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Women’s Health • Keeping Abreast • Treating Anorexia Nervosa • Risks vs Rewards of Medicine • Clinicals: HRT, Hyperhidrosis, Breast & Bone Density

May 2017

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EDITORIAL

Violent World; Violent Homes It might be that time of year with the Federal Budget looming, but reports of all kinds have been flying around the office thick and fast. More often than not they’re not telling a happy story, nor even a new one. Take the two recent reports on Family and Domestic Violence (FDV) from WA Health and the Australian Institute of Health and Welfare. They’re sobering, when they’re not heartbreaking. We go into some of the more hideous figures in our By the Numbers column on p13 but it really got us wondering what is being done by those up the chain from the GPs and ED health workers. They are the ones who comfort and patchup the hundreds of walking wounded, and then there are the WA families who, on 19 occasions in 2016, buried women and children who had been murdered by someone close to them. In 2015, The Australian of the Year Rosie Batty courageously committed herself to open up the national conversation about FDV just a few months after her estranged husband murdered their young son. It proved to be a landmark year for not only conscious-raising but government commitment from the top down. So in the interest of accountability, here’s what our past prime ministers have had to say about FDV. •

In 2009, PM Kevin Rudd announced a $41.5m strategy to tackle domestic violence. He aimed to ensure that a domestic violence order taken out in one state or territory was automatically registered across the country and threw $3m into the ring to make it so. In 2016 (2017 in the NT) legislation was passed by all state and territory governments – a mere seven years after the drum was sounded – and still it needed a hefty push by PM Tony Abbott in 2015. Money also flowed to a 24/7 crisis line and $9m to a schools program and $17m on a public information campaign.

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In September 2015, PM Tony Abbott said “enough is enough”. The spur for Mr Abbott was the deaths of three Queensland women in the space of just a few days, and he promised to fast-track domestic violence reforms. In the May, he convened a COAG advisory panel to reduce violence against women chaired by Victorian Police Commissioner Ken Lay and Rosie Batty. And $30m went to frontline services.

In October 2016, PM Malcolm Turnbull described Australia's domestic violence rates as a "national shame" at the first leaders' summit to reduce violence against women and children. He outlined his Third Action Plan – $20m for the prevention and early intervention programs; $25m for ATSI services; $15m to improve and expand national domestic and family violence services; $30m for frontline legal services to support women; $10m to respond to ‘revenge porn’ and online abuse. We can mourn the growing list of lost and damaged lives, we can spew the figures out forever; we can tot up the ledger and shake our head at the money spent. We can also feel overwhelmed and helpless that these things continue to happen in our community despite all of the above.

Shock commentator and former Labor leader Mark Latham was partly right when he said domestic violence was caused by poverty not patriarchy. It’s why so much money has been channelled into social support. But his refusal to acknowledge the part our culture plays in this tragedy is why it will be rerun time and time again. It’s a strange world where we can quote Tony Abbott without talk of a leadership spill, but his words back in 2015 hold the key: “My message to everyone – to our brothers, to our sons, to our mates, is: no more. Never, ever again.” But are they listening?

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May 2017 | 1


CONTENTS MAY 2017

41

16 FEATURES 16 Breast Cancer Research 18 Healing Power of Dance 26 Doctors Drum: Serving the Community 41 Dense Breasts NEWS & VIEWS 1 Editorial: Violent World; Violent Homes

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Jan Hallam Letters to the Editor ATAPS Chop Devastating Dr Jane Ralls ATAPS Responses Ms Learne Durrington Dr Nathan Gibson Patient Rules Ms Alison Verhoeven Raw Deal for Rural GPs Dr Philip Green WACHS Response Dr Tony Robins End-of-Life Choices Mr Robin Chapple Listen to Experts Dr John Hayes Rethinking Training Mr Kim Snowball

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12 13 14

Have You Heard? Beneath the Drapes New Boss at WACOSS Louise Giolitto 20 Dying to be Thin 25 100 Women Giving Circle 49 Practice Management: Do Not Call

Lifestyle 44 Angel Flights 52 My Local: Mr Gill’s of Subiaco 52 Recipe: Prosecco Jelly 52 Wine Winner: Dr Di Hastrich 53 Beer Review: Gage Roads

Dr Sergio Starkstein & Dr Bradleigh Hayhow 54 Arts: Enoch Arden 54 Funny Side 55 Competitions

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Bone turnover markers – update on bone resorption Dr Johan Conradie, Dr Melissa Gillett, Dr Kalani Kahapola Arachchige, Dr Chanika Ariyawansa

41

Dense Breasts and Mammograms Clinical A/Prof Liz Wylie

42

Dense Breasts Management Dr Corinne Jones

43

Women’s Breast Imaging Dr Maria Vanessa Atienza-Hipolito

45

Axillary Hyperhydrosis Dr Sanjay Sharma

39

MenW Vax for Teens Dr Astrid Arellano

47

Hormone Therapy For Women Reconsidered Dr Angamuthu Arun

guest columns

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More Data, More Care Ms Pip Brennan

Thursday, June 22 7:15 - 8:50am Royal Perth Yacht Club Generously supported by….

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Equity for Women Prof Steve Chapman

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Visit www.doctorsdrum.com.au to reserve your place • Styled after the ABC’s entertaining Q&A with stimulating light-hearted discussion • Enjoy a delicious breakfast, courtesy of the sponsor • Independent MC Andrea Burns keeps it relaxing and relevant

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Negative Cycle of Sexualisation Ms Caitlin Roper

How much do doctors need to know from the bureaucracy? How much do consumers need to know from doctors? Economic and clinical transparency – what’s to hide? Why do we need Transparency?

Come along and have your say, meet up with colleagues, or just sit back, listen and enjoy the discussion and breakfast. 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 May 2017 | 3


LETTERS To THE EDITOR ATAPS chop devastating Dear Editor, Thank you for your feature article about Mental Health’s direction by Nathan Gibson (Inside WA’s Psychiatry Services, March). I was disappointed not to see any reference to Access To Allied Psychological Services (ATAPS). As a GP in North Metro, I do a lot of mental health and have established some really supportive teamwork with two excellent local psychologists who have used ATAPS for financially challenged patients and the Lighthouse program (unlimited free sessions for a set time period) for those at risk of suicide. I also use these psychologists for private referrals via Better Access. ATAPS has been very useful especially as there were 12 sessions instead of 10, and it could be extended to 18 where necessary. One of the most important prerequisites of good mental health care is continuity of care. With ATAPS, extremely vulnerable people could start with Lighthouse two or more times a week, then, as things settled, could transition to ATAPS. If they had a little money and needed ongoing long-term help we could use Better Access for brief periods until they were eligible for ATAPS again. This has worked well and I have seen amazing results in patients who see the same psychologist for ongoing therapy. Suddenly the psychologists told me that ATAPS was ending, with no new patients being accepted and existing patients only given one more session. What an extraordinarily cruel way to treat vulnerable people! Black Swan informed me via a letter about a patient they rejected that he could make an appointment under Better Access with one of their counsellors. I have no idea of the credentials of their ‘counsellors’ and am doubtful that such a service can provide continuity of care. This also means vulnerable people having to front up the full fee before getting a rebate with a larger out-of-pocket cost. The most vulnerable simply can’t do that.

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4 | MAY 2017

I am incredulous that I have had no letter from the PHN about this change. I wonder under what justification it is OK to withdraw treatment from people who were already accepted into the system? I wonder whether the same will happen to the Lighthouse program at the end of the financial year, and whether anyone will tell GPs? Are other people having the same experience in other regions, and is anyone going to recognise the devastating loss of continuity of care that this means? Dr Jane Ralls, GP, Woodlands ........................................................................

ATAPS Response Dear Editor,

Referring doctors will receive initial assessment feedback on their patients and ongoing progress reports allowing them to adjust their care provision as required. Information packs for GPs and practice managers will be available and will detail the evidence underpinning stepped care models, as well as information about the transition to the new treatment options. WAPHA will provide GPs with the support and resources they need to explain the change to their patients. The Commonwealth guidance indicates that long-term psychological therapy is not in scope for WAPHA-commissioned services. Nonetheless WAPHA is aware that a small number of individuals with enduring and/or severe mental health problems are managed by GPs who rely on ongoing access to psychological therapy as a component of long-term care.

Your GP’s letter captures one of the issues inherent in the ATAPS program, which was that for many years, patients have had to move in and out of programs to get the mental health care they need.

WAPHA is keen to hear from affected GPs to gauge the extent of this issue. Phone 6278 7913 or email steppedcare@wapha.org.au.

In accordance with Commonwealth Government guidelines, we are transitioning to an evidence-based model of stepped care for mental health, which gives patients access to a wider range of care options so they receive the right level of care at the right time.

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

All patients presently accessing mental health care through ATAPS will be able to complete their cycle of care with current ATAPS providers who are contracted until June 30, 2017.

Primary care access to sustained, quality psychological services is critical. There are issues of access, and then there are issues of continuity. They are linked but separate.

In the future, GPs will have the option to refer patients to a virtual psychology clinic known as Practitioner Online Referral Treatment Service (PORTS). PORTS will offer face-to-face, telephone and clinician supported internet based CBT treatments for patients aged 16+ with mild to moderate anxiety, depression or problematic substance use. PORTS will provide GPs with a single referral point for all patients. Like the ATAPS program, PORTS is for people who hold a health care card and/ or are in genuine financial hardship. Unlike ATAPS, however, PORTS will not have any co-contribution, ensuring cost is not a barrier to care.

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Learne Durrington, CEO, WAPHA Ed: Next issue we will investigate what these changes will mean for doctors and their patients

ATAPS Response Dear Editor,

As Chief Psychiatrist, my concern is that where psychological services are not accessible, affordable and reliable, restricted options may lead to higher rates of psychotropic prescription as the initial treatment. Psychotropic medications are an essential component of therapy in a range of complex and serious mental disorders. However, in cases of mild-moderate anxiety or depression, the RANZCP Guidelines tell us that non-pharmacological therapies are often the most effective initial treatment. We have to advocate for access to best practice for our patients and families. continued on Page 6

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Major Sponsor: Western Diagnostic

The biochemistry department at Western Diagnostic Pathology has expertise across multiple disciplines including clinical biochemistry, toxicology and clinical endocrinology. We also have an accredited registrar position with a wide variety of teaching opportunities.

Bone turnover markers – update on bone resorption CTx (Beta – CrossLaps/ C-terminal telopeptide of type 1 collagen) The prevalence and incidence of metabolic bone disease is increasing with an aging population. In conjunction with imaging and clinical history, biochemical bone markers have become integral to diagnosis and monitoring. Bone undergoes constant remodelling dynamic formation and resorption. Bone turnover markers offer a non-invasive way of assessing bone turnover. Several are available, either as markers of bone resorption (including plasma/serum CTx and urine NTx) or bone formation (total ALP, bone ALP or P1NP). Bone comprises about two thirds mineral and one third osteoid, most of which is type 1 collagen. Type 1 collagen is a helical protein that is crosslinked at the N- and Cterminal ends of the molecule. During bone resorption Beta CTx fragments are released into the blood stream and excreted via the kidneys; serum/plasma levels of CTx serve as a specific marker for degradation of mature type 1 collagen.

N-propeptide), a specific marker of bone formation, may compliment CTx and provide a comprehensive assessment of bone turnover.

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Clinical cautions Bone turnover markers fluctuate - turnover is highest in the morning and additionally meals may suppress markers, particularly bone resorption markers; this variability may be limited by assessing fasting early morning specimens. CTx is renally cleared, therefore results may be falsely increased with renal failure. Results should be assessed against appropriate age and gender specific reference intervals. Proposed harmonised Australian reference intervals have been published for CTx and Western Diagnostic Pathology reports have adopted these and they are outlined in table below.

Phone 9317 0999 and ask for the Chemical Pathologist.

CTx Reference intervals Gender

Age (years)

CTx (ng/L)

Female

20-49

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50-70

50-800

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Male

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CTx is also useful in the investigation and diagnosis of medical conditions associated with increased bone turnover such as Paget’s disease, osteomalacia, hyperthyroidism, hyperparathyroidism, multiple myeloma and bone metastases. P1NP (procollagen type1

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P1NP is recommended by the IOF as the preferred marker of bone formation and is also available onsite at Western Diagnostic Pathology.

The International Osteoporosis Federation (IOF) has recommended the use of serum/ plasma CTx as the reference standard marker for bone resorption in clinical trials. This has also been endorsed by the National Bone Health Alliance.

In conjunction with radiological testing, CTx may be used for assessment of fracture risk and monitoring of treatment response in osteoporosis. Commonly used antiresorptive therapies for osteoporosis, including bisphosphonates and Denosumab, should suppress CTx.

Dr Melissa Gillett FRACP, FRCPA, MAACB Consultant Chemical Pathologist/ Endocrinologist

>70

100-1000

20-24

400-900

25-70

100-600

>70

100-750

Simply request “CTx ’’ on a Western Diagnostic Pathology request form along with appropriate clinical and medication history.

Patient instructions

Patient should be fasted and collected as an early morning sample.

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The International Osteoporosis Federation has recommended serum/plasma CTx as the preferred marker of bone resorption

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References available on request.

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May 2017 | 5


LETTERS To THE EDITOR continued from Page 4 Regarding continuity, changes to funding options for subsidised psychological and psychosocial services is destabilising for patients who require longer-term psychosocial interventions. It is important to note that 10 sessions or less of talk therapy within a year is often sufficient for many patients, but not all mental disorders respond to this type of package. An important example of this might be Borderline Personality Disorder with potentially significant distress and dysfunction impacting the individual, family, workplaces and broader community, but where extended psychological treatment often leads to good outcomes. We see significant numbers of very disabled individuals in the public sector who cannot afford paid psychological services or even to pay a gap fee. Why should these folk be barred from accessing basic mental health care? Access to subsidised and sustainable psychological therapy makes ethical, clinical and economic sense. Dr Nathan Gibson, WA Chief Psychiatrist ........................................................................

Public/private, the patient rules Dear Editor, Re: Reform or Await the Revolution (April) The right of privatelyinsured hospital patients to choose their own doctor, whether in a private or public hospital, is fundamental to our healthcare system and outlined clearly in the Commonwealth Government’s Private Patients Hospital Charter and in the National Health Reform Agreement. However, it seems to have been glossed over in recent negative statements about patients electing to use private health insurance in public hospitals.

The idea that this is somehow driving annual increases in private health insurance premiums does not make sense when private health insurers generally pay more to private hospitals for an admitted patient than they pay to public hospitals. It doesn’t make sense when the amount private insurers pay to public hospitals is just 7% of what they pay out in benefits overall. It doesn’t make sense when profit-making private health insurers, regulated by the Australian Government, are already being subsidised to the tune of $6b a year by the Australian Government. It doesn’t make sense if you are in a rural area, and the public hospital is the only hospital around, and you would like your own doctor to be there. It doesn’t make sense when your kids are seriously ill—there are very few private hospital options available to support very seriously ill children, and parents naturally want the security of having the doctor of their choice wherever their children are treated— which by necessity will almost always be in a public hospital. And it doesn’t make sense when several health insurers offer lower-cost policies that only allow treatment in a public hospital—a tacit admission that public hospitals are cheaper—yet they don’t want you to use the policy! Those criticising the use of private health insurance in public hospitals could also spare a thought for the doctors who work in both public and private sectors, as many do. Any move to limit this flexibility will have a serious impact on continuity of care for patients as well as workforce implications, especially in rural and regional areas. Private insurers would be better off working with private hospitals to drive efficiencies in the private system. The Senate’s current inquiry into prosthesis pricing, which is substantially higher in the private system than the public system, is a good place to start. Alison Verhoeven, CEO, Australia Healthcare and Hospitals Association

Raw deal for rural GPs Dear Editor, It is my opinion that the WA Country Health Service (WACHS) is doing a disservice to the Rural GPs who have provided a longterm service to the small rural health facilities in our state, which usually have nurse-staffed 24-hour "Emergency Departments" and sometimes provide short-term inpatient services. The local GP provides on-call services to these facilities. This is often a solo GP whose availability may be restricted to 3-5 days a week. For the rest of the time, nurses provide the cover with the support of remote Emergency Telehealth Services. It then seems hypocritical that when the local GP needs to leave for private or professional development, the locum cover, which is sourced by the GP (with the admirable support of Rural Health West), has to meet very strict criteria to have credentialing accepted. That level of credentialing is not required for the 2-4 days each week when the local GP is unable to provide on-call services. It is also incongruous that the locum GP must apply to each area health service for each health facility credentialing. This puts extra pressure on the locum GP's referees who are repeatedly approached for an additional reference. This has been reduced to some extent by online profiles (Mercury eCredential) but this has not resolved the issue where one area health service provides privileges while another may decline them. The criteria used to determine clinical privileges, I have been advised, were never intended to be used in this way. If WACHS is not going to support rural GPs in continued on Page 8

CURIOUS CONVERSATIONS

Home away from Home Vascular surgeon Dr Patrik Tosenovsky loves it when his patients get better and hates stupidly offensive films like Dirty Grandpa. If I practised medicine part-time I’d love to… do more research and plenty of teaching. I’d like to make science entertaining and more easily digestible for a wider audience. If I could live in another country for 12 months it would be… Prague in the Czech Republic, which was my original home. My next choice would be in North Queensland because that was my second home.

6 | MAY 2017

The most disturbing film I’ve ever seen was…Dirty Grandpa. I lasted 10 minutes before walking out so I guess that says it all. One of the happiest moments in medicine I’ve ever had was…I always have a happy moment when very old and sick people survive a major vascular event. The book I’m reading now is… by Bud Shaw entitled, Last Night in the OR: A Transplant Surgeon's Odyssey.

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EST 1972

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May 2017 | 7


LETTERS To THE EDITOR continued from Page 6 this way then they should have their own pool of doctors to provide clinical services while the GP takes leave, with or without locum cover for their own practice, which would continue to be supported by Rural Health West. Dr Philip Green, GP, Australind ........................................................................

Response WA Country Health Service is fully supportive of the care provided by dedicated GPs throughout regional WA and recognises the importance of GPs being able to take time away from their practices. WACHS works in partnership with Rural Health West and other agencies to fund and support initiatives which identify and attract leave relief cover. Local GPs may be credentialed at the local hospital when they meet the clinical governance requirements to provide safe emergency medicine services. WACHS is bound to apply the WA Department of Health Policy for Credentialing and defining the Scope of Clinical Practice for Medical Practitioners. This policy guides credentialing requirements around the standards of qualification, emergency experience and ongoing professional development. These standards are a minimum requirement in WACHS to ensure that patients who attend an emergency service will be attended to by an appropriately qualified and experienced GP. Dr Tony Robins, Executive Director Medical Services, WACHS ........................................................................

End-of-life choices Dear Editor, Re: End Palliative Care Nightmares, (April), first and foremost I would like to extend my condolences to the family of Clive Deverall, who was a champion in this area. I too, have been fighting to allow patients suffering terminal illness the freedom of choice over end-of-life decisions since I was first elected to the Western Australian Parliament in 2001. This has been a very passionate area of interest for me since I watched my mother helplessly and hopelessly go through a traumatic and unpleasant end to her life. Although unsuccessful, Dr Lancee’s decision to stand at the state election represents just how far this movement has come – 8% of the vote on a single issue is massive by anyone’s measure. But it was more than that – her actions have widened the debate, particularly around some of the unintended consequences of the status quo.

8 | MAY 2017

During the passage of my Voluntary Euthanasia Bill 2009, rejected by the former Liberal National government and much of the newly elected Labor government, Premier Colin Barnett identified that one of his own family members had died in a manner similar to the admissions of Dr Lancee.

greatly from the 1990s which is why palliative medicine physicians overwhelmingly oppose euthanasia. They are the experts in end-of life care and their views should be heeded.

At the time, the Premier said this situation “demonstrated that there was no need for any law which might make this legal”.

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

This is not a new or controversial practice and I applaud Dr Lancee for having the courage to come forward, speak about it publicly and challenge lawmakers. In direct contrast to Mr Barnett’s comments, I would say this demonstrates exactly why there is a need for legislative change not only to protect doctors but to give terminally ill people the legal right to choose the manner in which they die. Mr Robin Chapple, MLC, Mining and Pastoral Region ........................................................................

Listen to experts Dear Editor, Dr Lancee headed the candidate list for the Seat of Cottesloe and thus secured the ‘donkey vote’. This significantly reduces her share of the vote to around 3%, which effectively means that few people regarded euthanasia as a significant political issue. Recently there has been a media blitz on TV, radio and print by EXIT convert, columnist Nikki Gemmell, whose mother suicided because of chronic foot pain. Gemmell wants assisted suicide for the 2.4m chronic pain sufferers who are not terminally ill. The failure of Dr Lancee and her supporters to condemn Gemmell's extremist views is significant as ‘silence condones consent’. Similarly agencies such as BeyondBlue, Lifeline, etc and the AMA should also be condemned for their silence. About 98% of people die peacefully with palliative care. Analgesia is provided on demand to dying patients even if it shortens their lives. The remaining 2% are often treated in this way. Palliative Care has improved

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

Dr John Hayes, Consultant Physician, Subiaco

Rethinking training Dear Editor, I read the interview with Dr Janice Bell with interest (Perils of Place and Politics, April). It is well known that there has been a chronic shortage of medical practitioners in WA. Work undertaken in 2013 showed WA had almost 1000 less medical practitioners per head of population than other states. A review of the GP workforce in WA last year showed that there is a shortage of about 20% of full-time equivalent GPs compared with the national average. This shortage is not uniform and in some areas it could be argued there is an oversupply. However, in rural, remote and outer metropolitan areas there are many patients who cannot easily access GPs and we continue to rely on international recruitment in these areas. The government has responded by supporting the new Curtin Medical School to reduce this reliance on overseas recruitment and work to support the graduates from all the medical schools to work in the areas of shortage. As Dr Bell describes, it is now more important than ever to have attractive opportunities for newly graduated doctors to train in the areas where they are needed most. I also agree with her view that our approach to medical education and training needs to include better integration between hospital and communitybased training. We rely far too heavily on hospitals as the primary focus of training. The international thinking is that about 60% of the medical workforce should be community based, the rest in acute care. In WA, we have the reverse. This is a problem when we are faced with growth in chronic health conditions and so many preventable hospital admissions. A clear integrated training plan that ensures adequate prevocational training for new graduates and attracts them to areas of need will be the lynchpin. Strengthening training pathways is now the challenge for the WA Health system. Kim Snowball, Consultant ........................................................................ ED: In the March edition we incorrectly attributed workforce figures to the 2016 AIHW Australia’s Future Health Workforce Report. In fact the figures were from Health Workforce Australia and were 2014 figures.

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Letters to the Editor

INCISIONS

More Data, More Care Sharing information can be of immense benefit for the health consumer, says Executive Director of Health Consumers’ Council (WA) Ms Pip Brennan. It wouldn’t be completely earth-shattering news to hear that many people feel quite strongly that our health system doesn’t make it all that easy for consumers to make fact-based decisions about their health. This includes some pretty basic information such as the best place to have your baby, where to have your hip replacement or even some cautionary advice on rehabilitation after a surgical procedure. We have consent forms that are informationrich but a consumer is expected to sign the form and accept that they won’t get a copy unless they specifically ask for their medical records. Consumer Medicine Information sheets are not routinely provided by pharmacies and information about tests and treatments can be difficult for consumers to access amidst the confusion and noise of the internet. Over the past few years, individual advocacy cases at the Health Consumer Council regularly feature consumer confusion about what to do post-discharge. One woman had her treatment for kidney disease amended to include medication. Unfortunately, she was under the impression that was instead of dialysis – not, as well as. That sort of confusion can be fatal. Luckily, it wasn’t the case on this occasion. The point being that there are many different aspects of patient care and one of them is that the facts should be easily available to the consumer. It is no small wonder that

consumers are mistakenly asking for tests that will, in all likelihood, have no appreciable positive effect on their outcomes. In most cases they simply are not aware of all the options. In the absence of publicly available information, the onus is on the health service provider to have the necessary conversation to ensure the patient is making the right choice for their specific circumstances. It goes under the banner of Shared Decision Making and, as the name implies, it requires the sharing of information. It’s also, in a very real sense, a sharing of power with health consumers. It underlines the importance of conversations with patients and families. There must be some

understanding and respect when substitute decision-makers are appointed by consumers. It recognises the important difference between asking a consumer ‘what’s the matter?’ and ‘what matters to you?’ It acknowledges the all-important fact that the biggest impact always falls on the consumer’s shoulders when unhelpful treatment choices are made. I’ll leave the final word to the Australian Commission on Safety and Quality in Health Care: “Better-informed patients often make different, more conservative and less costly choices regarding treatment. [Hopefully] such information provides a realistic appreciation of likely benefits and risks and enables decisions to be made about potential outcomes in a more considered way.”

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10 | MAY 2017

MEDICAL FORUM


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HAVE YOU HEARD?

Owners push the envelope Medical Forum caught up with Hills GP Dr Sean Stevens to talk about the momentum of the newly formed national Australian GP Alliance, which met for the first time in March. AGPA was forged from the fires of the ongoing pathology rental issue (which this month’s budget will hopefully clarify). However, it has taken on greater complexity which may startle some of the representative organisations around town. The aim of the group, says Sean, is to find solutions for issues such as pathology rental, Health Care Homes, dealing with the PHNs and risk and governance management that reflect concerns of independent practice owners. There has been growing disquiet that when it comes to owners’ specific needs, the AMA and the College are hamstrung to help because of conflicts of craft interests and charters. They needed some muscular lobbying of their own and like all good grassroots movements, local politicians will be targeted. Sean said there is a strong appetite among the 75 owners who attended the Sydney meeting and subcommittees have been formed and action plans drawn up. The strategic planning committee will meet in Melbourne on May 13 to discuss the fallout from the Federal budget which will be handed down on May 3.

Screening: better not more On P16, we speak to Prof Christobel Saunders about breast cancer research and she also had some interesting things to say about the hot topic of screening and the need to tailor it to avoid unnecessary treatment. "At the moment the only discriminating feature is age. We offer everyone a mammogram over the age of 50. If we could work out who is at very high risk and screen them more often and differently, and determine who was at very low risk and wouldn't benefit from screening, that would be useful," she said. "Screening has great value for a limited number of women and of less value for another group of women. Surely we should work out who would benefit. We also need better technology." She said while technology

had improved, it was still essentially the same test as 30 years ago. Breast screening services around the country were united in the need to find better ways to screen. "Overdiagnosis is a real issue but we don't know who we are overdiagnosing and overtreating," she said. Research into tailored screening was in the wind and Christobel hoped that WA and Victoria would be the trial sites.

Rollout woes adds confusion Still on the subject of screening, the confusion around the national bowel cancer screening rollout is taking its toll on GPs' faith in the project. A study published in the open-access journal, BMC Family Practice, showed that GPs’ perceptions of the screening were that it was a diagnostic or risk-assessment process rather than a population screening of asymptomatic people. That may have influenced their attitudes and practice. Surveyed GPs across NSW acknowledge they had an important role to play in bowel cancer screening but confusion over the program’s role and delivery were making them hesitate in promoting it to asymptomatic patients.

Capital boost It was a big month for WA-based online appointments company HealthEngine with its founders Dr Marcus Tan and Adam Yap sealing a capital raising deal with Sequoia India (through Alium Capital) for $26.7m. The Australian Financial Review reported that the deal was a $7m bonus as it was believed the company was looking to raise $20m. Sequoia will have a seat on the board alongside what Marcus described as “cornerstone investors” Seven West Media and Telstra Ventures. He also signalled the intention of HealthEngine to enter overseas markets. The AFR quoted him as having “grand aspirations and we want to improve healthcare globally" which he added would likely to be done through acquisitions. HealthEngine was also named among Westpac’s 200 Businesses of Tomorrow alongside fellow Perth company, Chemo at Home.

The whole nine months PHD candidate and KEMH’s chief sonographer Michelle Pedretti’s research into preterm birth is indicates that a shortened cervix between 16 and 26 weeks of pregnancy is strongly associated with preterm birth. She told Medical Forum that the length of the cervix should be routinely measured at the standard mid-trimester foetal anatomy scan and hopes that GPs will record this in a patient’s record. While the majority of scans are transabdominal, there was a case for some women to have their cervixes measured transvaginally for greater accuracy. “Women who have had a previous preterm birth, surgery on their cervix or a pre-midtrimester pregnancy loss are considered higher risk of preterm birth and should have their cervix measures transvaginally at 16, 19 and 21 weeks,” she said.

12 | MAY 2017

New guy on the block In other business news, those WA medical and diagnostic services under the aegis of Primary Health Care will be interested to hear that Henry Bateman, son of Primary’s founder Dr Ed Bateman, has forged out on his own multimillion dollar GP corporate venture, Cornerstone Health after being overlooked in 2015 as Primary’s CEO. Last month he enlisted RACGP doyen Prof Michael Kidd as a director. Set up earlier this year, it is believed one of the backers is WA mining heir Angela Bennett. While national aspirations are not apparent they probably can’t be ruled out. It comes at a time when Primary Health Care is reeling from wobbly revenue and losing its CEO Peter Gregg.

Help for grieving Sands WA is a not-for-profit support organisation for parents and families who experience the death of a baby. They are funded until June 2017 by the Commonwealth. Sands says every year in WA, 285 babies are stillborn or die within the first 28 days after birth and over 11,000 pregnancies end in miscarriage. Sands WA is there to help those who have experienced miscarriage, ectopic pregnancy, medical termination, stillbirth or newborn death on a 24/7 helpline (1300 072 637) and also offers resources and education for healthcare professionals (www.sands.org.au).

Terminations via telehealth We haven’t heard much from Dr Marie’s clinic in Midland, which we thought had the contract for delivering non-Catholic services for the new Midland Hospital, such as contraceptive advice. Dr Marie’s website shows they offer bulk billed “tele-abortion” for women over 16 years who request medical abortions before eight weeks gestation with certain safeguards in place. At the World Congress on Public Health in Melbourne last month, Darwin University’s A/Prof Suzanne Belton said telehealth abortions using tablets was a safe and afforable way for Australian women to seek a termination of pregnancy. “It is a low-risk procedure. Very few women needed extra support at a hospital for assistance with bleeding or additional pain relief. Since September 2015, more than 1000 women have used the service which is very affordable”.

Patchy HPV uptake The HPV immunisation rates (2014-15) for both girls and boys aged 15 have improved in the current round of reporting according to a new report from the AIHW but there is still room for improvement. The national average for girls has risen to 78.5% from 72% in 2012-13. Reporting was divided into PHN districts and Perth South registered the best overall figures of the three PHNs with 80% of girls fully immunised compared with 78.3% in Country WA and 70.2% in Perth North. Boys in Perth South exceeded the national average (67.3%) with 73.2% fully immunised and Perth North, again lagging, behind with just 62.1% while 63.3% of Country WA boys were immunised.

MEDICAL FORUM


HT resurgence? Over recent years, three doctors have written in Medical Forum that HRT, on the available evidence and risk-benefit analysis, was underused. What do they think today? Dr Alison Creagh (ex-FPWA medical educator) thinks GPs not prescribing Hormone Therapy (HT) is part of the problem. “This is unfortunate because the risks of HT for perimenopausal women are low and there are significant benefits. It’s time we took a balanced approach,” she said, adding that taking a good history was key as contraindications to HT were mainly “past breast cancer, stroke, ischaemic heart disease and VTE”. For significant hot flushes she recommends hormone therapy and gabapentin and consideration of SSRIs and SNRIs (although less effective). The risks and benefits of HT should be discussed with the patient – “for combined HT, the benefits are effective treatment of symptoms, small decreased risks of colon cancer and osteoporotic fracture and a decreased risk of death. The small increased risks are for breast cancer, VTE, heart disease and stroke.” Dr Margaret Smith (retired gynaecologist) is tired of the profession’s post-2002 response to the Women’s Health Initiative data and recommends the Jean Hailes website as a great resource, saying HT is “safe and effective”. Like others she points to flaws in the WHI study – different hormones studied to those used today, women studied were older and had a different risk profile, etc. “The major deficiency symptoms that [may] need oestrogen are hot flushes, sleep disturbance and vaginal dryness. HT can also relieve depressed mood,” she said. On the main issue of breast cancer scare she said “oestrogen does not cause breast cancer but can encourage its growth when it already exists” and “heart attack and stroke risks are usually due to other factors but may be enhanced by HT.” She re-emphasised the same risks and benefits as Dr Creagh, adding that “all women should have a mammogram before HT is started.” Prof Tim Welborn (endocrinologist) clarified his stance. “Doctors and patients continue to show extreme caution about the use of HT since the critically flawed Women’s Health Initiative report. Recent evidence-based guidelines indicate that women with moderate to severe menopausal symptoms will get substantial relief from early supervised therapy. Oestrogen treatment also gives vascular protection and improves bone density.” “There is further data that the added risk of breast cancer is negligible for 20 years. Clear contraindications to HT include long duration menopause lasting beyond 5-10 years and/or a family history of hormone-dependent cancers. Those at risk of thrombo-embolic disease should be offered transdermal oestrogens. Women with an intact womb can be prescribed an oestrogen-progesterone combination, to protect against endometrial hyperplasia or cancer, or be given cyclical oestrogen (with withdrawal bleeds) or oestrogen plus a Mirena coil.”

BY THE NUMBERS

$51,879,096 The inpatient cost of Family and Domestic Violence (FDV) in WA 2009-15

Women’s Health in WA • About 750 women were hospitalised in WA between 2012 and 2014 for domestic violence injury • 9% of these cases the woman was pregnant • From 2012 to 2014, 156 women were hospitalised for sexual assault related injuries • 71 women nationally died as a result of FDV in 2016; 19 people (aged from two months to 81 years) died in WA (gender breakdown not available)

• Rural Health West held its annual awards night at its conference last month. Dr Stephen Langford received a Life Membership award; Dr John Rosser Davies, (Manjimup), and Dr Siew-Lee Thoo, (Kimberley) received the Above and Beyond Community First award. Dr Steven Lai (Narrogin) was recognised for Outreach Services, Dr Alison Turner (Manjimup) for service to Rural and Remote, Dr Susan Downes (RFDS to East Kimberley) and Dr Olga Ward for Remote and Clinically Challenging Medicine. • Dr James Bowie (Manjimup, pictured), is the first doctor to be recognised by Rural Health West for 50 years of rural service. • Acknowledged for 40 years’ service were: Dr Jane James (Denmark), Dr May Ure (Albany), Dr Basudeb Saharay (Collie), Dr Thomas Jones (Bridgetown), Dr Gary Mincham (Bunbury), Dr Kim Tee Ong (Mandurah). • Acknowledged for 30 years’ service were: Dr Gary Tapper (Busselton), Dr William Walker (Mandurah), Dr Matthew Hodge (Albany), Dr Hugh Leslie (Albany), Dr Susan Shaw (Narrikup); Dr Christine Hartley (Australind); Dr Kevin Christianson (Northam), Dr James Murray (Geraldton). • Acknowledged for 20 years’ service were: Dr Sally Edmonds (RFDS), Dr Michael Massey (Busselton), Dr Cathryn Milligan (Margaret River), Dr Marie Fox (Northam), Dr Noreen Parshad (Geraldton), Dr Anne Richards (Kununurra), Dr Craig Drummond (Karratha). • Mr John Van der Wielen is the new CEO and Managing Director of HBF. His background is in insurance in the banking sector. • Dr Monica Gope director of WACHS Postgraduate Medical Education Unit has been named national Clinical Educationist of the Year. • Prof Shirley Bowen will leave her position as Dean of the Notre Dame medical school in Fremantle to take up the post of CEO of SJG Subiaco Hospital on June 12. Mr Ben Edwards is the new CEO at SJG Murdoch Hospital. He has been acting CEO at SJG Mt Lawley hospital since November. • Emily Higham, from UWA’s SPINRPHEX Rural Health Club was the only West Australian to be awarded a HESTA scholarship for travel to the National Rural Health Conference in Cairns last month. • The Women and Infants Research Foundation (WIRF) have appointed its inaugural Chief Operations Director, Deb Attard Portughes.

Sources: WA Women and Newborn Health Services; WA Department of Health; AIHW; Women’s Council for Domestic and Family Violence Services

MEDICAL FORUM

May 2017 | 13


Spotlight

Big Ideas Filling Big Shoes Ensuring WA’s disadvantaged are never far from the gaze of government is a job WACOSS has done for decades. It now has a new CEO. Stepping into the shoes of a high-profile CEO is never easy. The new head of the WA Council of Social Services (WACOSS), Louise Giolitto admits it is a little nerve wracking. But she’s both pleased and proud to be taking the reins of an organisation with a long commitment to serving the most vulnerable members of our community. “I was working here for about 15 months before Irina Cattalini [former CEO] left and I reported directly to her. Irina was a wonderful mentor and I learnt a lot from her. It’s no secret that WACOSS punches way above its weight, so it is a little daunting stepping into Irina’s shoes.”

She had a big influence on my thinking and we both share a belief that the world could be changed for the better.” “There’s certainly no doubt that the social services sector is changing in terms of its intrinsic professionalism. It’s now a recognised qualification that requires three years of tertiary study and, in the past five years, the level of required skills has increased considerably.” “The face of the sector is changing, too. People working in community services – from youth support to social workers – come from increasingly diverse backgrounds.” More having hard times

“There’s that feeling of not wanting to let down people who’ve come before you.”

Louise pinpoints a couple of critical social justice issues currently affecting WA.

“I’d really like to improve the level of collaboration across the sector so we can speak with a more powerful collective voice. Nonetheless, it’s important to acknowledge that there’s great diversity across community services and we don’t want to dilute that either.”

“We’re all too aware that we have high unemployment at the moment. That fact, combined with a leaning towards deficit State budgets, produces knock-on effects that impact on a large number of people, particularly those living below the poverty line.”

Dealing with government The vicissitudes of dealing with government departments is always interesting, says Louise. “It’s a fluid and sometimes problematic relationship. But, having said that, I think it should be a little tricky because if we were all sitting on the same page and patting each other on the back we wouldn’t be doing our job. We had a pretty strong relationship with the Barnett government through the Partnership Forum but it wasn’t what I’d call a blue ribbon outcome every single time.” “We intend to build on the positives with the new Labor government. The important thing to realise is that what we want and what the government wants is essentially the same thing, and that’s a healthy, happy community with plenty of opportunity for every West Australian.” “The best way we can achieve that is by building trust through open and honest relationships.” Louise has had a long career in the social services sector stemming back to the values imbued within her own family. Raised on values “I have to give credit to my parents, which sounds corny, I know. I had two very loving parents and we did a lot of travelling so I came to realise quite early on that we aren’t all living on a level playing field. A lot depends on where you’re born and who your parents are.” “My mother worked in the highly demanding area of child sexual abuse in the Kimberley.

14 | MAY 2017

“And, sadly, there are an increasing number of people doing that. It stands at more than 240,000 at the moment.”

poverty levels are alarming. We need to listen more closely to Aboriginal leaders in these communities so we can foster the skills needed for employment. There are about 60 different service providers in Roebourne but some of them are just not culturally appropriate.” “Ideally, we should be training and employing local people to address that problem and increase the level of mutual trust. WACOSS has a strong focus in this area but it’s a long journey.” Political courage needed “The short election cycle doesn’t help the situation. These are entrenched and longterm problems that require courage, honesty and political integrity. When just over half the children taken into care are Aboriginal, and they represent just 6% of our population, the solution is not just around the corner!” “More broadly, there needs to be improved levels of consultation. We continue to have political decisions made at both state and federal level that result in unintended and seriously flawed consequences. And so often, it’s the most vulnerable people who are left out of the discussion.”

By Peter McClelland

“It’s clear that it’s more economically efficient to catch people before they fall off the ‘poverty cliff’ rather than trying to haul them back up the slope. It’s a challenging time and we need effective long-term planning at a political level. We have a huge divide between the haves and the have nots, particularly in regional WA.” “If we’re speaking in specifics, the lack of available social housing is one such critical issue. If a person doesn’t have secure housing and you combine that with mental health and/or domestic violence issues, they will struggle to make positive changes.” Housing shortfalls “There are more than 10,000 people on the waiting-list and that translates to about three years in the queue for a place to live.” When it comes to Closing the Gap, Louise is cautiously optimistic. “It’s so important for young Aboriginal people to finish Year 12 and go on to tertiary studies because it’s a well-known fact that education is a vital precursor to social mobility.” “I’ve lived in the Kimberley and worked in the Pilbara and the

Ms Loiuse Giolitto

MEDICAL FORUM


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MEDICAL FORUM

May 2017 | 15


FEATURE

Breast Cancer: A Model of Care Activism has accelerated our knowledge and treatment of breast cancer. Will it be part of an overhaul in the way we deliver health care? More than 40 years ago, the First Lady of the United States Betty Ford announced to the world that she had breast cancer and had undergone a mastectomy. It was a defining moment in the transformation of a taboo disease into a cause célèbre that has seen the likes of Nancy Reagan, Angelina Jolie, Kylie Minogue, Olivia Newton-John and a host of other highprofile women fight for more money for breast cancer research.

Trials and translation

The result is a marketer’s dream – pink means breast cancer awareness, October is Breast Cancer Month, and cash rolls into fundraising organisations at an everincreasing rate. In farewelling its celebrity patron Sarah Murdoch, wife of media mogul Lachlan, in 2015, the chair of the National Breast Cancer Foundation Elaine Henry said that Sarah had been “instrumental in raising the organisation’s profile and funding. During her tenure fundraising has increased from under $1 million per year to more than $27 million in 2014.”

Another exciting area of the future is health outcomes research and Australia has the potential to be a world leader.

For the clinicians and researchers on the ground such as Prof Christobel Saunders and a host of others in WA, this activism has helped improve knowledge and treatment of breast cancer which has given patients better choices and outcomes. It is a gift not to be wasted. Teamwork the key “This awareness has empowered women to seek better treatment and ensures that we are able to deliver. As a result we have been at the forefront of things like multidisciplinary and specialist coordinated care as well as close auditing of what we do,” she said. Research by former WA GP Dr Jon Emery and E/Prof D’Arcy Holman into the attitude of rural patients to cancer highlights just how successful the breast aware campaign has been. “It shows that people with prostate, colorectal and lung cancer tend to present late, whereas breast cancer tends to present early because people know it improves their treatment outcomes,” Christobel said.

Christobel said WA hosted a broad range of research programs in cancer and breast cancer, some taking a national lead. Projects such as the ROLLIS trial which will change the way breast imaging and surgery is conducted. “Seeing local trials leading to a change of practice is an exciting thing, but research takes a long time.”

“We are hoping to establish a study of value-based health care, which is essentially measuring the outcomes of our care using both conventional and patientreported outcomes. We will be looking at how we deliver services that achieve value for the patient and value for the system.” “It is a concept that came out of Harvard Business School which led to the establishment of the International Consortium of Health Outcome Measurements (ICHOM). I was fortunate to be the chair of the international working group on breast cancer which developed a whole suite of standards.” “It’s rethinking how we look at outcomes to very much include what the patient wants. For example what does a man with prostate cancer want? He wants to survive, he doesn’t want the cancer to come back but he doesn’t want to be incontinent nor lose sexual function and he doesn’t want to lose his job.”

hard to do initially but eventually it leads to better value care because you’re not doing things that are ineffective or that are not in the patient’s best interest. There is growing enthusiasm in WA for this idea.” In the Doctors Drum write-up on p26, the forum explored the inevitability of cultural change brought on by the growth of technology and the increasing demand on the health system. It was put to the meeting that if the profession did not lead the charge, the tech companies and bureaucrats would. Having clinicians take charge of this value-based health care could be a good start. For while IT is important, determining what information was to be put into those systems and what to get out of them was crucial. For if done well, Christobel said, data input became feedback from clinician and patients, which was in turn embedded research results and from there it was clear to see what activity was going well and what needed improvement. The next step is not surprising. “In the US and Holland, they are exploring how to fund good value health care. How they measure that value is the next thing to solve.”

By Jan Hallam

Ask the patient “We have to ask the patient what is important to them and ask if we are achieving that in our health system? We really don’t know because we don’t measure that.” “A lot of big cancer institutions around the world have taken this up and are now asking their patients what they want. It’s

“That awareness has also been good for research funding. It always causes argument but breast cancer has undoubtedly the largest portion of the research pie. But that’s good for all cancers. Some of the research is generic. We understand more about immunotherapy of cancers, the biology of cancers because of breast cancer research. We also understand the importance of psycho-social support. Breast cancer research has led the way which has translated into other conditions.”

16 | MAY 2017

MEDICAL FORUM


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MEDICAL FORUM

May 2017 | 17


FEATURE

Breaking Down Cultural Barriers As WA becomes increasingly ethnically diverse, the challenge to combat social isolation is being tackled in multiple ways in the community – and warning – there will be dancing. The Courageous African Women Network have danced, laughed and cried together and in the process have shared their stories and healed some of the trauma many of their number have experienced with the help of Richmond Wellbeing, which launched the program last year in association with the African Women’s Association.

worker in her homeland and was married with four sons.

Bouah Kardio, who has been working in the mental health space in Perth for about six years, is the coordinator of the program. She understands, first hand, the toll social isolation has on particularly middle-aged and older women.

Culturally aware doctors

“There are issues that African women, because of their cultural beliefs and expectations, find difficult to discuss broadly but the team at Richmond were committed to develop culturally sensitive ways for these issues to be addressed so appropriate help could be found for them,” Bouah said. The Courageous African Women Network has members from all over the African continent – Nigeria, Ghana, Zimbabwe, Mozambique, Tanzania among them, so with such a number of disparate cultural groups, how does the network achieve its goals? “Dancing!” Bouah said. “We dance to others’ traditional music and the group is told the significance of the music.” Music breaks down barriers It may be something of a hidden process but special moments in people’s lives are brought out by the dance and music which opens up channels of communication. “If issues arise, they know they can call me and I will talk to them and I can then help them access health services. But it starts by creating an environment where it is safe for them to share their stories.” Bouah arrived in Australia from war-torn Liberia via Canada in 2006. She was a social

18 | MAY 2017

“I lost my husband in the civil war – like a lot of people. Some lost their entire families. I know when I first arrived here I felt totally isolated. I didn’t know who to turn to. So when I started this group I knew what these women were going through.” Overcoming barriers to appropriate health services is a question of trust and understanding, which take time to develop. Bouah said there were unspoken subtleties for some African women in going to see a doctor even though a growing number of GPs were training to treat CALD patients. “Some only feel comfortable with female GPs and often the referral to a doctor will come from the community network.” There are also different views on illness. “Mental illness in some African cultures is viewed very differently to Western medicine. There is a spiritual aspect and often if they hear voices that person is considered a prophet! Here it’s the other way around.” Adrian Munro, the Executive Manager of Operations at Richmond Wellbeing, believes services for such groups as the Courageous African Women Network are essential. “These people have seen unspeakable things in their home countries and it’s understandable they find it difficult to get established and forge links. It’s vital they are brought together where they can support and help each other with the trauma they’ve experienced and have some connection in the community while keeping links with their culture,” he said. Welcome to all

and as a community to help them feel welcome and accepted.” “The African Women Network doesn’t just help those women who attend but also those women’s families and friends because they feel more comfortable to reach out and more likely, we hope, to access some of our services and other services in the community. It is a question of knowing that these services are available and that they are culturally appropriate.” The unexpected bonus of programs such as the Partners in Recovery, of which the African Women Network is a part, has been the cultural diversification of the Richmond workforce. Adrian said that it has been a steep learning curve for the organisation but the result is much more culturally sensitive service delivery. “Diversifying our staff has been a really important thing for us because that’s how you create culture change. You learn to communicate more effectively and be more attuned – it’s how we learn. Our goal as an organisation is to have staff who can work with people from all backgrounds.” “It’s the responsibility of each staff member to understand cultural differences and be able to work with them. It’s the same for all groups – migrants, indigenous people, LGBTI – we are committed to be diverse and inclusive.”

By Jan Hallam

“Perth has a diverse population from a number of different cultures and we recognise we have a responsibility as an organisation

MEDICAL FORUM


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CLINICAL OPINION

Treating Anorexia Nervosa The statistics surrounding eating disorders and anorexia nervosa in particular are grim as you would expect from a serious illness but psychiatrist Dr Urvashnee Singh is a tireless campaigner for her patients – this disease is eminently treatable. She writes here to inform doctors of the process that will save lives. changes that occur in a person as a result of severe restriction of caloric intake.

Anorexia nervosa is a psychiatric illness with devastating physical sequelae. It has the highest mortality of any psychiatric illness. In the general population, lifetime prevalence of anorexia nervosa is around 1% in women and < 0.5% in men. Genetic predisposition and dieting are the major risk factors.

The changes included: Physical • Weight loss up to 25% of original body weight • Reduced strength and increased weakness and tiredness

Anorexia nervosa usually manifests in adolescence but can persist into adulthood, often impacting on the developmental trajectory of the individual as well as resulting in a significant burden on both the family and health care system.

• Decreased need for sleep • Increased hunger • Gastrointestinal discomfort and constipation • Dizziness, headaches, hypersensitivity to noise and light, visual and auditory disturbances (e.g. unclear vision and ringing in the ears)

According to the DSM-5 criteria, to be diagnosed as having Anorexia Nervosa a person must display:

• Oedema

• Persistent restriction of energy intake leading to significantly low body weight (in context of what is minimally expected for age, sex, developmental trajectory, and physical health).

• Hair loss, decreased tolerance for cold temperatures (cold hands and feet) • Decreases in body temperature, heart rate, respiration and a 40% reduction in basal metabolic rate (the amount of energy the body needs to carry out normal bodily functions)

• Either an intense fear of gaining weight or of becoming fat, or persistent behaviour that interferes with weight gain (even though they may be significantly low weight).

Psychological • Depression, anxiety, emotional distress, mood swings, irritability and outbursts of anger

• Disturbance in the way one's body weight or shape is experienced, undue influence of body shape and weight on selfevaluation, or persistent lack of recognition of the seriousness of the current low body weight.

biochemistry to detect hypokalaemia, metabolic alkalosis or acidosis, hypoglycaemia, hypophosphataemia, and hypomagnesaemia, serum liver function tests, serum prealbumin levels and a full blood examination looking for evidence of starvation-induced bone marrow suppression such as neutropaenia and an electrocardiogram (ECG).

Subtypes Restricting type: with or without compulsive exercise Binge-eating/purging type: episodes of uncontrolled over-eating with or without laxative and diuretic misuse and purging It is interesting to note that there is no longer a BMI criteria or the need for amenorrhoea for the diagnosis of anorexia nervosa to be made. Prior to a diagnosis there may be warning signs – the person may adopt overly restrictive diets, exercise compulsively, develop secretive or avoidant behaviour around food and become preoccupied with their body image. There is often a history of impaired socialisation and impaired school or work performance.

• Assessing psychiatric comorbidity, e.g. anxiety, depression, substance misuse, suicidality, personality disorders, anxiety disorders and deliberate self-harm. Comorbidity in people with anorexia nervosa is common and therefore assessment for such should be routine. Treatment Goals This can be divided into three phases: 1.

Weight restoration and normalisation of eating

2.

Engagement in an evidenced-based psychological therapy (Cognitive Behavioural Therapy-Enhanced for Adults and Family-Based Therapy for children/adolescents younger than 19)

3.

Relapse Prevention

Assessing medical risk • Physical examination should include height, weight, BMI, lying and standing pulse and BP, temperature • Investigations should include serum MEDICAL FORUM

Starvation Syndrome This refers to the physical and psychological

Attitude and Behaviour Related to Food and Eating • Food preoccupation • Binge eating followed by self-criticism • Altered table manners - licking plates, long meal times, playing with food, smuggling food Social warning signs • Withdrawal and isolation • Reduced libido Weight Restoration and Reversing Effects of Starvation Weight restoration is the most robust predictor of remission from anorexia nervosa and is necessary, if not sufficient, for recovery. The starved brain will reinforce the symptoms and make it impossible to engage in any therapy directed at recovery. Therefore, weight restoration is the first phase of treatment. This can occur in an outpatient setting, using the expertise of a specialist dietician where the goal would be to restore 0.5-1kg/ week. If inpatient admission is required for any of the indications noted above, the goal would be to restore weight at between 1-2kg/week. continued on Page 23

May 2017 | 21


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MEDICAL FORUM


CLINICAL OPINION continued from Page 21

Treating Anorexia Nervosa The biggest risk of refeeding is a condition known as ‘Refeeding Syndrome’ which comprises several potentially life threatening medical complications including low serum phosphate and magnesium levels, severe hypoglycemia or congestive heart failure. This risk can be reduced by monitoring serum phosphate and magnesium and prescribing prophylactic phosphate in the refeeding period. Counter-transference and therapeutic nihilism Patients with anorexia nervosa are often viewed by clinicians and by healthcare systems in a negative way. The patient's denial, hostility and ambivalence to treatment, the concerned family and friends, the possibility of medical compromise – all serve to heighten a clinician’s anxiety, resulting in reluctance to treat such patients. Yet this is a serious mental illness with equally serious medical complications that require our continued efforts to keep the patient engaged. So enlist help from those around, re-evaluate progress and seek advice or refer on if necessary. It is important to keep in mind that most patients recover outside of hospital, with minimal support.

However, others instil ongoing anxiety, frustration, despair, and ultimately demoralisation in their medical carers. This is particularly likely to be the case if adequate tertiary support and treatment is not available. It’s essential to acknowledge that anorexia nervosa is not a lifestyle choice and recovery can take years though early intervention is predictive of a shorter duration of illness. The first step in treatment is to reverse the physical and cognitive effects of starvation, so that the person can engage in outpatient psychotherapy which is the hallmark of treatment. The long-term aims of psychological treatment are to reduce risk and to encourage weight gain, normal eating and exercise behaviours, with full psychological and physical recovery being the ultimate goal. Patients are best managed by a multidisciplinary team which includes their GP, psychiatrist, psychologist and dietician. ED: Dr Urvashnee Singh is the lead psychiatrist for the eating disorders inpatient services at Hollywood Clinic.

Public Resources Last year, the state government moved to shrink the gaping gulf in services for those with eating disorders who are over the age of 16. At that age, young people must leave the embrace of PMH’s eating disorders program and find programs where they can. The WA Eating Disorders Outreach and Consultation Service (WAEDOCS) located at SCGH provides consultation and education services to clinicians caring for patients with eating disorders. And the statistics show a serious need with eating disorders falling within the top 10 contributors of disease in Australia for those aged between 16 to 24 years. Anorexia nervosa has the highest mortality rate (20%) of any psychiatric condition. WAEDOCS offers support for health professionals across all settings, including GPs and community health and mental health care services across public, private and communitymanaged organisations. Ph 1300 620 208 9am-4pm Mon-Fri

Table. Indicators for consideration for psychiatric and medical admission for adults (Bold parameters highlight adolescent criteria different to those for adults) Psychiatric admission indicateda

Medical admission indicatedb

Rapid weight loss

1 kg/week over several weeks or grossly inadequate nutritional intake (<100Cal daily) or continued weight loss despite community treatment

Re-feeding risk

Low

High

Systolic BP

< 90 mmHg (80 mm Hg)

< 80 mmHg (70 mm Hg)

Postural BP

> 10 mm Hg drop with standing

> 15 mm Hg drop with standing ≤ 40 bpm (50 bpm) or > 120 bpm or postural tachycardia > 20 bpm

Heart rate Temperature

< 35.5°C or cold/blue extremities

< 35°C

12-lead ECG

Normal sinus rhythm

Any arrhythmia including: QTc prolongation, Non-specific ST or T-wave changes including inversion or biphasic waves

Blood sugar

Below normal range*

< 2.5 mmol/L

Sodium

< 130 mmol/L*

< 125 mmol/L

Potassium

Below normal range*

< 3.0 mmol/L

Magnesium

Below normal range*

Phosphate

Below normal range*

eGFR

<60ml/min/1.732 or rapidly dropping (25% drop within a week)

Albumin

Below normal range

< 30 g/L

Liver enzymes

Mildly elevated

Markedly elevated (AST or ALT > 500)*

Neutrophils

<1.5 x 109 / L

< 1.0 x 109 / L

Weight

Body Mass index (BMI) <14 ** (75-85% IBW)

BMI < 12 ** (<75% IBW)

Risk Assessment

Suicidal ideation, Active self-harm, Moderate to high agitation and distress

a b

Patients who are not as unwell as indicated above may still require admission to a psych or other inpatient facility Medical admission refers to admission to a medical ward, short stay medical assessment unit or similar

*Any biochemical abnormality which has not responded to adequate replacement within the first 24 hours of admission should be reviewed by a medical registrar urgently. Source: RANZCP, 2014

MEDICAL FORUM

May 2017 | 23


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MEDICAL FORUM


News & Views

The Circle of Giving Small acts of kindness can reap large benefits for women and children at home and abroad as the work of 100 Women is proving. Giving Circles are democratising philanthropy and, in WA, one group, 100 Women, is improving the lives of women and girls at home and overseas by facilitating access to health, education and economic independence. Dr Jenny Brockis is a member of 100 Women and explained how the group worked. “The initial premise was that 100 women each donate $1200 a year, although I hasten to add that we have more than that number now. And yes, we do have men, too!” “Every cent of the money donated goes to the various recipients, and it’s important for people to know that because so often when we do make a donation we have no real idea how much actually goes to where it’s intended.” Everyday philanthropy

Dr Jenny Brockis

“This organisation, founded by Alicia Curtis, makes it easier for the everyday person to become an everyday philanthropist through the structure of collective giving. Not too many of us can enter the realm of someone like Bill Gates!”

Recently she attended an evening which heard the experiences of last year’s grant recipients. “It was a wonderful night and very inspiring. Everyone who’d been part of that particular Giving Circle felt they’d done something really worthwhile. And one of the unique aspects of this model is that each individual contributor can vote exactly where they’d like their money to go.” In the past three years 100 Women has awarded nearly $300,000 in grants. The 2017 allocation saw $90,000 shared by recipients ranging from an intensive performing arts program for Aboriginal girls in Halls Creek to creative sewing workshops at Bandyup Prison and ongoing cervical cancer screening in rural Vietnam. Ripple effects “It’s worth noting that there is a health component in the grants this time around. We’re all well aware of the importance of effective cervical cancer intervention and we heard one story of a 35-year-old woman in Vietnam with two children who was screened, treated and survived. That’s a great outcome because the alternative would have been a young family left without their mother.” “The human dimension to these stories of hope and positive change is always powerful.” While practising as a GP, Jenny always had one eye on a wider professional orbit. The publication of her book, Future Brain and her embrace of the maxim, ‘it’s not what we know but how we think that matters’, reflects a deep interest in the area of cognitive enhancement. “I’m a firm believer in living life to the full and it became impossible to run a clinical practice and maintain a commitment to empowering others to improve their mental performance and take greater responsibility for their lifestyle habits.” “As a doctor I was seeing so many people who were approaching retirement and struggling with cognitive issues. And, I have to be honest, I felt pretty useless some of the time. So I did a lot of reading, particularly in the area of prevention, and now I work as a consultant with individuals and the education and business sectors.” Serving the community

Projects to which 100 Women contribute.

“As a GP I used to see so many patients who were super-stressed and getting sick as a result. The medical system is groaning under the burden of chronic disease and we just can’t afford it, in every sense of the word. But, as we all know, encouraging people to change their behaviour can be the hardest thing in the world.” “Being part of something bigger of philanthropic persuasion is a wonderful way of having a life outside work. Being able to help others who have a greater need than we do is both enriching and rewarding.”

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May 2017 | 25


Serving the Community – Risk vs Reward

Set against a backdrop of inevitable reform brought on by technology and unsustainable health care costs, the discussion at the first Doctors Drum of 2017 took some interesting turns – from work-life balance to artificial intelligence – and how these might impact on the medical profession in the future. Medicine was a healing profession, said one of the panellists, and as such was a community service. It was also the reason why most doctors entered it in the first place – to make a difference. However, that could take its toll on the health and wellbeing of individual doctors and their families.

Past, Present & Future The April e-poll shows that about 55% of respondents thought new doctors were not ably trained to tackle problems in the community – so was that a question of training or a generational shift? One panellist remarked that there seemed to be a sense of complacency amongst junior doctors – rather than exploring routes such as research, they opted for job security and a work-life balance. “I want to hear people say they want to change the world and improve the lives of others when they go out to their first clinical rotations. We are seeing people who are increasingly focused on a career, lifestyle and income. That is a big generalisation because we as doctors are in a luxurious position of being able to go home knowing we’ve done something bigger

(people’s health and wellbeing) than simply making money.” But as another pointed out: “older physicians always seem to say young doctors come out of medical school not knowing anything but knowledge evolved. In looking at the medical education of tomorrow, we have to keep up with society’s expectations.” Those expectations meant more community medicine. “We have come a long way with problembased learning and changing the focus of medical schools towards the patients’ needs and community’s needs but we have to turn the training model to where medicine is practised, which is in the community. That will be intensely uncomfortable for a lot of people but we need to do it.”

Work-Life Balance The old chestnut in any discussions about ‘then and now’ is the number of hours spent at the coalface. Few if any in the room thought that a return to the bad old days was a good thing. However, while acknowledging that this issue was pendular, some wondered if worklife balance had swung too far into the relaxed and comfortable zone. One doctor said a good work-life balance meant happier and more productive doctors but if that increased the challenge of meeting ‘demand’, the solution was teamwork. It created a better working environment and better outcomes for patients.

While most agreed the ‘old normal was abnormal’ one doctor suggested that with greater doctor numbers, it should be easier for doctors to look after themselves better and to have longer careers, which meant they could care for their patients better.

Bucking the System The alarming and tragic incidence of suicide in the profession, particularly among junior doctors, was raised. One doctor said she had run around looking after her community and missed out on her children growing up and she now felt very badly. “That old normal is incredibly abnormal.” A registrar in the public system spoke out about the demoralising work junior doctors were asked to perform. “Increasingly, interns and RMOs are treated as cogs in this big patient flow machine where a manager tells them what they can or can’t do to a patient. If your job is to put in the cannula, that’s all you do. There is no emphasis on getting to know the patient, to get passionate about the patient’s issues or have time to research because when your shift is over the emphasis is to get you to leave.” “The community has a very different idea of what doctors should be doing with their patients and that is what medical schools encourage you to do. The reality of being a junior doctor is so different from what they told as when we were students, it’s understandable we get disheartened.” Another DiT said her time was spent behind

Supported by:

See www.doctorsdrum.com.au 26 | MAY 2017

MEDICAL FORUM


a computer screen doing discharge summaries with computer systems that were ‘heinously’ cumbersome. One doctor who works in the palliative care field said when med students and RMOs came to the service on rotation, they all “absolutely love the experience because they have the time to talk to patients and communicate with them. They find that very satisfying and often say it is what we were trained to do.” One panellist suggested that while stewardship was essential on issues such as antibiotics use, doctors were losing the ability to act on what they instinctively knew. While a focus on quality and safety unquestionably resulted in better outcomes, junior doctors were intimidated and some consultants did not give their registrars room to grow and make treatment decisions. It should be about leadership rather than control. One voice said our system had become very bureaucratic and it did not respect doctors as professionals who were able to make independent decisions. “Evidence comes from the scientific literature but a part of that

above yourselves, you’re a worker just like us’. It’s not surprising people stop work at 5pm.” But this angst could all be for nought. evidence comes from our patient’s perspectives and what they want out of their life. If we have the freedom to practise like that, then we will be doing good and feeling fulfilled. But if we let generic managers and bureaucrats lead our profession, we will become functionaries. We have to fight against it because we are fighting for what we’ve been trained to do.”

“We are holding back a dam wall here and the profession has to change. Medicine of the future will be managing computer programs. Kaiser Permanente in the US has data that proves a computer-based algorithm is much more effective in managing patients than a doctor’s brain. The art of medicine is increasingly becoming a thing of the past,” one doctor said

The Robot Will See You Now

Medicine urgently needed leaders in the profession to take charge of the technologies otherwise tech companies will take over, said another.

The rise of system-based medicine had one senior doctor rueing the loss of selfdetermination within the profession. “When the medical profession felt they ran the show in hospitals, they took responsibility for own education, governance – you took pride and you stood out. That has been taken away at the hospital, governance and government levels and young people are told ‘don’t get

“Our inherent conservatism as a profession will be the killer of us all if we don’t take charge. I am heartened though because I do know there are young people like those who are here today who are passionate and committed but you have to be subversive in order to bring the profession forward and we need to stop putting up barriers for them to take us forward.” So what is the role of the doctor of the future? “It is the human side we need to promote,” said one.“That’s what people are going to want and right now the system is being dictated by a series of metrics, so we have to reassert the human side. Whether you believe it or not, the computers are coming. Patient outcomes will improve but patient satisfaction might be a different story.” “Medicine has to stay a human, caring profession and we must adapt to preserve our role as something that’s critical in a person’s treatment. Some people will have to put their heads up above the parapet and some may get their heads chopped off but we need to act.”

continued on Page 29

See www.doctorsdrum.com.au

MEDICAL FORUM

May 2017 | 27


28 | MAY 2017

MEDICAL FORUM


continued from Page 27

Serving the Community – Risk vs Reward Patients as Consumers Along with the rise of the machines, increasingly, patients are asserting their power as consumers. One panellist said some consumers didn’t want to have a relationship with a doctor. “They want a diagnosis and the right treatment. Perhaps, commonly, in older people with chronic illness, that relationship with their doctor is fundamental in the management of their condition but if machines become so good at mimicking humans, perhaps people won’t know if they are talking to a person or a machine.” Communication could solve a lot of the problems. One doctor recounted the hospital journey of one of her patients where complex and successful medicine was performed but no one spoke to the patient throughout the process, leaving the patient unhappy. Another added: “I see a lot of patients at the end of their life who have had months of expensive rounds of chemo and radiotherapy and doctors in the hospitals have not even looked them in the eye to ask them if that is what they wanted. If they had, they would have saved a lot of time and as a result a lot of money.” The power, said one, resides with the doctor. “If we don’t start looking our patients in the eye, we will be taken over by celebrities who will freely give their advice. If we are not communicating in the way our patients want us to communicate, we will go down the gurgler because there are plenty of other people who want to do it.”

See www.doctorsdrum.com.au

MEDICAL FORUM

May 2017 | 29


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E-poll Comments

Politics, Cost & Waste – Your Say In April, e-poll respondents were invited to make comment on the big things confronting the new Health Minister Roger Cook. Responding to the statement that growing health demands were outstripping supply, most pinpointed money – or lack of it – as the biggest challenge. However, there were those who put waste at the heart of the problem. “Vast wasted resources through poorly informed political decisions have cost the WA taxpayers a fortune over the last few years of Liberal government. The new government could save millions through better decisions, especially in rationalisation of hospital care across the state.” Another succinctly wrote: “Sell off FH, PMH and RPH.” “Why does Australia pay $10K for a total-knee replacement prosthesis when the exact same item is available in Europe (Portugal) for 1500 euro? The same applies to drugs as well as implants.” “We need greater emphasis on prevention and primary health care and less on tertiary medicine, especially hi-tech, expensive medicine and surgery at the extremes of life. This comment comes not from a primary health provider but from a tertiary medicine specialist.”

Many also gave testament to the changing times and systems. “The entire community needs to take part in the rationalisation of health services. It can't just be the propeller heads at Medicare, or clinicians, or politicians, or patient groups. Another doctor wrote: “I sincerely hope that the post-election will witness the engagement of senior health practitioners and health staff in the decision-making process…” “Need to change the health mindset of a population – no easy task.” “Who 'demands' it? Sometimes doctors need to take responsibility for their actions and say...no; Or politicians, but it won't happen.” Politics also brought out the sceptics (or perhaps they’re the realists). “No political party is brave enough to ensure patients pay something on presentation to a doctor – whether it is ED hospital or GP.” “Health policy seems to be ‘apolitical’ because decisions do not seem to be different whichever party is in power!” “I’m completely disillusioned by politicians. When an unneeded third medical school can be created because of lobbying and in which electorate!”

e-Po ll

The state’s financial situation and the spirally costs of health delivery were hot responses. “The issue is distribution of funds, not supply,” said one doctor. Another suggested where that money was going: “Too much money is being channelled into bureaucracy and too little into health workers.” A number of doctors pointed to the fact that there were a lot of doctors – one suggested “There are many (I for one) specialists in WA unemployed or underemployed currently. The supply is there, the need is there, the funding isn't because of underfunding or misappropriation/wasting of funds.” The unsustainability of the current trajectory of the health spend was of concern and some thought it was time to bite the bullet. “People are demanding more tests, more imaging and more medications despite there being no evidence for many things. We need to stand up to the patients! We also need to stop duplication of tests e.g. doing ultrasound just so it is on the hospital PACS rather than being bothered to get a copy of the previous one.”

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GUEST COLUMN

Still Striving for Equity Add parity and flexibility into medicine and women will show how valuable their contribution can be says ECU's Prof Steven Chapman. It’s an unenviable statistic, but WA now has the highest gender pay gap in Australia. The facts? Women working full-time for WA-based employers earn, on average, 30.9% less than men. And this equates to more than $43,000 a year (2015-16). It’s not a good look when you see that the national average remuneration gender pay gap is 23.1% ($27,000). If you drill down to look at the medical side of the equation, that doesn’t look too good, either. Health economist Prof Tony Scott surveyed 3618 GPs and found that female GPs earnt $83,000 or 54% less than male GPs. And the specialists? A 2013-14 analysis from ANU’s Centre for Social Research showed surgeons had an average taxable income of $405,000 compared with $215,000 for women. This disparity raises the question – if men and women desire success, wealth and power equally and, if they have equal capabilities, why do women continue to take home less pay in their chosen profession? Clearly we don’t yet have equal opportunity, equal recognition and equal rewards.

Lack of flexibility in our approaches only reduces choice for women. Parental and carer roles continue to be predominately carried out by women and play a significant part in creating barriers for career progress. We know that women are more willing to take on work that contributes to societal good, but attracts lesser remuneration. Thus with women having significantly less power in the economy, their overall personal earning capacity and sense of financial independence is felt community wide with negative impacts. In 2016, I became a Workplace Gender Equality Agency Pay Equity Ambassador, joining other national leaders on this agenda. In the same year, the Edith Cowan University received a Citation for Employer of Choice for Gender Equality by the Agency to mark their achievements to date. It is imperative that we address gender pay disparity in our science, technology, engineering, mathematics and medicine (STEMM)-based professions. This will require

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34 | MAY 2017

more robust processes for matching role competencies against assessments of career performance and regular monitoring of existing pay structures. ECU is participating in the pilot of the Athena SWAN (hosted by the Science in Australia Gender Equity initiative) – a response to the chronic under-representation of women in science leadership. It has the aim of addressing the loss of women in STEMM-based disciplines and currently has 40 universities and research institutions in its membership. In growing the community’s talent pool, it is important to consider greater flexibility in medical training programs and jobs and examine workplace cultures within speciality areas to achieve the participation of women across the full spectrum of the medical workforce. Being aware of the existing status quo and letting go of rigid and outdated modes of practice is the first step in working towards significant change. Lack of flexibility in our approaches only reduces choice for women in selecting specialities for medicine and we need to venture outside the box. References on request

10/04/2017 10:06:13 AM

MEDICAL FORUM


Guest Column

Helping People Help Themselves It is crucially important to address the barriers to effective methamphetamine treatment, says UWA’s Craig Cumming. It is an inconvenient truth that methamphetamine use has been increasing in WA, leading to an increase in associated health and social justice issues. Treating methamphetamine dependence is complicated. With no effective pharmacotherapies currently approved in Australia, counselling-based therapies are relied upon almost exclusively. One of the major challenges is getting individuals who require treatment to seek assistance in the first place. Consider the example of a male prisoner participating in health-related research prior to his release from prison who had disclosed long-term methamphetamine use prior to his imprisonment. He was well aware that his physical and mental health were negatively affected by drug use, and that it was a significant contributor to his prison sentence. When questioned about seeking help to abstain from drug use post-release, he stated that he didn’t have a problem with methamphetamine and that he did not need treatment. He also went on to question the efficacy of treatment. This particular individual’s opinion regarding

methamphetamine treatment is, sadly, consistent with many others. And, equally sadly, it is a poor reflection on the perception of counselling-based therapies. Research has consistently found that it is the internal thoughts and attitudes of methamphetamine users that play the

Getting individuals to the point where they are comfortable taking that first step should be a key area of focus for policymakers. greatest role in preventing them from seeking treatment. More specifically, perceived embarrassment and stigma linked with the actual need to seek treatment in the first place. Getting individuals to the point where they are comfortable taking that first step should be a key area of focus for policymakers. There is little hope of a change in lifestyle when embarrassment and/or stigma prevent treatment being sought.

Ongoing denial that a problem even exists is the usual outcome. The implications of all this are less than favourable. An untreated addiction is likely to progress even further, with larger amounts being used to achieve the same ‘high’. This situation can be addressed by educating methamphetamine users about two evidencebased facts: firstly, the sooner they seek help the better their chance of success, and secondly, that psychosocial interventions such as counselling (particularly acceptance and commitment therapy) are effective in helping individuals to cease methamphetamine use. Getting these two basic messages across can help to normalise the process of an individual recognising that their drug use is a serious problem. This will hopefully destigmatise the decision to seek help, and increase confidence in the effectiveness of treatment. This is an important message to promulgate, and a relatively simple, cost-effective strategy to address the growing problem of methamphetamine use in WA. ED: Craig Cumming is a Research Officer at the School of Population Health, UWA.

Recommend the free flu and whooping cough vaccines to your pregnant patients. health.wa.gov.au

MEDICAL FORUM

May 2017 | 35


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Guest Column

Negative Cycle of Sexualisation It’s important to speak out – and loudly – regarding the overt sexualisation of young women, says Caitlin Roper. Collective Shout is a grassroots campaign movement highlighting the objectification of women and their sexualisation in popular culture. We believe serious problems arise when: • A person’s value is derived from her/his sexual appeal. • A person is sexually ‘objectified’. In other words, regarded as a ‘thing’ for the sexual use of others.

having a diminished view of human sexuality. In a submission to the NSW Parliament, the Australian Psychological Society outlined some of the consequences of exposure to highly sexualised and objectifying material. It stated that young women learn to regard their bodies as objects of desire and one of the effects is impaired cognitive function. Such negative sexualisation has also been linked with depression, low self-esteem and eating disorders.

• ‘Sexuality’ is imposed. Mass media and popular culture routinely depict females in a highly sexualised and objectified manner. This has a profound impact on how both women and girls are perceived by others and, more importantly, how they ‘see’ themselves. A recent meta-analysis of relevant publications found consistent evidence that regular exposure to sexually objectifying content is directly associated with higher levels of body dissatisfaction, greater self-objectification and increased tolerance of sexual violence toward women. And there are a number of recent studies suggesting that exposure to this type of material results in both men and women

It’s very difficult, as a parent, to counter these endless cultural messages. The mainstreaming of internet pornography is also having significant negative health outcomes for young people. Easily accessible online pornography is a significant factor in the escalating rates of surgical labiaplasty among healthy young women. It’s no surprise that women end up comparing their vulvas to female porn performers and end up believing that their own genitalia is abnormal.

GPs are also reporting a rise in sex-related injuries in adolescent girls. Many of them are being pressured to engage in porn-inspired ‘rough sex’ with predictable consequences. This culture of objectification permeates our lives. I was recently helping my six-year-old daughter put on a pair of jeans that she was rapidly growing out of. I was horrified when she said to me, ‘I like them, they make me look skinny, and skinny is pretty’. All those countless conversations we had about healthy bodies that come in all shapes and sizes! It’s very difficult, as a parent, to counter these endless cultural messages equating female thinness with being physically attractive. A friendly chat in a GP’s surgery regarding unhelpful, and often dangerous, cultural messages may well prove to be a timely intervention. And what a wonderful thing if more doctors participated in ongoing advocacy to tackle the increasing problems linked with sexual objectification. References available on request. ED: Caitlin Roper is WA State Coordinator and Campaigns Manager for Collective Shout.

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MEDICAL FORUM


CLINICAL UPDATE

MenW vaccination for teens – how will it work?

Dr Astrid Arellano Infectious Diseases Physician Palmyra

A few years ago my children complained bitterly about receiving MenB vaccine – swollen arms that hurt, twice. I’m not sure if it was the evidence or a desire to spite anti-vaxers that lead to vaccinating them again last Christmas, this time with quadrivalent ACWY meningococcal vaccine.

Will the planned vaccination of mainly teens work against rising invasive meningococcal disease?

ED

In hindsight, MenB vaccine probably wasn’t necessary as the rate of invasive meningococcal disease (IMD) due to this serogroup has steadily dropped in WA from the predominant serogroup to just a handful of cases in 2015. In contrast, MenW IMD continues to rise nationally from 2% of cases in 1991-2002 to 8% in 2013 and 19% in 2015. In Victoria MenW was the most common notification of IMD in 2015, accounting for 50% of cases. Nationwide, the predominant serogroups causing IMD vary. MenW has become the most common in Victoria whilst MenB is still the predominant serogroup in South Australia. The reasons for the epidemiological differences are unclear but probably relate to a natural shift in serogroups. The uptake of MenB vaccine has been too small to account for the steady drop in this serogroup however the decrease in MenC prevalence probably correlates with the introduction of vaccination in 2003 (incidence <0.3/100,000 cases since 2009). MenW has a higher fatality ratio of around 1015% and in 20% of cases the presentation is atypical including septic arthritis, pneumonia and epiglotittis. The bimodal distribution of affected age groups (0-5 years and 15-25 years) is similar to other meningococcal serogroups but an additional peak in the older 45 year age group has been noted. Western Australians aged 15-19 will receive the conjugate meningococcal ACWY vaccine NimenrixTM starting in April/May 2017 via schools and community centres. This program is state-funded and comes at a cost of $6M over the next three years. Sixty to 70% coverage is expected in 2017 with the reduction in meningococcal throat carriage in this age group spilling over other age groups reducing the incidence of IMD. However, a third of MenW cases in WA between 2013-2016 were in children under 4 years old and 43% were in those over 20 years. The vaccine will not be available in General Practice except on private scripts

Key Clinical Points • Menincoccal W strain invasive infection is increasing. • MenW infection is more dangerous and 1 in 5 cases present atypically. • It is intended that the WA government vaccination of teens will reverse these trends.

MEDICAL FORUM

WA notifications by serogroup

and children aged 0-5 years are not eligible for free vaccination. Individuals aged 18 and 19 no longer attending school will only have access to vaccination through community centres which may lead to a lower uptake and thus lesser coverage of vaccination. This program will run for three years and it is hoped that either MenW rates will drop and

vaccination will no longer be required or that a national program will replace it. Time will tell. The author acknowledges the support of Dr Gary Dowse from Communicable Disease Control Directorate in preparing the article. Author competing interests: no relevant disclosures. Questions? Contact the author on 9319 3811.

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CLINICAL UPDATEs

Dense, Denser, Densest In the next three pages we read what Drs Liz Wylie (BreastScreen WA), Vanessa Atienza-Hipolito (radiologist) and Corinne Jones (breast surgeon) say about breast density. The medical, legal, and ethical consequences of breast density are real. The influence that breast density has on cancer detection seems important. In fact, important enough for the Queensland Institute to sponsor Dr Nancy Capello to come from the US talk at a two-day symposium on why breast density delayed the diagnosis of breast cancer in her; important enough for a WA nuclear technologist to invest in the only camera for molecular breast imaging in Australia and now housed at Hollywood Hospital; and important enough for BreastScreen and both the Australian and US colleges of radiologists to release position statements. In a nutshell, the higher the breast density, the greater the ‘white-out’ on standard mammograms so the harder it becomes to

detect cancer, and the more likely (although only slightly) a woman is to get cancer in the first place. As they say: “BreastScreen WA recognises that breast density has an important impact on mammographic screening. Increased breast density is associated with an increased risk of breast cancer while leading to a lower accuracy or ‘sensitivity’ for cancer detection.” The difficulties arise because: • There is observer variation when it comes to defining breast density. • Even women with low density (i.e. fatty) breasts can have breast cancer. • No one wants overreaction to high density (“tests that miss cancer”) or complacency when density is low (“failure to do extra tests”).

Dense breasts and mammograms

Breast density as a risk factor for breast cancer relates to the amount of the breast’s glandular and stromal elements. As breast cancer most commonly arises in glandular cells a greater amount of glandular tissue increases the chance of cancer. International evidence based review studies indicate there is considerable variation in the subjective classification of breast density by radiologists.

MEDICAL FORUM

Again: “BreastScreen WA is recommending to women with dense breasts that they see their GPs for regular breast examinations and that women with signs or symptoms of possibly significant breast disease are referred for additional breast imaging.”

Breast density varies considerably and can influence the detection of breast cancer using mammography?

ED

screening with whole breast ultrasound in women with dense breasts. Trials consistently demonstrated that supplementary breast ultrasound in women with dense breasts does increase cancer detection by 50% at the cost of a very high false positive biopsy rate.

High breast density reduces the sensitivity of mammography because of its masking effect for cancer detection. Sensitivity may exceed 85% in fatty breasts and decreased to 65% in very dense breasts.

Factors that influence breast density

• If supplemental screening works in some circumstances, should government pay for this or do those who can afford it pay?

By Clin Assoc Prof Liz Wylie Medical Director BreastScreen WA

Mammographic breast density affects breast cancer screening and women increasingly ask their general practitioners for advice. Breast density refers to the relative amount of radio opaque stromal and glandular tissue compared to the amount of radiolucent breast fat demonstrated at mammography.

High breast density increases the risk of breast cancer. The relative risk for cancer in women with extremely dense breasts compared with average woman is approximately 2:1. Approximately 3040% of women over the age of 50 have mammographically heterogeneously dense or extremely dense breasts.

• Nothing shows that adding either ultrasound or MRI to mammography screening saves lives, even though MRI can detect malignancies undetected by mammography in high-risk women (but with more false positives that lead to unnecessary breast biopsies).

A mammographically dense breast: glandular tissue can easily mask a significant lesion of comparable density.

A mammographically fatty breast: expect highly sensitive mammography for breast cancer detection.

A woman’s breast density tends to vary with time due to menopausal changes, hormone replacement therapy and weight gain or loss. The relative risk for breast density is much smaller than other major risk factors for breast cancer such as age, family history, reproductive history and genetic mutations Is supplementary screening of benefit? There are no randomised controlled trials evaluating the use of supplemental

The value of tomosynthesis, (3D mammography) as a supplemental screening modality in women with dense breasts is not yet proven. No studies have evaluated the benefits of adjunctive screening breast MRI in women of average risk with dense breasts. Supplemental screening of women with dense breast who are average or low risk is not currently recommended by international evidence based review studies. The American College of Radiologists/ Society of Breast Imaging appropriateness criteria state that in women at intermediate risk of breast cancer due to a family history, a personal history of breast cancer, or other risk factors including premalignant lesions such as lobular neoplasia may benefit from regular supplemental whole breast ultrasound. References available on request Author competing interests: nil relevant disclosures. Questions? Contact the author on 9323 6706

May 2017 | 41


CLINICAL UPDATE

Dense breasts: management advice Women with dense breasts have an increased risk of breast cancer. Mammographic detection of breast cancer in dense breasts can be difficult. Hence breast tissue density has become topical. While it is quoted that screening mammography alone, has demonstrated a reduction in breast cancer mortality in the target population, the clinician should not be deterred from the addition of breast examination and breast ultrasound, when managing women referred to them with dense breasts.

By Dr Corinne Jones Breast and Endocrine Surgeon

The pubertal breast is all dense glandular tissue. The breast usually remains dense during regular menstruation and throughout the reproductive years. Pregnancy, breast feeding, obesity and hormonal fluctuations from around 40 years, tend to reduce the tissue density. Perimenopausal and menopausal women who are slim, nulliparous, taking HRT or have a strong family history of breast cancer are more prone to ongoing dense breast tissue. Clinical significance Very dense glandular breast tissue looks and feels like cooked squid at operation, and is the white tissue seen on mammogram.

What’s happening in the community Where relevant, asymptomatic women with dense breasts who undergo a free BreastScreenWA mammogram, may be given a letter telling them they have dense breasts and to see their GP for further management. The GP receives a similar letter of notification. Every two years BreastScreenWA contacts the target population of women, 50 – 74 years, inviting them to attend for a mammogram. Asymptomatic women from 40 – 49 years and 75 years and over, can also attend two yearly of their own volition. Women under 40 years cannot obtain a mammogram through BreastScreenWA. Anatomical understanding The breast is a modified sweat gland that sits between skin (including the subcutaneous fat) and the chest wall muscle. The post-pubertal non-lactating breast is glandular tissue with multiple breast ducts that open together at the nipple summit. At the peripheral margins of the ducts are inactive breast lobules (greatly expanded in the lactating breast). The filling tissue between the ducts and lobules is fibrotic tissue and some yellow fat.

Abnormal lumps and calcification, benign or malignant, are also white on mammogram. Hence if the breast is very dense, lumps and some abnormal calcification can be hidden in the solid white glandular tissue, during clinical examination and on mammogram. How the films are reported The ‘dense breast’ letter issued by BreastScreenWA usually refers to breast tissue density > 50%. In non-BreastScreenWA mammogram reports, the radiologist may convey breast tissue density by including descriptive information; such as mixed density tissue, or by using a complex scoring system (e.g. Volpara), or giving percentage ranges (which I find the most reproducible and clinically functional - see Table). What should we do about it? All women of all ages should be encouraged to regularly check their own breasts. One to two yearly breast examination with their GP can be invaluable. The peripheries and edges of the breast should always have a detailed examination. Lumps in these locations can be

As breast density increases so does ED the risk of cancer and difficulties in detecting it with the usual mammograms. What can be done about this dilemma?

missed as they ‘slip out’ of the mammogram plate as the breast is compressed. Any breast abnormality in any woman or girl, should be followed by a bilateral breast ultrasound if < 35 years, and bilateral mammogram and breast ultrasound if ≥ 35 years, with a request for reporting by an experienced breast radiologist. Breast MRI has limited use in the private sector because only women with PIP implants or <50 years with a very strong family history of breast cancer qualify for a Medicare rebate. The majority of lesions in the breast can be detected with good clinical examination, mammogram and breast ultrasound. Only mammogram can detect fine, potentially malignant calcification. Breast ultrasound can look at white glandular tissue and convey the nature of any rounded opacities seen on mammogram: benign simple cysts, complex cysts, solid lesions that are benign, indeterminate or malignant. The only way to define a solid or complex lesion is by tissue biopsy, usually a core biopsy or FNA if mostly a cystic mass. Outside of BreastScreen WA there is no Medicare rebate for mammography in asymptomatic women. However it is still possible to obtain a Medicare rebate for the asymptomatic, screening breast ultrasound. Hence the GP can provide a valuable service in continuing the management of women who present with dense breasts.

Table: Working Guide on Breast Tissue Density in Women 40 Years and Over –Dr Corinne Jones © % Density

Usual Breast Shape

Breast Tissue Type

Mammographic Appearance

Mammographic Breast Cancer Detection Rate

Breast Cancer Risk

0

Pendulous and soft

Fatty, all glandular tissue fat replaced

Translucent, all pale grey

Very high

Very low

0 – 25

Pendulous and soft

Mostly fat replaced, occasional glandular

Pale grey with faint white streaks

High

Low

25 – 50

Less pendulous, soft and lumpy

Fat replaced some glandular

Pale grey with patches of white

High

Low

50 – 75

More rounded and more lumpy

Glandular with some fat

White patches with some grey patches

Moderate

Moderate

75 – 100

Rounded and lumpy

Mostly glandular, minimal fat

Mostly white with grey streaks

Low

High

100

Rounded and firm

All glandular and solid

Total white out

Very low

Very High

42 | MAY 2017

MEDICAL FORUM


CLINICAL UPDATE

Women’s breast imaging • More than 75% fibroglandular = extremely dense

CASE REPORT A 50-year-old asymptomatic woman presented for routine two-yearly mammogram.

Visual designation of breast density may be subjective, inconsistent and not reproducible due to inter-observer and intra-reader variability.

By Dr Maria Vanessa Atienza-Hipolito Radiologist Cottesloe

Supplementary imaging has is important role in women with dense breasts, to help detect otherwise hidden cancer.

ED

Volpara is a volumetric breast density measurement tool, software used to help radiologists assess breast density more objectively (Volpara Density Grade is usually stated in the patient’s radiology report). Ultrasound use Being radiation free, it is the first imaging of choice for pregnant and breastfeeding women and for symptomatic patients aged < 35 years.

Fig 1A

Fig 1B

Right craniocaudal (Fig 1A) and mediolateral oblique (Fig 1B) mammograms show dense breasts with more than 75% fibroglandular tissue (Volpara Density Grade 4). There is an irregular solid lesion with suspicious sonographic features in the right breast 12 o’clock position (Fig 2). The biopsy procedure was done under ultrasound guidance using a standard 14-gauge biopsy needle.

Breast ultrasound has long been a diagnostic tool in evaluating mammographic abnormalities and for evaluation of clinical abnormality or symptoms of any age and gender. It is also commonly used to evaluate women with past history of breast cancer, breast implants and for image guided biopsy or other minimally invasive breast procedures. Ultrasound can detect invasive breast cancer before it becomes clinically evident. Adding ultrasound to mammography makes a lot of sense, particularly in women with dense breasts. In women with dense breast tissue, several clinical studies have demonstrated that breast ultrasound can pick up both clinically and mammographically occult breast cancer. However, no trials have proven a mortality benefit of this imaging modality. False positives are significant, reducing with succeeding ultrasounds in a surveillance series. Breast ultrasound does not replace mammography in evaluation of breast calcifications, asymmetric densities and architectural distortions.

Fig 2

The biopsy confirmed an invasive lobular carcinoma, ER and PR positive and HER2 negative. She underwent mastectomy, axillary clearance and reconstruction. Discussion Breast density may be reported as percentage visually, using BIRADS lexicon, and can be classified into four categories: • Less than 25% fibroglandular density = almost entirely fatty • 26-50% fibroglandular density = scattered fibroglandular tissue • 51-75% fibroglandular density = heterogeneously dense MEDICAL FORUM

Mammogram and ultrasound are complementary imaging modalities and one does not replace the other. Biopsy and DBT use The standard of care for clinically, mammographically or sonographically detected breast lesions is to perform needle test (Triple Test Assessment) either an image-guided fine needle aspiration or core biopsy - for diagnosis and to guide further management. Digital breast tomosynthesis (DBT), or 3D tomosynthesis, is an advanced mammography technique. It is a new technology, an accepted adjunct to the standard 2D mammogram, now used in screening and diagnostic centres both locally and internationally.

Volpara Density

Several clinical trials indicate DBT improves cancer detection rates, decreases recall rates (especially in women with dense breast tissue) and reduces the number of unnecessary biopsies. Its suitability for all patients, regardless of age or breast tissue type, comes from its better visualisation and characterisation of masses, distortions and asymmetric densities. High risk patients benefit from DBT, including those with a strong family history of breast or ovarian cancers or those with a first degree male relative with prostrate or breast cancer, and those with dense breasts. Those with previous breast disease/cancer and those requiring further assessment following a 2D mammogram also benefit. In DBT, the X-ray tube moves through an arc while acquiring a series of low-dose images and then converted into a stack of thin slices, typically 1 mm thick – combined 2D and 3D study images increase patient radiation by about twofold but still within safety limits and similar to the traditional film-screen mammogram studies. According to researchers, 2D-image generating software may replace the conventional 2D mammogram and potentially reduce the radiation dose by up to 45%. References on request

May 2017 | 43


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CLINICAL UPDATE

Taking the sweat out Axillary hyperhidrosis may lead to complaints of clothes wet with sweat and body odour. Those affected often wear black or sleeveless tops to conceal sweat stains, showering frequently and packing multiple changes of clothes. Lack of selfconfidence and avoidance of social interaction ensues.

PIVET MEDICAL CENTRE Specialists in Reproductive Medicine & Gynaecological Services

ASPIRE Meeting in Kuala Lumpur … revisiting Malaysian IVF after 30 years Axillary ED hyperhidrosis severely affects 4% of people with complaints of excessive axillary sweating. What can be offered these difficult patients?

When the patient considers it severe enough to intervene, palmer hyperhidrosis can be treated with endoscopic thoracic sympathectomy (ETS), by ablating the sympathetic chain over the second and third ribs. However, axillary hyperhidrosis treatment requires ablation over the second, third and fourth ribs for which there are unacceptably high rates of compensatory hyperhidrosis from the back, trunk and lower limbs. As well, nonpermanent treatments such as Botox, iontophoresis and aluminiumbased gels, have poor compliance due to cost and poor effectiveness. Instead, a microwave-based system that non-invasively destroys axillary eccrine (sweat) glands and apocrine (odour) glands, has been both FDA approved (US; 2011) and TGA approved (Australia; 2014) but is neither covered by Medicare nor private insurance. It is important to remember that significant palmer hyperhidrosis may occur in up to 60% of patients with axillary hyperhidrosis. As well, axillary hyperhidrosis can be secondary to cancer (carcinoid, lymphoma), endocrine disorders (thyrotoxicosis, diabetes, acromegaly) and medications (sertraline, tricyclic antidepressants). The method Treatment uses the differential absorption of microwave energy, higher in water and lower in fat. A hand held device delivers microwave energy to the dermal fat junction, heating the area where sweat and odour glands are most concentrated, and permanently destroying them (thermolysis). Hair follicles are also destroyed, leading to reduced hair growth. The target area is the hair-bearing area of the axilla where the highest concentration of apocrine and eccrine glands exist. Patients are asked to shave axillary hair three days prior to treatment, for which a temporary tattoo is applied so that marks correspond to points of energy delivery with the hand held delivery device.

L-R: normal sweat glands; necrotic sweat glands two weeks after microwave thermolysis; and absence of sweat glands at 6 months.

Treatment can be given under local anaesthesia in an office setting, with about 90mins to treat both axillae. When the local wears off, most patients require simple oral analgesics such as paracetamol and ibuprofen for 2-3 days to control erythema and swelling. Ice packs are applied for 48 hours to reduce oedema and inflammation. About 85% of patients require one treatment only and can resume work the next day. Patients describe a temporary feeling of “having a tennis ball in the armpit”. Patient satisfaction is high at 12 months. References available on request Author competing interests: no relevant disclosures. Questions? Contact the author on 6162 0233

MEDICAL FORUM

by Medical Director Prof John Yovich

Successful IVF and GIFT programs were started at the Subang Jaya Medical Centre in Malaysia in March 1986. These programs were initiated by a Malaysian Branch of PIVET with the transfer of laboratory, clinical and administrative skills from Perth. In the first 12 months, 20 couples undertook 23 treatment cycles of IVF with 19 progressing to ET and 4 pregnancies resulting, the first starting as a twin but one fetus suffered intra-uterine demise at 24 weeks from placental abruption whilst the other, a healthy girl of 2.45 kg was delivered by caesarean at 37 weeks (accompanied by the sibling fetus papyraceus). In the GIFT program 42 couples had a total of 53 GIFT treatment cycles with 14 pregnancies ensuing - 9 of which proceeded to livebirths, the first being twin girls weighing 2.11 kg and 2.09 kg. These pregnancies were the first arising from IVF and GIFT programs in Malaysia and were reported in both our MJA and the prestigious Journal of IVF and ET in 1987. I undertook this venture to assist KL gynaecologist Haris Hamzah, brother of our very own Perth anaesthetist Dr Hamid Hamzah. Following a management handover a decade later Dr Haris has expanded his activities, maintaining Subang Jaya MC and also joining with colleagues at the Alpha Fertility Centre, headed by Dato’ Dr Colin Lee.

The 7th ASPIRE Congress was held at the KL Convention Centre surrounded by amazing architecture.

At the recent 7th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE) I heard of many advances arising from all over the Asian arena, along with excellent outcomes from the preimplantation genetic screening at Alpha Fertility Centre. In fact, the reputation from many of the medical facilities within Malaysia has risen to attract over 1 billion RM last year, projected to rise to 5 billion RM. The Malaysian Government has established both a Healthcare Travel Council as well as Accreditation processes for Quality Control in the industry. PIVET is proud to have initiated a venture that has become so advanced at an international level.

NOW AT 2 LOCATIONS PERTH & BUNBURY

For ALL appts/queries: T 9422 5400 F 9382 4576 E info@pivet.com.au W www.pivet.com.au

May 2017 | 45


Fertility, Gynaecology and Endometriosis Treatment Clinic

When your patient’s family plan isn’t going to plan... Fertility North can help. l Cycle Tracking

Timed Intercourse l Artificial Insemination l Ovulation Induction l In-vitro Fertilisation (IVF) l Intra-cytoplasmic Sperm Injection (ICSI) l Specialised Embryo Selection l Pregnancy Monitoring l Donor Services l Sperm / Egg Freezing l Oncology Fertility Preservation l Egg Freezing for Social Reasons l Semen Analysis (including DNA fragmentation and anti-sperm antibodies testing) l

Dr Vince Chapple

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Dr Santanu Baruah

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Dr Megan Byrnes

Medical Director

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MB, BS (London) FRANZCOG MRepMed

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Dr Jane Chapple

Suite 30, Level 2, Joondalup Private Hospital, 60 Shenton Avenue, Joondalup WA 6027 Phone: (08) 9301 1075 Fax: (08) 9400 9962 Email: admin@fertilitynorth.com.au

www.fertilitynorth.com.au

Fertility, Gynaecology and Endometriosis Treatment Clinic 46 | MAY 2017

MEDICAL FORUM


CLINICAL UPDATE

Claremont Pain Clinic

HT in women reconsidered Hormone replacement therapy used to be a standard treatment for women with menopausal symptoms. Hormone therapy (or HT as it's now called) was also thought to have the long-term benefits of preventing heart disease and possibly dementia. This changed abruptly when a large clinical trial found that treatment for one type of hormone therapy actually posed more health risks than benefits.

Dr David Holthouse Neurosurgeon/Pain Specialist Our views on hormone therapy in post menopausal women involve weighing up all the risk factors, including the risk of breast cancer.

ED

Review of clinical trials and new evidence shows that hormone therapy may be a good choice for certain women, depending on their individual risk factors. These include current age, age at menopause, risks of heart disease and family history. Patients with a family history of oestrogen dependent cancers such as breast cancer, ovarian cancer, endometrial cancer or with preexisting heart disease must be referred for specialist advice. Patients with uncontrolled hypertension must control this before starting HT. The Institute of Cancer Research in London is following more than 100,000 women for 40 years to investigate the causes of breast cancer. Some 39,183 women whose age at the start of menopause was known were monitored for six years, with questionnaires gathering data on their use of HT. Those on combined HT for an average of 5.4 years were 2.74 times more likely to get breast cancer while taking HT than women who had never used it and the risk rose with length of use. Women using oestrogen-only HT were at slightly increased extra risk of breast cancer, with 17 in 1000 (base rate 14 in 1000) when taken for 5 years.

FRACS FRACGP FPMFANZCA

Dr Pat Coleman Anaesthetist/Pain Specialist

FANZCA FPMFANZCA FRACGP DRCOG

We have formed a pain unit and are now ‘Claremont Pain Clinic’. David has a neurosurgical background and Pat an anaesthetic background, and both are qualified GP’s (FRACGP), and as such provide a broad range of experience with regards to all pain issues. David remains open to seeing neurosurgical cases but the major focus of the clinic is procedural pain management. Pat is an anaesthetist who has a FPMANZCA and is experienced in pain interventions such as spinal injections and rhizotomies. He is also able to see cases with pain issues such as CRPS and post-surgical pain in any region of the body or other pain states. The practice has a clinical educator and a registered nurse experienced in pain. We also have a focus on neurostimulation as a potential treatment. We are able to see insured patients (privately insured and workers compensation). We have a keen interest in the rehabilitation of workers compensation patients and aim to expedite appointments. We do not see patients with active MVIT claims, public liability cases or non-insured patients. We are unable to cater for drug addicted patients who should be referred to a public pain clinic. We have a close working relationship with a number of other spinal surgeons who are sub specialists in fusion surgery and often assist in the workup and selection of patients for this surgery. We also work closely with a clinical psychologist and psychiatrists with experience in pain management and pain conditions. We work in collaboration with Pain Options, a specialist physiotherapy practice which assists in the rehabilitation of pain patients and workers compensation patients.

When to consider hormone therapy? The benefits of hormone therapy may outweigh the risks in healthy women with moderate to severe hot flushes or other menopausal symptoms, who have lost bone mass and either can't tolerate or aren't benefitting from other treatments, or who have a premature menopause (onset before 40) Women with early menopause, particularly those who had their ovaries removed and don't take estrogen therapy before 45, have a higher

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

continued on Page 48

MEDICAL FORUM

May 2017 | 47


continued from Page 47

HT in women reconsidered Minimally invasive laser eye surgery changing the paradigm SMILE SMall Incision Lenticule Extraction represents the third generation of development in laser vision correction after PRK and LASIK. Unlike previous generations, SMILE employs focused femtosecond laser incisive pulses delivered directly inside the cornea to create a lenticule and a 2.8mm incision. This lenticule optically represents the patient’s myopia or astigmatism. The lenticule is then extracted through a small incision and the refractive error is thereby corrected.

“This treatment approach is similar to other keyhole surgeries such as laparoscopic surgery.” The key advancement is the laser technology. The Excimer laser used in traditional laser eye surgery can only sculpt on the surface like a sander and therefore requires epithelial debridement or a retracted corneal flap wound to deliver the treatment. The Zeiss femtosecond laser can deliver incisive pulses directly to a focal point inside the cornea. The laser energy does not cause collateral injury before or after the focal point. By using rapid laser pulses and precise, three dimensional control, the laser can create accurate incision of complex shapes within the cornea without injuring the ocular surface or other parts of the eye. Typical laser treatment time is 25 seconds regardless of the refractive power. SMILE has been available internationally for more than five years and over half a million successful cases have been performed. We have been providing this treatment since 2015. Later in the year, other Perth practices will also be introducing SMILE. As SMILE doesn't require a large flap, studies have shown less dry eyes from SMILE compared to LASIK due to less nerve plexus injury. SMILE has also been shown to be more accurate in higher power correction and corneal biomechanics is better preserved. Therefore, higher levels of myopia can be corrected safely with SMILE. Not every patient is suitable for SMILE as hyperopic treatment is still under development. However, patients who request for laser vision correction should be counselled about this advanced option, which offers improved results and safety.

risk of osteoporosis, coronary heart disease, Parkinsonism and anxiety or depression. Early menopause typically lowers the risk of most types of breast cancer. In premature menopause, the protective benefits of hormone therapy usually outweigh the risks. Women with current or a past history of breast cancer, ovarian cancer, endometrial cancer, thrombosis, or stroke should usually not take hormone therapy. Women without menopause symptoms, who start menopause after 45, do not need hormone therapy. It is not generally recommended for women over 60. Menopausal hot flushes can be managed with healthy lifestyle approaches, such as keeping cool, limiting caffeinated beverages and alcohol, and by practicing paced relaxed breathing or other relaxation techniques. Alternative medicine approaches — such as tai chi, yoga and acupuncture — can be tried. For vaginal dryness or painful intercourse, a vaginal moisturizer or lubricant may provide relief.

Key points for HT • HT is the most effective treatment at reducing vasomotor symptoms (within 4 weeks). • It is indicated in women who have had early menopause (less than 45 years), premature menopause (less than 40 years) and in fully informed women with whom the benefitrisk ratio is discussed. • In healthy women aged 50-59 years, HT does not increase cardiovascular risk (and may decrease the risk). • Combined HT can increase the risk of breast cancer if taken beyond 5 years, by almost three times. • HT should not be commenced in women over 60 years of age.

Author competing interests: no relevant disclosures. Questions? Contact the author 9550 0300

Dr Ian Chan, FRANZCO Refractive Surgeon Hollywood Medical Centre Suite 63A, 85 Monash Avenue, Nedlands Ph (08) 9388 1828 Fax (08) 9388 1868 W: www.aculase.com.au

48 | MAY 2017

MEDICAL FORUM


It’s All In The Fine Print Do you have your mobile registered not to get ‘spam’ calls. If not you could be in trouble! The terms and conditions of many on-line competitions often have entrants agreeing to be contacted for marketing purposes; wording like ‘when you register your details or enter a competition, you agree to ‘XX Business’ using your details and supplying them to other organisations for purposes of: sending you information, offers and promotions about products and services by mail, phone/SMS/MMS or email.”. Almost no-one reads this ‘fine print’. How your mobile can be targeted When they give the OK by ticking the box, competition entrants are in effect providing express consent for three months (unless longer is stated on the entry form e.g. You agree we can use your details for an indefinite period or until you notify us or opt out from receiving offers.’). Awake to this, entrants sometimes enter mobiles that are wrong. If your mobile number happens to be the fake mobile what then? First, some vendors of contact lists promote the “live” nature of their data, so you will have to move fast. No one checks mobiles against email addresses, and mobiles are the preferred contact method of many businesses with something to market. Either way, expect calls or SMS messages from all sorts of people trying to sell you educational packages, insurance, energy, etc.

Have they got the balance? By limiting the Register to private and domestic fixed line and mobile numbers the government thinks it has provided an appropriate balance between the rights of individuals to privacy and the needs of businesses to promote their products and services. Political parties, charities, educational institutions, social researchers and opinion pollsters are exempt. Washing a calling list allows a marketer to determine if a number is on the register or not but they are only obliged to do this every 30 days. The Do Not Call legislation applies to businesses that make or cause to be made telemarketing calls e.g. a call centre that makes calls on a business’ behalf. The Do Not Call Register legislation does not apply to businesses that provide actual contact lists.

By Dr Rob McEvoy ED. Unsolicited marketing by SMS falls under a different piece of legislation, the Spam Act. It is generally safe to unsubscribe from SMS senders

when you know the business or have a business relationship with it. If you are not certain, you can try to contact the sender by telephone or in writing to withdrawn consent. However if the SMS looks suspicious, do not respond to it - just delete it or report it with the ACMA. Further information about spam including how to report spam SMS can be found at http://www.acma.gov.au/Citizen/ Phones/Mobile/Dealing-with-mobile-spam/spamcomplaints-reports-and-enquiries

If you say “I wish my phone number to be taken off your list” there is a requirement for that telemarketer (in the Philippines?) to stop ringing you on behalf of that business but no requirement for the business that sold them the list to ‘wash out’ your phone number before they onsell to another business. If an individual telemarketer doesn’t stop ringing you, you can lodge a complaint by calling the Do Not Call Register on 1300 792 958. How the ‘Do Not Call Register’ works Because sellers of lists can have many clients and their affiliates, you may find yourself repeating yourself while registration of your personal mobile with www.donotcall.gov.au has an effect (at least 30 days) - this website belongs to the Australian Communications and Media Authority. We suggest you pre-empt misuse and register your phone numbers today. The Register commenced in 2007 and now has over 10 million fixed line, mobile and fax numbers registered. Businesses that make telemarketing calls, or cause telemarketing calls to be made, need to comply with the requirements of the Do Not Call Register Act. The Act requires that marketers do not make unsolicited telemarketing calls to people listed on the Do Not Call Register (which theoretically only lists mobiles that take mostly personal calls, home phone numbers or faxes – you, the consumer, decide).

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lifestyle

Angel Flight to the Rescue Regional patients with chronic conditions are growing wings to get them to their city appointments.

There’s no such thing as a free lunch but, for people in regional WA who are struggling with health conditions and facing a daunting road trip for medical appointments, a flight in an aeroplane at no cost is an attractive option. The charity, Angel Flight provides about 20 non-emergency flights across Australia every day. Medical Forum spoke with pilot, Ron Griffin. “I’m in a syndicate that owns a light aircraft, a Cessna 172 RG. The RG means that the wheels are retractable. It’s a nice safe aeroplane that gives our patients a comfortable ride. And that’s a good thing because we fly them home again and sometimes they’re feeling a bit fragile after treatments such as chemotherapy or dialysis,” Ron said. “I fly during the day, primarily under visual flight rules (VFR) so we don’t have too many problems dodging bad weather. And, as every pilot based in Perth knows, we do get fog in the Wheatbelt that often doesn’t clear until 10am. Thunderstorms make things interesting, too. But the overarching rule is, if it’s not safe we don’t go.” Ron stresses that the service provided by Angel Flight is designed for patients who are medically stable and ambulatory. “The people we fly to and from Perth aren’t critically ill because that would require an air ambulance from an organisation such as the RFDS. A typical patient would require a medical appointment for dialysis, chemotherapy or clinical pain relief and would find a long road journey a little arduous.” “Angel Flight posts the flights coming up on their website and the pilots bid for them. The entire operation is run as a charity, the pilot supplies the aeroplane and BP pays for the aviation fuel. That helps a lot because it’s currently sitting at around $2/litre and some aircraft use 30 litres an hour. It all adds up!” “The Royal Aero Club at Jandakot provides great support and the airport authority waives all fees and charges.” “We have volunteer drivers called Earth Angels who meet the aeroplane, take the patient to their appointment and bring them back to the airport for the return flight.”

Colin Street Day Surgery Plastic and Reconstructive Surgery, Cosmetic Surgery, Otolaryngology, Oral and Dental Surgery Three decades of efficient and quality service to surgeons and their adult and paediatric patients. For all enquiries regarding available operating time contact CEO Ms Marie Sheehan on 0411 738 809

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By Peter McClelland MEDICAL FORUM

May 2017 | 51


FOOD & WINE

Mr Gill’s of Subiaco

MY LOCAL

175 Rokeby Rd, Subiaco https://mistergills.com It was a Friday night and we were all determined to be disciplined – home, one glass of wine, spag bol on, watch the news, money saved. However, something happened between the one glass of wine and the spag bol. Oh, yes, it was a second glass of wine. Then the cry went up – “I don’t want to cook”. The voice of reason and economy suggested scrambled eggs on toast. Nup, only fish and chips – takeaway in butcher’s paper – would do. But there was the dilemma. The chippie down the road uses frozen fish and even deader potatoes – the parking around the next closest is heinous. “I know, Murray Gill’s – that seasoned man of good times – new fish and chip shop in Rokeby Rd.” By this time it was nearly 8pm when the chauffeur reached the near-empty carpark. On this cool autumn evening the restaurant was packed like sardines inside and out. It is a flash place, so loins were girded for prices to match. A serve of hake and chips, $16.50; not bad, we made that two and we threw in three fishy mash croquettes, which came with enough hand-cut chips to sink a diet completely. Total bill: $43 to feed three. Voice of economy was quietened if not silenced. The urge for perfect fish and chips – totally satisfied. This is a great fish and chip shop! Share details of your favourite Local. Email editor@mforum.com.au

Prosecco Jelly Ingredients 1 x 175ml bottle of Prosecco (or another white wine of choice) 250ml water 300g caster sugar Gelatine leaves to set 1 litre ½ tspn vanilla essence Berries of choice (fresh preferably) Orange liqueur to serve Cream or ice cream if desired

DIRECTIONS 1. Lightly grease a jelly mould with flavourless oil (or if unmoulding is a bridge too far, set aside a decorative glass bowl with a 1.5l capacity) 2. Pour prosecco and water in a saucepan, add sugar and gently stir to help dissolve the sugar (do this before you put it to the heat because you must not stir while the liquid is heating). 3. While the wine mixture is heating to the boil, soak gelatine leaves in cold water for five minutes. 4. Boil wine mixture for 1 minute then add vanilla and simmer for another minute before removing pan from the heat. 5. Carefully ladle about 250ml of the mixture into a measuring jug. Squeeze liquid from the softened gelatine leaves and add to the jug and whisk to incorporate. 6. Pour the contents of the jug into the wine mixture and whisk again. This is to ensure the even distribution of the gelatine. 7. Pour into the prepared mould or serving dish and refrigerate. If you would like the fruit to be distributed within the jelly, add washed and dried fruit to the setting after about 45-50 minutes. They will sink about midway. Otherwise, wait until fully set after at least four hours, preferably longer, and dress the jelly once unmoulded or on top of the set jelly in its serving dish.

Wine

Winner There’s nothing better than taking a phone call on a Friday afternoon telling you that you’ve just won a carton of Juniper Estate wines. Just ask Dr Diana Hastrich! Diana was very happy indeed, and some of her colleagues with BIG BIRTHDAYS looming will have smiles on their faces, too.

52 | MAY 2017

MEDICAL FORUM


Food & Beer

For Gage, still a road to go We have the opportunity of tasting five different ales from Gage Road Brewing, a more than interesting addition to the usual, and somewhat boring, local ales. This time, we were joined by a beer-seasoned Dubliner psychiatrist, Dr Alex Hegarty, which makes for a true international tasting committee. We have added the brewery notes to our comments.

Dr Sergio Starkstein & Dr Bradleigh Hayhow

T he Beers

Indian Pale Ale (5.4% ABV) A malt-drive English IPA, with slightly spicy aroma, lingering bitterness and unfiltered. Our verdict: a nice amber-coloured and cloudy IPA, lightly carbonated, malty and dry. This beer has a nice IPA smell, but is limited in bitterness and depth of flavour. Regardless of this, the IPA was the best of the lot. Rating: ****/***** Little Dove (6.2% ABV) A Pale Ale with tropical fruit character, with aromas and flavour of melon, grapefruit and guava, balanced by red caramel malt and a bitter aftertaste. Our verdict: Nice amber colour for a Pale Ale, sweet and floral, and less bitter than the IPA. Gentle to the palate and with a strong aftertaste. On a par with the IPA. Rating: ****/***** Single Finn (4.5% ABV)

Light bodied and chockful of aromatic Galaxy and Enigma hops. Our verdict: An ale with a light colour, decent head and a clean refreshing taste. This is a very drinkable beer, but rather soft in the palate for an ale. Good for very warm days. Rating: ****/***** Atomic Pale Ale (4.7% ABV) An American-style pale ale, dry hopped with four different American hops. Our verdict: With a nice orange colour and cloudiness, this is unfortunately a very light pale ale, tasting more like a lager and lacking the typical aftertaste of ales. Perhaps good for the American market only. Rating: **/***** Break Water (4.5% ABV) Crafted with 100% Australian malts and hops, a light-bodied, dry and unfiltered pale ale. Our verdict: The worst of the lot. Lacking in depth, watery and with no aftertaste. It may be that the 100% Australian materials are not that helpful. Rating: */***** The Verdict Gage Road Brewery is on the way to providing a wider selection of unfiltered ales (which is very welcome, in our view) but their creative use of hops produces mixed results. They present a highly competitive IPA, an interesting and more alcoholic pale ale, a light ale that is easy to drink, and two that still need more work.

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Competition Rules: One entry per person. Prize chosen at random. Competition open to all doctors or their practice staff on the mailing list for Medical Forum. Competition closes 5pm, May 31, 2017. To enter the draw to win this month's Doctors Dozen, return this completed coupon to 'Medical Forum's Doctors Dozen', 8 Hawker Ave, Warwick WA 6024 or fax to 9203 5333.

MEDICAL FORUM

May 2017 | 53


Entertainment & Leisure

Where Strauss Meets Tennyson The heart-wrenching text of Tennyson’s epic poem Enoch Arden found an unlikely but perfect home in the hands of the late Romantic German composer Richard Strauss, who wrote an extraordinary score to accompany a dramatic recitation.

and pianist Emanuel Ax. I adore Richard Strauss and when I listened to the work, I fell in love with it and thought it would be very notable and distinctive collaboration to undertake,” Simon told Medical Forum.

The prodigiously talented Australian pianist Simon Tedeschi has brought this project to a local audience with Bell Shakespeare founder John Bell bringing his own sonority to the task of narrating.

When we spoke, he had not long been out of the recording studio in preparation for a national tour. While Simon is a seasoned recording artist, it was an alien landscape for the veteran thespian Bell and the composer doesn’t give away too many hints.

The story is set in a fishing village and follows the fortunes of three friends – the two young men both in love with the same girl. When one marries the girl, the other boy fades into the background until the husband is lost at sea, presumed dead.

“Strauss doesn’t give cues where the verse has to adhere to the music. There’s very little direction, just a few key words underlined which I take to mean certain key musical cadences or moments should intersect with those words.”

For Simon, Enoch Arden has been 10 years in the making.

It was also a puzzle for the few brave hearts who went before them. Another interesting pairing was Canadian Glenn Gould and Claude Raines.

“I had not heard of it until a colleague told me about it when I was living in the US and I was intrigued. Several pianists and actors have done it, most notably actor Patrick Stewart

“This was very different. Glenn Gould, like a lot of his interpretations, takes it at a very

slow tempo while Claude Raines does an oldschool orthodox Shakespearean recitation. John was adamant from the beginning that he didn’t want to do that. The poem is melodramatic enough without that sort of melodramatic presentation.” “However, the poem and music speak very much to our world in its current state with millions of people identifying with not having a home.” While the tale is oft-told, Strauss’s music is something else besides and central to the presentation. “Strauss is a composer I would not classify as melodramatic – he’s certainly a great Romantic but not melodramatic and it’s interesting that he chose to do this. He has written this piece almost as a cousin of lieder and those who know Strauss’s lieder will understand just how amazing this music is.”

By Jan Hallam

The Bargain Two Kiwis, Trevor and Jeanette, are walking down a street in Bondi when Trevor happens to look in one of the shop windows and sees a sign that catches his eye. It says 'Suits $10 each, Shirts $4 each, Trousers $5 a pair' Trevor says to his pal, 'Jeanette, look! We could buy a whole lot of those and whin we get beck to InZid, we could make a fortune. Now whin we go unto the shop, you be quiet, OK? Just lit me do all the talking cause uf they hear our accint, they might not be nice to us. I'll speak in my bist Aussie accint.’ They go in and Trevor says, 'I'll take fufty suits et $10 each, 100 shirts et $4 each, and fufty pairs of trousers et $5 each. I'll beck up my truck and...' The owner of the shop interrupts, 'You're from New Zealand, aren't you?' 'Well...Yis,' says a surprised Trevor. 'How the hill dud you know thet?' The owner says, 'This is a dry cleaners!'

54 | MAY 2017

MEDICAL FORUM


COMPETITIONS

FEATURE

COMP

Entering Medical Forum's competitions is easy! Simply visit www.medicalhub.com.au and click on the ‘Competitions’ link to enter. Movie: 20th Century Women Set in the 1970s California, a single mother (Annette Bening) of a young son runs a boarding house and welcomes into a range of young people who confront the vicissitudes of a changing world together. In cinemas, June 1

Music: WASO Swing on This It’s a rare treat to have the state orchestra get their swing swung and with the help of four of the country’s top crooners –Michael Falzon, Luke Kennedy, Ben Mingay and Rob Mills – it shows its big band chops. It’s the brainchild of Michael Falzon and was devised specifically for the Adelaide Cabaret Festival in 2014. It has proved so popular the concept has been developed and toured. Michael said while the show features the evergreens from the likes of Irving Berlin and Cole Porter, he was keen to give the evening a contemporary spin. So expect influences such as Oasis, Michael Buble and Robbie Williams with some good dose of Australian classic rock and pop. WA will be familiar with the work of all four men – they have graced the musical theatre stage and TV screens as actors and singers in various guises and now with an orchestra behind them, the result will be special. Perth Concert Hall, June 16 & 17, 8pm

Movie: The Shack Sam Worthington stars in this allegorical drama, based on a best-selling book of the same name. It tells the story of a child who goes missing on a camping trip with her family which opens up a beehive of stings for her father who is emotionally and physically derailed by the tragedy. In cinemas, May 25

Movie: Hounds of Love This is Perth writer Ben Young’s first feature film and had rave reviews at the Venice Film Festival. A teenage girl is kidnapped by a deranged couple and she must plot her escape. Shades of the Birnies here. In cinemas, June 1

Theatre: Endgame

Winners from March Movie – Dance Academy: Dr Monica Wertheim, Dr Tammy Barrett-Izzard, Dr Ric Bergesio, Dr Christine Lee-Baw, Dr Heather Brand, Dr Mela Brankov, Dr Tom Shannon, Dr Shannon Rodrigues

Hidden Symptoms t Doctors’ Health Matters t Psychiatry Services Expand t Peter Greste on Resilience t Clinicals: Pain in ED; Stroke Imaging; Parenting; Allergy to RCM & More

This is one of master playwright Samuel Beckett’s finest works which casts a seering eye on existence and meaning. The key to Beckett is to laugh at the absurdity of it all and in doing so open up the mind to its immense possibilities. A rare treat for theatre lovers. Heath Ledger Theatre, May 27-June 11, 7.30pm

March 2017

Major Sponsor

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Movie – Smurfs: Dr My Nguyen, Dr Julie Copeman, Dr Tanya Subramaniam, Dr Jenny Tu, Dr Thomas Lee, Dr Tuck Chin, Dr David Storer, Dr Andrew Christophers Movie – Life: Dr Catherine Civil, Dr Lin Chin, Dr Jeff La Valette, Dr James Flynn, Dr John Tomasich, Dr Russell Date, Dr Bill Thong, Dr Paul Laidman, Dr Cameron Britton, Dr Husain Nazir Kids Theatre – Jurassic Creatures: Dr Ben McGettigan Music – WASO 3-Concert Package: Dr Kynan Feeney

Theatre: Enoch Arden Bell Shakespeare founder John Bell teams up with virtuoso pianist Simon Tedeschi to present a rare performance of this 1864 poem by Tennyson set to music composed by Richard Strauss. With Ulysses overtones, a shipwrecked sailor returns home after 10 years to a changed world. His Majesty’s Theatre, June 14, 7.30pm

MEDICAL FORUM

May 2017 | 55


medical forum CLASSIFIEDS FOR LEASE MURDOCH Medical Clinic SJOG Murdoch Specialist consulting sessions available. Email: gcford56@gmail.com

NEDLANDS Specialist Suite for lease at Hollywood Specialist Centre, 64 sqm, 2 offices, large reception area. Heavily discounted rent for clinician(s) starting private practice for first 3 months. Please contact Julie-Anne Powell 0403 209 363 or Email: powellhollywood@westnet.com.au NEDLANDS Fully furnished consulting suite available for sessional use. Monday - Friday at Hollywood Medical Centre. Please contact: Jade on 0433 123 921 or Email: jadethyer@mac.com SUBIACO Fully furnished consulting rooms available in a newly and beautifully renovated old warehouse in Subiaco. Lease of consulting room within the office for exclusive full-time or shared sessional use. The whole office consists of 3 large consulting rooms, including procedure room, attractive reception area with dedicated space for own receptionist, separate staff and patient toilets, endof-trip facilities, and on-site pathology collection centre with part-time phlebotomist. On-site under cover car parking available. Contact: npennell23@optusnet.com.au SUBIACO Sessional Suites available at brand new specialist consulting rooms in Subiaco. Fully furnished and fitted out, ideal for medical specialists and allied health practitioners with the option for reception and secretarial support. Located near SJOG Hospital Subiaco. All enquires to gemma@hipnknee.com.au or 0413 767 562 MURDOCH Wexford Medical Centre consulting rooms available for lease. Modern and well lit. Secretarial support available if required. Please contact Ai on 0410 786 007 or Email: aptran@jointswest.com.au NEDLANDS Specialist Consulting rooms available for lease. Suite 31 Hollywood Specialist Centre 95 Monash Avenue Nedlands WA 6009 Please telephone Rhonda 9389 1533 or Email: Suite31.hollywood@bigpond.com

Rural Positions Vacant

Urban Positions Vacant

BUSSELTON Busselton Sin Cancer Clinic Seeking skin cancer doctor to join our expanding clinic in the beautiful southwest, close to wineries, beaches, arts and entertainment. Small privately owned clinic. Excellent admin team and practice nurse. PT or FT available. Opportunity for eventual purchase of practice. Contact Practice Manager Ken on 0412 921 669 or Email: bscc1@bigpond.com

ELLENBROOK F/T or P/T male or female VR/NON-VR GP’S and nurse practitioners’ required urgently in DWS/AON location. Flexible shifts, Mixed Billing Practice, fully computerised paperless and modern medical equipment. Existing huge patient Database, Assured income at start 75% or more of the billing based on experience offered Also rooms available for any Allied health Sponsorship available if needed. Please ring 0431 143 460 or Email at pmanager@ghmpwa.com.au ASAP

ALBANY • St Clare’s is an established occupational and family practice based in Albany. • Small friendly practice • Full time nursing and administration support • Pathology on site • Full or part time GP wanted to join our team • Special interest in skin would be ideal • Keen interest in Pre-Employment and Worker’s Compensation favoured • Currently no DWS • GPs not requiring supervision required Please contact Practice Manager, Helen Williams: 08 9841 8102 Email: helen@stclare.com.au Or send your CV through and we will get back to you. SOUTH WEST WA Bridgetown Medical Group Is seeking a VR GP (flexible hours) to join our friendly, busy practice. Experience the rewards of rural practice in this beautiful town. We are a privately owned, accredited, mixed billing practice, DWS, fully computerised clinical software with onsite Nurse and excellent admin support. A&E experience necessary to cover the local hospital and provide phone support to nearby towns. Obstetrics desirable but not essential. Remuneration consists of 60%-70% billings (in/out of hours), in addition to generous government incentives for participation in the call roster, making this a financially rewarding position. Contact Practice Manager on 08 9761 1222 or Email your details directly to btn_medical@wn.com.au SOUTH WEST WA GP’s Required • Excellent Opportunity to join expanding Medical Group in the beautiful South West WA • Established medical group in Harvey & Waroona with 2 new locations • Brand new locations in new development areas Treendale & Dalyellup • Fully computerised & accredited modern practices with nursing & admin support • 65%-70% of billings depending on experience • DWS and AoN Please email CV to gpapplications@bigpond.com

OSBORNE PARK GP required for Osborne City Medical Centre. Flexible hours Monday to Thursday with optional afterhours. Excellent remuneration / $135 - $200 per hour. Predominantly private billing practice. Modern fully computerised practice with nursing support. Please call Michael on 0403 927 934 MOUNT LAWLEY Long established After Hours clinic Looking for a VR GP to work after hours shifts Flexible with hours Fully computerised and AGPAL accredited Private billing only Contact Gina on 0412 760 871 for further details MELVILLE Opportunity mid-year to replace experienced GP in a fully supported private practice. Confidential enquiries to Sheryle health4u@westnet.com.au or 0403 128 300

SORRENTO F/T or P/T GP for busy Sorrento Medical Centre, Normal/after hours available , we are like family, nurse & allied services on board , remuneration (70%-75%), Please call Dr Sam 0439 952 979 OSBORNE PARK RAPHA CENTRE is dedicated to Women’s Health specialising in BioIdentical hormone optimization. Private billing, non-corporate, fully computerised, friendly team. Suitable for VR GP for rewarding experience in treating the root cause of most diseases with combination of nutritional and hormone balancing and more. Email: drnoel@westnet.com.au for confidential enquiries. Mentorship provided.

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

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DUNCRAIG Duncraig Medical Centre requires a Female GP for immediate start. Fulltime patient load available. However, flexible with Monday to Friday hours. Excellent remuneration / $135 - $200 per hour. Predominantly private billing practice. Modern fully computerised practice with full time nurses. Please call Michael on 0403 927 934 or Email: michael@duncraigmedicalcentre.com.au

COMO

VR GP required PT – Como comogp.com.au FRACGP and an Australian University Undergraduate Degree essential. Up to 70% private billings. Unique opportunity to join a new modern practice in one of Perth’s fastest growing inner city suburbs. Enjoy working for a doctor-owned noncorporate practice. Long term potential in a high exposure location. Flexible start date. Please contact the practice manager on 6165 2444 or Email: reception@comogp.com.au MIDLAND Swan Medical Group, Midland (DWS). F/T or P/T VR GP required for our wellestablished accredited Medical Centre. We have a large patient list and you will be well supported by our able staff of nurses, diabetic educators, dieticians, CDM nurse and visiting physician. We have onsite pathology, are fully computerised and have an active involvement in medical student and GP registrar training. If you are motivated and interested in working in a non-corporate, fiercely independent practice. Please contact our practice manager Elma on 08 92746100 or Email: edward.cheuk@swanmed.com.au to arrange a visit. GREENWOOD – NOR GP required for Contracted hours (parttime) & Holiday relief. Preferred with Fellowship. Private billing practice. Please call Lucinda on 9246 1662 Email resume to manager@coolmed.com.au HOCKING Great opportunity to work in Northern suburb! Non- cooperate new practice in Hocking looking for FT/PT, male/female VR or non VR GP on very attractive terms. Please call 0434 967 915 or Email: eastroadmedical@gmail.com

JUNE 2017 - next deadline 12md Monday 15th May – Tel 9203 5222 or jasmine@mforum.com.au


medical forum CLASSIFIEDS

Medical Director Are you ready for a challenging role in a Dr owned and operated practice? Join an innovative multidisciplinary hub where care comes first. We are seeking a motivated, enthusiastic and experienced individual with a passion for teaching to join our team. Your role would involve teaching registrars and supporting Rural Locum Relief Program Drs. This is a full time role. Our network of sites has grown creating this vacancy. We are also growing our service range at present. Procedural skills would be a welcome bonus. For a more information/JDF or to submit an application with CV and covering letter please email or call Dr Brenda Murrison – 0418 921 073 brenda.murrison@breckenhealth.com.au

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North Street Medical Centre, Midland We are seeking more Dr’s to join our happy team, as a group we plan to increase our opening hours to include full days Saturday and Sunday. Clinical autonomy, computerised, accredited, full nursing support, collocated with allied health and pharmacy. Procedural GPs welcome – Ft/Pt Email manager@northstmed.com.au or call: 9274 2456 and ask for Zoe or Damian

GPs Wanted! Procedural GPs for our women’s clinic and GPs for our busy family practice based in Rockingham adjacent to the district hospital which offers a full after hours service. All the usual bells and whistles! We would love to hear from you.

RACGP WA practice of the year award 2016 and WAGPEt training facility of the year award 2016

Call Kate or Pauline on 08 9527 2211 or email Manager@woodbridgefp.com.au to arrange an interview with our clinical team.

GP Obstetrician Role in Bunbury

405 Oxford street, Mount Hawthorn

Large number of deliveries available in town where number of GP Obstetricians is shrinking

Beautiful new premises with extensive patient base. Join a fully committed patient team in a prime location for growth.

Clinic co-located in Greater Bunbury Medical Centre alongside Brecken Health Care.

All interested GPs applications to the Practice Manager

Submit CV or call 0418 921 073 / 0400 052 119 Reception@bunburymaternity.com.au

www.mthawthornmedical.com.au Phone: 9444 1644 or email office.mthawthorn@buildingblocksmedical.com.au

JUNE 2017 - next deadline 12md Monday 15th May – Tel 9203 5222 or jasmine@mforum.com.au


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