) is that you simply couldn’t hack it.

The NSW AMA president Prof Brad Frankum wrote in response that mandatory reporting had a lot to answer for. Here in the West it has sparked other concerns from DHAS WA’s David Oldham and Eileen Tay. Toxic culture needs challenging “The causes of stress and suicide in doctors are complex and multifactorial including individual, departmental, organisational, college and medical cultural issues. The problem is not only endemic in Australia but also most Western health systems,” David said.

a cohesive and comprehensive investigation process when a doctor suicides.

“Doctors suiciding is appalling and heartbreakingly sad but the fact that these investigations are often left to the Coroner’s Court alone has a far more insidious impact on an increasingly fear-based culture of medical practice,” she said.

Doctor deaths need investigating “Progress into this very serious matter requires the attention and support of the Health Department by way of clear commitment and leadership in formulating timely and appropriate referral pathways for doctors needing assistance of an emotional,

psychological nature and simultaneously establishing processes to investigate doctor suicides, at the very least to the equivalent level of critical incident investigations undertaken for patient deaths on the wards or in community settings. Doctors are a very neglected group of patients in this regard.”

“Without the establishment of these processes, with the clear intent of gathering more information to understand these suicides in detail, we will all be left with an ongoing sense of frustration and cynicism that our cries for help will ever be taken seriously.”

By Jan Hallam

“A toxic culture is a factor common in these and, as the author indicates, is worse in medicine than most other professions.

Unfortunately there is no simple fix – though recognising it is a problem is the first step.”

Doctors for Doctors Workshop

David acknowledges the work being done

by RACS, which reviewed bullying and harassment in its ranks and found that it was rife. The Anaesthetic and O&G colleges have similar concerns, he said, and all three were embarking on programs to address the problem.

• Doctors’ health issues

Getting solutions happening “The support of the Department of Health, hospital executive and senior consultants will be crucial to its success. In January 2017, the Postgraduate Medical Council of WA included ‘Junior Dr Wellbeing’ as a criterium that departments and hospitals must now meet if they employ an intern or resident.”

“There is still a long road to travel, but at least the first steps are being taken.”

Dr Eileen Tay

MEDICAL FORUM

For psychiatrist Eileen, the blog highlights the lack of

The DHAS WA is hosting a full-day training workshop in doctors’ health for interested doctors to help them better prepare to be ‘doctors for doctors’.

Topics include: • Doctors with mental illness

• Barriers to doctors seeking health care

• The drug or alcohol affected doctor

• What do doctors want form a check-up?

• Tricky situations (eg billing)

• The cognitively impaired doctor

• Self-treatment

Date: Saturday, May 6, 9am-5pm Cost: $55 (includes lunch, morning & afternoon tea and all materials);

Category 1 RACGP QI&CPD points RSVP: seminars@amawa.com.au; phone Liz Connor 9273 3097

or fax 9273 3073 by Thursday, April 6

Doctors Health Resources in WA • DHAS WA (24/7) 9321 3098 • JMO Health www.jmohealth.org.au • RACGP members 1300 366 789 • Rural Health West Family Support Program 9389 4500 • Welfare of Anaethetists 6188 4555 (WA Branch) • Lifeline 13 11 14 • BeyondBlue 1300 224 636 • Alcohol & Drug Information Service http://alcoholthinkagain.com.au (live chat) For the complete list email Elizabeth.Connor@amawa.com.au

MARCH 2017 | 21

Feature

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UPCOMING EVENTS Perth Clinic will be hosting a series of monthly dinner club events.

Our Executive Chefs will provide an evening of great food in a relaxed setting while providing General Practitioners an opportunity to attend the presentation/education sessions delivered by Consultant Psychiatrists on a variety of specialist subjects.

This dinner club is also an opportunity to see Perth Clinic’s environment, discuss available services, meet the clinical staff and ask questions about how to manage patients within your practice.

The networking element will hopefully assist in the development and maintenance of current and new relationships between Perth Clinic and General Practitioners.

Our skilled team of health professionals provide patient-focused, evidence-based care. The environment and patient experience are enhanced by our committed administrative and hospitality staff.

We have a series of events over the next few months all presented

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Our commitment to provide high quality recovery oriented care, maximise patient outcomes and maintain high levels of patient satisfaction is underpinned by our rigorous evaluation and research program.

Should you wish to attend these events or register your interest for any upcoming events, please register your interest / attendance with Perth Clinic’s Executive Assistant (Natalie Fazari) on (08) 9488 2980 or email natalief@perthclinic.com.au

DATES

TOPIC

PRESENTER

8th March

Depression: When to refer to a Psychiatrist

Dr Daniel Morkell

10th May

Attention Deficit Hyperactivity Disorder (ADHD)

Dr Zlatan Golic

7th June

Treatment of Borderline Personality Disorder

Dr Gordon Wang

5th July

Depression in the Elderly

Dr Nick De Felice

“Empowering you on the journey to mental health recovery”

Perth Clinic 29 Havelock Street, West Perth WA 6005 Phone: (08) 9481 4888 Fax: (08) 9481 4454 Website: www.perthclinic.com.au 22 | MARCH 2017

MEDICAL FORUM

Medicolegal

Q.“My father had a stroke and is

mostly recovered now but wants to know if he can do an Advanced Health Directive or Will without either document being contested later because he is ‘not quite right’.

Can he?”

A

Making key health and financial decisions as we get older is a major concern for many of us, as is not having our decisions contested.

A valid Advanced Health Directive (AHD) or will requires the person making them to have the necessary mental capacity.

While every adult is presumed to have mental capacity, someone can contest whether an individual had sufficient mental capacity at the time they made an AHD or will. Having capacity is not a ‘one size fits all’ concept. It is decision-specific, that is, a person’s mental capacity to make one decision is judged separately to a different decision. The degree of ‘legal’ mental capacity to make AHDs and wills varies with decision complexity and context.

Advanced Health Directive An AHD is a written instrument made by an adult with capacity, which, in effect, sets out a person’s wishes for the acceptance or refusal of future treatment, including end-of-life treatment. Any treatment contrary to a valid AHD will constitute unlawful interference.

The Guardianship and Administration Act 1990 (WA) sets out that a treatment decision in an AHD is invalid if it is not made voluntarily or if it is made as a result of inducement or coercion. An AHD is also invalidated if, at the time the directive is made, its maker does not understand:

Answered by Enore Panetta Director, Panetta McGrath Lawyers

the legal effect of every clause but must understand the practical effect of key clauses, particularly those concerning the disposal of their property.

Back to the scenario A stroke can cause physical, emotional and cognitive impairments. Cognitive impairments can include difficulty in processing information, planning and organising, as well as limited ability to pay attention and follow conversation. Mental capacity following a stroke may also vary from time to time.

However, infirmity does not necessarily negate mental capacity. A person who has suffered a stroke, and largely recovered, may be able to make an AHD or will as their awareness and ability to understand the relevant decisions remains sufficiently intact at the time of their decision.

Assessment of capacity is usually made by the drafter of the AHD or will (usually, a lawyer) when taking instructions and when signing the document. Capacity is a question of fact that, if challenged, must be decided by a court or tribunal. Medical evidence is neither necessary nor conclusive but can be

useful. When mental capacity is an issue, it is common for treating health professionals to give evidence as to their perception of the person's mental capacity.

Where there are some doubts about legal capacity when making an AHD or will, a medical assessment can be critical if there is a subsequent challenge. The medical assessment should provide a global assessment (general cognitive assessment of judgment, reasoning and planning skills) and a functional assessment (the person can demonstrate their understanding and requirements of the decision at the time of assessment).

If you have a firm view as to your future health treatment or your testamentary wishes for your property, talking to and writing to your partner, children, siblings or other close relations may help them understand your wishes, and in so doing, provide a context against which a particular AHD or will may be assessed if there is any concern as to your mental capacity. In the case of wills, this ‘informal’ understanding of your wishes can, following your death without a will, help support an application to the Supreme Court for your property to be disposed of in accordance with your ‘communicated’ wishes.

Making an AHD or will while you have mental capacity remains the best option.

(a) the nature of the treatment decision; or (b) the consequences of making the treatment decision.

The decision’s validity does not depend on its rationality but on the maker’s ability to demonstrate they can make reasoned decisions about their future health and safety, and display insight into the consequences.

Will A ‘Last Will and Testament’ sets out the final wishes of an individual as to what is to happen to their property (i.e. real estate, personal possessions, money, shares, stamp collection etc). To execute a valid will, a person must have testamentary capacity, that is, understand they are making a will and its general effect, the nature and extent of property disposed of, and the transactions which are given effect by the will.

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A person does not need to understand MEDICAL FORUM

MARCH 2017 | 23

Feature

BACK TO CONTENTS

The 2016 graduates from Manjimup/Bridgetown (three of whom attended the Rural Clinical School): (from left) Dr Merredith Cully, Dr Georgia Mather-McCaw, Dr Dylan Prunster, Dr Geoffrey Ryan, Dr Callum Peet and Dr Danielle Malatzky. Photo: Sam Shipley

The Allure of the Bush More students from rural areas are studying medicine and now, demonstrably, there are more graduates heading to the bush. We explore why.

A few years back, the then head of the Rural Clinical School, Prof Geoff Riley, spoke to Medical Forum about his cautious optimism that programs to attract rural students to medicine and city medical students to the bush were working. It was slow but steady progress.

It’s no doubt taken some diplomacy and enormous effort to calm nervous knees in high places from kicking out the plug but sound policy seems to have prevailed.

The Medical Training Review Panel’s (MTRP) latest report of the 2015 data shows a national upwards trends and UWA’s Rural Student Recruitment Program, which is 16 years old, reported in November that 60 rural students from 22 country towns graduated from UWA’s medical school. This was the biggest number of rural-background doctors to graduate in a single year and the fifth consecutive year of growth in graduation numbers. Since 2000, 325 rural WA students have graduated from UWA. But will they go back to the bush? Head of the RCS Prof David Atkinson says there’s good evidence to suggest that this cohort is three times more likely to return to the country than their city counterparts.

“In addition, 19 students from this year’s rural graduating cohort spent a year training in the country with the RCS, making it even more likely that they will return to the bush,” he said.

“I’ve been drawn to it ever since I was mentored so positively when I was at RCS in Kalgoorlie and I’ve sought opportunities to mentor students for a long time now,” she said.

Dr Sarah Moore

“I love hearing young doctors and students talk about their dreams and passions.

It’s wonderful to be able to give them the information that will help them connect the dots because there are not necessarily clear pathways to becoming a rural doctor. It doesn’t have to be a one-track journey.”

“The RCS can help students to determine where they want to get to and help them with the skills, connections and training opportunities they need – not just to get there but to stay in rural practice.”

“What the students give me is a reminder of how to dream big. They don’t allow the confines of bureaucracy and cynicism to cloud their dreams. It keeps me young and creative and looking at challenges as just that, not as barriers.”

Mindful professionalism

Positives of mentoring

Last year, Sarah wrote an eight-week online mindfulness course for RCS students to help them cope with the stresses of being away from their networks. The downloaded digital tools are theirs to keep.

The RCS Medical Coordinator at Busselton, GP obstetrician Dr Sarah Moore, said mentoring students was the favourite part of her job.

“About half of the 80 cohort opted in and, while not all completed the program, we have enough to evaluate its effectiveness.

There are stresses in the job and these tools

24 | MARCH 2017

and practices aim to help students positively focus their stress and use it in a way that will help them be better and more compassionate doctors,” Sarah said.

“I was particularly interested in how students looked after themselves and what time they gave to themselves and to others. Stress can impact on their professionalism and their capacity to show compassion and by learning how to be mindful in their practice improves the doctor-patient relationship.”

Cohort complexities The ageing of the student body has been dramatic in the past 10 years. The MTRP report found in 2014, 35% of commencing students were 20 years and younger, 45.8% were between 20 and 24, and 13.4% were 25 to 29 and the rest were 30 years and over.

Sarah said that today’s students were often navigating and competing for limited training pathways with a partner or a family to consider and that affected the choices they made.

The one thing that is certain for all students is what they learn today will be out of date sooner than later and Sarah believes that this underscores the importance of teaching core professional skills such as compassion and communication.

“While medical knowledge will change, the need for those skills will remain throughout a doctor’s career. Doctors today need to be open to change and knowing that whatever you’re learning, there is always another way of looking at it. It’s important to have flexibility and resilience.”

By Jan Hallam MEDICAL FORUM

FEATURE

Views from Rural Alumni Dr Anna Robson Senior Paediatric Registrar, Rural Paediatric Service, PMH

Anna grew up in the Kimberley, Pilbara and Wheatbelt. As a social worker, she returned to the North for several years before transitioning to medicine as a self-confessed late starter.

And so, when RCS came along in 2007 – the first year that the University of Notre Dame was involved in the program – Anna needed no urging to join.

“I am very thankful that I went to Kalgoorlie. I went with a great group of people – we mixed with students from UWA and I still keep in touch with many of them.

“And then we had fantastic mentors like Dr Christine Jeffries-Stokes, Dr Murali Narayanan, Drs Andrew and Clare Kirke, Dr Barney McCallum and others from whom I learnt a great deal. Christine and Narayanan were influential in my choice to do paediatrics, and of the 10 students in Kalgoorlie two others have also done paeds.”

“The gains from that year were very evident when we came back to Perth and our peers; we were miles ahead in our clinical experience.”

“Students worry that you miss out on the complex medicine (on rural placement) because that all goes to tertiary hospitals in Perth. The reality is that because much of that pathology comes from where you are working, you do get involved and it is more contextualised than tertiary hospital medicine.”

However, it was about the people and the lives they live in rural and remote WA that won Anna to rural medicine.

“There was a sense of rightness of place, I guess, in just being there. My extended family has been on stations and in remote areas for generations and I feel both an affinity for, and an understanding of, people who live in that context.”

Anna completed her undergraduate studies in 2008, interned at RPH (including a surgical term in Port Hedland) and then joined PMH. Her work with the Rural Paediatric Service involves regular clinics in Wiluna, Warburton, Merredin and offshore on Cocos and Christmas Islands.

In 2016, as the Paul Carman Fellow, she continued her rural paediatric learning with Dr Rex Henderson, a distinguished clinician who as work for years with the Ngaanyatjarra people.

Anna sees a return to Western Australia’s north – the Pilbara or Kimberley regions – as her long term future when her formal learning is completed, always mindful of the significant paediatric skills required in rural and remote settings.

MEDICAL FORUM

Dr Jared Watts Obstetrician/ Gynaecologist, Broome

Jared, like so many others now working in rural and remote medicine, has experienced the RCS and its benefits from both sides – firstly, as a student, and now as a specialist Obstetrician Gynaecologist working in Broome and helping to mentor students.

“The reason I am back here these days is because I get to work as a colleague with those who taught me,” he says.

“I think country doctors in general have teaching and the patient’s interest at heart, so they want to train the next generation.

Therefore, they are willing to teach and actually get you involved. And that’s the thing that makes RCS special – you actually become part of the patient’s team, you are not just the 14th person at the end of a ward round.”

“Quite often it is a ‘one-on-one’ learning experience with the doctor you work with; you learn so quickly because you are part of the patient’s treatment.”

“The year in RCS was probably one of the best in my life. It was just an amazing learning opportunity; fantastic life-long friends made; and you end up going back to the city with a very impressive knowledge base and clinical skills set.”

Jared’s initial disposition was towards becoming a rural GP, but in the process of broadening his skills in obstetrics and gynaecology, he was persuaded to take on the discipline as a specialty.

And that, too, was a turnaround from the young med student who when asked ‘what do you want to do’, always responded with ‘anything but obstetrics, gynae or geriatrics’. But the more he learned, the more he got the ‘rush’.

“There’s a lot of adrenalin in obstetrics and 98% of the time it is a very happy specialty; and then there’s the gynaecology and lots of gadgetry – gynaecology sort of invented laparoscopic surgery and have been leaders in the field.”

Now Jarad is back in Broome 12 years after he had done his RCS there.

“Some of the challenges of the place are also some of the attractions – as the obstetrician gynaecologist, I am often here on my own and when things go wrong, they can go wrong quickly. But I can always be sure that other doctors will be available and more than willing to come and help. The team work is incredible and people are willing to step out of their comfort zone and their routine job to help each other out.”

Dr Robyn McIntyre GP, Esperance

“We had – and have – a marvellous supervisor here in Dr Donald Howarth who is just one of those very, very clever and dedicated teachers,” Robyn says. “He will have his students in the coffee shop at 7 o’clock every morning giving tutorials on all sorts of medical topics, both standard and bizarre! That was an experience to value the rest of your life.”

“I actually get the sense from other RCS sites that a lot of them have these very dedicated doctors and teachers who are just so keen to impart their knowledge. That is really special.”

“In terms of attracting rural doctors to the country, RCS does a fantastic job. Evidence is now showing the benefit of that. We already have two registrars coming back who went through RCS – that is the proof of the pudding right there; that is what RCS is doing for Esperance, a rural town on the south coast of Australia.”

Before medicine, Robyn taught music and was lured to Esperance by friends on the pretext of a holiday, but in reality it was to matchmaket with farmer Alistair McIntyre. It worked! Robyn and Alistair married, had two children and at 40, the couple decided that Robyn should pursue her dream to pursue medicine.

“I had a husband at home on the farm and he would have probably liked me to stay and help him out, but off I went to Perth. At every opportunity I had to do any of the learning in Esperance I was allowed to do so, and that was really great.”

When it came to her RCS year, Robyn discovered what others have before her.

“You are actually given more autonomy – you have higher responsibility, you are allowed to tackle things on your own a lot more. You have more scope. You are not just a number in a hospital in the city, you are actually well known, you are given far more opportunity to go and see patients, manage patients.”

“The GPs run the hospital down here, so if a patient went to hospital you would go and see them in hospital and then see them out of hospital – there is no loss of care when the patient has to be admitted.”

Apart from the professional fulfilment Robyn has found in Esperance, she has also found a community.

Footnote: Robyn has opened a new practice with others, among them, Dr Donald Howarth.

“The Kimberley has some of the worst obstetric outcomes seen in a developed country, and to be back and using the skills I first started to learn as a 5th year medical student here in Broome, is actually quite a privilege and honour.”

MARCH 2017 | 25

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Fertility, Gynaecology and Endometriosis Treatment Clinic 26 | MARCH 2017

MEDICAL FORUM

BACK TO CONTENTS

AntiSocial

FEATURE

Developed by Bugbean, Melbourne

Overall Rating

Ease of Use

Review by Ms Karen Huggett Clinical Psychologist, Direction Psychological Services It’s purpose Designed for those “addicted” to their mobile phone or social media. For many, this is a confusing and distressing thing with impacts on quality of life, work, study and relationships. Many of us have habits and choices that we can stop successfully, but some feel compelled and dependent on an activity.

Chris Eade, creator of AntiSocial, said: "Overuse of our cell phones and social media is creating issues with some of the basic human mechanisms that are fundamental to us being a happy, healthy society. We are slowly losing the ability to build meaningful relationships and the concept of what is real, while we constantly search for that next hit of gratification or acceptance from artificial sources."

AntiSocial helps determine whether smartphone use is a normal habit, or a more serious problem. It’s designed for people looking to restore balance back into their lives by ‘switching off’.

Using the app, the user is able to monitor the time spent on social media such as Facebook, Snapchat and Instagram as well as emails and listening to music, gaming, texting, phoning, etc. It compares your use with others around the world and can block certain apps during times when you need to focus and be productive.

For adults overseeing kids, the use is more exciting.

“The idea sprang from having kids and trying to separate them from devices, and seeing other parents have the same problem,” Chris said. “My kids are young, so as they get older it will just get worse. They have android tablets and when I turn on a software prototype I noticed that their behaviour was different. If they had 30 minutes to play and then the automatic block kicked in and locked their tablets, they just sort of went, ‘Oh well’, and started doing something else!”

angry or annoyed. When it is software they just accepted it and moved on!”

“Testing on phones we saw the same thing, the kids did not blame the parents, they blamed the software and it helped reduce arguments. We’ve incorporated simple things like the schedule, which allows parents to block phones at certain times of the day (e.g. dinner time). It also helps parents know what apps kids are using and can block apps (you don’t want a child having tinder installed). It also provides an ability to teach your child appropriate phone usage.”

“So as with many apps it was spawned from a problem that I have, and saw that many parents have.”

App Details AntiSocial is a free app for Android systems only (4.1 or later). It requires 7.8MB. It has not been written for iPhones because iOS imposes limitations on what you can access and control on the phone.

The paired version (designed for compliant adult and child usually) will have an iOS version for monitoring and controlling an Android phone but cannot report anything from an iOS device.

The paired version, designed to be put on children’s phones, will have an option to track the location of the child’s phone during installation.

There are no advertisements or in-App purchases. How will the developers recover costs? The paired version (due for release in mid-April) will have a free trial and then be on subscription (probably $3.99 per month).

become problematic.

The app reports pictorially the total number of minutes spent on social media or favourite apps per day. It also has a section with tools and resources to assist in breaking the habit if needed once the twoweek challenge has been completed.

Minuses It only operates on Android tablets or smartphones (not iOS, see reason above), precludes a large number of people from using it.

Tools to break the habit are only available after the two-week challenge.

For those interested in privacy, Bugbean says: “None of the data captured will be used unethically and our Privacy Policy ensures that we can’t read into sensitive information pertaining to individuals.” To make the App functional, the following is accessed.

• Device & app history: sensitive log data – reads this as the core of the app • Identity of accounts on the device.

• Finds Contacts accounts on the device – to check for a Google Account (required to work on versions of Android older than 4.0; newer versions of Android must have the Play Store application installed).

• Phone status, identity and call information – to include phone usage information.

• Update component usage statistics.

“When it was me trying to physically take the tablet away they would want more time, get

Pluses The App runs in the background for twoweeks initially, gathering critical data about the way you use your smartphone. Users receive a comprehensive, easy to interpret, free report that could provide insight into whether the user’s smartphone use has

Keeping it Clean

1. When initially hiring people get police clearance on all.

5. Limit the person's access to your funds and stipulate how much in writing.

2. If CV referee checks are important, pursue people who oversaw your prospective employee and not only those listed on their CV.

6. If things go pear-shaped, remain transparent by notifying anyone in authority and responding to questions openly.

Tricksters can take senior medical positions and cause financial damage, either directly or indirectly. The medical profession is a sucker for punishment, often expecting the best of people and ill prepared for what follows.

Prompted by a reader tip-off, here are some safeguards:

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3. Do everything during their probationary period by the book and document it.

4. Make the probationary period as reasonably long as possible, and put in place KPIs and measureable performance milestones.

• Data from the Internet.

• View network connections.

• Full network access.

• Runs at start-up and prevents device from sleeping.

7. Use the episode as an example to other staff that you won’t tolerate fraud.

Pursuing someone for recompense may not be worth it financially but be wary of avoiding confrontation mainly for reasons of damaged reputation.

MARCH 2017 | 27

GUEST COLUMN

Drop Out and Drop Dead Keeping teenagers at school longer leads to a longer, healthier life, according to public health physician Dr Bret Hart.

Prof Sir Michael Marmot in last year’s Boyer lectures urged action on the unfair social gradient in health. In 1999 I invited him to speak at a forum in Perth entitled “Is Inequality a Health Hazard?” While chauffeuring him around I asked what he considered to be the most significant determinant of health. “Education” was his instant reply. Since then the evidence affirm his view.

The US National Institute of Health used Marmot’s Whitehall study cohort to compare outcomes of interventions in terms of Quality Adjusted Life Years (QALYs). The secondary prevention intervention of taking Pap smears adds a few days; mammography, about a month; identification and treatment of LDL cholesterol, six months; hypertension, eight months; tackling smoking; about six years.

Those with a degree compared to those who haven’t completed high school have a 12 year difference in QALYs. If adult Americans who hadn’t completed college experienced the same health as college graduates, the resulting improvements in health status and life expectancy would translate into potential

One of the reasons for leaving school early is “failing” and this can be predicted even before a child starts school. gains estimated at more than US$1 trillion annually.

While most studies emanate from the US, Dr Rosemary Korda at ANU recently found a discrepancy in the rates of CVD in those with no educational qualifications versus those with a university degree.

But what can doctors do about high school students voting with their feet? One of the reasons for leaving school early is “failing” and this can be predicted early.

In 2002, my Public Health Unit in North Metro Perth initiated a trial of the Canadian Early Development Index which ultimately led to the three-yearly Australian Early Development Census. Although we were banned from further involvement, others subsequently found there was a correlation between the 4500 children’s EDI scores and NAPLAN results.

This added to the evidence that before and during the first few years of life influences how well children grow and ultimately work, live and age. The message for doctors and health professionals is the importance of providing excellent preconception health promotion, exemplary antenatal care and superb child and school health services, especially for those who benefit most.

Even if this is provided, there will still be some students wanting to drop out. Over 20 per cent of Australian students feel they don’t belong, aren’t happy or satisfied with school.

Dr Jonathan Fielding, Commissioner of Public Health in Los Angeles, said: “If modern medicine wanted to do one thing to save lives it would be to deal with the high school dropout problem.”

It is also one of the reasons why I became a board member of the newly established Wellbeing in Schools Australia. It is about building welcoming and trusting supportive relationships in schools. It helps save lives.

ED: Questions? Contact the author bret@ausdoctors.net

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MEDICAL FORUM

Guest Column

ED: More Integrated Pain Care Dr Andrew Jan, an Emergency Physician currently researching medical acupuncture in the ED setting, touches on his view on pain management.

Pain sends patients to Emergency Departments (EDs) and up to 75% who attend have pain. Current pain relief measures are predominantly pharmacological along with procedural and surgical interventions. However, our current approach to pain relief may have negative consequences.

Over the past two decades opioid prescribing has markedly increased. The director of the US Centre for Disease Control and Prevention, Tom Frieden, says of opioid prescribing: “We know of no other medication that’s routinely used for a non-fatal condition that kills patients so frequently.” In Australia, there were 806 oxycodone deaths 2001 to 2011 and this figure is rising.

EDs commonly use oxycodone as an analgesic although they only prescribe a small proportion of all oxycodone used in Australia.

We do know that opiates initiated in ED increase the risk of later misuse and addiction.

Are we helping or hurting patients with our current approach, given both the short and long-term side effects of pain medications? Do we need other models of care in the ED and for pain medicine in general?

Prior to the medical (or Cartesian) model introduced in 16th century, pain management was dominated by various cultural and spiritual aspects. We now know tissue injury and pain does not have a one-to-one relationship – that there are emotional, cultural and spiritual dimensions for pain.

Are we helping or hurting patients with our current approach…?

For example, the narrative medicine model highlights the humanistic psychology perspective. The humanists would see the pain experience as a ritualised initiation into some sort of mystery, that patients must on their own, ‘figure out’ and then move onto a new direction in their life. Pain may be regarded positively as an education or even a gift – as negotiating the path between pain and pleasure, happiness and despair is an inherent part of the human condition.

by Medical Director Prof John Yovich

Is our medical model becoming a shortsighted assembly-line medicine for managing body parts? Should we consider therapies from other paradigms that have some evidence of efficacy and do less harm, while encouraging personal growth?

Even in the ED there are opportunities to introduce such alternative pain therapies for a patient’s pain crisis, as a stand-alone or as an adjunct to simple analgesia (while there will always be a place for standard analgesia, opioids and procedural interventions).

These therapies may include guided imagery, breathing and relaxation techniques, acupuncture, explanation, comfort positions, attentional techniques and cognitive behaviour interventions.

This more integrated approach offers a middle path where the ‘whole person’ is treated and their individual life story is foremost with the medical model assisting their journey. Further research into alternative pain therapies to investigate their efficacy and suitability in this setting is needed.

ED. References available on request from the author at drandrewjan@gmail.com

Specialists in Reproductive Medicine & Gynaecological Services

PIVET MEDICAL CENTRE

IVF Children show normal development … can be assessed at first birthday The first IVF child, Louise Brown was born in Oldham, UK, in July 1978 to a mixed reception. Some views criticised the pioneers, scientist Robert Edwards and gynaecologist Patrick Steptoe for interfering with God’s work (human reproduction) and some prominent scientists expressed concern about the “in-vitro” process. However, the IVF technology led to explosive gains in the scientific knowledge of human reproduction over the next 38 years, with the international scientific community “settling down” and belatedly conferring the Nobel Prize in Physiology & Medicine to Robert in 2010. His courageous partner Patrick had already passed on in 1983.

The first publication indicating that IVF children showed normal development came from our pioneer facility in Perth, Western Australia.

PIVET’s first 20 children had extensive documentation at their first birthday applying a Griffiths Quotient to each of the children where the developmental scales measured locomotion skills, personal and social interactive skills, hearing and speech development, eye and hand coordination, as well as performance responses to various stimuli. Mums also added in their observations with respect to feeding, sleeping and NOW AT 2 LOCATIONS PERTH & BUNBURY

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play patterns along with parent-child interactive gradings. These 20 children all received a “gold-ribbon” pass but the GQ scores ranged widely from the lowest at 83 to a high of 143 (Yovich et al, JIVET 1986; 3:253-257).

We have kept in touch with these families and can report that each of the children has progressed into adulthood with high levels of achievement, virtually commensurate with their GQ score.

Dr Christian Ottolini checking The 12th child (actually #13 as one out the labs at PIVET where returned to Singapore prior to the study) he was “conceived” almost 34 years ago. had the top GQ and we have followed his life with great interest. Christian Ottolini is pleased to share his story which includes graduating BSc from UWA, then joining PIVET to train as an embryologist, and thereafter completing his PhD at the University of Kent in 2015 supervised by my close friends and colleagues Alan Handyside and Alan Thornhill. That thesis is titled Chromosome segregation and recombination in human meiosis: Clinical Applications and insight into disjunction errors. Ten highlevel publications were generated, two of which hit the highest mark with the journal Nature.

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MARCH 2017 | 29

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Examination done on the same patient at the equivalent dose.

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30 | MARCH 2017

MEDICAL FORUM

Guest Column

Claremont Pain Clinic

How Does Your Garden Grow?

Never underestimate the importance of a green space, albeit a small one says GP Dr Richard Yin. It may be merely symbolic but, for me, our surgery garden is an extension of what we do as doctors. We all know that the major determinants of health sit outside consulting rooms and hospitals so here’s the story of our very own green space.

A few years ago the original garden in front of the surgery was looking pretty forlorn so we decided to plant fruit trees and vegetables. We had lots of enthusiasm but hadn’t planned for the weeds, the fruit-flies and the couch grass. So, with minimal time and zero horticultural skill on our part, nature took its course.

I’ve walked out to the garden to call in the next patient and we’ve started the consult right there, surrounded by plants and under a blue sky.

We quickly became a blot on the landscape.

This time around we thought about space, ease of maintenance and functionality and there was no shortage of good ideas bouncing back and forth. There were doctors keen on permaculture and sustainability, ideas that are very much part of our practice ethos.

So there we all were on a Sunday morning, a very unprofessional-looking group of doctors eradicating all traces of our previous efforts. As we began to build the new garden it generated a lot of interest in the local community, ranging from amazement to appreciation.

When the first lot of benches went in it looked like a mini-Stonehenge!

On a number of occasions I’ve walked out to the garden to call in the next patient and we’ve started the consult right there, surrounded by plants and under a blue sky. I could feel the day’s accumulated stress gently leaving my body. There’s plenty of good evidence that gardening is therapeutic and it’s easy to understand why.

And, while what we do within the practice is important, so too are the social bonds of friends, families and community. Our garden contributes to social capital and that’s a wonderful thing to share with the local primary school across the road. Every afternoon a flock of parents descend for the school pick-up and some of them spend time in the garden.

We’re very proud of our small, quiet, green space and it reminds us all of the importance of a healthy environment and an equally healthy workplace.

Dr David Holthouse Neurosurgeon/Pain Specialist FRACS FRACGP FPMFANZCA

Dr Pat Coleman Anaesthetist/Pain Specialist

FANZCA FPMFANZCA FRACGP DRCOG

We have formed a pain unit and are now ‘Claremont Pain Clinic’.

David has a neurosurgical background and Pat an anaesthetic background, and both are qualified GP’s (FRACGP), and as such provide a broad range of experience with regards to all pain issues.

David remains open to seeing neurosurgical cases but the major focus of the clinic is procedural pain management.

Pat is an anaesthetist who has a FPMANZCA and is experienced in pain interventions such as spinal injections and rhizotomies. He is also able to see cases with pain issues such as CRPS and post-surgical pain in any region of the body or other pain states.

The practice has a clinical educator and a registered nurse experienced in pain. We also have a focus on neurostimulation as a potential treatment.

We are able to see insured patients (privately insured and workers compensation). We have a keen interest in the rehabilitation of workers compensation patients and aim to expedite appointments. We do not see patients with active MVIT claims, public liability cases or non-insured patients. We are unable to cater for drug addicted patients who should be referred to a public pain clinic.

We have a close working relationship with a number of other spinal surgeons who are sub specialists in fusion surgery and often assist in the workup and selection of patients for this surgery. We also work closely with a clinical psychologist and psychiatrists with experience in pain management and pain conditions.

We work in collaboration with Pain Options, a specialist physiotherapy practice which assists in the rehabilitation of pain patients and workers compensation patients.

Claremont Pain Clinic Phone: 9385 1323 Fax: 9463 6333 Address: 12/237 Stirling Highway, Claremont WA 6010 PO Box (please send all mail here): PO Box 563, Claremont WA 6910

MEDICAL FORUM

MARCH 2017 | 31

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BACK TO CONTENTS

CLINICAL UPDATE

Part II: Radiocontrast media reactions Physiological reactions to radiocontrast media (RCM) relate to dose and infusion rate – transient warmth, flushing or vomiting (chemotoxic), or faintness, hypotension and bradycardia (vasovagal).

Idiosyncratic reactions include immediate and delayed hypersensitivity, largely independent of dose and infusion rate.

Immediate hypersensitivity reactions are similar to those of anaphylaxis, onset 5 to 60 minutes after administration –cutaneous (flushing, itching, urticaria or angioedema), respiratory (bronchospasm, laryngeal oedema and stridor), or cardiovascular (hypotension, loss of consciousness or, rarely, shock). Reaction rates have reduced to low osmolality RCM, now estimated at 0.2-0.7% (severe acute reactions reported as 0.04%).

Treatment as for anaphylaxis.

The pathogenesis of most acute allergiclike reactions to RCMs is unknown but likely involves multiple mediators including histamine, complement and the kinin system.

A minority of patients have positive skin testing and an allergic IgE-mediated aetiology.

By Dr Meilyn Hew Allergist and Clinical Immunologist, Murdoch

Table: Approach to next use of RCM following immediate hypersensitivity reaction

Pathogenesis of RCM reactions is ED mostly unknown. Past track record is important, so switching to less reactive media and premedication can prevent repeat mild reactions.

Choice of RCM

Change to a low osmolar or iso-osmolar agent (iodixanol), different to culprit agent, or do MRI with gadolinium

Choice of premedication

Non-emergency: Prednisolone 0.5-0.7mg/kg up to 50mg orally or methylprednisolone 0.5mg/kg up to 40mg IV – at 13 hrs, 7 hrs and 1 hr prior to procedure. PLUS Non-sedating oral antihistamine (e.g. cetirizine 20mg) 1 hour before procedure.

Emergency: Methylprednisolone 40mg IV immediately and then every 4 hours until completion of procedure. PLUS Non-sedating oral antihistamine stat (e.g. cetirizine 20mg)

NB. Test dosing is not recommended, to prevent hypersensitivity reactions to RCM

Author competing interests: no relevant disclosures. Questions? Contact the author on 9332 2861.

Delayed hypersensitivity manifests up to several days later with various cutaneous eruptions including urticaria or angioedema, flexural rashes, fixed drug eruptions, erythema multiforme minor, vasculitis or more severe cutaneous adverse reactions such as SJS/TEN. Predicting and preventing reactions Patients with atopy in general are at slightly increased risk. Asthmatics benefit from optimising their asthma management prior to exposure and the use of low or iso-osmolar contrast agents. There is no association between gadolinium-based contrast agent reactions and RCM reactions, or with elemental iodine, shellfish or topical antiseptics containing iodine.

Premedications are generally not used for primary prevention of RCM reactions.

Previous RCM reaction is the greatest predictor of repeat reaction. Most preventive premedications regimens use corticosteroids (best 4-6 hours beforehand) and antihistamines (non-sedating oral preferred), developed before the widespread use of low or iso-osmolar RCM. Mild reactions are reduced but there is no randomised controlled data on the efficacy of premedications on moderate to severe RCM reactions. Breakthrough reactions occur despite premedications, often similar in severity and symptoms to the initial reaction.

Be prepared to treat reactions.

References available on request.

MEDICAL FORUM

MARCH 2017 | 33

Intentionally left blank to comply with Medicines Australia Code

BACK TO CONTENTS

CLINICAL UPDATE

Basic principles in stroke imaging

Dr Jolandi van Heerden & Dr Manoj Tharakan Radiologists.

Affiliation: Perth Radiological Clinic

In the context of acute stroke management, the mantra “time-is-brain” is well recognised. To this end, a patient presenting at a general practice with acute onset stroke-like symptoms (within 4.5 hours) will have the best long-term outcome if considered with the same clinical urgency as a patient presenting with chest pain.

• To assess for the presence/extent of already infarcted (non-salvageable) brain.

Prompt referral to the closest hospital-based Stroke Unit is of paramount importance.

Although well-intended, outpatient brain imaging prior to hospital referral will likely lead to unnecessary delays that may adversely affect long-term patient morbidity and mortality.

In the non-acute setting (stroke/TIA beyond the treatment time-window), various imaging approaches can be employed. A CT brain will help assess established stroke and exclude major stroke mimics, however, a small subacute stroke can be occult on CT imaging, requiring follow-up MR imaging.

Once at a Stroke Unit, specialised stroke neurologists/physicians carefully consider clinical and imaging findings to determine the best management pathway – this may range from intra-venous thrombolysis (IV-tPA) to mechanical intra-arterial clot extraction.

MRI is highly sensitive in detecting stroke, particularly in areas of the brain (like the pons and midbrain) often obscured by artefact on CT. Additionally, MRI can more accurately determine the age of a stroke and assess for more subtle stroke mimics. The intra-cranial MRA sequence included in the MRI stroke protocol allows assessment of the intracranial artery status without intra-venous contrast administration. If requested, an MRA of the extra-cranial (neck) arteries can also be performed.

The usual in-hospital acute stroke imaging includes a non-contrast enhanced CT brain, a contrast-enhanced CT angiogram of the major intra- and extra-cranial arteries and at some units, a CT perfusion study.

The main aims of imaging are: • To identify proximal large artery occlusion (embolic clot) [Fig 1].

• To exclude acute haemorrhage (contraindication for thrombolytic therapy).

• To exclude stroke mimics [Fig 2].

Given the time-sensitive nature of acute stroke imaging, the role for MRI in hyper-acute stroke assessment is limited.

For anterior circulation symptoms, a carotid Doppler study helps exclude a causative carotid artery lesion. Please remember that the posterior circulation cannot be fully

Fig 1: Acute stroke imaging – left middle cerebral artery thrombus.

A: Non-enhanced CT brain shows a high-density acute clot in the left middle cerebral artery M1 segment. B: CT Angiogram confirms a filling defect (thrombus) in the left middle cerebral artery M1 segment.

C: MRI following intra-arterial clot extraction demonstrating a small area of acute infarct involving the left corpus striatum – clinical deficit minimal. D: Time-of-Flight MRA performed after mechanical clot extraction confirms recanalization of the left middle cerebral artery.

MEDICAL FORUM

ED. Acute stroke may need ED intervention by a Stroke Unit within 4.5 hours. Non-acute stroke is less urgent. Both require the correct imaging, which varies.

assessed with a Doppler ultrasound study and thus a CTA or MRA is required when vertebro-basilar insufficiency is suspected clinically.

CTA or MRI/MRA are best suited to exclude vertebral or carotid artery dissections.

Conclusion Imaging of acute strokes is best performed promptly at a hospital-based dedicated Stroke Unit, where CT is usually the modality of choice. In the non-acute setting, a range of imaging modalities can be used in the strokeassessment pathway - the most appropriate choice often dictated by the expected vascular territory involved.

References available on request.

Authors competing interests: No relevant disclosures

Fig 2: Stroke mimics. A: Acute onset left arm and hand weakness due to acute haemorrhage into a metastatic lesion in the right pre-central gyrus (other brain metastatic lesions discovered during imaging).

B: Acute onset dysphagia and speech change due to a right lateral medullary tumefactive demyelinating lesion. C&D: Acute onset left arm and hand weakness due to an arterio-venous malformation that has bled with intra-ventricular haemorrhagic break-through.

MARCH 2017 | 35

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CLINICAL UPDATE

Parenting – your history becomes their destiny?

Most parent’s want the best for their children but some come to the role better equipped than others. Much of this seems to relate almost directly to their experience as a child.

By Dr Julia Feutrill Perinatal and Infant Psychiatrist Claremont

Experience as children influences how we parent but it is not as simple as ‘nature vs nurture’ given what we know now.

ED

so, thereby breaking the intergenerational cycle?

The most important first step is to treat any mental health disorder assertively to give the parent and child the best chance. In some psychiatric conditions, this may not happen quickly enough for the developing brain of their baby.

Connection and relationship are hardwired from birth. In the first 30 minutes of life infants will seek out a face in preference to other stimuli.

We are hard wired as parents, as are our babies, to interconnect.

If our caregiving system is so innate and instinctual, why does it go so wrong for some parents, despite them having the best of intentions?

Parenting connections Attachment research has shown that parenting seems to be inherited.

A securely attached 18-month old toddler will develop a secure attachment style when they grow up, and as adults be more likely develop a secure relationship with their 18-month toddler. Sadly, the reverse is also true. It is difficult for a parent with a disorganised attachment system to provide a secure base for their child, and so the cycle can continue for another generation.

The cornerstone to ‘good enough’ parenting is the ability to consider the experience of the baby in the context of the parents’ own emotional and cognitive state. This is known as reflective functioning, a scientifically validated construct. The higher the reflective functioning, the more likely there will be a secure attachment relationship. The best part is that we can ‘teach’ reflective functioning, often despite the presence of mental health disorder or parental early life adversity. This is the realm of infant mental health.

It is hard, but not impossible, for parents to give to their children what they were not necessarily given themselves. What is imperative is that we get all families off to the best start and preconception is the beginning of this, not the age of three or four.

Amidst the long discussion about nature versus nurture, we need to see nurturing as being able to modify the way nature impacts on biology.

History does not have to be destiny - it is easier to build strong children than it is to repair broken adults.

The neurobiology behind parenting is increasingly understood, particularly for those finding it difficult. Australian research on mothers with borderline personality disorder (BPD) showed they have difficulty in recognising infant mood states accurately and tend to have a negative interpretation of neutral facial expressions. This concurs with other research showing that women with BPD have disturbances in social cognition and emotion perception, making it difficult for them to provide the contingent responses an infant needs for emotional regulation.

We also know from animal and human research about the impact that ‘toxic stress’, the enduring exposure to traumatic situations, has on the developing child’s brain. This has lifelong implications for emotional and also physical health. We know that this idea of ‘toxic stress’ has merit for the developing foetus as well as young children.

Epigenetics provides a partial explanation. The epigenetic ‘tuning’ that occurs in early life is proposed to allow the developing child to biologically adapt to the environment to allow the best chance of survival. Once established, any epigenetic ‘codes’ are stable through further cell division and potentially passed down to the next generation.

For example, low socioeconomic status in early life is considered to ‘program a defensive phenotype’, with epigenetically coded resistance to glucocorticoid signalling and an exaggerated adrenocorticoid and inflammatory response. There is evidence that these metabolic and immune system changes may have lifelong physical and psychological ramifications for that generation and the next.

Effecting change Does this mean the intergenerational cycle of parenting is a fait accompli? It does not. Epigenetic marks are potentially reversible. In the study of low socioeconomic conditions in early life, the most powerful modifying factor was maternal warmth.

The importance of nurturing caregiving has been demonstrated repeatedly in multiple animal and human studies, whether they are genetic or attachment based research studies.

If a parent has had early life adversity, how can we support them to be a ‘good enough’ parent for their child, even if they are not ‘wired’ to do

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MARCH 2017 | 37

Sport

Life's Secret: Keep Moving

Main picture: Cecil Walkley (right) racing at White City London in the 1950s as part of the Oxbridge team that took on Harvard and Yale.

Right: Still competing in veteran events.

If your legs work and the other bits hang on, don’t stop is octogenarian Dr Cecil Walkley’s motto. And his legs have taken him on some wild runs.

Dr Cecil Walkley has led a life of perpetual motion and there’s no sign of that stopping anytime soon. The 87-year-old recently competed in a steeple-chase in honour of a running colleague and will be lining up for the Masters’ athletics next month.

“Running, for me, is all about keeping fit. We can’t do anything about our genes – well, not yet anyway – but you just have to keep

moving. That’s the secret and it doesn’t matter how old you are.”

“I’ve run 26 marathons and hold the WA record for the oldest runner to complete the distance. I was 80 when I ran it in six hours three minutes, and I was pretty angry about the three minutes!”

“How much longer I can keep doing this god only knows!”

Robin Williams' Revisited Ah, yes, divorce ... from the Latin word meaning to rip out a man's genitals through his wallet.

Politics: “Poli” a Latin word meaning “many”; and "tics" meaning “bloodsucking creatures”.

Short and Sweet That's What She Said Retired Bunbury GP Dr Donald Reid says this joke tickled him in the right places…

So I took off her shirt. Then she said, ‘Take off my skirt’. I took off her skirt. ‘Take off my shoes.’ I took off her shoes. ‘Now, my hose, bra and panties.’ I took them off. Then she looked at me and said, ‘I don’t want to catch you wearing my things ever again!’

38 | MARCH 2017

What do you get when you cross a rabbit and a pit bull? Just the pit bull.

What do you call people who use the temperature method of contraception?

Parents.

A guy asks his waiter at a restaurant how they prepare their chicken. The waiter goes blank for a second, then says, “Nothing special really...We just tell them they're going to die...”

Two flies are sitting on a pile of dog poop.

One suggests to the other: “Do you want to hear a really good joke?”The other fly replies: “But nothing disgusting like last time, I’m trying to eat here!”

A guy helps an old nun across the street.

She: Thank you very much, young man!?

He: No problem. Batman’s friends are my friends!

Bill Bailey's Best Lines Three blokes go into a pub. Something happens. The outcome was hilarious!

A lot of people say there's a fine line between genius and insanity. I don't think there's a fine line, I actually think there's a yawning gulf. You see some poor bugger scuffling up the road with balloons tied to his ears, he's not going home to invent a rocket, is he?

Relaxed Empiricism – I only believe something

MEDICAL FORUM

Running to medicine Cecil’s passion and talent for running goes back a long way and helped pave the way for a career in medicine.

“I grew up in England and in the late 1940s I won a Kitchener scholarship, which my running ability helped me secure. That gave me three years at Cambridge to study medicine and then another three at the Westminster Hospital in London.”

“In those days I ran against Roger Bannister (who ran the first sub-four-minute mile in 1954) many times, and he always beat me!

We both qualified as members of the Royal College of Surgeons on the same day. In fact, we did our vivas on the same morning.”

“It was very nice to be invited back to run for Oxbridge against Harvard and Yale in 1993.”

“It’s been a lot of fun and pretty interesting, too. I represented England against Scotland and Northern Ireland, and I also ran for Kenya once. But the latter was only because their runner was ill.”

That’s not the only connection Cyril has with Africa.

Working in volatile Africa “I joined the British Army, did six years in the Royal Army Medical Corps and ended up in the King’s African Rifles including a stint as a field ambulance paratrooper. I looked after Jomo Kenyatta and Idi Amin, and was seconded to work with Paramount Pictures on the film, Hatari, where I met John Wayne on a few occasions.”

doing some surgery. My best years in medicine were in the country, farming people are different and very special.

It did become a bit frantic at times and I was waking up in the middle of the night convinced that the phone was ringing. It wasn’t, so I guess I was a bit stressed.”

“After that I went back to England to train in rehabilitation medicine, it was called Physical medicine in those days. And then I came back here, did a lot of sports medicine and I actually still see five patients now and then.”

Family that runs together The running genes are a thread in the Walkley family and helped to give Cecil his most memorable longdistance race.

“My daughter is a very good runner and we ran together in the Comrades Marathon [89km] in South Africa. I did that when I turned 65 and it was a real thrill, probably the biggest achievement of my running career.”

“I think it’s a very good thing for an older person to have a small dog, and I’ve got two of them. Exercising them helps to keep you alive! I take them down to the local park and run around with them for 40 minutes.”

Cecil admits that he’s had a fortunate life and that fate could easily have dealt another set of cards.

“If I’d stayed in the army it would have meant moving more and more into administration and I didn’t want that to happen so I came to WA in 1962. I was intending to do tropical medicine but RPH had that position filled so I went to work as a GP in Narembeen.”

“My father was in the army when World War II broke out and we were evacuated from Egypt back to London. We ended up dodging a few bombs in the Mediterranean. I’ve hardly ever had an injury due to running but I had a few when I was a paratrooper.”

“It was a lovely practice, delivering babies and

“I got blown up in Cyprus. The chap standing

next to me was killed but I only received minor burns to my feet.”

“I’ve always led a pretty disciplined life but I do enjoy a glass of wine. I run about five kilometres every Saturday morning and I guess I’ll keep on doing just that.”

By Peter McClelland

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MEDICAL FORUM

MARCH 2017 | 39

FOOD & WINE

Yellow Pancake

RESTAURANT

38A Grantham St Wembley, (08) 9387 1702 www.yellowpancake.com.au

SNAP

SHOT

This little Vietnamese café has been open about 12 months and has quickly established itself as the anytime go-to for the local neighbourhood.

It’s delicious, cheap and BYO – a rare combination these days. Like the true local it is, the owners Haley and her chef brother Sin greet people by name; the front-of-house Adrian memorises regulars’ orders; and whisperquiet Nerissa heads to the espresso machine with the merest cock of an eyebrow. It’s that kind of place – family biz. But even the friendliest of businesses quickly fade if the food is not spot-on.

YP is comfort food made with skill. The eponymous pancake in its seafood and chicken variations is a crispy, non-greasy delight that looks huge on the plate but is so light it’s gone in a few short minutes. Wrap it in the cos lettuce supplied, dip in the chilli dressing and let the flavours burst into your mouth. The yellow pancake also features in a rice paper roll and with YP’s caramelised roasted pork is the pick of the selection. Sin’s stock is out of this world with a depth of flavour you can only get by long hours gentle simmering and it makes the Pho and Bun Bo Hue works of art. The menu is small but inspiring and once is not enough!

Everyone has a favourite restaurant or café that becomes part of their lives. Share your suggestions for your neighbourhood favourite, with the Medical Forum readers.

Contact Jan Hallam editor@mforum.com.au or 0430 322 066

Orange & Pistachio Orange Cake Ingredients 2 large oranges, washed 5 eggs 250g almond meal 250g caster sugar 100g unsalted pistachios Handful of mint 1 tsp baking powder 1 tsp cardamom powder

DIRECTIONS Preheat the oven to 190C and grease and line a 24cm spring form pan.

Wash oranges and place in saucepan and cover with water. Bring to the boil then simmer for two hours. Remove from water and cool. This step can be done the day before baking.

Remove core and pips of cooled oranges and pulp in a food processor.

Add mint then pistachios to chop roughly.

Beat eggs and caster sugar in an electric mixer until light and thick. Fold in almond meal, baking powder and cardamon. Add oranges and mint and stir.

Pour batter into the prepared tin and bake for 45-60 minutes. Check with skewer.

Cool in tin for about 10 minutes before turning out. Dust with icing sugar or glaze with warmed orange marmalade.

Serve with cream or yoghurt if desired.

Cook it

Wine

Winner

It’s definitely a case (pun intended) of three degrees of separation with this month’s Doctors Dozen winner.

Dr Rachel Hammond takes home a dozen bottles of Gilbert’s Wines and the sister of a work colleague taught the young Gilbert boys many moons ago at Mt Barker Primary School. One of Rachel’s favourite tipples, a Gilbert’s chardonnay, completes the circle.

40 | MARCH 2017

MEDICAL FORUM

FOOD & WINE

Force is with Juniper Estate A number of factors contribute to the unquestionable quality of Juniper Estate wines. In particular, the superb gravelly loam soils which lay over a clay subsoil. This, together with the close proximity to Wilyabrup Creek, means the grapes are dry grown without the need for irrigation.

The ocean-influenced moderated climate, together with these soils, gives the Wilyabrup sub-region of Margaret River a terroir comparable to the great Bordeaux region of France.

Vine age is also important. Original plantings were in 1973. This parcel of land was from a subdivision by WA artist family, the Junipers, hence the property name and interesting wine labels. The vineyard was planted by Henry and Maureen Wright and it was known as Wright's Wines in its early years. It is now is owned and run

by Gillian Anderson. Another factor to the wines’ stability and success is talented winemaker Mark Messenger (pictured below), who has been at Juniper for almost 20 years.

By Dr Craig Drummond MW

1

3

The wines are in several categories. The Estate series are top-end wines sourced only from the property and given careful hands-on care from vine to the bottle. The Aquitaine Rouge and an Aquitaine Blanc are made using a blend of the respective red and white varieties of Bordeaux. The Juniper Crossing wines are the other category (not tasted here), which consist of a blend of estate grown grapes with grapes from other vineyards across the Margaret River Region. They are good wines and represent value for money.

REVIEWER'S

PICK

5

5. Juniper Estate 2012 Cabernet Sauvignon ( RRP $70) My wine of the tasting and no surprise given such a quality producer in a region considered by many to be the premium producer of Cabernet in Australia! Here the Cab has been blended with Malbec (8%) and Cabernet Franc (4%) to round out the flavours. The nose has everything one would expect – rich intensity, oozing with varietal blackcurrant and cedary oak. The palate has supple fine-grained tannins, wonderful sweet fruit – cassis, black olive, ripe plum. It is youthful at five years’ age, with the structure, acidity and power to go to 20 years.

1. Juniper Estate 2016 Aquitaine Blanc (RRP $33) The first wine tasted and it absolutely blew me away. This classic Margaret River blend of Sauvignon Blanc and Semillon was whole-bunch pressed to French oak and underwent a natural yeast fermentation. In so many cases these varieties when oak-barrel fermented result in heavy, cumbersome wines, but not this wine. It is bright, intense with a beautiful fruit focus. The oak adds some weight and complexity but it’s ever-so integrated. Great linear acidity gives focused taut flavours of Granny Smith apple with citrus and some green bean. The clean acid backbone holds it all together giving a great finish on the palate.

2. Juniper Estate 2015 Chardonnay (RRP $40) Fruit for this wine was handpicked in small batches over four separate pickings to maximise ripeness and flavour. It was then wild fermented and aged on yeast lees for 10 months in French barriques (50% new). As a result it shows nice balance, complexity and integration. Aromas of nashi pear and stonefruit lead into melon and pear flavours with toasty notes from the oak.

WIN a Doctor’s Dozen!

Enter here!

3. Juniper Estate 2013 Aquitaine Rouge (RRP $37-$50) A melange of all the Bordeaux varieties – Cabernet Sauvignon, Malbec, Merlot, Cabernet Franc and Petit Verdot resulting in a savoury, red-berry nose with a slight bucolic, briary edge. The palate shows sweet fruit, grippy tannins and complex, slightly developed flavours of redcurrant and blackberry.

Overall, an integrated, friendly, easy-to-drink wine which has a few years left in it yet.

4. Juniper Estate 2013 Shiraz (RRP $37-$50) Hand-picked in small batches, matured up to 18 months in French oak (40% new) then a barrel selection process to create the best-possible wine. I found subtle restrained black fruit aromas, some white pepper and cinnamon spice from the oak. The fruit flavours were overt, with black cherry, plum and a savoury, spicy complexity. This is a wine to follow over 6-8 years.

.. or online at

www.medicalhub.com.au

Name Email Phone

P lease send more information on Juniper Estate offers for Medical Forum readers.

Wine Question: Which Juniper Estate wines use the grape varieties of the Bordeaux region of France?

Answer: ....................................................

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, March 31, 2016. 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.

MEDICAL FORUM

MARCH 2017 | 41

doctors in the arts

Clay in his Hands Sculpture and sketches have kept retired orthopaedic surgeon Dr Malcolm Hay’s hands busy over the years.

It’s not everyone who has a piece of their own artwork in the front garden. But retired orthopaedic surgeon Dr Malcolm Hay can top even that. His daughter recently found some sketches he did as young doctor on a ship heading for Heard Island in the Southern Ocean.

“I’ve done a few different sculptures, everything from a pair of clasped hands to the bust of a woman that sits at home in our beautiful garden full of native plants. The former obviously has some resonance with my work as a surgeon and the latter was made out of clay and then cast in concrete. I did both of them a long time ago at Claremont College. I’ve always had a passionate interest in the arts.”

“But I’d hasten to add that I really wouldn’t call myself an artist.”

“Nonetheless, my daughter unearthed about 20 pen and ink drawings I did on a trip to Heard Island in the 1960s. You’ve generally got a lot of time on your hands on-board a small ship on a journey like that so there’s plenty of time for sketching!”

Sport makes way for art As a schoolboy boarding at Wesley, Malcolm freely admits he wasn’t overly involved in artistic endeavours but did have a talent for middle-distance running.

“I enjoyed my time at Wesley. It wasn’t one of the ‘Big Four’ but it did have a strong sporting tradition and I’m proud to say I won the Mile race and represented WA as a junior runner.”

“I enrolled initially in dentistry at UWA and passed first year but then decided I wanted to switch to medicine. I went to see the course controller who told me I’d have to do first year all over again. They had a change of heart and set me some special supplementary exams so I studied hard for six weeks and managed to pass them all.”

“So in 1953 I found myself doing secondyear medicine at the University of Adelaide. I had some happy years there and thoroughly enjoyed myself.”

After doing his internship, Malcolm didn’t hang around for long.

Cold climes perfect for sketching “It was pretty soon after I’d finished my first year after graduating – the 366th day, if I remember correctly – that I was off and away.

I was determined to go to the Antarctic and as a doctor it was relatively easy to get a posting in those days.”

Dr Malcolm Hay with his sculpture 'The Surgeon's Hands' and his classical style bust that sits happily in his Cottesloe garden.

establishment of an Arts Precinct on the site of the old Sunset Home overlooking the Swan River in Dalkeith.

“It’s the perfect location, satellite photos show it’s exactly half-way between the CBD and Fremantle. I’ve been trying to get this up and running for decades and spoke with Premier Colin Barnett about the idea quite recently.

He made some enthusiastic noises and the next thing I knew he’d sold off a portion of the land for $8.5m!”

“My vision for all this stems from my time in Denmark as a young doctor. There’s an art gallery on the east coast of Zeeland known as Louisiana that really captures the spirit of the place. Knud Jensen, the gallery’s founder, put it this way ‘when art, architecture and landscape come together to heighten our experience of place we get a feeling that this is special.”

“Sadly, governments don’t do these sorts of things very well. It has to come from the private sector.”

By Peter McClelland

“I ended up in charge of Davis Station, a nineman base – and it was all men!

Another of Malcolm’s ongoing passions is the

Sapiens: A Brief History of Humankind

Book

Review 42 | MARCH 2017

(Yuval Noah Harari, Harper)

The chapter titles give you some idea of its span, from An Animal of No Significance to The Scent of Money and on to The End of Homo Sapiens. This is history writ long and large and the prognosis, according to the author, is not good. Harari, an Oxford graduate and lecturer at the Hebrew University in Jerusalem, writes simple, clear and elegant prose that makes even the most complex and chaotic turning points in human history understandable. With the advent of Trumpland, this book should be compulsory reading. – Peter McClelland

MEDICAL FORUM

Entertainment & Leisure

Leading by Example WASO’s concertmaster Laurence Jackson came to WA 12 months ago with a distinguished musical CV that reflected a lifetime spent in music. From his school days at Manchester’s Chethams School of Music graduating to the Royal Academy of Music in London then prizes and concert appearances in the great concert halls of Europe and the Americas as soloist, chamber musician and concertmaster, taking up a three-year contract with an orchestra 10,000km away seemed like a bold career move.

But accompanied by wife Sarah and his 1850 by J.B. Vuilaume violin he arrived for Christmas 2015. Here are some of his thoughts about life and work in the Great South Land.

MF: You have been with WASO for 12 months now. What, do you think, are the orchestra’s great strengths?

LJ: WASO is an incredibly versatile orchestra, not just with the regular Classics and Masters concert series, but also with its experience in the pit for both the opera and ballet seasons plus the many other concerts and projects we do every year. There is a very healthy roster of education work and family concerts. It all adds up to quite a variety of skills on display.

WASO is also a friendly and caring community and that shows itself from the top down. Liaising with management is much easier here in Australia that the UK as there is less of an 'ivory tower' mentality where the musicians’ needs are clearly a priority.

MF: Your ‘before WASO’ life appears filled with touring and various music projects throughout the UK, US and Europe. Are these continuing from your Perth base or are you exploring local collaborations?

LJ: I don’t really go back to the UK to work, although I had a concerto performance with my old orchestra, the City of Birmingham Symphony Orchestra last summer, which was very enjoyable. I don’t miss the day-to-day life

MEDICAL FORUM

of freelancing as a musician in London apart from the camaraderie of the other musicians, of course. In my old position with the CBSO, we travelled a lot and all over the world. I love to travel, the anticipation of the journey and the exciting and sometimes challenging experiences along the way, but touring is not travelling! There is more often than not no free time to see the sights or even take a leisurely walk from the hotel. It’s often gruelling, stressful, sometimes very funny and bizarre, but mostly a trudge! Just once in a while a concert would be amazing, or something would happen that would bring the orchestra together collectively on stage that night and the results could be amazing and memorable.

I do miss my quartet colleagues and the fabulous repertoire, but that was quite a long time ago now and working in a full – time quartet that rehearses (unpaid) every single day is very much a way of life, you cannot easily or successfully dip in and out of it, as you wish. I do hope to be forging more chamber music partnerships here in Perth and Australia. I love the piano trio repertoire and that is something I would love to rekindle over time.

MF: Do you feel creatively isolated in the most isolated city in the world?

LJ: Actually I don’t! I feel, in many ways, far less isolated here than I did in Birmingham.

There is so much going on in Perth, take PIAF for instance. I’m going along to all the Shostakovitch quartets being performed by the Brodsky Quartet, because I have the time and space to do that. In the UK, I would never feel I could devout an entire weekend to that!

MF: You will be soloist in April in the Stravinsky Violin Concerto – a rare treat – what is the thrill for you in this music?

LJ: It's such fabulous music, beautiful, quirky, humorous and so well written for the instrument. It’s a smallish orchestra and the interplay between the soloist and orchestra is quite unique. You are reliant on your colleagues to listen to you and not just watch

NOTE PERFECT WASO in conjunction with Medical Forum is giving a reader the chance to win a threeconcert package – with Asher Fisch conducting Sibelius (April 21), Schubert and pianist Jayson Gillham (August 18) and guitarist Karin Schaupp playing Rodrigo (October 6).

See the competitions page and go to our website to enter www.medicalhub.com.au

the conductor…and, of course, I have to listen and respond likewise! I'm looking forward to performing it. It will be a first for me so it should be a lot of fun!

MF: What are the projects that excite you presently?

I'm looking forward very much to some great concertmaster solos this year, with performances of Rimsky Korsakov's Scheherazade and Strauss Ein Heldenleben, probably the two biggest and most popular in the repertoire. Also some of my favourite symphonies are featuring this season, including Vaughan Williams 5th Symphony, Dvorak 7 and Elgar 2 plus a healthy mixture of seasoned WASO regular conductors and up and coming new talent...what more can you ask for!

MARCH 2017 | 43

Dr Markus Emerich and wife Charlotte Janz; below Charlotte's wounded ear from a needlefish.

Adventure

Living the Dream Dr Markus Emerich is a long way from his life as ENT resident at Frieburg, Germany, but a love of waves saw him in WA meeting other doctors in the surfing family.

Markus of the value of the organisation, Surfing Medicine International.

The Bluff, in the Ningaloo Reef Marine Park, is one of the most remote surfing spots in the world. It’s also a long way from land-locked Freiburg in Germany’s Black Forest. But for ENT resident Dr Markus Emerich it’s just one more exotic destination on a nine-month odyssey chasing perfect waves and taking photos of ear canals.

Markus was travelling with his journalist wife Charlotte Janz when Medical Forum caught up with them in Geraldton.

“I was working as an ENT resident at the University Hospital in Freiburg and we decided to leave the corporate world behind for a while. We’ve travelled through the USA, Mexico, Fiji and South-East Asia with the east coast of Australia and New Zealand.”

Help in isolated areas A medical emergency in Fiji convinced

“There’s a place called G Land with hollow waves breaking on a coral reef and a surfer was knocked unconscious, floating face-first and drowning. A couple of guys managed to get him into a boat but his breathing wasn’t great, lungs full of water and he was very unstable. I took over, got him into a medical room and became increasingly worried that he might die from hypoxia.”

“We tried to get a chopper to evacuate him but the weather wasn’t good. Luckily, another WA doctor [Phil Chapman Medical Forum June 2016] had set up some good medical supplies, things like oxygen and intubation equipment, and next morning he went out on the helicopter.”

“I’m a member of Surfing Medicine International, a group that runs training courses for doctors who might find themselves in a similar situation. You’re on your own at places like G Land and obviously that’s completely different to a hospital environment where you’ve got so many people helping you.”

Remote emergency medicine isn’t the only trick in Markus Emerich’s board-bag.

Practice at sea “I’ve got a project called Know Your Ears which focuses on a medical complaint known as Surfer’s Ear [exostosis in the ear canal].

It’s pretty much a cold water phenomenon.

There’s a general rule-of-thumb that if you’re able to surf without a wetsuit then you won’t have a problem with Surfer’s Ear.” “I’ve got a mobile autoscope and have been taking images of ear canals on my travels.

Needless to say, I didn’t find any evidence of it among Mexican surfers.”

“My plan is to get some really good data and write a paper when I get back to Germany.

There have been a few research studies already but there’s still a lot to be done.”

Apart from the incident in Fiji most of Markus’s medical interventions were fairly mundane. Although some of the suturing and general repairs were quite close to home.

“Charlotte and I were swimming in a lagoon and she felt a sharp jab in her ear. It was a Needlefish, they often fly just above the water and are attracted to shiny objects such as earings. It wasn’t too serious but it gave Charlotte a shock”

By Peter McClelland

cont...

An idea isn't responsible for the people who believe in it.

- Don Marquis

44 | MARCH 2017

MEDICAL FORUM

BACK TO CONTENTS

COMPETITIONS

FEATURE

COMP

Entering Medical Forum's competitions is easy!

Simply visit www.medicalhub.com.au and click on the ‘Competitions’ link to enter.

WASO: 3-Concert Package

Exclusive to Medical Forum readers, the chance to win a three-concert package – with Asher Fisch conducting Sibelius (April 21), Schubert and pianist Jayson Gillham (August 18) and guitarist Karin Schaupp playing Rodrigo (October 6).

Perth Concert Hall, April 21, August 18, October 6, 7.30pm

Exhibition: Jurassic Creatures Science and technology have always given children greater insight into lost worlds. First there were books and, for some time now, animatronics have been used to recreate mechanical versions of those extinct creatures most beloved of children of a certain age, dinosaurs. For the month of April, the Crown Pyramid will be a Jurassic forest full of big animals mostly with large teeth making a racket.

Jurassic Creatures feature mechanical mammoths, sabertoothed tigers and the odd T-Rex in the walk-through where kids can get up close to their favourite dinosaur. There are also activities where youngsters can embark on their own fossil dig as well as other amusements.

Crown Pyramid, from 31 March to 30 April

Movie: Smurfs – The Lost Village It’s not easy being blue. Little Smurfette is wondering what her purpose is in life when a mysterious creature leads her off the wellworn Smurf path into an adventure of magical proportions. Turn blue for a couple of hours.

In cinemas, April 6

Movie: Life The six-member crew (Jake Gyllenhaal and Ryan Reynolds in the acting credits) of an international space station research a sample from Mars and uncover evidence of extraterrestrial life – and it turns out to be smarter than everyone thinks!

In cinemas, March 23

M E DIC AL FO RU M $12 .50

Winners from December

Living Life to the Full

3961_BP_CHRISTMAS AD_A4_MF.indd 1

DECEMBE R 2016

Movie – A United Kingdom: Dr Michelle Rooke, Dr Laura Dotto, Dr Rob Hendry, Dr Jenny Phillip, Dr Colin Lau, Dr Jen Martins, Dr Vicki Westoby, Dr Farah Ahmed, Dr Maxwell Weedon, Dr Annette Finn

Movies: French Film Festival

• Passing On Values • Work Less, Give More • Travelling Broadens the Mind • Clinicals: Zika Virus; Traveller’s Kit; Anaemia; Glaucoma & More…

Major Sponsors

11/11/2016 11:48 am

Movie – Ballerina: Dr Belinda Lowe, Dr Nicole Cole Movie – Jackie: Dr Amir Tavasoli, Dr Jenny Fay, Dr Derek Scurry, Dr Michael Armstrong, Dr Claire Armanasco, Dr Simon Machlin Movie – Lion: Dr Sarat Rangaiah, Dr Indrani Saharay, Dr Janina Anderst, Dr Anup Naran, Dr Jane Weeks, Dr Lynette Spooner, Dr Carol McGrath, Dr Maria O’Shea, Dr Tricia Charmer, Dr Melanie Chen, Dr Geoff Mullins, Dr Bibiana Tie Movie – Resident Evil: Final Chapter: Dr Katherine Ng, Dr May Ho, Dr Louise Sparrow, Dr Simon Turner, Dr Jon van Bochxmeer, Dr Sally Price, Dr Helena Goodchild, Dr Germaine Wilkinson, Dr Caroline Chin, Dr Glen Liew

December 2016 www.mforum.com.au

Alliance Francais is behind a terrific line-up of French films for this year’s festival starting with a brilliant biopic of Jacques Cousteau, the legendary oceanographer, and finishing with the whimsical comedy, A Bun in the Oven.

Cinema Paradiso, Luna SX & Windsor cinemas, March 15-April 5

Movie: Dance Academy This is a movie spin-off of the popular ABC TV series of the same name and it features three of the key characters and actors that fans have grown to love and includes some Australian acting heavyweights in Miranda Otto and Julia Blake.

Musical Theatre – Singin’ in the Rain: Dr Katherine Shelley Fringe Festival – Ace’s Cabaret: Dr Jane Deacon

MEDICAL FORUM

MARCH 2017 | 45

82

medical forum CLASSIFIEDS FOR LEASE

NEDLANDS Specialist Consulting rooms available for lease.

Suite 31 Hollywood Specialist Centre 95 Monash Avenue Nedlands WA 6009 Please telephone Rhonda 9389 1533 NEDLANDS Fully furnished consulting rooms available.

HOLLYWOOD MEDICAL CENTRE Sessional basis Monday to Friday – including Full Receptionist Support in friendly professional rooms.

Available Saturday without reception.

Would suit practitioner starting new business or those with established practice.

Call Practice Manager 0412 164 224 or email: reception@hollywoodpsychiatry.com.au

NEDLANDS Specialist Suite for lease at Hollywood Specialist Centre, 64 sqm, 2 offices, large reception area.

Heavily discounted rent for clinician(s) starting private practice for first 3 months.

Please contact Julie-Anne Powell 0403 209 363 or Email: powellhollywood@westnet.com.au NEDLANDS

Hollywood Medical Centre - 2 Sessional Suites.

Secretarial support available.

Phone: 0414 780 751 MURDOCH

Wexford Medical Centre consulting

rooms available for lease.

Modern and well lit.

Secretarial support available if required.

Please contact Ai on 0410 786 007 or email aptran@jointswest.com.au WEMBLEY

CONSULTING SUITE – Sessional and/or

permanent consulting suite available in bright and modern consulting rooms.

Ideal for Occupational Physicians, Psychiatrists or Allied Health Practitioners.

Fully furnished with various options available from room use only to reception, secretarial and IT support.

Please contact Karla on 0409 033 041 or email kwhite@abilityopn.com.au SUBIACO Consulting Room available Full Time or sessional.

Rates negotiable.

Contact Keith Grainger 93845186

EAST FREMANTLE Consulting rooms available in a new medical clinic on the ground floor of the “Richmond Quarter” on Canning highway.

Includes minor procedures operating theatre.

Various options available from room use only, up to comprehensive secretarial, IT and promotional packages.

Contact Rick 0404 758 182 or email admin@vasc.com.au MURDOCH

Medical Clinic SJOG Murdoch Specialist consulting sessions available.

Email: gcford56@gmail.com SUBIACO Sessional Suites available at brand new specialist consulting rooms in Subiaco.

Fully furnished and fitted out, ideal for medical specialists and allied health practitioners with the option for reception and secretarial support.

Located near SJOG Hospital Subiaco.

All enquires to gemma@hipnknee.com.au or 0413 767 562 NEDLANDS Fully furnished consulting suite available for sessional use.

Monday - Friday at Hollywood Medical Centre.

Please contact Jade on 0433 123 921 or jadethyer@mac.com

RURAL POSITIONS VACANT ALBANY • St Clare’s is an established occupational and family practice based in Albany.

• Small friendly practice • Full time nursing and administration support • Pathology on site • Full or part time GP wanted to join our team • Special interest in skin would be ideal • Currently no DWS unless willing to work in afterhours period • GPs not requiring supervision required Please contact Practice Manager, Helen Williams: 08 9841 8102 Email: helen@stclare.com.au Or send your CV through and we will get back to you.

SOUTH WEST WA

GP’s Required • Excellent Opportunity to join expanding Medical Group in the beautiful South West WA • Established medical group in Harvey & Waroona with 2 new locations • Brand new locations in new development areas Treendale & Dalyellup • Fully computerised & accredited modern practices with nursing & admin support • 65%-70% of billings depending on experience • DWS and AoN Please email CV to gpapplications@bigpond.com

SOUTH WEST WA

SECRET HARBOUR

Bridgetown Medical Group

Oasis Drive Medical Centre formally

Is seeking a VR GP (flexible hours) to join our friendly, busy practice. Experience the rewards of rural practice in this beautiful town.

We are a privately owned, accredited, mixed billing practice, DWS, fully computerised clinical software with onsite Nurse and excellent admin support.

A&E experience necessary to cover the local hospital and provide phone support to nearby towns.

Obstetrics desirable but not essential.

Remuneration consists of 60%-70% billings (in/out of hours), in addition to generous government incentives for participation in the call roster, making this a financially rewarding position.

Contact Practice Manager on 08 9761 1222 or email your details directly to btn_medical@wn.com.au

Urban Positions Vacant BENTLEY

Rowethorpe Medical Centre is a nonprofit, friendly practice seeking a part time GP to provide visits to our onsite residential aged care facilities. Practicebased consultations are also available.

• Fully computerised • Newly renovated premises • Modern equipment • Onsite pathology • Hours to suit you For enquiries, please contact Jackie on 6363 6315 or 0413 595 676

SOUTH PERTH VR GP required Full-time and Part-time Positions available Well established South Perth/Como practice, situated very close to the city.

On site Pathology.

Fully accredited and computerised.

Full time RN support. Friendly and supportive team.

Contact by email: bhdpty@bigpond.com or Ben on 0413 437 985 MIDLAND

Swan Medical Group, Midland (DWS).

F/T or P/T VR GP required for our wellestablished accredited Medical Centre.

We have a large patient list and you will be well supported by our able staff of nurses, diabetic educators, dieticians, CDM nurse and visiting physician.

We have onsite pathology, are fully computerised and have an active involvement in medical student and GP registrar training.

If you are motivated and interested in working in a non-corporate, fiercely independent practice.

Please contact our practice manager Elma on (08) 9274 6100 or email edward.cheuk@swanmed.com.au to arrange a visit.

Contact Jasmine, jasmine@mforum.com.au to place your classified advert

Secret Harbour Medical Centre now relocated.

GP required for accredited, mixed billing, and computerised family practice.

Just relocated to new modern building.

Nursing support on site.

Email lyn@shmedical.com.au DALKEITH Full or Part Time GP required to join our vibrant, multiple doctor family practice.

We are a fully accredited, computerised, private billing practice.

Full time Nurse and Pathology onsite available.

Email resume to: admin@dalkeithmedical.com.au or call Yolanda on 08 9386 7417

BEECHBORO

Amazon Drive Medical Centre,

Beechboro Full Time GP req for After Hours & week days VR & Non VR GPs welcome to apply Up to 70% of billings Computerised practice Existing patient base Bulk-Billing practice Privately owned and managed.

Please email: phil@medibizz.com.au DUNCRAIG

Duncraig Medical Centre requires a

Female GP for immediate start.

Fulltime patient load available.

However, flexible with Monday to Friday hours.

Excellent remuneration / $135 - $200 per hour.

Predominantly private billing practice.

Modern fully computerised practice with full time nurses.

Please call Michael on 0403 927 934 or michael@duncraigmedicalcentre.com.au CLAREMONT We are seeking an enthusiastic VR GP to join our friendly team on a full or part time basis at our well established privately owned GP practice.

Onsite Pathology Free Parking Adjoining Pharmacy Fully Computerised / Best Practice Predominately Privately Billings Excellent potential / Flexible hours Percentage Negotiable Enquiries to manager@goldsworthygp.com.au or phone Practice Manager on

0417 992 007

CANNING VALE Canning Vale (DWS) requires Full-Time GP urgently.

Rates negotiable. Flexible hours.

Privately owned practice - fully computerised, huge consulting rooms, spacious treatment room with FT RN, and on-site pathology with other health alliances in the complex.

Phone: Julie 9456 1900 or Email: jphyo@nicholsonmedical.com.au

APRIL 2017 - next deadline 12md Thursday 9th March – Tel 9203 5222 or jasmine@mforum.com.au

medical forum CLASSIFIEDS OSBORNE PARK

THORNLIE

RAPHA CENTRE is dedicated to

Thornlie Medical and Skin Cancer Clinic (DWS) is seeking a VR GP to

Women’s Health specialising in Bio-Identical hormone optimization.

Private billing, non-corporate, fully computerised, friendly team.

Suitable for VR GP for rewarding experience in treating the root cause of most diseases with combination of nutritional and hormone balancing and more.

Email: drnoel@westnet.com.au for confidential enquiries. Mentorship provided.

help our friendly growing multicultural practice.

Mixed billing, accredited, fully computerised with full-time nursing support.

Computerised dermoscopy, offering training and support.

Please email: thornliemedicalcentre@hotmail.com Or Call 0403 009 838 WEST PERTH

West Perth Medical Centre: VR GP

LANGFORD

Langford Medical Centre is currently looking for a full time GP including Saturday mornings, to replace a male colleague who is moving into the hospital system.

We are a privately owned Community based, well loved, accredited bulk billing practice.

Situated south of the river, Langford is one of the closest practices to the CBD that still qualifies as a district of workforce shortage.

This is one of those opportunities to gain a ready-made patient base.

For confidential enquiries please email a cover letter and CV to brendankelly@amnet.net.au

BYFORD VR GP Female/Male GP required Full time or Part time Privately owned well established modern practice located in Byford, 30 minutes from CBD, DWS and area of need.

Full admin and practice nurse support.

Onsite Pathology, Podiatrist, Dental and Pharmacy.

Fully computerised GPA Accredited Practice.

Excellent remuneration, high billing from start, takeover existing patient base.

Please email: byfordfp@gmail.com or Phone Dr Naga 0434 049 767 CHURCHLANDS Full time VR GP required for our well established Accredited Medical Centre.

Stable and friendly work environment using Best Practice software.

Excellent full time nursing support.

Experienced reception and administrative team.

On-site pathology.

Mixed billing.

Please contact our Practice Manager Dianne or email practicemanager@herdsmanmedical.com.au

Contact Jasmine, jasmine@mforum.com.au to place your classified advert

required to replace 2 PT doctors who have left to get married!

Private billing, accredited practice offering GP, sexual health and occupational health services.

Stunning building and location.

Contact Stephen on 0411 223 120

ASCOT A non-corporate, new practice located near the domestic airport is looking for a male or female VR GP, hours are negotiable.

Friendly and professional environment with attractive remuneration.

Please contact Sue Fegebank on 9523 2000 or ridgemedical@gmail.com WHITFORD FT/PT Doctor required for friendly practice VR 70% of billings Non VR with general registration for weeknights and weekends from 65% Please contact Dr Michael Gendy dr.mike80@gmail.com Or Dr Rafik Mansour Rafik.mansour@ wcfp.com.au Phone: 08 9404 4400 SCARBOROUGH

Scarborough Beach Medical Centre Part time GP required For After Hours and relief Saturday, Sunday and 6 pm to 10pm. Sessions available.

Private Billing. Attractive Income.

Please contact Sue Della-Bona on

MADELEY VR & Non VR General Medical Practitioners required for Highland Medical Madeley which is located in a District of Workplace Shortage.

Highland Medical Centre is a noncorporate practice with 7 GPs, 3 Practice Nurses, 1 Chiropractor, 1 Physiotherapist, 1 Dietician, 1 Podiatrist, 1 Exercise Physiologist, 1 Diabetic Educator, 1 Psychologist, 1 Dermal Therapist and 1 Cosmetic Nurse Sessions and leave are negotiable and salary is compiled from billings not takings.

Up to 70% of billings paid (dependan on experience).

Please contact Jacky on 0488 500 153 or E-mail to jacky@highlandmedical.com.au

CLAREMONT Growing GP practice located in the trendy suburb of Claremont.

78% of billings.

Looking for VR GPs with unrestricted provider number on a full time/part-time basis for weekday and weekend (DWS) sessions.

Fully computerised with on-site pathology and RN support.

Located in a modern complex with access to the gym and pool.

For further information please contact Dr Ang on 9472 9306 or Email: info@thewalkingp.com.au

BYFORD Busy Coles Shopping Mall non-corporate new Practice needs FT or PT female/male VR GP on very attractive terms.

Please call 08 9525 6622 & email CV to drprasad@byfordvillagepractice.com.au

0413 646 154

Email: ptacman@sbmc.com.au WEST LEEDERVILLE & KINROSS FT/PT GP required for privately owned these 2 bulk billing practices. Non VR GP’s can apply for Kinross.

Most procedures are billed privately.

Excellent earning potential at both centres.

Onsite Pathology, Nurse & All allied health.

Contact sanjaykanodia2000@yahoo.com FREMANTLE VR GP required to join a new practice set in the heart of West End. Will service ND students as well as local residents and workers.

If you love good coffee and a great working environment contact Stephen on

0411 223 120

SERPENTINE VR GP Required for practice only 2 years old, located in an ASGC-R2 location east of Perth.

This practice is the perfect opportunity for a GP to work in the inner regional area of Perth located approximately 45 mins from the CBD. This is a DWS and AON location.

This large community busy practice is located next door to a pharmacy and can accommodate 2 full time GP’s. Admin and nursing services are provided along with onsite pathology and podiatrist/ Dietitian.

Excellent remuneration is offered.

For more information please call 0419 959 246 or 0401 091 921

MIDLAND

SORRENTO F/T or P/T GP for busy Sorrento Medical Centre, Normal/after hours available, we are like family, nurse & allied services on board, remuneration (70%-75%), Please call Dr Sam 0439 952 979

THORNLIE

GP POSITION AVAILABLE AND CONSULTING ROOM FOR LEASE KMG is seeking VR/Non-VR GP to join its Accredited Medical Practice Invitation is now extended to interested specialists for a consulting room to lease at our brand new surgery suite.

There is huge need for all specialties in Thornlie and immediate surroundings.

Allied health practitioners seeking a room to lease are welcomed.

Contact the Practice Manager: 08 9452 2055 Email: forestlakes@kingdommedicals.com.au

83

A well-established GP clinic in the Midland area (approx. 20km east of Perth) seeks a VR General Practitioner to join their friendly team.

Position Details • To replace an outgoing GP • Very busy appointment book • Flexible working hours / days (no weekends or a/h needed) • Great opportunity to increase your earnings with Corporate Health • Training in cosmetic procedures will be offered to the right candidate.

• DWS Approved • Guaranteed income for the first 3 months with a great % on offer • OTE to earn 320K – 400K per annum based on full time Please phone Brett van Grootel on 08 9215 3888 or email: brett@choiceone.com.au for a confidential enquiry FREMANTLE

INTERESTED IN WOMEN’S HEALTH? Fremantle Women’s Health Centre requires a female VR GP one day pw.

It’s a computerised, private and bulk-billing practice, with nursing support, scope for spending more time with patients, provides sessional remuneration, superannuation and generous salary packaging.

FWHC is a not-for-profit, community facility providing medical, nursing and counselling services, health education and group activities in a relaxed friendly setting.

Phone 9431 0500 or email Dawn Needham clinical-manager@fwhc.org.au

SECRET HARBOUR Secret Harbour Medical Centre VR GP wanted.

65-70% offered.

A generous relocation fee may also be offered Brand new, modern and computerised.

Contact: Dr Jagadish Krishnan

jags@perthgp.com.au Dr Vishnu Gopalan

g_vinu@yahoo.com

APRIL 2017 - next deadline 12md Thursday 9th March – Tel 9203 5222 or jasmine@mforum.com.au

84

medical forum CLASSIFIEDS

MOUNT LAWLEY Long established After Hours clinic Looking for a VR GP to work after hours shifts Flexible with hours Fully computerised and AGPAL accredited Private billing only Contact Gina on 0412 760 871 for further details HAMILTON HILL A female GP required for a clinic in a DWS and AON area 5 minutes’ drive from Fremantle.

3 Doctor GP Practice.

Part time or Full time doctor considered Fully computerised practice. Rates negotiable Contact Eric on 0469 177 034 or Send CV to eric@hamiltonhillfamilypractice.com.au

KARRINYUP St Luke Karrinyup Medical Centre Great opportunity in a State of art clinic, inner-metro, Normal/after hours, Nursing support, Pathology and Allied services on site.

Privately owned. Generous remuneration.

Please call Dr Takla 0439 952 979

OSBORNE PARK GP required for Osborne City Medical Centre.

Flexible hours Monday to Thursday with optional afterhours.

Excellent remuneration / $135 - $200 per hour.

Predominantly private billing practice.

Modern fully computerised practice with nursing support.

Please call Michael on 0403 927 934

Contact Jasmine, jasmine@mforum.com.au to place your classified advert

MIRRABOOKA VR FEMALE GP POSITION

LEEDERVILLE OXFORD STREET MEDICAL CENTRE Is seeking a part-time VR doctor to join our long-established family medical practice.

Ishar Multicultural Women’s Health Centre requires a VR Female GP for our

We are a non-corporate, well-equipped, predominantly private billing, busy boutique practice.

Fully computerised, AGPAL accredited (until February 2020). On-site pathology available.

REQUIREMENTS

This practice has excellent RN nursing support, very professional, friendly staff. Our doctors, nurses and reception staff have been with the practice long term as part of a supportive, friendly and professional team.

well established, bulk billing women’s medical clinic.

The clinic is open 4 days per week and this position is for one day per week.

* Vocationally Registered General Practitioner * Experience in Antenatal / Postnatal Care * Experience in Contraceptive Technologies If you are interested in working in a caring, multidisciplinary team environment and have an interest in migrant and refugee women’s health please contact Jan Ryan Manager of Health Services on mobile: 9345 5335 or email jan@ishar.org.au

BASSENDEAN Exciting opportunity to join an established city practice in Bassendean, WA. It is a Non-DWS mixed billing practice with a vast patient database.

Full time/Part time GP positions available to start immediately.

Practice in a warm, friendly workplace with attractive remuneration.

We have an excellent admin team, allied health and pathology on site.

There’s also an opportunity to do extra rural GP practice in a sister practice 2 hours from Perth and earn some rural incentives in the process.

Please contact the practice manager on 08 9279 1805.

For confidential enquiries: Please contact Carol, Practice Manager at caroloconnor@westnet.com.au or call 0422 506 878

VR OR NON-VR GP/REGISTRAR URGENTLY NEEDED! Homeless Healthcare is Perth’s largest general practice providing healthcare services to homeless and marginalised people.

Homeless Healthcare is a multi-doctor accredited general practice providing evidence–based care in a well-supported team environment. The service works with partner agencies to successfully re-house people.

We are seeking compassionate, dedicated and enthusiastic doctors to provide care in a variety of settings including Drop-In Centres, Shelters, Communities, Youth, Royal Perth Hospital InReach and Transitions.

A base salary is provided with bonus payments based on Medicare billings. Salary sacrifice is available. The positions available have flexible hours from part time to full time.

Qualifications required are FRACGP (or for short term contract up to 6 months equivalent qualifications). Experience and skills in working with homeless people an advantage.

Contact the Practice Manager Bobby Dougall to discuss.

Phone: (08) 6260 2092

VR GP required up to full time.

Ocean Reef, Western Australia.

An excellent opportunity to join a group of experienced and dedicated General Practitioners in an established, independent practice.

Our clinicians are committed to providing high quality, evidencebased care for the local community.

• Well established in Perth’s northern corridor; 20 minutes from CBD, 6 minutes from City of Joondalup.

• Private billing.

• Up to 70% of billings.

• Full support from practice nurses.

• Full range of services from iron infusions to weight loss management.

• Onsite pathology.

• Informal visits are welcome.

Please contact Mark on 0451 081 652 or mrobins@ormc.net.au and visit www.ormc.net.au

Apollo Health is seeking local Dr’s with an interest in: - Skin cancer - General family medicine - Walk in/Urgent care For our practices in Armadale, Cockburn, Cannington and Joondalup FRACGP required, Relocation incentives available For enquiries to join our dynamic team, please contact us via E: medservices@stjohnambulance.com.au or P: 9334 1451

APRIL 2017 - next deadline 12md Thursday 9th March – Tel 9203 5222 or jasmine@mforum.com.au

medical forum CLASSIFIEDS

85

Mount Helena Medical Centre Full Time VR GP Required Join now and receive a bonus $50k upfront

Fed up with the heat?

Need a climate change?

Our Practice is located in the fast growing hills region of Perth with work hours that are very sociable with plenty of opportunity for work/life balance ensuring you enjoy time with family.

Stay cool in Albany with Amity Health

ESSENTIAL REQUIREMENTS

Be part of a team of specialists visiting our leading south coast hub. Enjoy new, purpose built facilities, a stroll from Albany’s vibrant CBD along with: • Full administration, billing and reception support • 12 consulting rooms • Excellent client access • Referral pathways to Amity Health’s allied health team

Amity Health is a not for profit organisation.

Call Sian Bushell on 9842 2797 for more information www.amityhealth.com.au

Vocational Registration Full AHPRA Registration WHY WORK WITH US

70%

of billings offered

Owner operated, non-corporate Flexible work hours Stable, friendly and fun work environment Well established systems and processes Computerised Own room Excellent full time nursing support in treatment room Experienced reception and administrative team DWS location

If you are interested in this Full Time opportunity at Mount Helena Medical Centre please send your CV to Vishnu - g_vinu@yahoo.com

GP West Requires VR GP’s to our state of the art medical centers in AON and DWS locations Waikiki GP Super Clinic WAIKIKI

Mundaring GP Super Clinic MUNDARING

Woodlake Village Medical Ellenbrook

Wattle Grove Medical Centre Wattle Grove

Newpark Medical Centre Girrawheen

Egerton Drive Medical Centre AVELEY

New Gumnut Medical Centre WANNEROO

Harrisdale Medical Centre Harrisdale

Okely Medical Centre CARINE

GP Owned, 9 Consult rooms, 3 Minor Surgery bays. All allied health, pathology, pharmacy & Dental 70 % of billings for full time VR GPs Non VR GPs are also welcome

Please contact Dr Kiran Puttappa on 0401815587 or email kiranpkumar@hotmail.com

or visit www.gpwest.com.au APRIL 2017 - next deadline 12md Thursday 9th March – Tel 9203 5222 or jasmine@mforum.com.au

86

medical forum CLASSIFIEDS SELLING YOUR PRACTICE IS ABOUT MORE THAN JUST TALKING FIGURES

WASHC is looking for a part time VR Doctor to fill possibly the most rewarding GP position: Long consultation times Meaningful connection to patients Ability to make real changes to patient’s lives Very appreciative patients Incredibly positive feedback Opportunity to achieve professional status Excellent remuneration Position primarily focuses on functional male sexual health.

Working with a Clinical Male Urology Nurse means the position is suitable for both male and female Doctors.

Full training and support provided.

The Health Linc has 20 years’ practical experience and helped over 150 business owners realise their dreams.

Call Australia’s national award winning Business Broker when considering buying or selling your practice.

Brad Potter 0411 185 006 www.thehealthlinc.com.au

For more information please contact Dr David Millar on 9389 1400 www.wasexualhealthcentre.com.au

Certified and multi-award winning Business Broker

St John is seeking experienced doctors to work in our new Urgent Care Centres.

Relevant experience in urgent care, rural general practice or similar will be highly regarded.

Full or part time. Attractive salary package.

For enquiries to join our dynamic team, please contact us via E: medservices@stjohnambulance.com.au or P: 9334 1451

Beachside Medical Centre, in Yanchep

Metro Area GP positions available. IMG training available VR & Non – VR Dr’s are welcome to apply.

Send applications to gpapplications@betterhealthcare.com.au

Full Time VR GP Required Opportunity exists for a doctor to take over existing patient base.

Join now and receive a bonus $100k upfront Our Practice is located in the fast growing northern corridor with work hours that are very sociable with plenty of opportunity for work/life balance ensuring you enjoy time with family.

ESSENTIAL REQUIREMENTS Vocational Registration Full AHPRA Registration

Brand New Consulting Rooms for Lease North One Specialist Centre 109/9 Salvado Road, Subiaco Located opposite SJOG Subiaco main entrance on Salvado Road.

70%

WHY WORK WITH US Owner operated, non-corporate Flexible work hours Long established clinic Stable, friendly and fun work environment Well established systems and processes Computerised Own room Excellent full time nursing support in treatment room Experienced reception and administrative team

of billings offered

DWS location If you are interested in this Full Time opportunity at Beachside Medical Centre please send your CV to Vishnu - g_vinu@yahoo.com

Sessional or permanent - especially suit practitioners with interest in venous disease/varicose veins e.g. Phlebologist/Dermatologist/ Cosmetic Physician/Plastic Surgeons/Wound Management.

Exceptional clean and modern fitout Light and bright NBN connected Large reception/admin areas Plenty of patient transport/parking options Large consulting rooms (18.5m2 – 20m2) Amazing staff facilities include: spacious staff room, showers, gym, steam room, rooftop lounge/deck Undercover Dr/staff parking poss. (limited avail) Co-located with Dr Peter Bray, Vascular Surgeon Enquiries contact: louise@vascularsolutions.com.au

APRIL 2017 - next deadline 12md Thursday 9th March – Tel 9203 5222 or jasmine@mforum.com.au

medical forum CLASSIFIEDS Secret Harbour Family Doctors

MEN’S HEALTH – BUSINESS FOR SALE

Full Time VR GP Required Join now and receive a bonus $100k upfront Our Practice is located in the fast growing southern corridor with work hours that are very sociable with plenty of opportunity for work/life balance ensuring you enjoy time with family.

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Well established, centrally located clinic is looking for a new owner.

Practice is well resourced with full medical & administrative protocols. Training and transition period available complete with your own Urology RN Nurse. Rapidly expanding field of medicine with continued growth of patients.

This is a very rewarding opportunity for the successful buyer.

Confidential enquiries to Brad Potter on 9315 2599 or 0411 185 006 Email: brad@thehealthlinc.com.au

ESSENTIAL REQUIREMENTS Vocational Registration Full AHPRA Registration WHY WORK WITH US

70%

of billings offered

Owner operated, non-corporate Flexible work hours Stable, friendly and fun work environment Well established systems and processes Computerised Own room Excellent full time nursing support in treatment room Experienced reception and administrative team DWS location

If you are interested in this Full Time opportunity at Secret Harbour Family Doctors please send your CV to Vishnu - g_vinu@yahoo.com

Venosan Diabetic Socks

The Magic of Silver for Sensitive Feet 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 •

Soft-Spun Cotton - Ultra soft cotton

•

Fully cushioned foot and fully cushioned sock

•

Comfortable for arthritic patients

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

APRIL 2017 - next deadline 12md Thursday 9th March – Tel 9203 5222 or jasmine@mforum.com.au

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medical forum CLASSIFIEDS

GP’s ready to sell your practice?

Want to retire or to keep working without the administration burden for a doctor owned and operated company where patient care, clinical standards, teaching and clinical autonomy come first?

Is your practice a smaller practice ready to amalgamate with like-minded colleagues?

Do some of you want to keep a % share but allow other colleagues to move on?

North Street Medical Centre, Midland We are seeking more Dr’s to join our happy team, as group we plan to increase our opening hours to include full day Saturday and Sunday.

Clinical autonomy, computerised, accredited, full nursing support, collocated with allied health and pharmacy.

Procedural GPs welcome – FT/PT Email manager@northstmed.com.au or call: 9274 2456 and ask for Zoe or Damian

GPs Wanted!

Procedural GPs for our women’s clinic and GPs for our busy family practice based in Rockingham adjacent to the district hospital which offers a full after hours service.

All the usual bells and whistles! We would love to hear from you.

Call Kate or Pauline on 08 9527 2211 or email Manager@woodbridgefp.com.au to arrange an interview with our clinical team.

Looking for a fair price for business and property? We use third party independent valuer to determine value.

Does this sound like you?

Then we would like to hear from you.

Confidentiality is as important to us as it is to you as we grow our network of linked practices.

Please email doctorownedandoperated@gmail.com with your name, speciality, mobile number and a suitable time and day we can contact you.

405 Oxford Street, Mount Hawthorn Beautiful new premises with extensive patient base. Join a fully committed patient team in a prime location for growth.

www.mthawthornmedical.com.au All interested GPs applications to Molly Phone: 9444 1644 or email office.mthawthorn@buildingblocksmedical.com.au

APRIL 2017 - next deadline 12md Thursday 9th March – Tel 9203 5222 or jasmine@mforum.com.au

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  

  





 



  



  





  

  





 

 

 

















  



  



    





 



   



    



 

  



  





  



 

  

                 

  

 

   



 



      

   



  



















                  

  

  

 



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

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 

     

                  



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 





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 

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   

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    

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  



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