MedicalForumWA 0418 Public Edn

Hearts in our Hands New Rules for Data Breaches GPs on Lifestyle & Drugs CVD & Rural Dilemmas; HT; Endometriosis Research Focus & Results

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April 2018

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EDITORIAL Dr Rob McEvoy, Medical Editor

To the Heart of the Matter

With the first heart attack, stroke, or other cardiovascular event, a flood of motivation to tackle lifestyle factors is released. At least that’s what GPs said when we asked them. Throw in some thrombolysis and a stent or two and suddenly there is no problem talking to patients about diet, exercise, weight loss, smoking and other lifestyle measures. Until then, many GPs are struggling to make inroads and given their time pressures, they may need a hand to recognise those opportune moments.

As a profession, why are we bothering with lifestyle factors? Are we simply not moving the zero point on the graph and delaying the inevitable with these people ending up in similar dire straits in 10-15 years’ time. But hold on a minute! What if they have a better quality of life during those 10 years? Kicking the footy with grandchildren surely has value even though it doesn’t free up someone else to increase the GDP. The politicians have left their run a bit late. Rationing (by any euphemism) is now the imperative. However, there seems no hint of this in the private hospital cafeterias, full of greying people paying to stay alive and keep fit. There is no shortage of medicos willing to help them. It’s a thriving industry and it’s happening now.

BUPA is pushing for open referrals where consumers decide the right specialist for them. On what criteria, some ask – the receptionist, magazines in the waiting room, cost, wait times…

This consumerism may seem silly but is there a role for the gatekeeper GP? Maybe we can let the consumer choose for the mundane health problems, but for the more serious specialist referral,

PUBLISHERS Ms Jenny Heyden - Director Dr Rob McEvoy - Director ADVERTISING Marketing Manager Kirsty Fitzpatrick (0403 282 510) advertising@mforum.com.au

MEDICAL FORUM

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

the GP will get to know and understand (if they don’t already) who is conscientious and good at their job. More than that, a good GP will build rapport with those specialists. His/her value is not reflected by the number of ‘likes’ on Facebook.

I didn’t think there were philosophical differences on political sides until I heard a bigot from one side wade into the opposition on Q&A and a bigot from the other side do likewise. It was bigots at 40 paces! There are philosophical and political differences in the medical profession too but it is not so obvious and evidence-based medicine is eating into those differences.

General practitioners, on the one hand, tend to help the down and outs and are seen as underachievers hamstrung by a lack of resources while specialists, on the other, are seen as high achievers with more resources and appear often to compete with each other and their registrars for top spot.

On both sides we have people who take an inspired global view who are not immersed in vested interests. But they are few and far between. We need to nurture these people and trust them.

Altruism amongst medical professionals is harder to define.

Maybe legal protectionism has taken over, or less altruism simply reflects the pace and size of changes? Whatever the reason, technology is taking over. Some say that is a good thing but others mention the mobile phones on commuting trains and lament the fact that we seem to be losing the art of simple things like holding a conversation.

These are desperate times in health. Will new technology get us where we need to go? Will reliance on evidence-based medicine serve the profession well? There are many more questions. The people with the global view, with an eye on costs (but money is not king), are needed more than ever. Here’s hoping they are relatively young people with wisdom beyond their years.

Administration Jasmine Heyden (0425 124 576) jasmine@mforum.com.au Clinical Services Directory Editor Ms Jenny Heyden (0403 350 810) jen@mforum.com.au

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

APRIL 2018 | 1

CONTENTS APRIL 2018

INSIDE 12 14 21

WAHTN Connecting the Dots

Spotlight: Charlotte Roseby, Living with CF

22

New Data Breaches Legislation

GPs on Cardiovascular Patients

21

22 NEWS & VIEWS 1 Editorial: To the Heart of the Matter Dr Rob McEvoy 4 Letters to the Editor

12

14 MAJOR PARTNER 2 | APRIL 2018

6 6 11 17 20 38

Encouraging Pain Rethink - Ms Carol Bennett Pain Article Comment - Dr John Salmon Author Response - Prof Eric Visser Is it BEB? - Dr Jean-Louis deSouza WAASM influence on CTEC - Prof Jeff Hamdorf Have You Heard?

Beneath the Drapes Curious Conversation - Dr Stefan Ponosh Ending Rheumatic Heart Disease Sustainable Health Review Freo Street Doctor

LIFESTYLE 40 Hollywood Psychiatry Master Class 41 Wine Review: Lambert Wines - Dr Craig Drummond MW 42 Musical Theatre: Mamma Mia! 43 Theatre: Summer of the Seventeenth Doll 44 Funny Side 44 Beer Winner - Dr Tracey Muir 45 Competitions

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MEDICAL FORUM

CONTENTS APRIL 2018 CLINICALS

5

29

'Hard Pulse Disease' Dr Jonathan Grasko

18-19 EPOLL

Regional Cardiology Dr Tony Mylius

31

33

Hypertension Treatment Guidelines

Implantable Defibrillators in Elderly

Dr Edmund Lee

By Dr Benjamin King

Rural GPs on Cardiovascular Health We asked rural GPs about the challenges they face with their cardiovascular patients and they responded to questions regarding medication, lifestyle advice and the specialist help that was at hand (or not).

35

37

Adolescent Endometriosis Dr Jade Acton

Depression in T2 Diabetes Prof Sergio Starkstein

GUEST COLUMNS

11 Brand New Life – One-Month On

Dr Cassie Smith

27 Early Palliative Care Makes Life Easier

Dr Cameron Wright

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

APRIL 2018 | 3

LETTERS TO THE EDITOR Encouraging a pain rethink Dear Editor, Re: Dr Majedi's column Suffering vs Resilience (March, P11), pain is essentially the body’s way of protecting itself from further or potential damage. It is a signal of danger sent to the brain through a complex series of chemical processes through the nervous system, and interpreted by the brain as pain.

The most important part of the story is that the brain produces the feeling of pain.

This occurs even without apparent reason – such as when an injury has healed and the ‘danger’ has passed – and in limbs that do not exist – a phenomenon known as ‘phantom pain’ in amputees.

The pain experience – such as the level of pain, the amount of catastrophising and the potential for recovery – is also related to numerous other factors relevant to each individual such as their personality, belief system, history, ethnicity and even the people around them.

Pain is an entirely individual and subjective experience. Two people with the same kind of injury or condition can have marked differences in the way they perceive that pain and in their capacity for rehabilitation.

As doctors and specialists it is important to understand the whole individual and the factors likely to influence pain rather than focus on mechanical problems, especially in cases of chronic pain, in order to encourage behavioural change.

For chronic pain, real potential for improvement starts when patients learn to perceive pain differently. For example, by learning that pain is not ‘dangerous’ and exercising will not harm the body, patients’

mobility can improve with no increase in the experience of pain.

Evidence shows a multidisciplinary approach to pain management results in less pain, less disability and better quality of life. A team of health professionals working together can focus on different aspects of the pain experience. Physiotherapists or other movement specialists and psychologists trained in pain management are important in this team approach.

When patients rethink their pain and learn to manage themselves differently, they have the greatest chance of recovery.

Ms Carol Bennett, CEO PainAustralia (www.painaustralia.org.au) ....................................................................

Article objection Dear Editor, The recent article Spinal pain procedures: who and when? by Prof Eric Visser (March edition, p35) was disappointingly backward looking. The treatments we’ve been offering have been largely ineffective.

Endorsing more of the same is surely not appropriate.

The statement that 20-40% of chronic neck and back pain is associated with facet joint arthropathy and 20% of back pain is due to sacroiliac joint arthropathy or cluneal nerve entrapment over the iliac crest must be challenged.

The population that does not have significant back pain has as much arthropathy, degenerative change and pathology of all grades of severity as the population that does have disabling back pain.

Therefore, facet and sacroiliac joint arthropathy cannot be interpreted as

causative. Assessment of causation by injecting anaesthetic into the suspected structure is severely confused by placebo effects which we now know to be powerful and enduring in many patients.

Carefully orchestrated double-blind injection protocols give more reliable information but are quite impracticable in clinical practice.

The evidence supporting sustained efficacy from facet injection and radiofrequency denervation of facet joints and sacroiliac joints is said in the article to be ‘limited’ but in fact it is almost entirely lacking as far as high-quality evidence is concerned.

A recent large multicentre randomised controlled study of radiofrequency denervation of lumbar facet joint and sacroiliac joints compared to exercise therapy demonstrated absolutely no advantage for these denervations at the one-year follow up. In fact, the exerciseonly group did better!

Current thinking is that disabling back pain has more to do with the nervous system and vicious circular psychosocial interactions than degenerative and structural pathology of the spine.

Longitudinal neurological profiling including sensory testing of over 100,000 back-pain patients in Germany documents that while spinal pain may be initiated by nociceptive mechanisms, over time neuropathic or neural sensitisation mechanisms become dominant.

The biomedical model of treatment of presumed nociceptive dominant spinal pain remains firmly entrenched but has largely failed.

For the most disabled and intractable back-pain patients with predominant neuropathic or neural sensitisation pain patterns, strong evidence now supports implanted neuromodulation therapy. Highquality randomised control studies have

continued on Page 8

If you are going through hell, keep going.

Sir Winston Churchill (1874-1965)

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4 | APRIL 2018

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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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Major Partner: Clinipath Pathology

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'Hard pulse disease' in the Modern Era As far back as 2600 BC during the reign of the Yellow Emperor of China, the health of the heart, the essential vital organ could be assessed by using the pulse. A disease state of the heart called “hard pulse disease” was treated with venesection and bleeding by leeches.

By Dr Jonathan Grasko Consultant Chemical Pathologist & Toxicologist, Clinipath Pathology

Screening and Confirmatory Investigations: 1. Thyroid function tests (TSH, Free T4 and Free T3) 2. Thyroid antibodies (TPO and TSH receptor antibodies)

Sorovas of Ephesus in 120 AD felt that “hard pulse disease” was due to animal spirits and the only cure was to draw them down and out by cupping of the spine. However, it was not until Stephen Hales’ discovery of blood pressure in 1733 and the subsequent description of the pathology of the disease

by Thomas Young in 1808 that hypertension entered the clinician's psyche.

Screening Investigations: 1. 24 hr urinary free cortisol ( preferred for patients on the oral contraceptive pill and certain antiepileptic drug) 2. Low dose dexamethasone suppression test (preferred screening test for adrenal adenoma) 3. Late night salivary cortisol (2 measurements) Confirmatory Investigations: 1. Low dose/High dose dexamethasone suppression test 2. Petrosal sinus sampling Phaeochromocytoma

As early as 1900 the insurance industry provided consistent evidence of the risk of high blood pressure. In 1911, the medical director of the Northwestern Mutual Life Insurance Company wrote, “The sphygmomanometer is indispensable in life insurance examinations…”

Serial publications by the Actuarial Society of America meant there was no doubt that mortality for both men and women rose with an increase in blood pressure.

muscle weakness, osteoporosis, easy bruising and poor wound healing.

Stephen Hales discovers blood pressure

Despite extensive research, the aetiology of hypertension for most patients has remained elusive (with only about 5-10% having a definable aetiology as secondary hypertension including drugs and renal/ renovascular diseases and less than 1% of hypertensive patients due to endocrine dysregulation.)

Endocrine induced hypertension is of exceptional importance as it is the only group which is amenable to definitive treatment with the promise of cure and therefore should always be excluded.

Here, I outline biochemical investigation of secondary causes of hypertension due to endocrine dysregulation.

Hyperthyroidism Due to excessive circulating thyroid hormone; common signs and symptoms may include irritability, muscle weakness, sleeping problems, a palpitations/ tachycardia, hypertension, heat intolerance, diarrhoea, enlargement of the thyroid and weight loss.

Primary aldosteronism (Conn’s Synd.)

Autonomous production of the aldosterone by the adrenal glands which results in excessive sodium and water retention and therefore hypertension.

Screening Investigations: 1. Serum Aldosterone: Plasma Renin ratio a. result affected by antihypertensive drugs i. false positives with B-blockers ii. false negatives with angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARB’s) and if hypokalaemic, confirm normokalaemia prior to testing

Pheochromocytoma and paragangliomas are neuroendocrine tumours most commonly located in the medulla of the adrenal glands. They result in uncontrolled and variable release of catecholamines (adrenaline and noradrenaline), which makes clinical diagnosis difficult. Classical features, which are not always present include tachycardia, palpitations, hypertension, diaphoresis (excessive sweating) and headaches.

Screening Investigations: 1. Plasma free metanephrines 2. Urine fractionated metanephrines Confirmatory Investigations: 1. Clonidine suppression test Acromegaly Excess growth hormone is secreted by the pituitary gland after the growth plates have closed. Typically enlargement of the hands and feet, followed by enlargement of the forehead, jaw and nose. Long term sequelae may include Type 2 Diabetes, sleep apnoea, and hypertension.

Confirmatory Investigations:

Screening Investigations:

1. Saline suppression of aldosterone test 2. Adrenal vein sampling to lateralise aldosterone production.

Confirmatory Investigations:

Hypercortisolism (Cushing’s Synd.)

Extended exposure to excessive glucocorticoids, which may result in in some of the classic features that include high blood pressure, central obesity, red/ purple striae, moon facies, buffalo hump,

1. Insulin-like growth factor 1 (IGF-1) 1. Glucose suppression of growth hormone.

Hypertension, the most insidious and surreptitious of diseases, may with the insight cleaved from endocrine induced hypertension, finally extinguish this scourge that is “hard pulse disease”.

Main Laboratory: 310 Selby St North, Osborne Park General Enquires: 9371 4200

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APRIL 2018 | 5

HAVE YOU HEARD? Skyping high

WA Health hosted a day-long seminar in March with a gallery of local and national experts from ED physicians to academics tackling the hot health topics around obesity and alcohol abuse. Everyone was singing from the same song sheet and with the Minister Roger Cook in the audience he was very much the focus of their attention.

In February we reported Australasian College of Emergency Medicine’s snap survey of ED patients affected in some way by alcohol, revealing WA was the worst in the country. Former Perth physician now head of emergency medicine research at Monash Medical Centre Dr Diana Egerton-Warburton used the survey to call for political action. Many of the speakers mentioned introducing a minimum floor price for alcohol as the NT government has done. So what is the minister waiting for?

When Medical Forum caught up with him afterwards, he said it was not as simple as that. “What the seminar showed was that the health community was unified in its opinions, and that accounts for a lot, but it’s also their job to bring the community along with them. We didn’t have tobacco legislation because the health community said smoking kills you, it happened because the health community was able to convince the community how harmful it was. Risky alcohol consumption is the same. We have to get the community behind the restrictions and the laws will follow.”

Continuing on message is a theme the folks at Qoctor take seriously. Qoctor is a webbased GP clinic based in Melbourne, though when you think about that, does it matter where it’s based. We heard from their bugles that Qoctor delivered its 10,000th sick note recently. Patients access a doctor by filling an online form and booking in a Skype session with a registered GP. We recently spoke to one of the directors of Qoctor, Dr Aifric Boylen, who took umbrage at the suggestion the service was opening itself up to unscrupulous doctor shoppers.

As far as she was concerned, Qoctor provided the same level of service as a bricks and mortar surgery. Kalamunda GP Dr Sean Stevens, when asked his opinion, voiced probably a majority GP view that it sounded terrible for continuity of care and chronic disease patients. Dr Boylen said the world was changing and it was not only doctors’ time that was precious. It launched Dr Sicknote in 2015 and has issued 10,678 certificates online. They claim to have saved patients 16,017 hours and saved Medicare $491,188. The Qoctor team is now made up of eight qualified GPs and one pharmacist.

Flu blues Is there a more political season than the flu season! We have been inundated with updates regarding when to vaccinate for the best protection (not too soon and not too late, which is somewhat empty advice); which serum is the best – Superman v Batman – and of course the hoary old chestnut, who should give the patient the jab. Is little wonder the punters pick up their bat and head to the vitamin C shelf. Keeping the focus on getting people vaccinated in a timely fashion is probably all we need to worry about.

drapes beneath the

WA’s Chief Medical Officer Prof Gary Geelhoed is vacating the chair to take up the position of Executive Director of the WA Health Translation Network.

The acting CMO in the short term is paediatric gastroenterologist Prof David Forbes.

The Perth Bone and Tissue Bank, trading as PlusLife, has appointed

6 | APRIL 2018

AHPRA triage complaints We read with interest a media report of the 2018 Medico Legal Congress in Sydney which quoted Kym Ayscough, executive director of regulatory operations at AHPRA, announcing that a recent trial which triaged complaints against doctors to reduce time lags. WA was a participant, and apparently it was a huge success. So successful in fact the system will be rolled out nationally.

She told the meeting that triaging increased the proportion of assessments within 20 days from 8% to 37%. The system involves a committee with a smaller quorum than usual, but at least one health practitioner and one community member, who will decide whether a complaint can be closed early. We shot off a query to AHPRA to discover who was on the WA committee.

The spokesperson said that medical board members from WA, SA, and NT were eligible to participate in the triage

St John Ambulance deputy chief Anthony Smith, Former DonateLife WA state manager Hal Boronovskis, Gumala Enterprise’s director Bart Boelen and Wealth Management Partners Steven Perica to the board.

Peel Health Campus CEO Dr Margaret Sturdy has resigned from the board.

Jane Muirsmith, non-executive director of Australian Financial Group and Healthdirect Australia, has been appointed to the board to the Telethon Kids Institute, replacing former WA Attorney-General Jim McGinty.

Fiona Drummond was appointed to the board in December.

assessment in those three jurisdictions. So it is feasible that a WA case may be triaged by board members from both SA and NT.

After-hours shrinkage?

National Home Doctor Service announced that it would be curtailing some of its afterhours services in Bunbury, Mandurah and Rockingham when the Federal Government imposed a 30% cut in the Medicare rebate for after-hours visits by non-VR GPs and an advertising ban. The changes took effect on March 1. The GP rebate will stay at $129.80, while non-VR GPs’ rate has been cut to $100. The Medical Republic reported that non-VR GPs accounted for 60% of the afterhours workforce. Whether it is a reduced volume of calls due to the advertising ban or workforce issues, it is a development that will have the watchers watching.

Anxiety and heart attack Anxiety around heart attack is a good thing according to German researchers.

Those patients with anxiety disorder and symptoms of a heart attack sought medical treatment sooner, thus improving their chance of survival. Women took action two hours sooner and men 48 minutes, which is not statistically significant in terms of cardiac improved outcome for men. What’s the solution, we wonder – a lot of anxious people bedded down in EDs across Germany?

Who’s phased?

GlobalData sent Medical Forum two media releases around oncology trials. The first around immune-oncology Phase II trials showed they increased 57% during 200817. Phase III or IV trials increased little or remained the same. They concluded: “This shows the fast pace immune-oncology features with regard to the development of new drugs. It also highlights the relatively early stage the field is in, considering that 88% of the trials are in Phase II or below.”

The second said that most oncology clinical trials in China (2012-17) failed to meet the planned enrolment targets, particularly Phase II clinical trials. In fact, the greatest

Urologist and co-founder of Perth Urology Dr Trenton Barrett has won a Business News 40Under40 Award.

Mr John Pease, SJGHC’s group director of governance will be interim CEO while the SJG board decides on a permanent replacement for Dr Michael Stanford who left on March 21 after 16 years.

Biogen Australia, in consultation with the TGA, will withdraw Zinbryta (daclizumab) from the Australian market following cases of serious inflammatory brain disorders in Europe.

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Alcohol floor price

HAVE YOU HEARD? discrepancy between planned targets and actual numbers of enrolled subjects (enrolment efficiencies of 87.8%) was in Phase II trials. Not surprisingly, there wasn’t enough data to include Phase IV clinical trials. They listed the top drugs investigated.

Phase II trials often recruit up to 100 or so people taking part. In these trials a new treatment is compared with another treatment already in use, or with a dummy drug (placebo). If results show a new treatment is as good as existing treatment, or better, it then moves into phase III.

Health Care Homes sites Health Care Home trial sites are up and running until November 19. Doing a quick calculation, about 40% of the trial sites in WA are corporate centres, which we understand have a different funding arrangement. The clinics are AHG Super Clinic Midland, Ballajura Medical Centre, Bayswater Medical Centre, Beechboro Family Practice, Belridge Medical Group, Brookside Medical Centre, Claremont Medical Centre, Cottesloe Medical Centre. Craigie Medical & Dental Centre, DR7 Medical Centre, GP Superclinic @ Midland Railway Workshops, Hay Street Medical Centre, Highland Medical Madeley, Joondanna Medical Centre, Lindisfarne Medical Group, Homeless Healthcare, Walter Road East General Practitioners and Yanchep Medical Centre.

Dr Michael Stanford, Group CEO St John of God Health Care

WA Farewells the Stanfords After 16 years at the helm of St John of God Health Care, it was time for Dr Michael Stanford and wife Sally to say their goodbyes to the Perth medical community who turned out in force at a function at the Art Gallery of WA. Michael will be taking up a non-executive board position at Healthscope next month.

Aged care efficiencies The media release from August 2016 spoke of Bethanie Dementia Consultant Michelle Harris running podcast courses in dementia. She was a UK-trained nurse. It talked of the growing number of people with dementia. Where is she now?

Google says she studied at ECU, where Facebook says she completed her Aged Care studies. Bethanie switch says she left them in January after some 10 years with them, wasn’t replaced and the courses are now run externally. With most aged care facilities having at least 80% of the elderly with dementia, this sector is looking for efficiencies.

Mr Tony Howarth, Chairman St John of God Health Care and Mrs Sally Stanford.

Professor Shirley Bowen, CEO SJG Subiaco, Dr Krista Makin, Dr Greg Makin and Dr Caroline Crabb

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Dr Felicity Jefferies, Mrs Kathleen Faulkner Dr Kingsley Faulkner and Mr Kim Snowball

APRIL 2018 | 7

LETTERS TO THE EDITOR continued from Page 4 demonstrated that about 80% of these patients, who have failed all treatments including spinal surgery, obtain about 70% reduction in sustained back and leg pain from high-frequency spinal cord stimulation treatment at two-year follow-up.

This is a graphic illustration of the power of modulating the nervous system and not changing or denervating peripheral pathology. Spinal cord stimulation at the C2,3 and T2 segments provides similar powerful analgesia for upper body and truncal pain syndromes and headache.

Although this treatment is relatively expensive there, on evidence it is cost effective within two years. Coming improvements in invasiveness, costs and use of waveforms will make it more effective for a more patients. Yet it does not rate a mention in Prof Visser’s article.

There are many ways of modulating the nervous system. We are fortunate in Perth to have highly skilled therapists who can provide interventions that address risk factors for chronicity. But they struggle because of a lack of funding and lack of support from doctors who remain fascinated by imaged pathology and related biomedical treatment.

Treatment resources currently squandered on ineffective interventions should be redirected to evidence-based management.

Dr John Salmon, Pain Medicine Specialist

AUTHOR’S RESPONSE The correspondent should be aware that the editorial brief for this article was a ‘snapshot’ of spinal pain management procedures (SPMP) such as facet neurotomies and blocks, not other treatments such as physical therapies and neuromodulation.

The article contains caveats which address many of the correspondents concerns; ‘contemporary pain management is based on a multimodal approach; SPMPs are not a permanent ‘pain cure’; they provide pain relief to facilitate physical and psychological rehabilitation, reduced pain neurosensitisation and decreased analgesic use (particularly opioids)’ and; ‘evidence for effective analgesia with FJI and RF in the spinal pain population is poor, however there are individual responders.’

The correspondent may be unaware of evidence delineating the frequencies of

8 | APRIL 2018

various pain generators such as facet and sacroiliac joints in chronic spinal pain, based on selective nerve block testing. The recent large multicentre RCT of RF denervation of facet and sacroiliac joints that is quoted had significant methodological deficiencies.

Paradoxically, the correspondent is critical of SPMPs and yet strongly advocates highly-expensive and invasive spinal cord stimulation (SCS) for chronic spinal pain.

There is clearly a place for this technology in selected patients, such as failed back surgery syndrome and some CLBP patients. SCS is not indicated or feasible in the vast majority of spinal pain patients.

The correspondent states correctly that implantable SCS modulates nociceptive (pain) traffic from the spine to effect CNS pain processing. This statement in itself supports the notion that there are peripheral pain generators in spinal pain, thus contradicting his premise that we should not be ‘chasing’ peripheral back pain generators. Just like SCS, SPMPs also have a ‘pain’ neuro-modulating effect.

All of us who practice pain medicine agree that no one biomedical or psychosocial strategy reliably ‘treats’ chronic spinal pain, including SPMPs, SCS and indeed many highly touted physical and psychological therapies, based on the evidence available.

However there are clearly individuals who respond to SPMPs in selected cases.

Rather than being ‘backward looking’ this reflects a 21st century personalised medicine approach to treatment.

Prof Eric Visser, Pain Specialist ED. Pain Specialists argue about what is the appropriate treatment for chronic pain. There is no doubt that some patients gain from their pain experience. In between these poles sits the ‘average’ doctor, whose job it is to assist. To this we can add possible financial incentives. Pain management is a minefield of possibilities.

The onset is typically in the fifth to seventh decade with a prevalence of 5-13 per 100,000 and a female predominance of 3:1.

Diagnosis is often delayed with symptoms attributed to dry eyes or psychological disorders.

A related symptom, apraxia of eyelid opening, is caused by co-contraction of eyelid opening and closing muscles resulting in the inability to open the eyes voluntarily. To compensate, patients may hold the eyes wide open with no apparent blink and little spasm, making this disorder more difficult to recognise.

Differential diagnosis of BEB includes drug induced blepharospasm, Parkinson disease, motor tics and psychogenic blepharospasm.

Treatment is primarily with botulinum toxin injected into the overacting eyelid muscles. Toxin therapy is tailored to the individual patient and is highly effective, lasting 10-12 weeks. Surgery has a more limited role, although protractor myectomy is effective and may reduce the required dose of botulinum toxin. Less common helpful forms of treatment include coloured or neutral density spectacle lenses and sensory distraction techniques.

Patients and relatives should be offered advice and support before treatment.

Support groups such as the Benign Essential Blepharospasm Research Foundation (BEBRF) and Blepharospasm Australia (beb.org.au) and its local branch are highly active in support and education of patients and clinicians.

References available on request.

Dr Jean-Louis deSouza, Ophthalmologist, Lions Eye Institute ED. This description of BEB was sent to us by JeanLouis following an approach by a patient concerned about delay in diagnosis of this rare disorder.

....................................................................

Is it BEB? Benign essential blepharospasm (BEB) is a focal dystonic disorder affecting the eyelid muscles.

It is distressing and disabling— characterised by excessive blinking, eyelid spasms and the inability to open the eyes – causing difficulty with daily activities and social interactions.

We welcome your letters and leads for stories.

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You can also leave a message. www.medicalhub.com.au.

Presentation varies from increased blink rate to forceful, involuntary eyelid closure and functional blindness. Blepharospasm was first described by Talkow in 1870 but often regarded as a psychiatric condition until the mid-20th century when a neurologic problem based in the basal ganglia was postulated.

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MEDICAL FORUM

INCISIONS BACK TO CONTENTS

Brand New Life – One-Month On Dr Cassie Smith tells a tale of mixed emotions as she starts on her adventure as a newly minted junior doctor.

The Oxford Dictionary captures it rather nicely. Foray /ˈfɒreɪ/ 1. A sudden attack or incursion into enemy territory, especially to obtain something.

I could feel the signs and symptoms of ‘imposter syndrome’ rising to a peak as I made my first incursion into a clinical environment. All I had to demonstrate my legitimacy was a stethoscope and a brand new badge.

Medical school came with the reassuring knowledge that I was, for the most part, benign and supernumerary. A five-week break, supposedly facilitating the transition from student to professional, failed to broach that metaphorical chasm. Indeed, the chasm turned out to be a literal one.

The enormity of the situation was completely overwhelming and I spent most of my future earnings in a manner almost entirely divorced from what was around the corner.

Suddenly, bona fide credentialed, smitten with a salary and laden with responsibility, our first shifts instantly delegitimised the years of study that were intended to lay a foundation for success in the ‘real’ world.

The story isn’t new. Every year more than 1800 new doctors in Australia share a similar experience. A few skate through feeling every inch a doctor but for the rest of us, and some of our more experienced

colleagues, imposter syndrome is a very real issue. The fear that someone may politely tap you on the shoulder and take away your hard-earned piece of paper!

With little regard for our inner turmoil, the job begins and we forge on. Some of us – and I was one – begin our careers in supportive environments under the care of understanding consultants, helpful registrars and enthusiastic RMOs who provide comedic relief at just the right moment. Others struggle for the first 10 weeks, totally overwhelmed and hoping that someone will pull them up for air.

A transition in identity can be intellectualised, but the peaks and troughs of emotion were far greater than I ever imagined.

Most of this isn’t science. It’s art.

But isn’t this just what we’ve been yearning for? To be part of a team, fully functional and accepted, no longer addressed as ‘medical student’ and suddenly trusted to make decisions. I do feel a sense of pride that didn’t exist before the eighth of January 2018 but, in contrast, an entire shift can pass and I haven’t really helped one single individual.

And sometimes that’s got nothing to do with me.

I may have seen a dozen patients and diagnosed them efficiently but it’s simply been beyond the capacity of the ED to assist. When a patient’s primary status is measured in decimal points or one tenth of a gram, their family life is in chaos and they come in looking for chemical assistance, a solution is far beyond the reaches of my brain.

An ED shift will see elation, satisfaction, despair, and humiliation – sometimes all at the same time – as human beings with illness and ‘dis-ease’ relentlessly roll through the door.

I knew medicine would be stimulating but I had no idea what would greet me on Day One. But, one month-old, I am deeply happy to have chosen this vocation for better or worse.

I found this ‘human’ element to be exhausting and truly draining.

Now, for the next 50 years!

You just have to put aside your own feelings of inadequacy, attend to the suffering of the person in front of you, decipher their issues, stabilise them and send them on their way.

CURIOUS CONVERSATIONS Life, Family, Medicine and Trump Dr Stefan Ponosh wouldn’t swap his life with anyone, though he wouldn’t mind a crack at the Olympic ski jump!

In medical school I always remember … being in awe and also a little terrified of my consultants. They seemed to know everything and were supremely confident. I now know that medicine is more than just ‘science’, it’s an ‘art’ as well. And that’s something medical school just can’t teach you.

I’m glad I chose Vascular Surgery because … it’s never dull, always a challenge. It’s an amazing mix of medicine and surgery, the discipline evolves with new technologies and techniques and that means better outcomes for our patients. The balance of acute and chronic disease, open and endovascular surgery, threats to life and limb and cosmetic problems – that’s why I love what I do!

My parents were … selfless, and always there for us no matter what. And now nothing is

MEDICAL FORUM

too much trouble especially when it comes to their grandkids. They were amazing parents and are even better grandparents! If I’m even a little like them, my kids will be very fortunate.

I’d loved to have won a Winter Olympics’ Gold Medal in … ski jumping. Hurtling down a 140m slope at 100km/h would be mind-blowing. I’m not sure if winning Gold, surviving the landing, overcoming my fear of heights or getting away with wearing lycra would be the biggest achievement?

The book I’m reading now is … Fire And Fury: Inside the Trump White House. I’ve always had a strange interest in US politics and, whether you believe the hype and the spin, this is an amazing and pretty scary view of the world we live in. Believe me, you just couldn’t make this stuff up!

APRIL 2018 | 11

FEATURE

Making research a fundamental part of 21st century health care in WA is changing the culture of the research sector and there are many rewards to be had.

“I

f I were on a mountain top and looked down on Western Australia’s research centres, I might see five or six faint little lights.

By collaborating, we can produce one light that is much more clearly visible. We are not trying to take away autonomy or identity of any one institution but we are saying if that institutions work together for an enhanced product, that’s to everyone’s benefit.”

In what is now the post-Stephen Hawking era, the outgoing Executive Director of the Western Australian Health Translation Network (WAHTN) Prof John Challis’ cosmological aspirations for the Perth medical research community and WATHN’s role in connecting them is not only apt, it’s also looking increasingly achievable.

The WAHTN was formed in 2014 to encourage collegiality and co-operation among the state’s universities, hospitals and research institutes because, anecdotally, local health and medical researchers were growing increasingly despondent by the westward flow of NHMRC and other funds slowing to a trickle at the South Australian border.

John, a Cambridge and Oxford-trained biomedical scientist, arrived from Vancouver in 2013 to take up the position of Pro Vice-Chancellor for Health and Medical Research at the University of Western Australia. He took the view that the state’s health and medical research sector would grow only in a piecemeal fashion if siloed research groups continued to compete (unsuccessfully as it was turning out) for scarce research dollars.

He had most recently led the Michael Smith Foundation for Health Research in Vancouver which did for researchers there what he hoped the WAHTN would do for the WA fraternity.

“Local universities are starting to realise

12 | APRIL 2018

that they are not each other’s competitors.

They have to lift their sights. I’ve worked at Harvard and Toronto, and if we’re not playing at that level of excellence then we’re not really in the game,” he said.

unify research teams so they can become more competitive for Ottawa (the national capital) dollars. In WA’s case, it’s to draw dollars from Canberra or the NHMRC,” John said.

“So once research institutes start looking up and out, it’s not a stretch to think that maybe our ability to play that game is enhanced by collaborating through shared platforms – a clinical trials and data management centre at Curtin, or phenome centre based at Murdoch and FSH. That’s what is starting to happen and that’s a win for the sector and, most importantly, the people of WA who are benefiting from better, evidence-based medicine.”

“Already we’re seeing the $60m interest payments from the $20b national future fund flowing through. In the next few years that should grow to about $130m and then $600m a year. That’s really getting up there and will make Australia very competitive.”

“Research becomes less about individual egos, and more about better and more equitable health for the people of WA. We mustn’t lose track of that.”

All this may have been little more than fine sentiment if not for the commitment of the WA Labor Government and the staunch support of Health Minister Roger Cook, who has made good his pre-election promise to repurpose the state’s future fund to a medical research future fund.

“The $1.1-$1.3 billion future fund capital will generate about $33m a year. That’s huge and what’s needed to recruit some of the best clinical-research people to ensure that WA can participate in developing and delivering the best care to WA patients,” John said.

Success attracts success This state-based funding will give local researchers some stability and sustainability, which in turn will make WA projects more attractive to those distributing money from the $20 billion national medical research future fund and the NHMRC. That’s the logic, but the hard work needs to continue to keep the local institutions open and ready for such a future.

To give some idea of the state government’s commitment to research, the Michael Smith Foundation received from its provincial government about $35-45m a year for a population twice the size of WA. “The commitment from the WA government is significant. The Michael Smith Foundation uses these funds to recruit and

“The other important consequence of the WA future fund is the message it sends internationally that the WA government is serious about health and the health of its population because it is investing in building a culture where medical practice is based on solid evidence. They’re not just saying that in words, they are putting cash on the table. That becomes hugely important when you want to retain and recruit the best.”

“Research is expensive but it can be selfsustaining and it’s the role of the WAHTN to help local organisations achieve that.

Our core activities are to catalyse new research and new initiatives; facilitate the conduct of translational research; and unify partnerships and partners across the network.”

Finding the right team “We firstly need to attract physicians and allied health workers interested in being at the international cutting edge, who want to explore new concepts and new ways to better treat patients and who want to combine clinical practice with research.

We need to understand disease so we can diagnose and treat earlier and better.”

“The key aim must be to keep people out of hospital.”

“We know that for every $1 invested in health research you get $5 return in terms of population health and productivity. Then, of course, there is commercialisation of innovation outputs.”

John uses Murdoch University Professors Steve Wilton and Susan Fletcher’s work on Duchenne Muscular Dystrophy as not only an example of researching and developing a treatment that will change the lives of affected individuals across the world but also developing technology that can unlock

MEDICAL FORUM

BACK TO CONTENTS

WA Research: Connecting the Dots

FEATURE treatments for other diseases, which will improve outcomes exponentially.

“Developing a drug is one thing, creating the technology they have come up with, is quite remarkable. The object of the exercise is preventing disease, but if you can’t prevent, you need to find a treatment and to do that you have to maintain currency.”

With the interim report of the Sustainable Health Review suggesting that WA needs to spend much more on preventative strategies to stem the flow of patients into our hospitals, John argues that prevention of disease underpins the research culture.

He cites the cohort studies which have put WA in the research sights of hundreds of international researchers for decades. He explains that WAHTN has established a WA Cohorts Network so that studies such at the Busselton, Raine, Health in Men, Fremantle Diabetes and ORIGINS among others can work together in some key areas.

“These studies are all in different stages of maturity so WAHTN asked them how we could help. They told us they needed opportunities for data sharing and biobanking, if they could be assured of the quality, harmonisation and standardisation.”

It’s good to share “The potential of sharing data and biosamples across cohorts is enormous.”

“This takes a change in mindset and it’s my role to enable and facilitate that change.

You can’t force people to collaborate but you can create a supportive environment and hopefully colleagues will see that coming together is an opportunity worth pursuing.”

WAHTN has a number of online training workshops for researchers, from good clinical practice principles to data management and informed consent.

Some are online, some are face-to-face and its those workshops that incubate collaboration.

In June last year, WAHTN was accredited as one of seven NHMRC Advanced Health Research and Translation Centres (AHRTC) in Australia. It puts WA among the national players and puts some of the local innovations in front of a national audience.

The AHRTCs have national projects funded by the Commonwealth Future Fund – around indigenous health, data sharing, management and security, and the development of new innovative health care systems. John co-chairs a workshop on consumer and community involvement in research, which he suspects, though the project is still running, will show WAHTN’s consumer networks lead the country.

Well-respected health consumer advocate Anne McKenzie heads up the consumer network at WAHTN and is building on her work with WA and Telethon Kids to create a state-wide program, sponsored by

MEDICAL FORUM

Lotterywest, which will effectively mean all research projects will have consumer and community input at the outset.

“Consumer advocates will help shape the questions research will ask, how it will be done and even be involved in the review of grant applications. The Cancer Council has been doing this for a while now,” John said.

“It will mean that when research findings are ready to publish, they won’t just appear in esoteric scientific journals, they will also be understandable and relatable to a community that has been an integral part of the research pipeline.”

Having consumers at the table is also impacting on how clinicians and scientists communicate, which John says is no bad thing: “It focuses a researcher having to understand what issues concern consumers and what they want from research. It makes a researcher think and communicate differently. It’s a researcher’s job to ensure consumers understand.”

Opening minds As research institutes start talking to each other constructively and the funding environment becomes less combative and more supportive, universities are opening their minds and doors to collaboration.

A clinical trials and management centre supported by the WA Department of Health and facilitated by WAHTN is being established at Curtin University by Prof Christopher Reid, a cardiovascular epidemiologist and clinical trialist with a specific interest in quality improvement and outcomes research. The management centre will serve as a resource for all researchers wanting to do clinical trials.

“Professors Steve Webb and Peter Thompson along with Chris Reid have been fantastic running a seminar series rotating around partner institutes and hospitals giving researchers advice and support to develop clinical trials,” John said.

Openness improves chances “That’s a huge change. People are prepared to open themselves up to constructive commentary from their peers and it is bearing fruit. Peter Thompson told a team meeting that this year we could anticipate 3-4 trials to be submitted for NHMRC grants through the new WA centre. We are at last starting to get some structure.”

As John prepares to depart WAHTN as executive director – and former Chief Medical Officer Prof Gary Geelhoed readies to step in –he is not leaving the local scene.

He will continue as a consultant particularly around the establishment of a southern research hub based at Murdoch University, FSH and Perkins South.

Murdoch University with Prof Rob Trengove directing, is leading a consortium of all five WA universities, UNSW, Telethon Kids Institute, Perkins Institute, Imperial College London and the WAHTN to establish the Australian National Phenome Centre at Perkins South. It has received more than $7m from the Australian Research Council, Lotterywest and partner institutions.

The centre, which opens in 2018, is developing and delivering metabolic phenotyping services.

“This is all about personalised medicine, ensuring that before a person is treated with a particular drug, we determine if it is the right drug for the right patient at the right time. This is a big improvement for the patient and has the potential to offer significant dollar savings,” John said.

“The era of trial and error is rapidly passing.”

So too, it would seem, the era of crossed purposes and parochialism. Next stop, breaching the Federal-State divide.

By Jan Hallam

APRIL 2018 | 13

BACK TO CONTENTS

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MEDICAL FORUM

FEATURE

End of RHD Around the Corner?

Research, know-how and political will are winning the battle against Rheumatic Heart Disease.

T

he Minister for Indigenous Health Ken Wyatt recently chaired a roundtable of about 30 stakeholders in Darwin, including Aboriginal medical services and representatives of the WA, NT, SA and Queensland governments, to lay down a roadmap to end rheumatic heart disease.

what we are trying to do with Closing the Gap.” “It gives us something tangible to aim for because Closing the Gap is overwhelming in its scope – tackling life expectancy differentials is extremely hard.”

He also announced that the Federal Government had allocated $23.6m over the next four years for a Rheumatic Fever Strategy, which addressed the underlying social and cultural determinants that contribute to RHD, including poor housing.

Jonathan said the foundation of a strategy was already in train.

“Telethon Kids is into the fourth year of the five-year End RHD project which is bringing research and the economic and policy framework together with the view that by early 2020 we will have a detailed, costed plan for eliminating RHD as a public health priority in Australia,” he said.

“What the Minister managed to do was to get a wide range of stakeholders around the table, all unified in their position that this disease is shameful and tragic in such as country as ours, and to elicit their commitment to get rid of it.”

“The Minister recognised that of any disease, RHD was the epitome of what needs to be tackled to Close the Gap. It is the single biggest cause of differential of burden in cardiovascular disease between indigenous and non-indigenous people.

It is almost exclusively born of social determinants.

“That was the other aspect about the meeting that was particularly pleasing – people didn’t see this as just a dread disease but something that characterises

MEDICAL FORUM

“But one thing that was made very clear at the roundtable was that whatever happens, it has to be focused at the community level. We can’t do this with a top-down approach. We have to empower local communities to say ‘we want to get rid of this disease’ and the local Aboriginal leadership to take ownership of it. The focus has to be on all aspects of prevention and control. There is no silver bullet.”

Finding demonstration communities will be the next task.

“These demonstration communities will need resources and support to ensure they are buttressed but local people will be directing priorities. Essential is the need for local community workers who are trained and employed on a genuine career path,” Jonathan said.

A $5.4b national agreement, which funded states and territories to provide remote housing, is due to end on 30 June 2018 and Minister Wyatt said the Commonwealth had begun discussions about future funding arrangements.

With significant funds in the kitty, long-time workers in the area such as Telethon Kids Institute chief Prof Jonathan Carapetis, believe the time is ripe for decisive action that can make the disease history.

are most likely to work, and we have the evaluation capacity to see if it is working.

We can assist.”

Prof Jonathan Carapetis and Kenya McAdams, who was diagnosed with RHD and had to undergo surgery to repair damaged heart valves It is believed that Minister Wyatt will be taking the RHD strategy to COAG, which would ensure that the state and federal governments were on the same page.

While there have been national partnership agreements for individual control programs in the past, there has not been a unified approach on a uniform, national strategy.

In our story on the WA sustainable health review (see P20), Health Minister Roger Cook said the WA government was in constructive talks with the federal government on national commissioning models in the Kimberley.

And it was the Kimberley Aboriginal Medical Service at the roundtable that said it was important not to lose momentum on the RHD disease front.

“Their view is that regardless of what happens nationally, it doesn’t stop their commitment to eliminate RHD in the Kimberley. I thought that was a really positive statement. People can act now,” Jonathan said.

“They will be working with families to help them improve their physical environment and housing and to identify and manage sore throats and skin infections – the health problems we know lead to RHD. There is a lot that needs to happen but it must happen on the ground in local communities.”

Jonathan said RHD claimed the lives of between 50 and 150 people a year, almost all at far too young and age and almost all were Aboriginal or Torres Strait Islanders.

“And that’s not acceptable in the 21st century,” he said.

“But at this moment, I have never been more optimistic about defeating RHD and I have worked in this field for a long time. We have a group of individuals and organisations around the country serious about doing something.”

“I am also confident that we have a pretty good idea what needs to be done. What we’ve needed is the third step to bring people together and get political will.

With Minister Wyatt’s leadership, I am quite optimistic that we are taking that third step.”

By Jan Hallam

“Researchers have heaps of information on this disease – we know the things that

APRIL 2018 | 17

FEATURE

768 rural GPs were contacted for their opinions. While only 32 doctors used the five-day window and the long weekend to give us their opinion we are publishing the results here just in case results signify trends that cannot be ignored. See below.

E-POLL

Cardiovascular Prescribing

ED. Over three quarters of our sample of rural GPs agreed with this statement.

The question is, what do we do about it? Statins are one of the drugs targeted by doctors trying to deprescribe in the elderly, particularly in RACFs. Because of comorbidities and their advanced age it often means they have not featured in trials showing statin benefits beyond risks from side effects.

ED: It isn’t all doom and gloom! Just over half rural GPs agree that patients are following their advice to increase exercise. And the older GPs among us will remember the smoking, overweight GP who was the lifeblood of rural communities? Not anymore! About three quarters of our sample see themselves as a “good example of how healthier living can help” i.e. we presume they practise what they preach.

ED. While most of our respondents feel the newer anticoagulants are an improvement over the older drugs, we do not know if this relates to less risk from confusion over blood thinners or not, which have placed patients at risk, according to most respondents.

Comments on Lifestyle and Cardiovascular Risk (10 GPs)

Lifestyle Changes

“Many patients will eventually respond if you can make the changes a reasonable part of their daily / weekly routine.

“We need some sort of 'prescription' of changes e.g. exercise routine as a handout/reminder

“Patients usually lack motivation to change their lifestyle habits. The very few who manage to, do achieve good results.

“It is difficult for a lot of patients due to day and night working cycles that vary.

“I smoke so at least I am compassionate in my counselling!

“It would be good if we had more community options to engage people with free exercise classes – ongoing, beyond cardiac rehab.

“We have become too soft; the doctors need to call a spade a spade and not be too concerned about upsetting our patients.

“I struggle to encourage the patient to find their own motivation.

They too often have too many excuses.

“We can be guided by relevant research but we cannot say how much each individual responds to medication or lifestyle change.

“It’s never too late for an improvement.

ED. Agreement with this statement seems to echo the comments made by urban GPs (see P14). Most patients become motivated by the first cardiovascular event in themselves, a friend, or a close family member. In this regard, the majority response to the first lifestyle question is understandable.

18 | APRIL 2018

MEDICAL FORUM

BACK TO CONTENTS

Rural GPs on Cardiovascular Health

E-POLL Commercial Appeal of Cardiologists In your opinion, how do cardiologists compete with each other (more than one response possible)?

Their experience/knowledge? Ease of use e.g. facilities available to them at short notice? Personal manner towards me? On out-of-pocket costs to patients? Personal manner towards patient? Telehealth consults? Welcoming facilities - parking, wait room magazines, reception staff etc? Other -

Just for Fun! We asked our respondents to ‘Complete this sentence: A ‘Change of Heart’ means...’ Here’s a selection of the best responses. “trying to keep the one you've got but healthier! “seeing the grandkids grow up.

Comments “I only refer to cardiologists who do clinics in our town. This means that after a patient has had their acute event/ intervention in Perth, they can have their follow-up in their home town.

“I feel that a number of cardiologists over-service, especially on six-monthly follow-ups ‘forever’ that are easily within the scope of general practice. Weaning patients off their specialists can be harder than weaning them off opiates.

“Availability for advice is important.

“very little responsibility for heath resides in a physician's hands “a heart transplant if you ruin the heart your mother made for you in the first place “moving away from corporate medicine “avoiding an ‘Achy Breaky’ outcome! “a pacemaker, thank you

“I am unaware of this competition between cardiologists.

“a transplant of ideas

“Do they really need to compete with each other? Corporate medicine is taking over to the detriment of patients particularly those who cannot afford to pay.

“finding your own personal drive for change

“Not relevant to very remote rural practice; we accept all comers.

ED. A cardiac transplant featured heavily which may signify our reliance on technology these days or…?

“Self-marketing by the cardiologist; getting their name known.

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NEWS & VIEWS

Looking for a new challenge?

The Straight and Narrow The release of Sustainable Health Review interim report is a starting point for many deep and meaningful conversations to be had in the health sector and Health Minister Roger Cook is keen to keep the momentum.

He will be on the panel of our March 29 Doctors Drum meeting which is looking at Future Medicine: Playing the Change Game and being sustainable will be high on the agenda.

The review conducted by Ms Robyn Kruk pinpointed key areas: More funds for prevention.

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Better integrated systems to help those needing care to navigate, including improved connections between state and federal health jurisdictions.

Encourage telehealth beyond emergency medicine – for both rural and metropolitan consumers.

Action to improve mental health service delivery and an immediate review of mental health clinical governance.

Improve country access to metropolitan services with review of transport systems and ‘sister’ relationships between regional and metropolitan hospitals.

Joint federal-state commissioning to improve Aboriginal health.

Improved performance reporting and public reporting from departmental and clinical levels.

Technology to aid integration.

Harness and support health and medical research collaboration and innovation.

Workforce reform with improved recruitment processes; integrated workforce planning and programs to encourage rural generalists and nurse practitioners.

More meaningful consumer involvement.

When Medical Forum caught up with the Minister he said it was necessary to address what the report called ‘inconvenient truths’ around labour costs.

“We as a system of 44,000 have to come to grips with what is sustainable while maintaining a first class health system,” he said.

In 2012, Medical Forum interviewed the then Director General of Health Kim Snowball in what were admittedly boom times, where the attitude of the then Minister Hames and the department was if a consultant cost $450,000 then that’s the price the system had to stump up.

Mr Cook said: “There is no doubt that labour costs constitute a significant proportion of the health budget and to be brutally honest we need to have the conversation about just how we pay for the workforce. There are salary issues but we also need to think of circumstances where we can support and reward people, and continue to equip the system without busting the bank.”

“It’s clear that we have to reset the dial. WA Health is justifiably proud of its hospitals which deliver world-class clinical care but we do need strategies to keep people out of them, so we must look at prevention.”

In terms of better system integration, Mr Cook said constructive discussions were taking place with the Federal Government “because the current system of silo funding models is not working in the best interests of the patients or the funding parties.”

“We have been talking about joint commissioning models in the Kimberley which would require a bilateral agreement and that’s an exciting prospect. There are significant challenges in delivering health care to the Kimberley and we have to stop the cost shifting in order to address them.”

“The Federal Government certainly seems up for that and now we need to work on a specific proposal.”

By Jan Hallam

20 | APRIL 2018

MEDICAL FORUM

SPOTLIGHT BACK TO CONTENTS

Living with CF – a Growing Concept Just 30 years ago, it was a dire prognosis for those with cystic fibrosis.

However, science and new treatments have made life worth living … longer.

W

omen of Certain Age is a book that tells the stories of 15 Australian women with more than a few years under their belt. Charlotte Roseby tells a tale of people who didn’t expect to have much of a story at all.

“These are stories that celebrate getting older and wiser, women who’ve becoming more certain of who they are and where they want to be. I’m on the younger side of the pack so I was thrilled to be included!”

“I snuck in on a medical technicality because I’ve got Cystic Fibrosis (CF), which meant that my parents didn’t expect me to reach the age of six. And I didn’t expect to reach 16, let alone 36! Yet, here I am. A friend of mine with CF counts his ‘CF age’ in dog years. So, on that basis, I’m about 106. As far as health issues go I can match someone who actually is that age! I’m as surprised as anyone that I’m still here.”

“I’m a medical outlier but now in increasingly good company. Thankfully, there are more and more of us out there.”

and friends who wouldn’t be alive but for the grace of antibiotics.”

“Then Melbourne saw the first Australian lung transplant in the early 1990s.”

“In fact, CF has benefited from almost every medical advance of the 20th century.

The AREST CF project is pushing back the deterioration in lung function and things are looking good for babies born in 2018.

Physicians now have to get their heads around an ageing CF population.”

The manner in which a doctor engages with a patient is ever-changing. And thank goodness for that, says Charlotte.

Focus reset “What I’m seeing now, happily, is the gradual acceptance of patient-centred medicine. I can still remember the morning clinic, shiny linoleum, hard benches and stern instructions to my mother. The doctor was God, at the very least a messenger.”

“A clinic visit now is difficult to complete in less than four hours, but I’m thankful for its current form. It’s a lively, multidisciplinary structure with strict cross-infection cohort segregation and a nurse to keep everyone on track. Although it’s taking a ridiculously long time to incorporate mental health into CF care, some clinics now include

psychologists and psychiatrists. Or, at bare minimum, a nod towards the idea that the way you feel forms part of the wider CF landscape.”

“The burden of CF treatment is huge, and ‘adherence’ is a constant issue. That implies connotations of being a ‘good’ or ‘bad’ patient but I call it ‘doing the best you can while still having a life’.

For someone who’s seen a lot of medicos in her time, Charlotte has a simple message.

Patient goals “I need a doctor to know that I will do anything to catch that plane, sit that exam, party until sunrise, get pregnant, go surfing or just get home. A patientcentred approach is a team effort and once a doctor understands a patient’s values, diagnostic and treatment decisions should be made together. If I followed all the treatment, medication and physio advice – ‘health shit’, as the millennials put it – I wouldn’t have time to sleep.”

“I’d love to see a doctor do a ‘patient for a day’ in a typical CF burden of care. They’d have a heart attack!”

In her piece for the book, Charlotte writes

continued on Page 25

As Charlotte points out, she was smack-bang in the ‘middle period’ of CF treatments that rewrote medical history in relation to survival age.

Precious history “The historical trajectory of CF is pretty fascinating. Most of the significant developments in Western medicine are represented in its pathway from diagnosis to treatment and survival. The reason I’m still here is because there were so many breakthroughs, most of them in my lifetime.”

“For the current generation of doctors, the CF trajectory and, most importantly, the doctor/patient experience, are instructive.

“I was lucky to grow up in the 1980s, which was the golden decade of CF research and discovery. They isolated the CF gene and the cystic fibrosis transmembrane conductance regulator (CFTR) in 1989 and the introduction of new inhaled antibiotics resulted in a rise in median survival. It’s intriguing to think about your own family

MEDICAL FORUM

APRIL 2018 | 21

MEDICOLEGAL

N

ew privacy breach legislation has created a flurry of activity.

One legal firm issued a media release headlined 60% of patients don't trust their GPs with sensitive information. This was probably meant to frighten medical practices into action and why shouldn't it given the latest reported Facebook breach.

the litigious environment doctors find themselves in but on the other hand it would be a crying shame if a doctor suffered professional consequences because the practice did not implement adequate privacy breach policies. These most recent changes to Privacy Law apply to the behaviours of practice doctors, whether on contract or not.

Some say legal firms contribute to

The practice would have to decide within

30 days that an 'eligible data breach' had occurred. Big fines are in place if they do not. This press release lists: stolen or lost medical records, medical information being supplied to wrong person, or a database hack …as ‘eligible’ and therefore to be “reported to the Privacy Commissioner and to the patients themselves.”

Safeguarding Systems and Data

C

hris Mariani, an independent medical insurance broker based in Sydney, described doctors as great risk managers when it comes to clinical risks such as patient follow-up and recalls. They know when to ask their medical defence organisation (MDO) for help.

“It’s however the ‘business risks’ where many practitioners and their practices come unstuck.

One growing risk is the reliance on IT systems to run a practice and the closely aligned issue of privacy compliance,” he said.

In 2012, a headline made the medical media – Russian hackers hold Gold Coast doctors to ransom. The Miami Family Medical Centre was being asked to pay hackers $4000 to decrypt sensitive information held on their server.

In March 2014, the Privacy Act was updated and 13 Australian Privacy Principles were implemented, including: Patient consent needed to collect health information A complying Privacy Policy, accessible to patients Practices required a privacy framework (see www.oaic.gov.au/agenciesand-organisations/guides/privacymanagement-framework) The Office of the Australian Information Commissioner (OAIC) could seek fines (now about $2m under indexation) for breaches of the Privacy Act. Chris said new changes introduced on 22

22 | APRIL 2018

February this year may catch Australian businesses unawares. The Notifiable Data Breaches (NDB) scheme which would require notification to all affected patients and individuals, as well as the OAIC, where an ‘eligible data breach’ occurs.

“The primary purpose of the NDB scheme is to ensure individuals are notified if their personal information is involved in a data breach that is likely to result in serious harm. This has a practical function: once notified about a data breach, individuals can take steps to reduce their risk of harm. For example, an individual can change passwords to compromised online accounts, and be alert to identity fraud or scams.”

“For most other businesses, having a privacy framework or being subject to the full weight of privacy legislation doesn’t kick in until they generate annual revenue of more than $3m. For health businesses it kicks in from $1.”

“It is important to note doctors have ethical obligations to inform patients about adverse events, including breaches of privacy and confidentiality. So even if a breach is not deemed to require reporting under the NDB scheme, the patient may still need to be informed under the doctor’s ethical obligations.”

Chris recalled a large healthcare practice where the finance manager’s computer was hacked, resulting in the entire practice contact list of over 30,000 people being sent an email with ransomware embedded in the email.

Under the new legislation the practice would need to instigate a breach response, decide if the impacted individual/s were likely to suffer ‘serious harm’ and if so, report to both the OAIC and to every impacted person. On smaller cases, legal costs had exceeded $10,000 outside other IT costs, lost revenue,

and potential fines. In the hacking case, the costs are likely to be much higher.

He said all practices needed to take steps to become compliant with Privacy Law, including: Conducting an IT review and audit. Is the practice taking reasonable steps to prevent breaches? Is the system backup adequate to allow prompt enough return to full service? Have IT contractors, who have access to data and information about patients, signed confidentiality agreements?

Staff training on privacy and IT security (e.g. – how to recognise scam emails, what the practice policy says, what to do should a patient make a privacy complaint or request their patient file under privacy law.

Have up-to-date patient consent forms, privacy policy, breach response plans and other documentation.

“Staff need to understand the growing threat to the security of practice data and that the law has changed. Getting up to speed on privacy is not optional, it’s the law – compliance with the Privacy Act should be your first focus, then review your level of insurance and decide if a privacy/cyber insurance policy is appropriate.”

By Dr Rob McEvoy

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BACK TO CONTENTS

New Data Breaches Legislation

MEDICOLEGAL

Your Legal Responsibilities On February 22, the privacy law changed around notification of data breaches which will affect all medical practices. Lawyer Kate Reynolds, pictured below, explains.

D

ata breaches and cyber attacks are a growing risk for medical practices and can have a major financial and reputational impact for healthcare providers, particularly with the increasing reliance on electronic health records and billing systems.

In 2016, US researcher Ponemon Institute conducted its annual survey on privacy and security of healthcare data finding that nearly 90% of healthcare providers reported one or more data breaches over the previous year1.

PricewaterhouseCoopers also found that 65% of all Australian organisations have experienced cyber crime in the past 24 months2.

In Australia, the Privacy Act 1988 (Cth) a(Privacy Act) nd the Australian Privacy Principles (APPs) regulate how personal information is managed. All private sector healthcare practices who collect, use or disclose health information are bound by the Privacy Act and the APPs. With the introduction of new mandatory data breach notification obligations (mandatory notification) medical practitioners and healthcare practices should consider their approach to privacy and confidentiality of patient information.

What are the risks?

Cyber attacks are a significant risk to all businesses including medical practices, with attacks occurring in increasingly sophisticated ways. Prominent threats include3: integrity breaches – the manipulation of correct data; confidentiality breaches – theft or inappropriate access of personal information; availability breaches – shutting down critical infrastructure and online services.

laptops, phones or USBs which are unencrypted or not password protected are left in cars, offices or around the home, increasing the risk of information being lost, stolen or inappropriately accessed.

Not every data breach requires mandatory notification. A breach is only considered an eligible data breach if a reasonable person would conclude it sufficiently serious that it is likely the affected individual would suffer serious harm. Serious harm may include serious physical, psychological, emotional, financial, or reputational harm.

An electronic appointment reminder sent to the wrong patient, in circumstances where two patients of the practice have similar names, is unlikely to be an eligible data breach requiring notification, as it is unlikely to result in serious harm to either party.

Who do you notify?

If a data breach occurs, the organisation must attempt to contain the breach, assess the actual and potential harm, and if it is considered that an eligible data breach has occurred, notify the Office of the Australian Information Commissioner (OAIC) as soon as possible. The assessment and reporting of the incident should occur within 30 calendar days of the entity becoming aware of the breach.

The OAIC provides guidance on how to notify individuals without causing further harm. Direct communication in the form of a telephone call, a letter, an email or in person is preferred. Where a law enforcement agency is investigating the breach, clarify with that agency whether it is appropriate to make details of the breach public.

My Health Record The My Health Record system has its own mandatory reporting of data breach requirements and falls outside the scheme set out in the Privacy Act. The OAIC continues to regulate the handling of personal information under the My Health Record system and investigate complaints

about mishandling of information in an individual’s My Health Record.

If a medical practice becomes aware of a potential data breach affecting the My Health Records system, it must report this to the System Operator regardless of whether the breach meets the criteria of an eligible data breach under the Privacy Act. The System Operator or the medical practice may notify the OAIC of the breach and request the Australian Digital Health Agency (ADHA) to notify individuals who have been affected. If a significant number of people are affected, the ADHA will notify the general public.

When information is downloaded from a patient’s My Health Record to a practice’s computer system, the My Health Records Act no longer applies and the downloaded information will then be subject to the Privacy Act provisions.

While you can’t avoid cyber risk, you can take steps to prepare your practice and educate staff in ways to minimise the risk.

Further information about may be obtained from your professional indemnity insurer, the OAIC or an independent legal adviser.

ED: Ms Kate Reynolds is a solicitor with Panetta & McGrath. She is a registered nurse practising law in medical treatment liability, aged care, general health law and general insurance.

1 Ponemon Institute LLC, Fifth annual benchmark study on privacy & security of healthcare data, May 2016.

2 ASIC Media Centre, World Economic Forum and Cyber Security for The Australian newspaper, 20 January 2017.

3 ASIC Media Centre, World Economic Forum and Cyber Security for The Australian newspaper, 20 January 2017.

4 Ransomware attacks steal headlines, but accidental data breaches remain a major cause of loss, 1 August 2017, Beazley Insurance, www.beazley.com

See P25 for MDO and AAPM positions

While the risk of cyber crime is ever present, data breaches in medical practices more frequently occur by accidental error4 or intentional misconduct of employees accessing personal information of patients for non-health related reasons. Data breaches may also occur if patient information on

MEDICAL FORUM

APRIL 2018 | 23

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MEDICOLEGAL

Data Breaches­— what MDOs & AAPM Say

M

edical Forum asked the three major medical defence organisations if their policies covered the new data breach changes and cyber risks.

Avant said its: “Practitioner Indemnity Insurance Policy provides cover for defending a complaint in relation to privacy law (subject to the terms, conditions and exclusions of the policy). The policy also provides cover for any monetary fine or penalty, to the extent permitted by law, ordered to be paid by a practitioner based on their breach of privacy laws.

This was brought in to support members with the recent changes to the Privacy Act and the introduction of the notifiable data breaches scheme. From 1 July 2018, Avant will also be providing cover for any privacy breach notification costs.

MDA National said its: “Professional Indemnity Insurance Policy and our Practice Indemnity Policy cover claims against our Members and Practice Policyholders for unintentional privacy data breaches as well as inquiries by the Australian Information Commissioner into a breach. The policies also include cover for

replacing documents or data that may be lost due to an unintended breach, provided there are appropriate backups and security in place. The Cyber program extends to human error with respect to both:

We also spoke to the national president of the Association of Australian Practice Managers (AAPM), Ms Cathy Baynie, who said that it was business as usual for practice managers.

1) Data asset loss and

Privacy is daily fact of life for the 2000 plus AAPM members who will already have policies in place and staff trained.

2) business interruption Human error means an operating error or omission, including the choice of the program used, an error in setting parameters or any inappropriate single intervention by an employee or a third party providing services to you, which results in loss, alteration or destruction of your data.”

MIGA said its policy: “…principally covers doctors for claims arising from the provision of medical services in their field of practice, however, cover can encompass various matters arising out of a notifiable data breach, including for civil claims, legal expenses and certain other losses. Other types of insurances may also be relevant in the context of cyber risks and criminal conduct and in this regard, MIGA has a partnership with Guild Insurance through which other types of insurance can be obtained for a broader range of business risks, including cyber insurance.”

“However, privacy education is popular with members and we work closely with MDOs to deliver workshops and seminars most years. This year, privacy workshops for receptionists will include the notifiable data breaches changes among other things,” she said.

“There’s certainly no panic in our ranks.

Privacy training is ongoing and our members have been fully updated and resourced to meet the requirements. This is just one of the many changes we deal with on an ongoing basis.”

continued from Page 21

Living with CF that everyone in the 1980s was ‘ill-prepared’ for the entire CF experience.

just to take the raw fear out of it. And that then creates room for all the other stuff.”

“It was tough for everyone, doctors, nurses and patients. Gains were being made in median survival but the cruel numbers game of ‘median’ and ‘average’ meant that a lot of children were dying young, too.

Really young.”

“And in the adolescent ward, there was plenty of ‘other stuff’. Those kids were the most ‘alive’ people I’ve ever known!”

“Some nights I dreamed of funerals like other little girls dreamed of weddings.”

Having THE talk “CF mortality was pretty random. ‘Time left’ was hard to predict and harder to measure… and still is. It’s a cruel twist when a patient dies as a teenager while still hoping for a future as an adult. And it wasn’t talked about by anyone, which made it even crueler. “‘Death’ was the rudest word you could say in the ward, and the second-rudest was ‘dying’.”

“It’s better than it used to be, but what’s still tricky is a clear and obvious ‘right time’ for end-of-life discussions. The ‘death and dying’ conversations are really important

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Genetic mapping is a bright and shining star for CF patients but it’s not for everyone, for all the wrong reasons.

“I see a future with more personalised medicine based on the genetic mutation.

There are more than a thousand variations affecting the CF gene and some are less lethal than others.”

Gene warfare “Lumacaftor-ivacaftor (Orkambi) was recently approved by the US FDA for patients over 12 years who have CF due to two copies of the F508del mutation CFTR gene. Trials show that lung damage was slowed by 40%, on average. It’s a breakthrough that costs about $300,000 per patient, per year!”

Finally, Charlotte scans a roomful of brighteyed medical graduates.

“The most important thing to develop in your career, just ahead of a sense of humour, is empathy.”

“I’ve found this attribute chronically depleted in doctors but neural plasticity would suggest that it can be developed. If a doctor can put themselves in a patient’s shoes for even just a moment it makes a huge difference. A few well-chosen words revealing warmth and compassion go a long way. There’s a wonderful new program at the University of Melbourne that takes students into the Ian Potter Museum of Art to reinforce the idea that beyond a medical history there’s a whole new world.”

“If you really look and listen you’ll get the truth in return. You’ll also get adherence, compliance and that rewarding feeling of working together. You’ll see positive changes in your patients’ health and, with CF, perhaps even an improvement in life expectancy.”

“You’ll make all those differences that you dream of making as a doctor.”

By Peter McClelland

APRIL 2018 | 25

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Early Palliative Care Makes Life Easier Three Curtin University researchers set out to discover if early community-based palliative care resulted in less hopsitals admissions. Cameron Wright explains.

Does the timing of initiating community-based palliative care affect the time spent in hospital at the end of life for cancer patients? This was the question that spurred research my colleagues David Youens and Rachael Moorin and I recently published in the Journal of Pain and Symptom Management.

The research used whole-of-population individual level linked data, which allows records from mortality and cancer registries, hospitals and, in this case, a Perth-based palliative care service provider to be linked. For this study we looked at people dying due to cancer in Western Australia between 2001 and 2011. This gave us a population-level view of how people used community-based palliative care, and how often and for how long the same people were unexpectedly admitted to hospital in the final few months of life.

Transitioning to palliative care does represent a change in treatment goals, from curative to patient comfort and symptom management.

Access to community-based palliative care – an umbrella term for multi-disciplinary palliative care delivered in a person’s usual place of residence – is not restricted in WA in terms of time before death.

Thus, it is unsurprising that of the 16,439 people in our study, 64% accessed community-based palliative care in the last three months of life. Because some people accessed earlier than this, we had an opportunity to explore if earlier access was associated with fewer hospital admissions at the end-of-life.

This increases our confidence that the difference is linked with timing of initiation. Overall, estimated hospital costs were less among those who accessed the service early and the trends for hospital admissions mirrored emergency department presentations.

However, people initiating community-based palliative care earlier tended to spend longer in hospital when they were admitted.

This could be for reasons including more complicated admission reasons that could not be managed by community providers Our findings are broadly consistent with emerging literature from Australia, Canada and Taiwan. They also build on previous work from WA, which found that community-based palliative care was associated with fewer hospitalisations and a greater likelihood of dying outside of hospital.

A review of community-based palliative care, which included 23 studies, found that its availability reduced symptoms at the endof-life. Our single study should be interpreted in the context of evidence available and considering relevant community attitudes towards palliative care.

In jurisdictions where community-based palliative care is restricted to a certain expected time to death (usually for cost-saving reasons), our results argue that this may not always yield a net cost saving.

ED: Cameron Wright, David Youens and Rachael Moorin are members of the School of Public Health at Curtin University.

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While the difference was small at an individual level, it was important when viewed at the population level. Because we were observing what happened in the past, there are other reasons apart from use of community-based palliative care that hospital use might be different. To account for this, we adjusted for these other factors as much as the available data allowed.

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Regional cardiology challenges and opportunities

By Dr Tony Mylius, Cardiologist and Consultant Physician, Northam The most common question is, “Do I have to go to Perth for that Doc?” Being able to say ‘no’ often provides great relief. As well, challenges for both patients and doctors are often magnified in the country.

This town’s population of 7500 services about 40,000 people into the Wheatbelt.

While not the glamourous end of cardiology technology and intervention, better patient health outcomes require effective application of best practice diagnosis and management.

Identifying those for whom interventions, devices and medical therapeutic changes or adjustments are appropriate, and facilitating access to these, makes working in a regional centre rewarding.

Innovations like the Emergency Telehealth Service have made a huge difference to regional patients getting access to higher level emergency care and in supporting regional health care practitioners (including doctors and nurses).

Rural and regional patients can gain access to specialist diagnostic and management services and in this way ‘get into the system’.

This is more about innovation in health service design and implementation! Once patients need more advanced investigations and management most take up the opportunity but many don’t get access to know what they need in the first place.

ECG 1: Acute inferolateral infarction miss’. While such clinical challenges are not unique to regional areas, more limited access to specialist support is, as is the tyranny of distance. Mortality rates for coronary heart disease are 1.2 to 1.5 times higher in rural and remote areas than in metropolitan Australia – and there is a higher prevalence of heart, stroke and vascular disease.

SCENARIO 1: Atrial fibrillation and anticoagulation. Appropriate detection and management of atrial fibrillation challenge us everywhere. Regional patients are not acutely sick enough to fly to Perth as an emergency but this clinically serious condition requires assessment and management.

In a recent article from WA by Bellinge et al, The impact of non-vitamin K antagonist oral anticoagulants (NOACs) on anticoagulation therapy in rural Australia (MJA 2018; 208: 18-23) the authors identified that in regional WA “…about one-third of patients with AF and with an indication for anticoagulation therapy (according to their CHA2DS2-VASc score) received no anticoagulation therapy.

The authors added that “…the transfer of evidence-based knowledge into rural clinical settings remains difficult…”.

SCENARIO 2: Aboriginal cardiology.

The high prevalence of ischaemic heart disease, diabetes, cardiac failure, atrial fibrillation, rheumatic heart disease and coronary risk factors in Aboriginal patients challenges optimal health outcomes in regional areas.

CASE REPORT: Ischaemic Heart Disease. “Can you see this patient with atypical chest pain? I think he has musculoskeletal pain but it has continued for the last two days”. The patient’s history is concerning with more persistent exertional discomfort of late. ECG changes suggest inferolateral infarction (see ECG 1).

Transfer to Perth for urgent coronary angiography and stenting of a tight right coronary artery stenosis prevents a ‘near-

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Northam Health Access to expert cardiology assessment and care is important in achieving better outcomes in heart failure, valvular disease, obesity, secondary prevention and risk factor management. Population and primary healthcare services also have a key role in these increasingly prevalent and challenging clinical problems.

Specialist testing services including echocardiography and Holter monitoring and

Nothing is simple in rural areas!

One cardiologist reflects on what his regional services have to offer. detailed lung function testing, offered locally, support improved clinical care.

Many health service initiatives, such as telehealth and digital health, have been implemented or are being trialled to address the tyranny of distance – while these initiatives are valuable, they are best seen as a means to augment and complement face-to-face clinician services, rather than substitute for them.

Funding barriers impact on optimal care - siloes exist between the public and private sectors, the GP and Specialist funding and service models of Medicare, Commonwealth and State funded health services. Addressing these challenges offers some of the greatest opportunities for health service innovation and development for regional specialist service provision.

The teaching of medical students in Northam since 2013 has added challenge and reward for medical practitioners here and augers well for increasing the local medical workforce as post grads are more likely to return to rural locations.

Further reading: Australian Institute of Health and Welfare (2016).

Australia’s Health 2016. Australia’s health series no.

15. Cat. No. AUS 199. Canberra. AIHW: Page 248-9 ED. Dr Tony Mylius has been a Clinical Cardiologist for over 20 years. From 2010-2013 he worked as Regional Medical Director for the WA Country Health Service (Wheatbelt) and has been on the Department of Health Cardiovascular Health Network’s Executive Advisory Group since 2012.

He is Assoc/Prof in the Rural Clinical School of WA.

Author competing interests: nil relevant.

Questions? Contact the author on tmylius@wheatbeltmedical.com.au

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Changing hypertension treatment guidelines

By Dr Edmund Lee, Interventional Cardiologist, Murdoch The Joint National Committee (JNC) 7 released in 2003, advised a treatment threshold of 140/90 mm Hg for most adults but included a lower target of 130/80 mm Hg for patients with diabetes or chronic kidney disease. The lower targets were based on observational studies and expert consensus that treating to these would improve cardiovascular outcomes.

The JNC 8 guideline took a different approach by relying primarily on evidence from randomised controlled trials. They only found strong evidence for treating to a BP of 150/90 mm Hg in adults aged 60 years or older and eliminated the lower targets for patients with diabetes and chronic kidney disease, making the goal 140/90 mm Hg for most people.

The SPRINT trial was a study of 9361 participants with systolic blood pressure (SBP) ≥130mmHg with ‘high-risk’ hypertension randomised to either a lower more intensive goal of treatment as <120 mm Hg SBP compared with a goal of less than 140 mm Hg systolic.

The primary outcome here was a combined cardiovascular outcome that included myocardial infarction, stroke, heart failure, or cardiovascular death. The trial was stopped after three years (intended for five years) due to the strongly positive result. The primary endpoint occurred in 1.65%/year in the intensively treated arm (average of 121 systolic) versus 2.19%/ year in the standard group (average of 136mmHg systolic), a 25% relative risk reduction. There was also a 27% reduction in all-cause mortality.

However, 4.7% of the intensively treated arm developed symptomatic hypotension, abnormal electrolytes, acute kidney injury or syncope versus 2.5% in the standard arm. Falls with injury were not increased.

Latest guidelines

Doctors may feel somewhat bewildered at the back-and-forth of hypertension treatment recommendations over recent years.

Are lower goals really better, and how low is too low?

Older adults have the same treatment target as younger patients, and drug therapy is recommended for all older adults (age >65 years) with an average systolic pressure of 130 mm Hg or greater.

The guidelines also stress the importance of average BP measurements taken over several visits, as well as out-of-office measurements (see tables 1 and 2).

Whilst the change in the US hypertension guidelines is likely to be debated throughout 2018, it may increase hypertension awareness, encourage lifestyle modification and focus antihypertensive medication initiation and intensification in adults with high CVD risk.

Guidelines are just that. They are a demarcation of where we should aim but results vary patient to patient. We don't necessarily need to push the BP down in older, frailer patients, particularly if there are anticipated side effects such as pre-syncope or the risk of falling.

Table 1: Categories of BP in adults BP Category

SBP (mm Hg)

Normal

<120

and

<80

Elevated

120-129

and

<80

Stage 1

130-139

or

80-89

Stage 2

≥140

or

≥90

HTN

Individuals with SBP and DBP in two categories should be designated to the higher BP category.

Based on an average of two or more careful readings obtained on two or more occasions.

Table 2: Treatment Recommendations BP Category

Treatment or Follow-up

Normal

Evaluate yearly, encourage healthy lifestyle changes to maintain normal BP

Elevated

Recommend healthy lifestyle changes and reassess in 3-6 months

Stage 1 HTN

Assess 10-year risk for CAD/stroke using ASCVD risk calculator <10%, start with healthy lifestyle, reassess in 3-6 months >10% or known CVD, diabetes, or CKD, recommend healthy lifestyle changes and BP lowering drugs (1); reassess in 1 month - if goal met, reassess in 3-6 months - if goal not met, consider different medication or titration - continue monthly follow-up until control is achieved

Stage 2 HTN

Recommend healthy lifestyle changes and BP-lowering medications (2 drugs of different classes) reassess in 1 month - If goal met, reassess in 3-6 months - If goal not met, consider different medication or titration - Continue monthly follow-up until control is achieved

The new US guidelines, based mostly on the SPRINT result, have made a number of changes. The biggest change would be the new targets for treatment.

KEY POINTS Hypertension guidelines continue to change based on emerging evidence New American (ACC/AHA) guidelines now consider stage I HTN between 130-139/80-89 Home BP measurements are crucial for diagnosis along with a 24 hour BP measurement as the gold standard test Treatment targets should be individualised with potential benefits in achieving lower targets at the expense of sideeffects to treatment.

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DBP (mm Hg)

ASCVD = atherosclerotic cardiovascular disease; CAD = coronary artery disease Author competing interests: nil relevant disclosures. Questions?

Contact the author edmundl@wacardiology.com.au

APRIL 2018 | 31

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CLINICAL UPDATE BACK TO CONTENTS

Reviewing implantable defibrillators in the elderly

By Dr Benjamin King, Cardiologist, Perth Physicians implanting defibrillators have a well-prepared spiel about whether to implant an Implantable Cardioverter Defibrillator (ICD). The discussion includes procedurals risks, inappropriate shocks, quality vs. quantity of life, probability of sudden cardiac death (SCD), and evidence of survival benefit. But when the hardware goes in it is permanent. Do we have a routine for turning off defibrillator programming?

Relativity is changing The major trials (SCD-HEFT, MADIT-2, DANISH) investigating primary prevention of SCD in patient with impaired LV ejection fraction did not include octogenarians (historically excluded from clinical practice). In 2018, we need to mention to patients what we do not know about defibrillators in their age group.

Furthermore, heart disease survival is improving so The ethical end-of-life decisions around ICD those implanted as implantation are increasingly real. younger patients are now getting older and developing expected comorbidities. Even more older patients appear in the secondary prevention group as age is less of an implant contraindication for patients surviving ventricular arrhythmia.

The 2017 Heart Rhythm Society Guidelines for ICD implantation only recommends withholding ICD implantation to patients if survival with “reasonable quality of life and functional status” is estimated at under one year. Curiously, this same definition for withholding some treatments was used 2000 years ago in the Talmud. Therefore, the doctor should consider disabling the defibrillator in patients who arrive at the same sad landmark, or perhaps before this if patients request this.

In contradistinction to pacing and resynchronisation, which offers significant symptomatic gains and withdrawal may have immediate deleterious effects (some legally and ethically problematic), turning off tachycardia therapies can be a progressive discussion.

ICD patients should know that the ICD is only an insurance policy against SCD. Therefore, if a very quick ‘exit’ from this world becomes more attractive than enduring additional unpleasant ICD shocks, device function can be withdrawn simply by the programmer. While not conceding imminent death, it can still be anxiety-provoking, for which the decision can be easily reversed.

Reprogramming doesn’t have to be in the setting of terminal illness, pain or dementia. More ICD patients die of heart failure than die of VT/VF. All-cause mortality is roughly double cardiovascular death,

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There are indications for inserting defibrillators. But as longevity improves and ageing increases, how does this change what we do? such that as diagnoses other than VT/VF are made, it is reasonable to discuss with patients where their ICD therapy fits in.

My personal approach My approach is to insist a final decision not be made at the first discussion. Time to consider and discuss with loved ones is valuable. Indeed, annual ICD tests in stable patients presents opportunities to review patients’ health aspirations. The discussion should be composed and well documented, involving relevant stakeholders in the patients’ health like other matters in Advanced Directives.

It’s probably less traumatic to turn off shocks pre-emptively than during terminal arrhythmia, so if arrhythmia does come, it can gracefully escort the life to its close.

Author competing interests: the author has done research funded by device companies but has not been paid for this contribution. Questions?

Contact benjamin.king@heartcarewa.com.au

KEY POINTS VT/VF therapy (shocks) affects quantity not quality of life and can be simply electronically turned on and off.

There are not extensive robust survival data set of older patients with ICD. ICD patients more commonly die of non-cardiovascular death.

Discussing timing of turning off shock therapy is best done prospectively during reasonable and of mentation.

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APRIL 2018 | 33

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CLINICAL UPDATE BACK TO CONTENTS

Adolescent endometriosis

By Dr Jade Acton, Gynaecologist

Endometriosis is common, yet under diagnosed, in adolescents. Those assessing young women with pelvic pain and dysmenorrhea should consider endometriosis in their differential diagnosis to avoid delays.

It reportedly happens in 25-38% of adolescents with chronic pelvic pain. Traditionally, nonsteroidal antiinflammatory drugs (NSAIDs) and oral contraceptive pills (OCPs) are the first line of treatment.

However, many adolescents describe continuing pelvic pain despite these medications. Moreover, the Endometriosis Association says 38% of women had symptoms starting before age 15 years and when this happens, an average 4.2 physician consultations take place before a diagnosis is reached. That is, the younger the onset of symptoms, the more delayed the diagnosis.

Presentation and assessment Adolescents with endometriosis have a variable pain history (see table 1). Whereas 9.4% will complain of cyclic pain alone, more than 90% have an acyclic pain pattern with or without dysmenorrhea.

In addition, bowel and bladder symptoms may be common in adolescents found to have endometriosis. Complaints of difficulty participating in normal activities, missing school, or avoiding extracurricular activities because of pain suggest that medical intervention is appropriate. A family history makes endometriosis more likely.

Table 1. Presenting endometriosis symptoms in adolescents Both acyclic and cyclic pain

63%

Gastrointestinal pain

34%

Acyclic pain only

28%

Urinary symptoms

13%

Irregular menses

9%

Cyclic pain only

9%

Vaginal discharge

6%

are taken at the first onset of menses and continued for one to three days or usual duration of painful symptoms (those with severe symptoms may begin NSAIDs one to two days prior to onset of menses). The OCP can be taken in either a cyclical or continuous fashion.

Where disabling pain persists laparoscopic diagnosis is essential - numerous series have shown rates of endometriosis at 50-70% when adolescents did not have control of pelvic pain with OCPs and NSAIDs. There is no need to â&#x20AC;&#x2DC;timeâ&#x20AC;&#x2122; the laparoscopy and it can be performed whilst still on OCP and NSAIDs. Surgical management Importantly the gynecologist operating on an adolescent with pelvic pain should also be equipped to both diagnose and treat the disease, to avoid repeat procedures.

Surgery has been shown to reduce pain from endometriosis - endometriosis implants in this age group can vary in appearance (red flame lesions, shiny clear vesicular lesions, and peritoneal windows are more common) and may be missed.

Delayed diagnosis in younger women is a real problem. These notes, and clinical awareness of pain patterns, will help.

When there is no visible evidence of endometriosis, a posterior cul-de-sac biopsy for microscopic disease should be performed (as this is reported in 3% of adolescent girls with chronic pelvic pain unresponsive to conventional therapy and with a visually normal pelvis.)

Post-operative treatment Surgery alone is usually inadequate for endometriosis as microscopic residual disease must be suppressed with medical therapy. The general consensus is that adolescents with histologically confirmed endometriosis should receive medical treatment after surgical ablation/resection until they have completed childbearing.

The rationale for medical therapy is inhibition of prostaglandin synthesis, decidualisation and subsequent atrophy of residual ectopic endometrial tissue, and reduction of ovarian oestrogen production, thereby inhibiting the growth and activity of the endometriosis.

The oral contraceptive pill is the first line treatment for adolescents, followed by progesterone formulations. The MirenaIUD has been shown to be effective and placement at time of surgical diagnosis reduces the incidence of pain and bleeding for adolescents.

References available on request.

Author competing interests: nil relevant.

Questions? Contact the author on jade.acton@ health.wa.gov.au

Physical examination and pelvic ultrasound will most often be normal in adolescents with endometriosis, however, they importantly rule out underlying genital tract anomalies or ovarian cysts etc.

Empiric treatment For a tentative diagnosis of endometriosis, 3-6 months of NSAIDs and the oral contraceptive pill is recommended. NSAIDs

MEDICAL FORUM

APRIL 2018 | 35

O RT H O PA E D I C S

WA

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MEDICAL FORUM

CLINICAL UPDATE BACK TO CONTENTS

Depression and anxiety in Type 2 Diabetes

By Prof Sergio Starkstein, School of Psychiatry UWA, and Fremantle Hospital The prevalence of depression in type 2 diabetes is twice that in the general population. Moreover, patients with diabetes and depression have higher rates of diabetic complication and poor glycaemic control than patients with diabetes but no depression. They have more severe vascular disease, greater physical disability and higher mortality than patient with diabetes but no lifetime depression. Even the presence of sub-clinical depression is associated with adverse outcomes.

The cause of depression in diabetes seems to be multifactorial; but aetiological factors may include the stress and burden of managing a complex disease associated with chronic complications.

When depression occurs before the onset of diabetes, there is poor glycaemic control despite intensive diabetes management, as well as major vascular complications. This has been attributed to lower adherence to medication regimens and detrimental lifetime factors. It is important, therefore, to enquire about lifetime depression histories and these patients probably benefit from depression screening at intervals.

Anxiety affects up to 40% of patients with type 2 diabetes, and depressive and anxious symptoms occur together in about

17% of these patients. This comorbidity is associated with adverse psychological outcomes, poor health behaviour and worse glycaemic control.

Based on these findings, it is suggested that earlier identification and treatment of long-standing depression and anxiety, reduces the risk of more severe psychopathology, worse glycaemic control and associated risk for health complications.

The PHQ-9 is a self-assessed questionnaire for depression, whereas the GAD-7 is a self-assessed questionnaire for anxiety, which were validated in diabetes. Both may be completed in less than 10 minutes in the waiting room and may provide valuable information to the GP regarding the emotional status of the patient.

KEY POINTS Depression and anxiety can worsen outcomes in Type 2 Diabetes.

GPs can use screening tools to assess both problems in diabetes.

Researchers may find that screening for associated cardiovascular risk in affected patients is a good idea.

Type 2 Diabetes coupled with anxiety and depression is an untoward combination, increasing the risk of health complications.

How can doctors screen for this combination and is it simple?

There are new instruments, soon to be available to the GP, that combine the main items of the PHQ-9 with items from instruments to specifically screen for anxiety in type 2 diabetes. These instruments are short and can be easily completed in the waiting room.

They provide information on the diagnostic category of mixed anxiety-depression, which is most frequent in diabetes and has the strongest predictive value. Recent studies have identified a sub-group with major depression and anxiety which was associated with a higher incidence of coronary heart disease and cardiovascular mortality - future studies may demonstrate the usefulness in monitoring response to psychiatric treatment and assessment of cardiovascular risk.

Author competing interests: nil relevant disclosures. Questions? Contact the author on 9431 3333

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APRIL 2018 | 37

FEATURE

Taking it to the Streets Freo Street Doctor’s patients are among the most vulnerable in our community and its contribution to many aspects of their lives is absolutely crucial.

T

here’s something pretty wonderful about a medical clinic that comes to a corner near you! The Freo Street Doctor does just that and provides access to high quality, non-judgemental health care to patients, many of whom are homeless. The medical practice is fully accredited to RACGP standards, there are six doctors behind the wheel and Dr Neetha Purushotham is one of them.

“It’s a great service and the patient population we see would find it quite difficult to go anywhere else. Many of them are not all that aware of their own health needs and, to be honest, probably don’t think about it all that much,” she said.

“You just can’t pigeon-hole these patients.

I can’t really expect with any degree of confidence that they’ll do what I suggest.

I see them for a short time on a Friday and that’s a tiny sliver out of their lives.

And, quite often, their lives can be pretty complicated.”

“Usually they’ll have plenty of other things to worry about.”

“I keep any frustration at bay by picking my battles and getting a lot of joy when I have a small victory. It’s great when a patient comes back to have a dressing changed or a mum brings their child back for a scheduled review.”

The network works Neetha’s working week is a combination of GP surgery consultations and the Freo Street Doctor. And, for the latter, Medical Forum can take some credit.

“I work in a clinic in Armadale four days a week and every Friday in the mobile van. I was looking for a bit of variety in my work, I spotted the advertisement in your magazine and I thought it would be a great thing to do!”

“I really like the patients. This job stretches my brain and that’s a good thing.”

“Often a different approach is needed because their expectations of life vary enormously. And, for many of them, the state of their own health is merely an ‘add-on’.”

38 | APRIL 2018

Some workplace situations can be both demanding and difficult, but Neetha has no qualms fronting up for work on a Friday morning.

“I’ve never had any problems with personal safety here at the Freo Street Doctor. It’s just never been an issue for me.

Managing the precarious “We have a social worker who vets the patients and if any are under the obvious influence of drugs or alcohol we ask them to come back when they’re feeling a little better. Most of our patients are really nice and they’re so grateful for the service.”

Neetha trained in India before coming to Perth to reconnect with former university colleagues.

“I’m the first, and only, doctor in my family.

I did my postgraduate work in the UK, worked there for about 11 years and came here to see university friends who I hadn’t seen for a long time. I really like Perth and Margaret River and plan on spending a few more years here.”

“After that, who knows?”

“What I do know is that I love this job. I hope that a lot my colleagues read this story and might consider giving the Street Doctor a try. I’m sure they’d really enjoy helping these patients.”

Marina Trevino, Manager Community Medical Services at Black Swan Health, is the organisational face behind the Freo Street Doctor (FSD) program. It provides more than 2000 consultations a year and the majority present with more than one medical condition. The suburbs covered by the program are numerous (see below) and a salient statistic is that in excess of 90% of clients use FSD as their primary healthcare provider.

Growing services “The service has been going for 13 years and it’s developed to the point that we now have clinics five days a week at multiple locations. We use two vans, there are six doctors on the books and we’re always looking for more.”

Strait Islander people as well. Many of them are socially isolated and often feel very uncomfortable attending a conventional medical clinic. Most Freo Street Doctor clinics have a GP, nurse and support worker in attendance.”

Katrina and Leanne sat on chairs under the shade waiting for their appointment and were more than happy to sing the praises of the Fremantle Street Doctor.

“I’m here to support Leanne,” said Katrina.

“I live quite close by and I’ve been here a few times now. I also go to see Dr Davies (Dr Andrew Davies at Homeless Healthcare) in Leederville but this is so handy for me. The clinic is wonderful because the doctors spend a lot of time with you and go out of their way to help.”

“A lot of people are really struggling and it’s good to have someone who will just sit and listen.”

“This is my first time here so I’m a bit nervous,” said Leanne. “I’ve got some medical problems and it’s difficult for me to work. Hopefully the doctor can help me with a health assessment and I’ll be able to get the pension. I’m 65 years old and it’s not easy looking for work at my age.”

FAST FACTS Three-hour clinics are held MondayFriday across the suburbs of Fremantle, Cockburn and Melville.

No appointment is necessary and all consultations are bulk-billed.

By Peter McClelland

“A lot of our patients are homeless with a high proportion of Aboriginal and Torres

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One of the Freo Street Doctors' Dr Neetha Purushotham with patient Leanne.

EDUCATION

Psychiatry Master Class The third psychiatry master class organised by Dr Mathew Samuel from the Hollywood Clinic saw 160 psychiatrists, psychiatric registrars, GPs, psychologists and mental health nurses hear from some world leaders in the area of mood disorders and treatments.

Mathew gave us a short insight into the twoday event, which took place early in March.

Prof Guy Goodwin, from Oxford University, whose particular field of study is the treatment of bipolar disorder and the neurobiology of mood disorders with a focus on developing new treatments, spoke on these issues as well as individual responses to SSRI medications.

Prof Malcolm Hopwood and Prof John Tiller came from the University of Melbourne with Prof Hopwood looking at the mixed state in Bipolar Affective disorders and Prof Tiller, a recognised expert in ECT provided an update on the treatment.

Two expert psycho pharmacologists, Professor David Castle (anti-psychotic medications for depression) and Dr Darryl Bassett (anxiety) also presented papers.

Mathew said that a hot topic of discussion was shared care and how doctors and health professionals could better engage patients in their own treatment.

“The latest studies are showing that less than 50% of patients fill their scripts. We have to do more than give patients a script

and tell them we’ll see them in six months,” he said.

“Patients need more information and more open discussion about side-effects to enable them to make decisions about their illness and treatment.”

Mathew said planning would soon commence on next year’s master class because it had created a much-needed opportunity for genuine psychiatric education in Perth.

The event’s major sponsor was Hollywood Private Hospital with supporting sponsors from a variety of pharmaceutical companies.

Doug Brewer, Dr Robert Segal, Dr Davinder Hans

Peter Mott, Prof Guy Goodwin, Dr Mathew Samuel, Kevin Cass-Ryall

Dr Leighton Chadwick and Dr Urvashnee Singh

40 | APRIL 2018

Steve Wilson and Dr Anthony Zorbas

Prof Malcolm Hopwood

Dr Amanda North and Dr Tanya Devadason

MEDICAL FORUM

WINE REVIEW

Discovering Lambert Treasures The Barossa Valley, one of Australia's oldest and most classic wine regions, hosts about 550 grape growers, 170 wine companies and 80 cellar doors which make it impossible to be familiar with all (though not for want of trying). So it was exciting to find a quality producer previously unknown. Lambert Estate ticked all those boxes for me.

Wisconsin businessman Jim Lambert was visiting the Barossa in the 1990s and fell in love with the place.

He and his wife Pam bought a property just west of Angaston in the north-east corner of the valley.

Subsequently his son Kirk joined his parents in South Australia, studied oenology at Adelaide University where he met and married a fellow student, Vanessa from Peru, and now the pair oversees all production.

By Dr Craig Drummond Master of Wine

With over 40ha and 17 different soil types at varying altitudes, the various microclimates created have allowed them to produce an array of estate-grown wine styles.

Six high quality wines were submitted for tasting and I was surprised that only one wine was under screwcap with five under cork at a time when the Australian industry has moved almost exclusively to closures other than cork. But happily all wines were in good condition.

WIN!

A DOCTOR’S DOZEN

ENTER ONLINE! www.medicalhub.com.au

1. The Prologue 2017 Sparkling Pinot Noir, RRP $27 This wine shows a fine bead, a complex integrated nose with yeast autolytic characters reflecting the methode champenoise, and confectioned red fruits from the pinot noir grape. The palate has a fine mousse (mouthfeel), flavours of cherry and cranberry, and crisp firm acidity from early harvesting, hence the alcohol level of only 10%.

A full-bodied, rich style with lingering flavours. A very good example of Australian sparkling wine 2. First Kiss 2017 Rose, RRP $20 This wine, with its attractive salmon pink colour, is dry with savoury characters and reminds me of the rose wines of the Southern Rhone, France. The aromas are restrained, showing some caraway seed character, while the flavours are broad, with sour cherry. A wine to accompany seafood, in particular oysters. For short-term consumption.

3. A Thousand Words 2015 Chardonnay, RRP $27 A typical Barossa chardonnay – this wine is full-flavoured, complex, ripe (alcohol is a huge 14.5% ), golden in colour and 'big' on the palate. Aromas of ripe melon and fig are replicated on the palate. The acidity is sufficient to support the ripe fruit and high alcohol. Generally I'm not a big fan of Barossa chardonnay but I enjoyed this wine a lot. It shows integration, length and a flavoursome clean finish. In fact, it is my second wine of this tasting.

Silent Partner 2012 Cabernet Sauvignon, RRP $90 One may baulk at the price but it is worth it.

It is a privilege to be offered a super-premium wine that is at optimum maturity for tasting, and clearly my favourite of the wines reviewed.

Attractive deep purple/red colour with a slightly browning meniscus from gentle ageing. The aromas leap out of the glass and are as fresh as a daisy given the wine’s maturity. They show vibrant mint and eucalyptus followed by trademark casis, all coated in wonderful oaky aromas. Then there is the palate. Wow! Supple yet powerful with smooth silky polymerised tannins. Oozing blackcurrant, menthol, perhaps a touch of truffle, and cedary oak showing through. A wonderful wine that will drink beautifully for many years to come.

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4. Tempt Me 2016 Ternpranillo, RRP $28 This is a good varietal example of this increasingly popular Spanish grape. A vibrant garnet colour, a savoury, herbal nose with black cherry, deep brooding flavours of black plum, allspice, with a touch of tobacco. It displays the typical tempranillo 'milky' mouthfeel. An attractive wine for mediumterm consumption.

5. The Commitment 2013 Shiraz, RRP $42 Quality Barossa shiraz never disappoint and here is another iconic example – big, warm (alcohol 15.5%), ripe and mouthfilling. A bouquet of pepper and allspice, earthy with hints of liquorice. Rich blackberry and black pepper flavours and vanillan comes through from well-handled oak. It’s a full-bodied wine that has just commenced its journey.

MEDICAL FORUM

APRIL 2018 | 41

MUSICAL THEATRE

ABBA Dabba Do! The unbridled joy that is Mamma Mia! will be heading to the Crown Theatre in Perth from May 15 with its 22 infectious ABBA songs and a story that will relieve the burdens of daily life if for just a few hours.

The uplifting musical has been playing on a stage somewhere in the world continuously since its West End debut in 1999, breaking box office records and keeping the ABBA flame alive. The font of all wisdom, Wikipedia, says that on any given day at least seven performances of Mamma Mia! are being performed around the globe.

It is still on the West End making it the eighth longest-running show in London stage history … and counting.

The musical was written by British playwright Catherine Johnson around the ABBA hits with the band’s Benny Andersson and Bjorn Ulvaeus involved in the development of the show. Anni-Frid Lyngstad was an investor and it has proved to be a very wise investment.

The story is sweet simplicity and complicated by that fact. Sophie Sheridan is a young woman planning her Greek island wedding and she tells her mother, Donna, she would like to have her father walk her down the aisle. The trouble is Donna is not quite sure who that is (well she is but she’s not saying and it would spoil the plot anyway).

So, three likely dad prospects arrive on the island ready to take their cue.

Australian producers Michael Coppel, Louise Withers and Linda Bewick are the local team taking a chance on Mamma Mia!, which has now begun its year-long journey across Australia. Medical Forum spoke to actor Phillip Lowe after the show opened in Sydney.

The WAAPA-trained musical theatre star plays Harry Bright, one of the three likely dads. For those needing to reference the 2008 film, Harry was played by Colin Firth.

Phillip is somewhat in awe of the impact the show is having on audiences in Sydney.

“Grandmothers and their four-year-old grandchildren are dancing in the aisles. We have to discourage them from joining us on stage. It really is phenomenal,” he said.

“The show is a lot of fun but the secret of its success is certainly the ABBA songs.

ABBA has seeped into our DNA here in Australia, there’s no question. To hear the roar at the end of the show is simply wonderful. It makes me feel like I have the best job in the world.”

In the fickle world of theatre that feeling has to keep you warm through some lean times. For Phillip, the lean years were back in the mid-2000s when he felt that as he said, he “should try to get a proper job”.

“I did some study and joined a management

consultancy business but then the Global Financial Crisis hit and the first things to go are the consultants,” he said.

Theatre was a more secure prospect and he’s been busy ever since!

Most recently he was playing Keith Potger in Georgy Girl, the award-winning stage show on the music and times of The Seekers.

“That was enormous fun setting the foundations of an original theatre piece.

You don’t get to do that often and it was a privilege meeting the members of the band … they’re legends.”

While Phillip has had plenty of TV and film time (McLeod’s Daughter’s, All Saints, Home and Away, Blonde, Crownies, Thank God He Met Lizzie among others) he said that nothing matches the buzz of live theatre, even though his nerves are shattered every time he has to audition.

“I’m always very calm and collected going for screen roles, but performing for that panel of judges for a spot on the stage, sitting with everyone else and listening to how good they all are, it’s horrific!”

But he clearly is doing something right and looks forward to return to his student stamping grounds of Perth and dancing in the aisles with the local audiences.

Escaping to Greece with ABBA and Mamma Mia! – how can we resist you?

By Jan Hallam The cast of Mamma Mia! with Phillip Lowe third from left.

42 | APRIL 2018

MEDICAL FORUM

THEATRE

Walking, Talking, Living Doll Readers of a certain age will have almost certainly come across Ray Lawler’s 1955 play Summer of the Seventeenth Doll as 16-year-olds, who while staring out of a school window wondered how a woman could wait around for a man for 17 years. That was longer than most of us had been alive!

“Finding the right cast for this play was critical in order to do it justice. When I met Amy I knew I had found my Olive.

She is such a wonderful earthy actress.

I felt immediately confident, ‘We can do this play!’”

Lawler, who played the part of Barney in the world premiere in 1955, had reread the play and felt the first act needed a bit of work as did sections of the second which would help it spring more readily into the third and final act.

He has cast Aboriginal actor Kelton Pel, who has been a legend of the WA stage for 20 years.

Such is the perplexing and eternal drama of Lawler’s classic depiction of Australia of the 1950s, where rural came to the city; when we idolised the suburbs, and gender and sexual lines were being pushed and pulled in ways that would change relationships between the sexes forever.

“Casting Kelton offered a fascinating insight into the play. Clare and I both came to Pelton separately. We were looking for an actor who has this vulnerable, faded masculinity and being an indigenous man offers its own resonance.”

“I was blown away. Here was the playwright after 60 years still wanting to make changes. This play is a living breathing thing. It’s a privilege to be doing a new version of the Summer of the Seventeenth Doll and possibly the last version of the work.”

These are the big issues that our 16-yearold selves could never imagine.

Director Adam Mitchell, who will stage a production of The Doll at Health Ledger Theatre for Black Swan State Theatre Company in May, recounts a similar trajectory.

“I first came upon the play in high school and it didn’t speak to me at all,” he told Medical Forum. “Then when I started making theatre in my 20s, I still didn’t have a place for the play because I wanted to be out there making sexy, cutting edge drama.”

One thing Adam wasn’t expecting, though, was a call from the playwright himself.

Aged 96, Lawler had been reviewing sections of the play and had suggestions to offer Adam’s new production.

“I got a message from Black Swan that ‘Ray wants to talk to you’. I was delighted to think Ray still had something else he wanted to say, or wanted the audience to think differently about.”

Making her professional debut is Mckenzie Dunn who will play the role of Bubba. She too will have some inside information about The Doll. She is the granddaughter of theatre legends Jill Perryman and Kevan Johnston, who both appeared in the Hole in the Wall production in the 1980s.

So here we have it. The Doll for another generation.

By Jan Hallam

“Then 10 years later I read it again and was blown away by just how good it was.

There have been parallels to Eugene O’Neill’s work and I think that’s a fair comparison. After 60 something years of being played around the world it is a delight.”

“So when Black Swan’s artistic director Clare Watson began talking about the play with me, I felt I was ready.”

Part of Adam’s enthusiasm was finding the right actors for the hinge characters Roo and Olive.

Roo is the canecutter who spends the layoff months with Olive and her mother in her cottage in Carlton. Despite the picket fence and wedding ring morality of the time, Olive likes it that way. The past 16 years, marked by the giving and receiving of a fairground cupie doll, were fun and carefree. The 17th summer will be different.

Adam who also teaches at WAAPA has cast Amy Matthews as Olive. Amy established her career in Sydney with stage and TV roles, including a run on Home and Away.

MEDICAL FORUM

APRIL 2018 | 43

Anything Goes What do you call an imaginary colour?

A pigment of your imagination.

I was on a flight the other day when the air hostess came up to me and said, "Excuse me sir, would you like to have dinner?"

I said, "What are the options?"

How many surrealists does it take to screw in a light bulb? A fish.

The master smiled and said, "You are on the other side."

Pavlov is sitting at a pub enjoying a pint. The phone rings and he jumps up shouting, "Oh s---, I forgot to feed the dog!"

3. One Zen student said, "My teacher is the best. He can go days without eating."

A classics professor goes to a tailor to get his pants mended. The tailor asks, "Euripides?" The professor replies, "Yes. Eumenides?"

The third said, "My teacher is so wise that he eats when he's hungry and sleeps when he's tired."

It's hard to explain puns to kleptomaniacs because they always take things literally.

A Freudian slip is when you mean to say one thing but you accidentally say Mother.

“Welcome to plastic surgery addicts anonymous. I see a lot of new faces tonight, which is disappointing.”

The second said, "My teacher has so much self-control, he can go days without sleep."

4. For his 70th birthday, one of his students gave the zen master a big box with a ribbon around it. When the master opened the box, he found that there was nothing inside. "Aha," he exclaimed, "just what I wanted!"

5. A Zen student asked his master, "Is it OK to use email?"

She said, "Yes and No."

A palindrome walks into a bar, says "Syasraba Otni Sklawem Ordnilapa".

"Yes," came the reply, "But no attachments."

What do you call a Mexican bodybuilder who’s run out of protein?

The Art of Zen

6. Don't walk behind me, for I may not lead. Don't walk in front of me, for I may not follow. Just walk beside me and keep quiet.

Or even better, go away.

No whey Jose.

A frog telephones the Psychic Hotline. His Personal Psychic Adviser tells him, "You are going to meet a beautiful young girl who will want to know everything about you."

The frog is thrilled, "This is great! Will I meet her at a party?" "No," says his adviser, "in her biology class."

Honest Brand Slogans Hallmark: “When you care enough to give a card mass-produced by a corporation.”

Ritz crackers: “Tiny, edible plates.”

Cliffs Notes: “They’re still going to know you didn’t read the book.”

1. A Zen student went to a temple and asked how long it would take him to gain enlightenment if he joined.

"Ten years," said the Zen master.

"Well, how about if I really work hard and double my effort?"

"Twenty years."

2. Seeing his master on the other side of a raging torrent, a student waved his arms and shouted out, "Master, master, how do I get to the other side?"

Gillette: “We’re just going to keep adding blades.”

ChapStick: “You’ll misplace it before the tube’s empty.”

Clever clogs A linguistics professor says during a lecture that, "In English, a double negative forms a positive. But in some languages, such as Russian, a double negative is still a negative. However, in no language in the world can a double positive form a negative." But then a voice from the back of the room piped up, "Yeah, right."

Beer

winner Radiologist Tracey Muir was smiling all the way to the fridge with her Doctor’s Dozen 4 Pines Beer. And so was her husband, Jake, who loves a strong ‘hoppy’ brew while Tracey is rather partial to a crisp Lager or Kolsch. They’re looking forward to enjoying them after a busy stint of on-call radiology for Tracey and an even busier week of Play School for Jake and their two children!

44 | APRIL 2018

MEDICAL FORUM

COMPETITIONS

Entering Medical Forum's competitions is easy!

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

Movie: The Leisure Seeker Oscar winner Helen Mirren and Donald Sutherland star as an older couple looking for adventure on one boisterous and bittersweet final road trip. Based on the novel by Michael Zadoorian, Mirren scored a best actress nomination at the recent Golden Globes.

In cinemas, May 3

Comedy: Craig Hill Hill’s Someone’s Going to Get Kilt! is coming to the Perth Comedy Festival in May after a madcap year touring around the UK and international comedy festivals. Before all the tartan gags, Hill was a hairdresser. He credits is shiny dome to an experiment with a home bleach kit that went horribly wrong. But it did inspire him to pick up the scissors. In his own words, as “much as he loved the patter and the reward of perming an otherwise dull, flat bob” he had to give in to his real passion, performing.

At 20, he went to drama college, picking up roles in Panto, short films and theatre until he got bitten by the comedy bug and he found his place in the stand-up spotlight including gigs at the famous Comedy Store in London. He even got his own Friday night comedy show on BBC 1, Craig Hill's Out Tonight.

He’s a 14-year veteran of the Edinburgh Fringe and a comedy festival regular around the globe – Cape Town, Montreal, New York, Switzerland, Madrid, Paris, Sydney, Melbourne, Perth and Adelaide – everywhere turns a little tartan.

Movie: Tully Charlize Theron plays a mother of three including a newborn, who is gifted a night nanny by her brother.

It turns out that Mum forms a unique bond with the thoughtful, surprising and sometimes challenging young nanny named Tully.

In cinemas, May 10

Movie: Spanish Film Festival The 2018 Spanish Film Festival celebrates the culture, life and cinema of Spain with the comedy The Tribe (La Tribu) opening the festival with love and laughter. There are plenty of other award-winning films. For details www.spanishfilmfestival.com Cinema Paradiso, April 26-May 16

Hellenic Club, 75 Stirling St Perth, May 3, 7pm

Theatre: Summer of the Seventeenth Doll M E D I C A L F O R U M $ 12 . 5 0

Ray Lawler’s classic is revived by Black Swan State Theatre Company with a cast of local stars and fresh eyes from director Adam Mitchell. It’s set in 1950s Melbourne and revolves around two roustabouts returning for another layoff season.

This summer things are different.

Winners from February

Heath Ledger Theatre, from May 5-20; Medical Forum May 5, 7.30pm

TRENDS & INNOVATIONS F E B R U A R Y 2 0 18

Movie – The Mercy: Dr Sarah Harris, Dr Annette Finn, Dr Moira Westmore, Dr Barry Leonard, Dr Yohana Kurniawan

MAJOR PARTNER

Movie – Winchester: Dr Sue Martin, Dr Germaine Wilkinson, Dr Elena Monaco, Dr Helen Clarke, Dr Rosemary Quinlivan

February 2018

www.mforum.com.au

Musical: Mamma Mia!

Music – King's Singers & St George's Consort: Dr Liz Ferguson

The music of ABBA and the funny, feelgood story of young love and how it can get complicated is on the menu here. Young bride Sophie wants her father to walk her down the aisle, trouble is – there are three men to choose from.

Theatre – Senior Moments: Dr Max Kamien

Crown Theatre, From May 15

Movie – Early Man: Dr Susan Sperber, Dr Keren Witcombe, Dr Brendan Connor

Fringe – Flaws & All : Dr Tracey Muir

MEDICAL FORUM

APRIL 2018 | 45

Stop heavy periods.

Period.

Did you know 1-in-5 women suffers from heavy menstrual bleeding?1 The NovaSure® endometrial ablation procedure is a minimally-invasive treatment option to discuss with these patients – especially those who prefer to avoid hormones or a hysterectomy.

Premenopausal women who have completed their childbearing may be candidates.2 5 minute procedure*

No hormones

Effective in 9-in-10 patients3

97% avoid hysterectomy at 5 years4

Find a NovaSure specialist

novasuredoctorfinder.com.au

Proven outcomes. Extensive data.

Over 2 million women treated worldwide.

novasure.com

* The NovaSure® procedure is performed by a gynaecologist. The average treatment time is 90 seconds, and the entire procedure typically takes less than 5 minutes to complete. 2 References: 1. National Women’s Health Resource Center (United States). Survey of women who experience heavy menstrual bleeding. Data on file, 2005. Based on women aged 30-50 years.

2. NovaSure® Instructions for Use. Bedford, MA: Hologic, Inc. 3. Cooper J, et al. A randomized multicenter trial of safety and efficacy of the NovaSure system in the treatment of menorrhagia.

J Am Gynecol Laparosc. 2002;9:418-428. 4. Gallinat A. An Impedance-Controlled System for Endometrial Ablation: Five-Year Follow-up of 107 Patients. J Reprod Med. 2007;52(6):467-472.

ADS-01814-AUS-EN REV.001. © 2017 Hologic, Inc. All rights reserved. Hologic, NovaSure and associated logos are trademarks and/or registered trademarks of Hologic, Inc. and/or its subsidiaries in the United States and/or other countries. This information is not intended as a product solicitation or promotion where such activities are prohibited. Because Hologic materials are distributed through websites, eBroadcasts and tradeshows, it is not always possible to control where such materials appear.

Hologic (Australia) Pty Ltd, Level 4, 2-4 Lyon Park Rd, Macquarie Park NSW 2113. Tel. +61 2 9888 8000. ABN 95 079 821 275.