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Growing Healthy Men

t IT Security t Being Dr Dad t Male Role Models t Clinicals: Prostate Cancer, Orthopaedics, Infection & Lifestyle Risks, App Review & More‌

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July 2016

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Editorial

Altruism Defines the Profession This editorial caught me preparing for the ninth Doctors Drum, titled “It’s Always the Doctor’s Fault?!”. Would we get an audience full of selfabsorbed comment about how doctors get a raw deal? To be fair, one major contentious point is that doctors are often asked to intervene early, when evidence is flimsy and not all in – things will go wrong in these circumstances and they want some slack cut because of it. Perhaps Doctors Drum would take a wider view of how community desire and restricted resources interact, with doctors unfortunately caught in the middle? Political correctness comes into it too. In this Men’s Health edition, 43% of male doctors, seemingly respected in the community, are wary of displaying public affection to children. And I hear of teachers who are not comforting kids when they hurt themselves in school playgrounds. It seems that media attention around child abuse, plus the focus on men as perpetrators of family abuse and betrayers of vulnerable people, have left many male doctors in ‘no man’s land’.

such media release arrived today which said food insecurity in Australia was reaching crisis level, with Foodbank’s survey showing a quarter of hungry people are regularly going without food. In WA around 53,000 people are assisted each month (22,000 are children) – often from single parent families, the aged, or those with disabilities or a mental illness. The profession stood up for these groups in the past, urging a fair go for all. Now these people are getting lost in a sea of competing interests, while doctors come up with a set of their own demands. Within days of this edition hitting the streets the election will be over. As resources for health become scarcer, political parties of all persuasions will be more about consumer convenience, user pays, self-help resources, and patient rights. The gap between the ‘haves’ and ‘have nots’ will continue to widen.

That expression (‘no man’s land’) comes from early wars, where men would line up and kill each other. They still do, in a less personal and more technologically sophisticated way. Maybe situations like these point to an unhealthy influence from testosterone? This could explain the We will be thrust on a technology trail and doctor and gender differences evident in our e-Poll patient will be pushed further and results and we surmise, carry over into further apart in the interests of patient the medical profession when it comes autonomy in decision-making – as if These people are getting lost to bullying or suchlike. Do men need Dr Google hasn’t already affected that in a sea of competing interests, to question their stereotypes of male relationship. And who amongst us while doctors come up with a modelling and get more in touch with will profit most from interventions of set of their own demands. their feminine side? convenience? I must admit, I am wary of the men who There are interesting times ahead. say they represent the profession. As we head to an The generation of doctors who have known nothing but election, our professional representatives don’t seem to be bulk billing seem more prepared to go with the flow but standing up for the disenfranchised as doctors used to in there are generational differences. In 10 years’ time, will the past. It’s just more politics. we see a profession that cares more for others or one It appears the disenfranchised require agencies to that cares mainly about itself? produce media releases, to get heard these days. One

PUBLISHERS Ms Jenny Heyden - Director Dr Rob McEvoy - Director ADVERTISING Mr Greg Deck (0403 282 510) advertising@mforum.com.au

MEDICAL FORUM

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

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

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

JULY 2016 | 1


July 2016

Contents

14

16

21

18

FEATURES 14 Spotlight: AFL Umpire Dean Margetts 16 Profile: Cardiologist Dr Johann Janssen 18 Being Dr Dad: Dr Nick Cooke, Dr Peter Bray 21

and Dr Ben Roestenburg Where Are They Now?

NEWS & VIEWS 1 Editorial: Altruism Defines the Profession 4

10 12 23 25 43

Dr Rob McEvoy Letters to the Editor Fair Prosthesis Pricing Ms Suzanne Greenwood New Guidelines for PSA Testing Dr Tom Shannon Doctors of the Future Dr Anonymous STI Guidelines Update Dr Lewis Marshall Have You Heard? Curtin Medical School and GP Numbers Meet the CEO: Mr Neil Guard, Richmond Wellbeing Practice Management: IT Security Issues Mr Jerome Chiew Beneath the Drapes

LIFESTYLE 46 Medicos Making Music 48 John Fawcett Foundation 49 Wine Review: Zonte’s Footsteps 50 51 52 52 53

8 24

Dr Louis Papaelias Funny Side Meet the Punch Brothers Theatre: Little Shop of Horrors Join a Choir Competitions

July

Role Models; Public e-Poll Displays of Affection Consumer Expectations; Private Health Insurance; PTSD; Accountability; Androgen Prescribing; IT Use

FIND US ON FACEBOOK & TWITTER! /medicalforumwa/

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Our Cover: Dr Peter Bray with sons Remy and James

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Perth Pathology

MEDICAL FORUM


Clinical Contributors

5

Dr Stephen Lee & Dr Jason Lau New ISUP Grading System for Prostate Cancer

30

Dr Peter Thompson Lifestyle ModiďŹ cation for CV Risk

35

Dr Alan Donnelly Pitfalls in Dermatology: Part I

35

Dr Tim Welborn Guidelines for Menopausal HRT

37

Dr Ben Kimberley Aching wrists & Surgery

39

Dr Peter Smith Self-Fixing Mesh & Hernia Repair

40

Dr Matthew Scaddan Minimally Invasive Bunion Surgery

41

Dr Astrid Arellano Monoclonal Antibody & Infection Risk

42

Dr Sani Erak Knee Arthroscopy In Over 50s

45

Dr Clare Matthews App Review: MoodPrism

Guest Columnists

8

Mr Colin West Schools Bring Dads Together

26

Mr Owen Catto Working with Warriors

27

A/Prof Nicole Lee Young Men Vulnerable to Ice

29

Dr Sarah Egan, PhD Performance and Balance

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) MEDICAL FORUM JULY 2016 | 3


Letters to the Editor

Working for fair prosthesis pricing

New guidelines for PSA testing

så &ORåMENåOVERååORåWITHåLESSåTHEåYRSåLIFEå expectancy, explain the harms of testing may outweigh the benefits

Dear Editor,

For men of higher risk (family history, diabetes, obesity, poor lifestyle)

Dear Editor,

Prostate cancer is the second most common cause of cancer death in Australia, yet we have not seen a cohesive approach to the early diagnosis needed for cure and good functional outcomes. For a cancer more common and deadly than breast cancer, we have not had the same uniformity of test delivery and result interpretation.

Re: Costing an Arm and a Leg (June edition), Catholic Health Australia (CHA) represents Australia’s largest non-government grouping of hospitals, aged and community care services, providing about 10% of hospital and aged care services in Australia, including about 30% of private hospital care as well as about 5% of public hospital care. CHA is a participant in the industry working group comprising of health insurers, device manufacturers, private hospital providers, clinicians and consumers to reform the current Prostheses List arrangements. Currently each device listed on the Prostheses List attracts a benefit that private health insurers are required to pay on behalf of their members. The Minister and other stakeholders have pointed to differences between the List benefit paid by health funds in the private sector for some devices compared to Australian public sector and international prices in arguing the case for reforms that will reduce pressure on premiums. CHA has been active in working with other stakeholders to prioritise affordability of medical devices through the development of a more rigorous, evidence-based, benchmarking process. Prostheses list reform must also ensure access and affordability for consumers while ensuring clinicians are able to choose the medical device that is the most appropriate for the patient. However, CHA also notes that maintaining administrative simplicity for consumers, hospitals, doctors, health funds and suppliers is also a priority. This was a cornerstone principle of developing the present Prostheses List arrangements and needs to be preserved. CHA considers that, in undertaking reform, the working group should maintain some of the positive aspects of the current listing processes, including the involvement of expert clinical assessment of new and existing devices.

Whilst prostate cancer is managed by specialist urologists and medical and radiation oncologists, the initial detection is done mainly in general practice, making clear guidelines essential. We have previously published WA data showing a much later presentation, with higher PSA levels, extraprostatic extension and tumour grade than seen overseas. This limits our ability to not only cure, but to cure without significant potential side effects of erectile dysfunction and incontinence. A significant advance has been the release of the 2016 Australian guidelines for the diagnosis and management of localised prostate cancer, developed after an extensive evidence-based multidisciplinary review. This was led by the Prostate Cancer Foundation and the Cancer Council, and endorsed by peak bodies such as the NH&MRC, RACGP, Urological Society, and colleges of Pathologists, Radiologists and Rural and Remote Medicine. The guidelines give easy-to-follow advice on how to maximise benefits and minimise risks of testing: For men of average risk så 03!åTESTINGåEVERYåYRSåFORåMENåAGEDååTOå 69 years så 03!åTESTINGåFROMåTHEåAGEåOFååFORåMENå concerned about prostate cancer

så 03!åTESTINGåEVERYååYRSåFROMåAGEå Digital Rectal Examination (DRE) is not recommended in primary care, but must be done in specialist practice. Interpreting results: så 03!åTHåPERCENTILEåINåAåMANåLESSåTHANåå of average risk, do not repeat testing until age 50 så 03!å åREPEATåTHEåTESTåWITHINå åMONTHS å adding a free to total ratio så 03!åTHåPERCENTILE åREFERåTOåAåUROLOGISTå for assessment It is recommended that men are informed of the risks and benefits of testing prior to having a test done, with resources now being developed to help GPs do this. What these new guidelines mean for prostate cancer: sufficient evidence to back the recommendations; consensus between professional groups including the RACGP and urologists; and better outcomes for patients. Dr Tom Shannon, Urologist, Nedlands ED. Market forces need to be divorced from judgements when advising patients. A difficulty in applying consensus, as we see it, is that PSA testing has local ramifications and these are national guidelines. Australian doctors are more conservative than their US counterparts and these new guidelines appear to reflect that.

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

Doctors of the future need exposure Dear Editor, I have spent many hours trying to organise continued on Page 6

Waste no more time arguing about what a good man should be. Be one. Marcus Aurelius

Ms Suzanne Greenwood, CEO, Catholic Health Australia ........................................................................

SYNDICATION AND REPRODUCTION Contributors should be aware the publishers assert the right to syndicate material appearing in Medical Forum on the MedicalHub.com.au website. Contributors who wish to reproduce any material as it appears in Medical Forum must contact the publishers for copyright permission. DISCLAIMER Medical Forum is published by HealthBooks as an independent publication for the medical profession in Western Australia.

The support of all advertisers, sponsors and contributors is welcome. Neither the publisher nor any of its servants will have any liability for the information or advice contained in Medical Forum. The statements or opinions expressed in the magazine reflect the views of the authors. Readers should independently verify information or advice. Publication of an advertisement or clinical column does not imply endorsement by the publisher or its contributors for the promoted product, service or treatment.

advertisements comply with Commonwealth, State and Territory laws. It is the responsibility of the advertiser to ensure that advertisements comply with the Trades Practices Act 1974 as amended. All advertisements are accepted for publication on condition that the advertiser indemnifies the publisher and its servants against all actions, suits, claims, loss and or damages resulting from anything published on behalf of the advertiser. EDITORIAL POLICY This publication protects and maintains its editorial independence from all sponsors or advertisers.

Advertisers are responsible for ensuring that

4 | JULY 2016

MEDICAL FORUM


Dr Stephen Lee FRCPA

Graduated with honours from UWA in 2000, gained fellowship of the Royal College of Pathologists of Australasia in 2008 and has completed subspecialty fellowships in Urological Pathology at Johns Hopkins Hospital (USA) and Gastrointestinal Pathology (QEII). He has interests in urological pathology, gastrointestinal pathology and dermatopathology.

Perth Pathology (Perth Medical Laboratories Pty Ltd APA) 152 High Street Fremantle WA 6160 26 Leura St, Nedlands WA 6009 Ph 9433 5696 Fax 9433 5472

www.perthpathology.com.au

Dr Jason Lau FRCPA

There are 52 collection centres across inner and outer Perth, Mandurah, and Secret Harbour. Please refer to the website for opening hours and addresses

New ISUP Grading System for Prostate Cancer The Gleason score has been one of the most important prognostic factors in prostatic adenocarcinoma but has recently been superseded by the new International Society of Urological Pathology (ISUP) grading system. The Gleason score reects morphologic heterogeneity typically seen in tumours, and is the sum of the two most common grading patterns identiďŹ ed in a lesion (in some cases where there are three or more tumour patterns, the score is the sum of the most prevalent pattern and the highest grade pattern). The Gleason score ranges from 2 to 10. For risk stratiďŹ cation and therapeutic purposes, patients are currently placed in three-tiered groupings based on the highest 'LEASONĂĽSCOREĂĽ ĂĽ ĂĽn ĂĽĂĽ There are inherent limitations to this: briey, these include the misinterpretation by patients that a diagnosis of Gleason score 6 on biopsy is indicative of tumour in the midrange of grading scale of 0 to 10; and the LUMPINGĂĽOFĂĽĂĽ ĂĽĂĽĂĽĂĽANDĂĽĂĽ ĂĽĂĽĂĽĂĽINTOĂĽTHEĂĽ same prognostic group even though multiple studies have demonstrated worse outcomes for the latter. New grading system To address these deďŹ ciencies, the new ISUP grading system includes ďŹ ve prognostically distinct Grade Groups based on the original Gleason score groups (see Table 1). The ISUP

grading system has been validated by an international multi-institutional study based on a study of over 20,000 prostate cancers treated with radical prostatectomy and over 5,000 cases treated by radiation therapy. The ISUP grading system has several advantages over the current system: reduction of 9 possible Gleason scores (scores 2 to 10) into Grade Groups 1 to 5; the 5 Grade Groups are more accurate in predicting progression than the three tiered 'LEASONĂĽRISKĂĽSTRATIlCATIONĂĽGROUPSĂĽĂŞ ĂĽ ĂĽ nĂĽSEEĂĽ&IGUREĂĽ ĂĽANDĂĽTHEĂĽLOWESTĂĽGRADEĂĽ is now 1 rather than 6 as in the Gleason system, a more accurate reection of the less aggressive behaviour of such tumours. The new grading system has been accepted and recommended for use by the International Society of Urological Pathology, the Royal College of Pathologists of Australasia and the World Health Organization for the 2016 edition of Pathology and Genetics: Tumours of the Urinary System and Male Genital Organs. In accordance with these recommendations, Perth Pathology reporting of prostate cancer will incorporate both an ISUP Grade Group, as well as a Gleason score for each individually identiďŹ ed tumour, in the following format: Gleason score 3+3=6 (ISUP Grade Group 1). References available on request.

Figure. Recurrence-free progression following radical prostatectomy stratiďŹ ed by prostatectomy grade: ISUP Grade groups

Jason trained at the University of Western Australia, graduating in 2006, and then worked at several local hospitals before commencing specialist pathology training in 2009. Jason’s areas of interest include dermatopathology, gastrointestinal pathology and urological pathology.

Table. New ISUP Grade Groups (with matching Gleason scores), and ďŹ ve-year biochemical recurrence-free % (after radical prostatectomy) Grade Group 1

Gleason score 6 or less

96%

Grade Group 2

Gleason score 3 + 4 = 7

88%

Grade Group 3

Gleason score 4 + 3 = 7

63%

Grade Group 4

Gleason score 8

48%

Grade Group 5

Gleason score 9 - 10

26%

Perth Pathology General Pathologist / Managing Partner: Dr Wayne Smit Histology / Cytology: Dr Michael Armstrong Dr Tom Grieve Dr Jason Lau Dr Chanh Ly

Dr Tony Barham Dr Peter Heenan Dr Stephen Lee

Infectious Diseases (Microbiology): Dr Laurens Manning Haematology: Dr Rebecca Howman

1

Laboratory Director: Paul Schneider

3 4

5

Years Since Surgery Reproduced from A Contemporary Prostate Cancer Grading System: A Validated Alternative to the Gleason Score, Jonathan I. Epstein, Michael J. Zelefsky et al

Grade Group

Probability of RFP

2

Providing phone advice to clinicians and a comprehensive range of medical pathology investigations, including: sĂĽ (ISTOLOGYĂĽ3KIN ĂĽ') ĂĽETC sĂĽ #YTOLOGYĂĽINCLĂĽ0APSĂĽANDĂĽ&.!S sĂĽ (AEMATOLOGYĂĽYES ĂĽWEĂĽDOĂĽLAB controlled INRs) sĂĽĂĽ"IOCHEMISTRYĂĽINCLUDINGĂĽHORMONES and markers) sĂĽ-ICROBIOLOGYĂĽANDĂĽ3EROLOGY Professional personalised service from a non-corporate, pathologist owned and operated laboratory practice


Letters to the Editor continued from Page 4 Year 10 work experience for my 15-year-old son. No South/East Metro public hospital in Perth will support such a placement despite the school running a program to emphasise standards of behaviour and confidentiality.

Such placements should be facilitated and not hindered if we want to produce future generations of doctors who will hopefully choose medicine for reasons that are wellinformed.

In the end I had to ask favours of consultant colleagues in the private sector who were able to oblige. The private hospital I contacted was able to help but understandably had some restrictions placed upon where such a student could be in their hospital.

At present we are, in my opinion, failing future doctors by not facilitating Year 10 work experience.

The prevailing attitude seemed to be one of protecting the patient’s confidentiality at all costs. I would have thought that some form of discretion could be used where patients could be given the option of declining the presence of the student and that the doctor involved could ask the student to leave the room in anticipated sensitive cases.

STI guidelines update

My father was a doctor and I was well used to being around hospitals. This enabled me to make a more informed decision to pursue medicine as a career. Doctors have many different reasons as to why they pursue such a career. My son has asked me what my reason was. My reply was that I just felt stimulated by the whole medical environment and that it was where I could see myself. Otherwise how are the potential doctors of tomorrow supposed to get a feel for whether this is a suitable career for them? How are they supposed to make the relevant subject selections at school? No amount of TV documentaries can replace the experience of meeting real patients and doctors. The advantages of early exposure of potential future doctors to the hospital setting are more than offset by the potential pitfalls which are, in my view, easily overcome.

Name Withheld on Request ........................................................................

Dear Editor, The Australian guidelines for sexually transmissible infections (STI) for use by primary care professionals were launched in 2014 and have now been critically reviewed and updated. This review ensures the Guidelines are aligned with the latest research and best practice developments. The Guidelines are available at www.sti.guidelines.org.au. Being online means they can be continually updated. This web-based resource is highly useful for GPs and primary health care nurses who may not deal exclusively with sexual health, but need to make confident management decisions. It also contains useful links and resources, such as an STI Testing tool, instruction on taking a sexual history and contact tracing, as well as patient fact sheets, all of which are downloadable and printable for use offline.

There are also specific sections on testing in particular population groups. Given the increasing numbers of gonorrhoea and syphilis cases, these guidelines provide access to accurate and up-to-date management information. They complement the WA Department of Health Silver Book guidelines http://ww2. health.wa.gov.au/Silver-book which provide more local information. The Guidelines were written and reviewed by specialists in sexual health, under the auspices of the Australasian Sexual Health Alliance, a committee of the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM). Funding was provided by the Australian Government Department of Health. Dr Lewis Marshall, Sexual Health and Public Health Physician, Fremantle and Fiona Stanley Hospitals

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

Curious Conversations

Down to the Sea in Ships It was from the deck of a ship that Dr Simon Torvaldsen first saw the ‘land Downunder’and he still enjoys the view of the world from the ocean waves. One of the most formative moments I had as a child was… travelling to Australia by ship across the Southern Ocean as an 11-yearold ‘Ten Pound Pom’. Yes, children came for free! It was a trip I’ve never regretted taking. If I could change one thing about General Practice it would be… our dependence on bulk billing and the fact that so many of us allow the government to dictate our fees and income.

every major ocean race in WA and it’s always a thrill to cross the starting line. One of the most inspiring films I’ve ever seen is…The World’s Fastest Indian. It’s a true story about a New Zealander who built the world’s fastest motorbike in his shed. He raced it in America and beat the big-boys at their own game! It was a fantastic performance by Sir Anthony Hopkins who said it was his favourite role.

If I hadn’t done medicine I’d have loved to have been an… engineer. But it probably would’ve been too much maths for me. And I also recall being put off by the very low number of girls in the course. When I’m not working I love to…race my yacht offshore. We’ve won

6 | JULY 2016

MEDICAL FORUM


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With one simple, easy to remember username and password, you can access the App.

Access a list of your patient reports and images on your mobile device. The SKG Connect App offers the options to de-identify and save images, mark-up the images, or email as JPEGS.

To create an account, contact your Business Development Officer or call our Referrer Hotline on 9214 9696.

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JULY 2016 | 7


Incisions

Schools Bring Dads Together The positive spin-offs of being the best possible dad are impossible to quantify suggests Mr Colin West of the Fathering Project. The LADDS and the DUCKS – ‘Loving & Devoted Dads of Currambine’ and ‘Dads Unite for the Children of Kensington School’ are just some of the fathers and father-figures in local schools championing the cause of being a great paternal role model. Thousands of dads across WA are joining Champion Dads’ Group and having a wonderful time socialising with their peers while heading out for camping trips, bike rides and fishing trips with their children. A happy and engaged father has significant benefits for all concerned – themselves, their children, the school and the wider community. It’s all part of the wider Fathering Project and its mission to inspire and encourage fathers to be actively engaged in the lives of their children. The school groups are particularly effective and the whole program is supported by research and a website with advice and activities. The comments from one father with three young boys gives some idea of the positive impact of being a Champion Dad. “It’s completely changed my life and my outlook on being a dad. I can’t thank the people involved enough.” Professor Bruce Robinson – a respiratory physician, 2013 Western Australian of the Year and the instigator of the Fathering Project – has a deep commitment to fatherhood that stems from his professional background. The main catalyst for him were his male patients who, on hearing a fairly bleak prognosis, unanimously responded that they wished they’d worked less and played with their children a lot more.

LADDS at Bunnings with their Billy Carts

As Bruce says, fathers are the most powerful force in Australia to reduce the chances of our kids falling victim to drugs, suicide and crime. 4HEREåAREåNOWåå7!åSCHOOLS ååFATHERSå ANDååCHILDRENåINVOLVEDåINåTHEå&ATHERINGå Project School Group (FPSG). One of the outstanding features of the program is its supportive nature within a school environment and many principals have said that it’s impossible to quantify the value of the FPSG. “Our Champion Dads have been an outstanding feature of our school community for a several years” is a typical comment,

this one from Barbara Horan the principal of Booragoon Primary School. It’s not about being a ‘perfect dad’, but far more about fostering a commitment to create an environment in which fathers can interact with each other and share their knowledge and skills about parenting. The groups are relaxed and informal and I’d encourage anyone with an interest in this area to become involved. ED: For questions contact the author at Colin@ thefatheringproject.org , 0412 133 375 or www. thefatheringproject.org

July e-Poll

Men's Health – Formative Years

Q

In your view, during your formative years while growing up, did you have a satisfactory male role model?

Yes

73%

No

21%

Uncertain

6%

ED: 60% of females (against 78% of males) were happy with their male role model when growing up. Amongst craft groups 64% of GPs were satisfied against 78% of specialists. So it appears male specialists were most happy with the male role model they grew up with.

8 | JULY 2016

Q Yes

37%

No

51%

Uncertain



Doesn't apply

5%

Has child abuse coverage in the media made you think twice about showing affection to any child in public?

ED: 43% of male doctors (vs 19% of female doctors) are wary of showing affection to children in public because of the media’s coverage of child abuse. In comparison, 47% of males say they are unaffected (vs 67% of female doctors). It appears this is an issue where gender plays out amongst one of the community’s most trusted citizens, doctors.

MEDICAL FORUM


MEDICAL FORUM

JULY 2016 | 9


Have You Heard?

Bringing services into line

360 view of everything

After-hours and deputising services, which to the casual observer could be described as a free-for-all, are under scrutiny from the RACGP as well as their peak body, the National Association of Medical Deputising Services (NAMDS). The College released a four-page position statement responding to the sharp rise in the use of after-hours item numbers calling for better-qualiďŹ ed doctors, tighter links with general practices, and a crackdown on direct-to-consumer advertising. This last point picks up on a major national TV campaign by the National Home Doctor Service. But let’s not forget the new kid on the advertising block, social media. Dial-a-Doctor has been shaking its owl tail feathers in the Facebook space with some success if our feed is anything to go by but each of the other NAMDS afďŹ liated groups have a social media presence – Perth After Hours Medical Service, WA Deputising Medical Service and Australian Locum Medical Services. NAMDS president Ben Keneally agrees with the College that afterhours services need to work more closely with general practice adding that more recent players entering the after-hours space did not appear to be linked to general practice but instead initiated consultations directly with patients. However, he disputed the call to crack down on advertising. Mr Keneally is also head of the National Home Doctor Service. He said patients needed to be aware of after-hours services which prevented unnecessary ED presentations.

Speaking of Facebook, another prominent user of social media advertising is the not-for-proďŹ t 360 Health + Community. Undertaking a Facebook quiz to ďŹ nd which animal represented my personality, purely for research purposes of course, 360 Health + popped up incessantly to remind me that good health was only a call away. I was so fearful that the good folk down Cockburn way might discover I was a closet wombat I exited before completing the survey. The truth is, like the internet, 360 Health + Community seems to be everywhere.

interest a judgement from the Federal Court WHICHĂĽlNEDĂĽ"ETĂĽMĂĽFORĂĽMAKINGĂĽFALSEĂĽ representations to new customers, offering them ‘free bets’. The case was brought on by the ACCC when it discovered Bet365’s promotion, between March 2013 and January 13, 2014, was misleading and deceptive and involved false representations. In order to receive the offer, new customers were required to deposit and then gamble $200 of their own money ďŹ rst, before they could receive their $200 free bet. The ďŹ ne print was not brought to customers’ attention. Justice Beach described the company’s conduct as “seriousâ€?, “extensiveâ€? and “recklessâ€?.

ACCC after Medibank

Hefty ďŹ ne for Bet365 In the May edition we published some sobering ďŹ gures about the rise of online gambling and the potential health risks associated with it. Nearly half of non-problem GAMBLERSĂĽBETĂĽONĂĽSPORTSĂĽONLINEĂĽWHILEĂĽĂĽANDĂĽ ĂĽOFĂĽMODERATEĂĽANDĂĽPROBLEMĂĽGAMBLERS ĂĽ respectively, bet online. So we read with

The ACCC has instituted proceedings against Medibank Private, alleging it contravened Australian Consumer Law by engaging in misleading conduct, making false or misleading representations and engaging in unconscionable conduct. The allegations are in relation to Medibank’s failure to notify its members of its subsidiary brand, ahm, and its decision to limit beneďŹ ts paid to members for in-hospital pathology and radiology services. If the Federal Court upholds the allegations, it will be a serious moment for Australia’s biggest private health insurer, which has been LISTEDĂĽONĂĽTHEĂĽ!38ĂĽFORĂĽĂĽMONTHS

Ambos buy GP clinics News of St John Ambulance WA buying up Apollo Health’s four bulk-billing GP clinics (Cockburn, Joondalup, Armadale and Cannington) is a bold but not entirely

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Have You Heard?

surprising move into the primary care space. Ambulance boss Tony Ahern, who is also on the board of the WA Primary Health Alliance, the overseeing body of the three local Primary Health Networks, said this type of service was common elsewhere in the world and had been successful in reducing ramping and lessen stress on EDs. St John put its toe in these waters during the u season of 2013 (which he wrote about in the June edition of that year) using a GP clinic set up at Hollywood Private Hospital as the destination for non-urgent call-outs. Health Minister John Day said he wished the enterprise well while AMA spokesperson and head of ED at SCGH David Mountain was less than enthusiastic saying it could lead to confusion and put lives at risk. “They need to make these practices run I presume [at a proďŹ t], they’re not taking them on to make a loss so yes, there is a concern and they need to deal with any conict of interest to make sure there isn’t an incentive for their crews to go to the wrong place,â€? he told the ABC.

Out of the cauldron

Docos hit the trail

After two turbulent years as President of the RACGP, Dr Frank Jones’s two-year tenure has come to an end. Online elections were held in June with the declaration of the polls on June 29, after we had gone to press. Frank’s advocacy at a time when general practice was the focus of some brutal federal government policy offered the minister another forthright view to listen to. None of the four presidential candidates in this election is from WA.

Australian health campaigners are increasingly ďŹ nding commercially-released documentaries a good way of getting there message out. Following the popular release of That Sugar Film, created by Damon Gameau, Adelaide body image campaigner Taryn BrumďŹ tt’s Embrace hits the screen on August 4 in Perth. It is a ďŹ lm of its time. What began as a social media posting of two pictures – her competitively sculpted body and her post-baby No. 3 body – has turned into global media fodder. At the core though is the serious issue of women’s almost unanimous dissatisfaction with the way they look, of which we only scratched the surface in our May edition. Taryn has spoken to some interesting people for the doco – burns survivor Turia Pitt, Mia Freedman and US TV presenter Rikki Lake among a host of others. The trailer looks interesting and celebrity hoopla is kept to a minimum.

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JULY 2016 | 11


News & Views

All Eyes on GP Numbers “growing glut� of doctors for the record-high bulk billing rates. They said GP numbers had grown almost 50% over the past decade (more than twice the population growth) and called for a lowering of the intake of overseas-trained doctors and new limits on where Medicarefunded doctors, including those locally trained, were able to practise.

A couple of issues ago we reported that the CEO of WAGPET Dr Janice Bell (now adjunct professor) had been appointed chair of the Curtin Medical School External Advisory Board. The other positions on the board have since been ďŹ lled and it doesn’t lack interest.

Joining her are former AMA WA President and WAPHA The pair went on to dismiss chair Dr Richard Choong, warnings from the AMA and State Manager of AHPRA A/ the RACGP that the prolonged Prof Robyn Collins, former freeze on MBS indexation Senator Dr Alan Eggleston, could force GPs to abandon Chief Medical OfďŹ cer and Front row (L-R):Prof John Cordery, Adj/Prof Janice Bell, Prof Gary Geelhoed, bulk billing, saying that the former AMA WA President Mr Kim Snowball Middle row (L-R): Adj/Assoc/Prof Robyn Collins, Dr Richard competition for new patients Choong, Dr Karen Pitman, Mr Kieran Gulvin Back row (L-R): Dr Alan Eggleston, Prof Gary Geelhoed, student was so stiff few GPs would risk Prof William Hart (Dean), Prof Bryant Stokes rep Kieran Gulvin, consumer Absent: Prof Con Michael, Prof Michael Berndt, charging a co-payment. advocate Michele Kosky, chair Ms Vicki O’Donnell, Ms Michele Kosky of the WA Medical Board Prof While the report focuses on Con Michael, Aboriginal Health cutting the number of OTDs, it was concerned disease, ageing, Indigenous and regional Council member Vicki O’Donnell, GP Dr about the growth of local medical graduates, health. Karen Pitman and former DGs of Health Kim a concern shared by the AMA WA. It is an Snowball and Prof Bryant Stokes. outspoken critic of the Curtin Medical School This came in the thick of a federal election with the then President Dr Michael Gannon campaign in which doctors, especially GPs, Adj/Prof Bell said the board and the medical writing in Medical Forum in July last year had been especially outspoken about policies school had a shared intention to develop describing it as “one of the worst decisions in to cut health costs. “capable, compassionate doctors willing and WA health in decadesâ€?. able to work where they are needed mostâ€?. Just a couple of weeks ago a report written The statement went on to say that a Curtin “After talking with many colleagues and by former Victorian president of Rural Doctors degree would allow graduates to meet the hearing their extensive concerns about training Australia Dr Mike Moynihan and economist needs of currently under-serviced areas of bottlenecks as they already exist, I do not resile Bob Birrell blamed what they described as a health care including primary care, chronic from this view,â€? he added. Accusing the government of making a decision based on “votes, property development and urban renewalâ€? Dr Gannon wrote: “This was a backroom deal struck by a small number of powerful players with vested interests none of whom would have been able, or indeed willing, to provide critical thought on the likely impact on training places, on already limited teaching opportunities, or ask in a genuinely critical way how another 60 or 100 medical graduates will provide more GPs to remote and rural areas.â€?

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Now national AMA President, Dr Gannon was a little more temperate in response to the Moynihan/Birrell claims. He was reported as saying in the national media that their argument about GP numbers was “slightly false�, applying only to densely populated areas in capital cities, and arguing that a growing GP workforce was a plus for Australia as such an investment kept patients out of hospitals and emergency departments.

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Spotlight

Umpire's Lucky Bounce AFL umpires may not have too many friends at the ground but Dean Margetts found a friend for life in Dr Michael Livingston when a ight from Melbourne turned ugly. It’s not uncommon for medicos to attract some ‘bad press’ but nothing compares with the verbal tirade hurled at the ‘White Maggot’, aka an AFL umpire. Perth’s Dean Margetts has heard it all. However, on a recent ight from Melbourne to Perth the ight attendant call button was very nearly the last thing he’d ever hear. “I’ve never had a serious illness in my life. It seemed like one minute I was running around Etihad Stadium blowing a whistle and the next I was being off-loaded into an ambulance at Adelaide airport and rushed off to hospital.â€? “A ruptured ulcer caused a tear in my stomach and I was in a lot of pain. Luckily there was a doctor on board and he made the decision that an unplanned diversion to Adelaide would be a very good idea.â€? That medico was Dr Michael Livingston who, with his wife and daughter, was on his way to a country posting in Ravensthorpe, WA. Michael’s decisiveness proved to be spot-on but he’s obviously not an AFL aďŹ cionado. Sticky wicket “I was on my hands and knees at the back of the aeroplane and really wanted to be left alone. This guy came up and started asking questions about what I’d been doing and I told him I’d been umpiring in Melbourne. He told me that he ‘didn’t know much about cricket’!â€? Dean told Medical Forum. “It turned out to be Michael, trying to get a handle on just what my problem might be. It wasn’t until I spoke with some of the doctors

in hospital that I realised how serious it could have been. I was very lucky that he was onboard.â€? Dean is one of four Perth-based umpires with 264 AFL games under his belt. He’s easing back into work by ofďŹ ciating in the WAFL and hopes to return to the ‘big top’ by midseason. “I’m feeling a lot better now but still not at the peak of my powers. I’ll get my conďŹ dence back and then do a block of a dozen games to ďŹ nish the year. Finals are probably out of the question for me but I’m looking forward to AĂĽGOODĂĽPRE SEASONĂĽINĂĽvĂĽ “I’ve been really buoyed by the support I’ve received from both within the footy world and from complete strangers. Ross Lyon and Alistair Clarkson got in touch and people I’ve never met wished me well on social media. Although there were a couple of tongue-incheek messages from people who said I’d been giving them a stomach-ache for years!â€? Scrutiny on umpires One of the least understood aspects of umpiring at the top level is the close scrutiny umpires receive of their on-ďŹ eld performance. “It’s a misconception that we’re not accountable for what occurs out on the ďŹ eld. We’re not just given games week after week and if our form isn’t up to scratch we’re back blowing the whistle in the WAFL pretty quickly.â€? “The full gamut of our performance is closely

watched and continual assessment is an important part of who gets the big games. There are 33 contracted AFL umpires and only three will be out there for the Grand Final.â€? “It’s always nice to be drafted in but you can just as easily be drafted out. It’s a challenging environment.â€? They’re called ‘stadiums’ for a reason, 36 young men full of testosterone and up to 100,000 ‘experts’ only too willing to scream helpful suggestions at the man in charge. “It does feel like a cauldron at times. Any umpire who says they don’t hear the abuse from fans is kidding themselves and once you get a bit of a proďŹ le they’ll actually start abusing you by name! But if you worry too much about what’s being said then you’re not focusing on the game.â€? “If you retaliate and start engaging with the crowd, it’s a win for them. A teon coating comes in handy.â€? Protect junior umps When it comes to inappropriate behaviour by people on the sidelines, one area that concerns Dean is ofďŹ ciating at junior level. “This sort of thing can actually stop young umpires remaining in the game and we don’t want that to happen. We lose some every year and you can’t really blame them when you’ve got some idiot swearing at them. They think to themselves, ‘do I really need this?’.â€? “If I see it happening I’ll say to the person continued on Page 19

14 | JULY 2016

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JULY 2016 | 15


Close-Up

Taking the Road Less Travelled Arriving in Australia with no job and a fair-to-middling golf game, cardiologist Dr Johan Janssen has shown just what can be done with determination.

One suspects that Dutch-born and trained cardiologist Dr Johan Janssen is not a great believer in fate – his diverse and adventurous career speaks of boldness and adaptability but he does mark as life changing a moment in 1989 that, in a blink of an eye, left him in a wheelchair for two years. “We were returning by car to Maastricht from a holiday – my wife and three children – when the accident occurred. In those two years I realised that there were more important things than chasing an academic career and maybe I should look at doing something else with the family.” Johan was a professor in the medical school at Maastricht University doing ground-breaking research into digital cardiac catheterisation and the world was watching. “People talk about life changing events and the car accident was it for me. I left the University where I had been for 15 years and we moved to Rotterdam. It was there I was approached by connections of the King of Saudi Arabia to set up a cardiovascular service at the new hospital in Jeddah.” “I didn’t jump at it but they were persistent partly because they needed the service to fulfil the deeds of the hospital contract and I had done exactly that at Maastricht and was doing the same in Rotterdam. They asked me to do a locum but as to living there, I told them ‘are you kidding’!” Power of oil “I said I’d help organise a couple of colleagues to do rotations but it seemed ridiculous to pack up our lives. I had a career path in Europe and if I left to work in Saudi Arabia, I’d lose that and my pension. They jumped back with, ‘we’ll pay for that’ and I countered a little naively, ‘you can’t afford me’. I was soon to learn that the King of Saudi Arabia can afford anything.” That began four years of career highs and family adventures. For wife Marie-Louise and their three children who were aged nine, eight and six, it was a lifestyle and a culture a world away from The Netherlands. Of parties with princes, rides in Rolls-Royces and desert hikes. For Johan it was a professional eye-opener. “Everything you wanted you could get. I had to build a cath lab and because of x-ray exposure it needed to be clad, back then, in lead. I found out that 1mm of Carrara marble had the same radiation screening as lead so I got them to line the lab in marble! It seemed appropriate that the King and his family, who have marble bathrooms, should have a marble cath lab as well!” “The medicine was very exciting. We had pioneered ablation for arrhythmias in Maastrich, so I would get one of my mates to come in for the weekend and I would line up 10 patients each day and he’d been back at his desk by Monday afternoon. These were early days

16 | JULY 2016

and these were not common practices – it was cutting edge health care for the happy few who could get it.” Delicate diplomacy He grins and points to a picture of a US nuclear submarine on the wall of his Joondalup office. “That was very interesting. A US fleet of submarines was in Jeddah and the guy whose job was to push the ‘red button’ was having heart palpitations, so he needed treatment from a trustworthy person. But because I was not American I couldn’t see him on the sub, so he came to see me. There were phone calls flying all over the place, armed MPs escorting him and me. It was a complex network of politics for one man’s medical treatment.” “I’m grateful for our four years in Jeddah and I’m happy that I didn’t pursue a normal route. This was an adventure, which has given us all more colour and warmth to our lives. It also taught me medically that there are not answers for everything and that’s made me more focused on what is best for the patient. It has made me a different person.” Not yet 40, Johan and the Janssen family decided to settle in Perth in 1995 because Marie-Louise’s sister lives here. “Retiring on the Italian Riviera was on my list but we had been coming TOå0ERTHåONåHOLIDAYåSINCEåTHEåS åSOå)åCAMEåHEREåFORåMYåWIFEåANDå to retire. It was the most boring chapter of my life. Playing golf with octogenarians is no fun.” Brick wall of Immigration And then there was the immigration department to negotiate. “I’m going to write a book about that.” Johan’s experience is an insight into the difficulties all overseas-trained doctors face and reveals a particularly ugly side of the process. “You come to Australia and you want to make a life here but it’s not easy.” Because he thought he’d left medicine behind, Johan started an IT business employing Australians but an immigration officer rejected his residency application because the business was in his family trust’s name and not his own. “He made that decision on his own bat because he told me ‘I think it’s wrong in law and I make this decision’. I’ve got his name…for the book!” By this time, his children were settled in new schools, his wife was happy and he had fallen in love with the big blue sky. “So it was down to being a doctor in an area of need. That wasn’t easy either. I didn’t want to do general medicine, I was a cardiologist. They sent me to a registrar’s job in the nephology department at RPH while they decided if I needed to sit an exam.”

MEDICAL FORUM


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Bureaucracy gone wild “What about my family? What about my job? I was on call on Monday and this was Friday. I was allowed to make one phone call, so I strategically rang Fraser Moss who was the medical director of Kalgoorlie at the time. It was a good call.” “It took the personal intervention of Immigration Minister Phillip Ruddock and the people of Kalgoorlie who rallied around me to turn the tables – I was permitted to stay while reapplying for a visa. That’s why I have a loyalty to Kalgoorlie.” [In May, Johan’s Kalgoorlie work was recognised by Rural Health West, which awarded him its 2016 Outreach Services Award.] Johan doesn’t consider himself so much an outsider in the system as an independent agent who can see things perhaps a little more simply than those who have grown up in the smallish pond of WA medicine.

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Johann, now a partner at Western Cardiology, still spends every Monday in Kalgoorlie (“up at 4am and back at 9pm”), so what keeps drawing him back? The answer is, once again, the immigration department. “I would go to Perth every fortnight for intensive care meetings and on one occasion I went into the Immigration office just down the road from RPH to get my Medicare card renewed. When it was my turn I showed the officer my passport and she told me my 411 visa had expired. The next thing I know, two big guys were at my elbow arresting me. They took my phone, passport and my shoe laces and told me I would be deported in three days and would not be allowed back into the country.”

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“I fell in love with the patients and doctors in Kal. I also learnt firsthand about the inequality of health care if you live in the bush. It’s undeniable.”

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“I was finally told that I didn’t have to sit an exam but I could only be a specialist under supervision and I had to work in Kalgoorlie. I just put my head down and said thank you and left my family in Perth and went to Kalgoorlie. I would come to Perth every fortnight.”

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“I like nephrology, it’s a nerdy field but I love the way the kidneys talk to the heart and the heart talks to the kidney. I worked at RPH for six months and had an absolutely great time. Years later, I learnt that my colleagues were as afraid of me as I was of them. I hadn’t been a registrar for a long time and they weren’t so keen on a cardiologist telling them what to do.”

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He has the confidence of his own distinguished credentials but has also felt the slam of a closed shop and believes it’s unconscionable that a medical licence here is different to a licence in the US or Europe. June 2016

“Why would that be? Why can one doctor do something to a patient here while another from elsewhere with the same type of training be prohibited to do the same thing? But when push comes to shove no one is prepared to speak up. The law (HIC regulations) says that for the first 10 years I can only work in the private system in the city, though I’m allowed to work in Kalgoorlie in the public system. I can only think that is to protect whoever is there.” “I don’t have a problem with anyone. I don’t work for the government. I work for the person sitting in front of me – the patient.”

By Jan Hallam continued on Page 18

MEDICAL FORUM

JULY 2016 | 17


Feature

Being Doctor Dad It’s not easy juggling work and family when you’re treading water in the demanding whirlpool of medicine. Three Perth doctors tell their stories about life, love, children and the whole damn thing.

Dr Nick Cook Dr Stephanie Davies and their brood.

GP, Dr Nick Cooke Nick has a ‘blended’ family with fellow medico, Dr Stephanie Davies. That translates to a household with the patter of 16 feet, four more if you include Nick’s and Stephanie’s. “I never assumed I’d have children and, in fact, I worried that I might never be a dad. Then I ended up marrying Stephanie, which meant that I became a member of a family with eight children. We each have four, a total of seven daughters and one son.” “It’s meant that I’m now a part-time GP and house-husband, while Stephanie works as a full-time pain specialist. I’m the kids-pickerupper, shopper and supper-cooker!” Nick regards the role of being Modern Dad as being pretty ill-defined. He outlines a few of the things he shares with his patients when asked about rearing children. Most of it, he says, isn’t particularly difficult. “One of the most important things a child can do is to gather as many adults around them who support, nurture and protect them. There’s the old saying, ‘it takes a village to raise a child’ and that means family, friends, neighbours, schools, sports clubs and anything else you can lay your hands on – even the mad old lady across the road with chronic cats!” “In short, don’t rely on government or the authorities.” “So, for what it’s worth, here’s my mantra: Feed them… hungry children are grumpy children. Be consistent… always be there for them, but set boundaries. Our first rule when we moved in together was ‘No wet towels on the floor’. That works well, so then we introduced the ‘Come to dinner when the bell rings or your dinner will be inside the dog’ rule. That works well, too. Have fun… They’ll remember the fun times, not the bad ones.

18 | JULY 2016

Dr Ben Roestenburg and family.

Be their dad, not their friend… they have friends and you aren’t necessarily one of them. Do one thing every day… with them on weekends and holidays. They’re usually pretty good at amusing themselves. Remember, you’re not a professional clown. Never be afraid to admit you’re wrong... and say ‘sorry’ when you are. And just occasionally… sparkle!” “The only other thing I’d add is take each child out on a solo special trip. The last ‘Dad Date’ I had involved taking my 14-year-old daughter to see the Antonov 225 land at Perth Airport. She wants to be a pilot but I had more fun than she did!”

MEDICAL FORUM


Feature continued from Page 14

Dr Ben Roestenburg

Umpire's Lucky Bounce

At the beginning of 2016 former electrical engineer Ben started his new career as a fully-fledged, stethoscope-wielding doctor. He’s also the father of three children with one more due this month. “I’m busily juggling family life, a medical career and a part-time second job as a consultant to Western Power. There’s several different ‘hats’ involved and one of them is a ‘good enough’ Dad.” “I say that not in a negative sense and completely without guilt. I see my children almost every day, read to them, listen to them, play with them, take them to interesting places, make their lunches and hold them tight when needed. But most of the true ‘raising’ is done by my wife.”

concerned, ‘here’s a whistle, next weekend you can umpire a game anywhere you like’. They back down pretty quickly after that. And when it comes down to it, try having a game of footy without an umpire. It’ll descend into anarchy pretty quickly.”

“Raising children is neither easy nor passive and requires a constant state of learning and application, just like any career worth pursuing. I’m really fortunate that this arrangement is possible because the children benefit from a dedicated parent at home and I benefit from being mentored by a great parent.”

It can be both a lonely place and a highly public stage out on the centre-square says Dean, and even more so when you make a real ‘clanger’.

“I do the best I can with the time I have available which, I guess, is the modern reality for most fathers.”

Dr Peter Bray Vascular surgeon Peter concedes that medicine can impose on family life in a significant way but also maintains there are ways to minimise the impact. “When you’re a busy trainee it can be difficult to plan a family. I worked in a different state capital every year for five years plus some time overseas and Louise and I decided that carrying toddlers around was not a great idea.” “But, then again, if you delay too long sometimes those things don’t happen quite so easily.”

Dr Peter Bray with Remy and James.

“There have certainly been some generational changes, too. My dad was very busy and we’d often only see him a couple of nights a week and on the weekends. But that builds resilience and I don’t feel I missed out on a lot.” “I married a nurse so that makes things easier and I’m here in my home state with a large, close extended family.”

By Peter McClelland

“I’ll always remember a particular incident between Mark LeCras and Sean McManus in the 2005 Western Derby. It was a high tackle on Mark, a bigger decapitation you’ve never seen! I think his head is still bobbling down Hay St. I just didn’t see it. I was blocked by other players, called Play On and glanced up at the replay. All you can do is explain the situation and apologise but even now, 10 years later, people still ask me ‘how Mark’s head’s going?’.” “The ‘four-umpire’ system is coming in next year and that will ease the physical component of the game. I love the game and I think our best umpires come from the senior ranks. As long as I’m performing well at this level I’ll go on as long as I can.”

By Peter McClelland

“We had James when I was 36 years-old, life got pretty busy after that but it all lined up and our beautiful Remy is now six months old. It’s worked out really well.” “I’ve got a bit more control now because I’m one of those rare doctors who tend to underbook surgical lists. I’m not trying to blow my own trumpet but I enjoy what I’m doing, I like to finish on time and I don’t like going home to my wife who’s a little peeved that I’m late – again!” “I plan my calendar very carefully so that I’ve got plenty of time for Louise and the boys.” As Peter points out it’s all about the choices you make, and ‘informed’ ones are usually preferable. “My dad was a vascular surgeon so I went into it knowing exactly what it was like. There are obviously areas within medicine, such as on-call trauma and transplants, where you’re not going to have a lot of control. Vascular is an area in which endo has taken over a bit more so it’s a lot easier to plan ahead.”

MEDICAL FORUM

JULY 2016 | 19


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Leaders in MedicalMEDICAL Imaging FORUM


Feature

(left-right) Dr Janelle Jurgenson, Dr Dustin Sprigg, Dr Frances Tolman, Prof Geoff Riley, Dr Pippin Holmes, Dr Erin Staines and Dr Kyle Fairclough.

Where Are They Now? Just 18 months ago these young graduates of UWA’s rural recruitment program were on the threshold of their lives. Here’s where they have got to so far… UWA’s Rural Student Recruitment Program was launched in 2000, it’s got a great track-record and that’s good news for health care in regional WA. The number of medical graduates from country areas is on the rise and every one of them has a story to tell. In 2014, we received a picture of a proud Prof Geoff Riley with six of the graduates – Dr Janelle Jurgenson (Bunbury), Dr Dustin Sprigg (Narembeen), Dr Frances Tolman (Esperance), Dr Pippin Holmes (Mingenew), Dr Erin Staines (Kondinin) and Dr Kyle Fairclough (Denmark). We thought it would be an interesting exercise to see what they are up to nearly two years on and we managed to track down four. (We believe Dr Pippin Holmes is practising in Albany and Dr Dustin Sprigg is at SCGH.) J Dr Janelle Jurgenson A combination of ED and GP training is on the agenda for this former Bunbury local. “I did an Emergency Medicine Certificate at Joondalup Hospital to develop my procedural skills and increase my exposure to different presentations. I’m interested in both adult and paediatric medicine and have just applied for GP training next year.” “My goal is to combine the advanced specialised training with an EM Diploma and then finish my GP qualifications down Albany way. I love the Great Southern.”

In fact, Janelle was the first person in her family to attend university but her younger sister has also followed a medical path. “I was a bit fearful of going to medical school, I didn’t really know what to expect. My sister graduated as a nurse and she’s living in Perth so it’s good to share stories. At Joondalup we see a lot of people in ED who really could just as easily be presenting at a GP clinic so we’re getting a broad spectrum of experience.” “I loved being part of the rural program, we were like a mini-family and it was always interesting to hear how people were adjusting to life in the city and tertiary hospitals. Medicine is a great career, full of the unexpected and you never stop learning!” J Dr Erin Stanes Former Kondinin local Erin is honing her skills in the Kimberley and loving every minute of it. “It’s so good to get away from the large hospitals. I’m working at the medical inpatient ward four days a week and one day at the Kimberley Aboriginal Medical Service. It’s just so nice to know everyone you’re working with. The patient load is pretty much what I expected but there are plenty of surprises up here!” “I’m from the country, but all these places are different in their own way. The Rural Training Program gives us plenty of opportunities to get out there and experience that. I chose not to take a bonded scholarship because I

wanted to be able to go to a rural posting in a flexible way. It’s not an easy thing to sign a LONG TERMåCONTRACTåWHENåYOUREåONLYååYEARSå old.” “I’m looking at GP Obstetrics and I’d definitely love to be somewhere in the country. My partner is leaning towards Urology, which is quite city-based so a regional centre might be a good compromise.” J Dr Frances Tolman It’s a long way from Esperance to the big city hospitals in Perth but it’s a journey Frances has relished. “I’ve definitely got a long-term goal to go back to the country. I don’t enjoy living in large cities all that much and my preference would be to work in a smaller rural hospital. I’ve done placements in Karratha and Kalgoorlie so I’ve seen a bit already and it’s really made me aware of how the access to health care varies across WA.” “The smaller hospitals are very supportive places to work, everyone knows your name and the social side is a lot of fun, too.” “I’m in my second year out from university now as a RMO at Royal Perth. There’s lots of interesting challenges and some are quite confronting at times. You’re encountering things you’ve learnt about in theory but never actually seen before and it forces you to get the hang of handling challenges in a practical way. Learning by experience, I guess.” continued on Page 36

MEDICAL FORUM

JULY 2016 | 21


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Meet the CEO

Emphasis on Wellbeing /FFERINGĂĽSERVICESĂĽTHATĂĽHELPĂĽTHEĂĽMENTAL ĂĽEMOTIONALĂĽANDĂĽPHYSICALĂĽWELLBEINGĂĽOFĂĽ CLIENTSĂĽISĂĽONĂĽTHEĂĽTOPĂĽOFĂĽ2ICHMONDĂĽ7ELLBEINGSĂĽNEWĂĽ#%/ĂĽ Richmond Wellbeing’s new CEO Neil Guard knows ďŹ rsthand how important physical exercise is to mental and emotional wellbeing. He and his family enjoy the sporting lifestyle but it was an especially inspiring trek to Everest Base Camp with his wife in 2013 that resonates with Neil.

Neil Guard

“We were trekking for 19 days in the Himalayas reaching about MĂĽANDĂĽITĂĽ was one of the most brilliant holidays I’ve ever had,â€? he said.

It wasn’t just the physical challenge that shaped his perspective but also seeing how people lived in these harsh conditions that reverberates. .EILüHASüSPENTüTHEüPASTüüYEARSüINüTHEüHUMANü services sector here and in the UK and, up until July last year, was executive director of

the WA Drug and Alcohol OfďŹ ce for seven years. And a busy time it was with the formulation of the Mental Health Commission and the amalgamation of the commission and DAO. He was also heavily involved with the development of the 10-year WA Mental Health, Alcohol and Other Drugs Services Plan. He sees Richmond Wellbeing as a perfect next step. “Richmond has a long history of service to the community with a strong focus on recovery. For 40 years it has promoted a holistic approach to service provision, which includes family, community connection, friendship, housing and recreation among other things,â€? he told Medical Forum. “There is a growing recognition that encouraging good physical health aids in better mental and emotional health so Richmond is looking to add services that will help people improve their physical wellbeing. We have recently engaged a health promotion ofďŹ cer and exercise physiologist to develop services and incorporate them into the mental health recovery program.â€?

This additional focus will enhance Richmond’s core business which is supported residential accommodation in the metropolitan area, Rockingham and parts of the South West. “We also provide some carer services including carer respite, community outreach services, including in-home support. Over the past two years we have been involved with the NDIS trials particularly in the Hills and SW. We serve about 500 individuals we support more than 1000 family members and carers.� Richmond is externally funded and as such as built up strong ties with government agencies including the WA Primary Health Alliance, which will fund federally-funded mental health programs. Neil said Richmond was in the process of developing its strategic plan for the next three years. “There’s a lot of optimism as an organisation but it is important that we don’t spread our butter too thin and ensure what we do is high quality.�

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JULY 2016 | 23


July e-Poll

Doctors’ Concerns in the Spotlight The snapshot of doctor opinion brought some interesting results – some held over until our coming Child Health edition. $EMOGRAPHICSååRESPONSESåFROMå'0Så å3PECIALISTSå åANDå$)4Så ånååOFåRESPONDENTSåWEREåMALEåWITHå that bigger gender difference explained because only 10% of specialist respondents were female (vs. 40% of GPs). Winner of our Medical Forum wine pack was Dr TT (so better luck next time to everyone else!).

July e-Poll

Consumers and Public Hospitals

Q

How do you think the public hospital system will perform in coming months, compared to health consumer expectations?

Below expectations*

58%

In line with expectations

34%

Above expectations

4%

Uncertain

4%

Men’s Health - HRT Prescribing

Q

Do you think overall prescribing of androgen to men has dropped since PBS changes were introduced?

ED: *Amongst specialists, whom we assume are more in the know, 63% held this view. Overall, not a good look for public hospitals.

Yes

24%

No

2%

Adverse Events in Private Hospitals

Uncertain



Q

Should problems caused by medical examination or treatment while in a private hospital (iatrogenic illness) be covered by private health insurance funds? 84%

Yes No

6%

Uncertain

10%

ED: We understand private funds like HBF and Medibank Private don’t believe they should pay if someone attending a private hospital for one problem, contracts another through the fault of the hospital or doctor. We can see how murky it can get with superbugs around. Interestingly, most doctors are against the private health funds on this one, with no significant difference between GP and Specialists

Traumatised Doctors

Q

Have you worked with any doctor who has shown adverse effects of their past traumas, whether work-related or not

Yes



No

47%

Uncertain

16%

ED: Interestingly, 31% of males answered ‘yes’ compared to 52% of females, with ‘uncertain’ answers the same across both genders. So it seems that more female doctors than males (mostly GPs in this cohort) have worked with a colleague who appears traumatised.

ED: 29% of males responded ‘yes’ (with 3 times as many GPs as specialists responding this way) whereas 92% of females were uncertain. So, it appears that about a third of male doctors, GPs in particular, have noticed that androgen prescribing for men has dropped since the PBS changes came in.

Q

Can you think of an instance amongst your male patients where PBS changes around androgen prescribing have forced a man, against your better judgement, off HRT altogether? Yes

15%

No

23%

Uncertain

14%

Doesn't apply

49%

ED: About one quarter of GPs say men they see, needing androgen therapy, have been forced off this treatment by PBS changes. Slightly more males were more likely to respond ‘yes’ (18%) and this increased further to 24% in the craft group of General Practitioners (similar amongst male and female GPs, with only 26% responding ‘doesn’t apply’).

“It’s always the doctors fault?”

Q

In preparation for our get together to discuss "It's always the doctor's fault?!", can you tell us please, if any of these statements align with your attitudes?

It is not a bad thing if doctors are more accountable for their actions.*

26%

Medicine is often not an exact science and things can go wrong.#

44%

It is very demoralising for doctors to have to practice 'defensive medicine'.



None of these statements reflect my point-of-view.

2%

ED: *61% of Specialists vs 42% of GPs in total supported this idea. #Over 84% of both Specialists and GPs supported this concept, while just over half of both groups supported the third idea. On the one hand, many doctors are saying accountability is not a bad thing but the making of decisions in medicine is often not an exact science and things can go wrong.

24 | JULY 2016

MEDICAL FORUM


Practice Management

Security Issues on the Rise Keeping your IT system secure is becoming a full-time job. IT expert Mr Jerome Chiew has some sound advice for all practice managers. IT security is more challenging with each passing day. Evolving versions of ransomware, a malicious piece of software that encrypts all your data requiring you to pay a ransom fee to obtain the key to decrypt (www.us-cert.gov/ncas/alerts/ TA16-091A), now is able to propagate itself across removable media, from USB flash drives, to writeable CDs and DVDs (https://blogs.technet.microsoft.com/ mmpc/2016/05/26/link-lnk-to-ransom/). Ransomware is typically delivered one of two ways, firstly as legitimate looking emails from trusted sources like banks, government agencies and your friends. Secondly, through compromised websites that serve up the virus when you visit, or through the advertising space that the hackers have purchased. Ransomware scans and encrypt all files it can find locally and on all remote computers and servers. Nothing is safe, as long as it is connected and accessible in some way, even backups, rendering a recovery impossible. There is no guarantee that paying the ransom fee gets the key to decrypt the files – instead, a second ransom demand may result. Therefore, the only way to recover is to ensure multiple backups are kept offline, going back far enough from the infection date to obtain a ‘clean’ restoration.

incorporate upper case letters, a number ANDåAåSYMBOL åANDåSPANåAåMINIMUMåå characters.

Here are some general security tips: så 7HENåBROWSINGåWEBSITES åDOåNOTå download or run any files you did not specifically request. Close all unwanted pop-ups by clicking the X at the top right hand corner of the window – many popups feature fake buttons, which when clicked, provide consent to download and execute the virus. så )TåISåIMPORTANTåTHATåSTAFFåMEMBERSåAREå trained to not click on any links or open any attachments in emails that they have any inclination of being unauthentic. Some fake emails are easy to spot with obvious grammatical and spelling mistakes, others are meticulously crafted and even the sender’s details seem genuine (i.e. close to impossible to identify as fake). If in doubt, always verify the email or attachment by contacting the sender. så )FåYOUåSUSPECTåTHATåYOURå0#åHASåBEENå infected, stop using it and notify your practice manager immediately. så #REATEåAåSTRONGåPASSWORDåPOLICYåINåTHEå practice to reduce the risk of becoming compromised: set a finite number of attempted logins to lock out the user for a set time; change passwords regularly; and

så %NSUREåTHATålREWALLSåAREåENABLEDåFORåALLå servers and PCs in your local network including the Internet modem router. så 'OODå0#å@HYGIENEåWARDSåAGAINSTå infection. Keep fully up-to-date with the latest Windows patches and fixes through Windows Update. Ensure that you have a good antivirus and antimalware software running to stop the virus before it can load. Change default settings and security policies. US Government provides useful guidelines at www.us-cert.gov/ncas/tips/ ST15-003. så #ONSIDERåINVESTINGåINåAåUNIlEDåTHREATå management (UTM) device. This sits between your modem and network, acting as a gatekeeper, filtering all incoming Internet traffic, before forwarding to the PCs. It protects against viruses, malware, SPAM and mitigates hacking intrusion attempts by scanning for malicious activity. https://en.wikipedia.org/wiki/Intrusion_ prevention_system ED: Jerome is at www.critical-it.com.au

July e-Poll

IT Use in Health

Q

What is stopping doctors from using Information Technology (IT) to its promised potential?

Strongly agree

Strongly disagree

Disagree

Resistance to change, in general

6%

36%

23%

32%

3%

Red tape involved

0%

5%

20%

47%

28%

Fearful of security risk around stored information #

3%



12%

43%

16%

Poor understanding of what can be done

3%

21%



50%

8%

Generational differences

5%

15%



42%

12%

Don’t trust health IT, in general

4%

33%

15%

39%

9%*

Waiting for it to be near perfect

2%

26%

29%

35%



Neutral

Agree

ED: #For this question on security risk, 67% of females agreed against 43% of males – otherwise, the questions failed to bring out major gender differences. In summary, most respondents felt doctors were not generally resistant to change, but instead were put off by the red tape involved, fearful of security risk around stored information and had a poor understanding of what could be achieved. Generational differences were touted by just over half respondents but about another third of them were neutral on this idea.

MEDICAL FORUM

JULY 2016 | 25


Guest Column

Working with Warriors A family background in farming has given Mr Owen Catto a passionate belief in the importance of effective health strategies for men living in rural communities. Working with Warriors is an innovative approach to encourage and empower men to take responsibility for their own health and wellbeing. It falls under the banner of the Regional Men’s Health Initiative (RMHI), a statewide community education program that’s delivered in three different ways:

We men are often well aware of the issues but think that we’re the ‘only one’ with a problem.

så %DUCATIONåSESSIONS så &ASTå4RACKå0ITå3TOP så !DVOCACY All these programs focus on the importance of holistic health and on understanding that we all share the difficulties of problems and issues cropping up in our daily lives. The Fast Track Pit Stop, for example, encourages men to pause and reflect on how they’re feeling and whether it’s time for useful strategies to be implemented. The RMHI strongly believes that we’re considerably more than just physical beings – we’re people with social and psychological needs as well. It’s important for all of us to know and understand the story that lies behind our own identity and just what it is that makes us an individual.

All too often modern medicine is all about ‘diagnosing ills, prescribing pills and sending bills’ and the human dimension can easily be lost in the medical mix. In our education sessions we talk about ‘situational distress’, which is that important transitional space between coping well and being diagnosed with a mental illness. We quite often fail to realise that many mental illnesses begin in situations of unresolved conflict and stress. Nonetheless, it’s also important to allow men to acknowledge that it’s perfectly acceptable to have a normal reaction to an ‘abnormal’ event. We men are often well aware of the issues but think that we’re the ‘only one’ with a

problem. We associate a ‘weakness’ with ‘failing’ instead of realising we’re battling issues beyond our making or control. Sometimes it’s just a matter of giving blokes permission to admit they’re struggling and to point them in the right direction for the best help they can get. The unhelpful perception that blokes are ‘warriors’, that ‘winning’ with a ‘macho’ attitude is something to be admired is distinctly unhelpful and can inhibit a much-needed call for help. And, of course, the distance factor and a relative lack of services in rural settings doesn’t help much either. Our motto, and the basis of all our initiatives, is ‘talk to a mate before it all gets too much!’ We stress the importance of mateship, empathy and the use of humor in our programs and presentations. Effective health awareness is what we strive for and it’s often the missing link for men in regional communities. ED: Questions about the Regional Men’s Health Initiative can be directed to 08 9690 2277 www. regionalmenshealth.com.au

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MEDICAL FORUM


Guest Column

Young Men Vulnerable to Ice Methamphetamine use among young men is a concern says Curtin University’s A/Prof Nicole Lee. Australia has one of the highest rates of methamphetamine use in the world. About 2.1% of Australians aged 14 years and over report using it in the past 12 months. Most (70%) use less than 12 times a year. SigniďŹ cantly, there is no evidence of a large increase in new methamphetamine users. In fact, the percentage of users among the general population has been decreasing since 1998.

Bethesda Health Care General Practitioner Education Program (RACGP Accredited Program)

The key problem over the past ďŹ ve years has been an apparent shift among people who already use the lower-grade ‘speed’ to higher-grade ‘ice’. Purity and availability have increased while price has gone the other way. Worryingly, the number of people using weekly or more has increased. Some of these changes have created a ‘perfect storm’. As a result Australia has seen a signiďŹ cant increase in ambulance callouts, hospital visits, treatment seeking and police arrests related to methamphetamine use. The use of a range of drugs (including alcohol) by young people has decreased substantially over the past 10 years. The largest group of users of methamphetamine are in the 20-29-year-old cohort. Young men have a HIGHERĂĽRATEĂĽOFĂĽUSEĂĽWITHĂĽNEARLYĂĽĂĽOFĂĽMENĂĽREPORTINGĂĽTHEYDĂĽUSEDĂĽTHEĂĽDRUGĂĽINĂĽ THEĂĽPASTĂĽĂĽMONTHS ĂĽCOMPAREDĂĽWITHĂĽĂĽOFĂĽWOMENĂĽINĂĽTHEĂĽSAMEĂĽAGEĂĽGROUP Methamphetamine affects a range of neurochemicals in the brain causing an increase in serotonin and noradrenaline. Noradrenaline regulates the ďŹ ght or ight system, which increases ‘threat sensitivity’ while methamphetamine increases dopamine levels. After moderate to heavy use the dopamine system can be seriously depleted resulting in a â€˜ďŹ‚at’ feeling after using the drug. )TĂĽCANĂĽTAKEĂĽASĂĽMUCHĂĽASĂĽ ĂĽMONTHSĂĽOFĂĽABSTINENCEĂĽBEFOREĂĽTHEĂĽBRAINĂĽ recovers to baseline levels. During that period, prefrontal cortex and limbic system functioning can be severely affected. High levels of dopamine have been linked to psychosis symptoms and low levels to depression. Serotonin also affects mood. This partly explains the high rates of mental HEALTHĂĽPROBLEMSĂĽAMONGĂĽTHISĂĽGROUPĂĽ3TUDIESĂĽHAVEĂĽFOUNDĂĽTHATĂĽATĂĽLEASTĂĽĂĽOFĂĽ regular users will experience symptoms of signiďŹ cant depression and 25% will experience psychosis. The stimulant effects of methamphetamine can also affect sleep quality. One of the big risks linked with methamphetamine use It can take as much as 12-18 is an increase in sexual months of abstinence before risk-taking. Young the brain recovers to baseline gay men have high rates of use with many levels reporting that they use speciďŹ cally to increase sexual pleasure. High levels of dopamine increases impulsivity, reduces decision-making ability and lowers inhibitions. Harm reduction is critically important for this group.

Now in its 4th year, the program offers a range of high quality educational sessions including orthopaedics, pain management, prostate cancer, bariatric surgery, breast cancer surgery and palliative care. To join Bethesda Health Care's GP database, please email your details to rsvp@bethesda.org.au or call (08) 9340 6396 www.bethesda.org.au/events

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There is no pharmacotherapy that helps with dependence, but medicines for symptom management may be an option. Psychological therapy is proving effective with as few as two sessions of CBT and motivational interviewing resulting in increased abstinence, even among heavily dependent users. Nonetheless, relapse rates are high compared with other drug users. The lGURESĂĽSTANDĂĽATĂĽAROUNDĂĽĂĽATĂĽTHEĂĽONE YEARĂĽPOINT ĂĽPROBABLYĂĽRELATEDĂĽTOĂĽTHEĂĽ long neurocognitive recovery time so post-treatment support is crucial to reduce the risk of relapse.

MEDICAL FORUM

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JULY 2016 | 27


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Guest Column

Striving for Performance and Balance Dr Sarah Egan, PhD, asks whether online self-help treatment for perfectionism can help reduce eating disorders, anxiety, and depression in people who engage in regular sport/exercise

PIVET MEDICAL CENTRE SPECIALISTS IN REPRODUCTIVE MEDICINE & GYNAECOLOGICAL SERVICES

by Medical Director PROF JOHN YOVICH

Uterine reconstructive surgery ... still very important in this high-tech era Nonna Susan was becoming disheartened after her daughter Sonia lost her 5th pregnancy, mostly in the ďŹ rst-trimester, despite conceiving quite easily. Sonia had been told by her surgeon after appendicectomy at age 11 years, that she had a heart-shaped bicornuate uterus, but it should not cause her any trouble.

In the ďŹ eld of clinical psychology one concept which has received increasing interest is perfectionism. Perfectionism has been deďŹ ned as always striving to achieve the highest standard in one or more aspects of life and engaging in highly self-critical thoughts about mistakes associated with meeting those standards. Obviously no one would ever succeed in their professional life or in pursuits such as sport unless they worked hard and strived to achieve their standards. There are two basic ‘types’ of perfectionism: positive achievement striving (striving to achieve high personal standards and goals) and perfectionistic concerns (focusing on errors and mistakes in performance). There is extensive evidence that perfectionistic concerns are related to a range of psychological disorders including anxiety, depression and eating disorders. In contrast, there is some evidence to suggest that positive achievement striving may be linked to positive outcomes and functioning. Our research has found through numerous randomised controlled trials that reducing perfectionistic concerns through brief cognitive behavioural therapy (CBT) for perfectionism can decrease a range of psychological symptoms. CBT for perfectionism is a part of a range of newer CBT therapies referred to as ‘transdiagnostic’ as they can be applied as one brief (e.g. eightsession treatment) across a range of disorders and result in a wide range of symptom Many athletes can experience relief, without needing difďŹ culty with perfectionistic to speciďŹ cally target one psychiatric disorder. concerns...those who struggle This is an advantage to have rest days, or feel when typically people anxious when they cannot meet criteria for more than one disorder. exercise due to injury. One area that people commonly experience perfectionism in is sport and exercise. Many athletes can experience difďŹ culty with perfectionistic concerns (e.g., I come second in the race therefore I have failed). This can be seen in people who struggle to have rest days, or feel anxious when they cannot exercise due to injury (e.g. think of the runner who continues to train despite a stress fracture). We are interested in ďŹ nding out if self-help CBT for perfectionism treatment is effective for people who engage in sport and exercise twice or more per week, in improving sporting performance, and decreasing negative outcomes including burnout, overuse injuries, anxiety, depression, compulsive exercise and eating disorders. 4HISĂĽISĂĽIMPORTANTĂĽGIVENĂĽBETWEENĂĽ ĂĽOFĂĽCOMPETITIVEĂĽATHLETESĂĽHAVEĂĽ been found to suffer from eating disorders. This will be the ďŹ rst study to examine if an eight-week online self-help program which reduces unhelpful perfectionistic concerns can improve athletic performance and decrease negative psychological outcomes. The research team is seeking people who regularly exercise and play a wide range of sports. They do not have to be elite or competitive athletes, we are interested in a range of people. Phone Emily Valentine 9266 3436.

MEDICAL FORUM

Fig 1. Hysterosalpingogram showing bicornuate appearance (left) and ultrasound showing septate conďŹ guration (right) before hysteroscopic remodelling under laparoscopic control.

When we ďŹ nally repaired this uterus it required resection of the septum at hysteroscopy, virtually down to the internal cervical os to enable a sufďŹ ciently capacious cavity. An incidental left horn myoma was also resected and a strictured area in the right horn released. However the cervix was now widely incompetent, requiring a tight, high McDonald suture in both her spontaneously ensuing pregnancies. The ďŹ rst, a singleton daughter, Taja with birth weight 3095g, was DELIVEREDĂĽATĂĽĂĽ weeks by elective caesarean. The second was a spontaneous dichorionic twin gestation Fig 2. Happy nonna, mum and children with – a pigeon Dr Yovich April 2016. pair delivered by elective caesarean at 35 weeks. These are a healthy boy Kynan at 2435g ANDĂĽSISTERĂĽ3HANIAĂĽATĂĽGĂĽ!LLĂĽHAVEĂĽTHRIVEDĂĽANDĂĽ-UMĂĽ'0 ĂĽ may now retire satisďŹ ed that her own Mum, Susan is content with her brood of grandchildren.

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JULY 2016 | 29


Clinical Opinion

Lifestyle modiďŹ cation for cardiovascular risk

By Dr Peter Thompson Cardiologist, Director Heart Research Institute SCGH, Dep. Director Perkins Institute

data collection and other scientiďŹ c aws. Meta-analyses in reputable journals have failed to conďŹ rm that protection comes from low consumption of total saturated fats. On the other hand these meta analyses have been criticised as “seriously misleadingâ€? and a recent Cochrane review concluded that evidence from randomised trials is that reducing saturated fat can reduce the risk of HAVINGĂĽAĂĽCARDIOVASCULARĂĽEVENTĂĽBYĂĽĂĽ/THERĂĽ re-examinations of the data have suggested that the main culprit may not be saturated fat but trans fat intake. A recent controversial study showed that a diet low in saturated fats and higher in polyunsaturated fat led to a reduction of cholesterol but not to lower cardiovascular mortality. No doubt more research is required to clarify the confusion. Despite the controversy, a diet low in saturated fats and avoidance of trans fats still has the strong support of both the current US as well as Australian dietary guidelines.

The evidence for lifestyle modiďŹ cation to mitigate cardiovascular risk is light, which is both surprising and disappointing, given I am an enthusiastic supporter of the Heart Foundation’s health promotion campaigns and I recommend lifestyle modiďŹ cation to patients almost daily. Despite the voluminous literature on improving risk factors with lifestyle modiďŹ cation there is limited hard evidence that modiďŹ cations reduce heart attack and stroke. There are undoubted beneďŹ ts for quality of life and overall health with reductions in smoking, improving ďŹ tness, maintaining ideal body weight and a low saturated fat diet. Such advice over 40 years has coincided with an overall decline in fatal and non-fatal cardiovascular events in the community. However, the limitations of clinical trial evidence may encourage a more realistic view of what can be achieved by lifestyle modiďŹ cation. The puzzling discrepancy between the observational studies that show distinct beneďŹ ts of a healthy lifestyle and the randomised trials that have failed to show clear beneďŹ ts in those at risk, is a challenge for further research. Smoking cessation BeneďŹ ts on cardiovascular risk will never be quantiďŹ ed in randomised trials because the observational data is so strong; it would be unethical to ask trial participants to continue smoking. The US Surgeon General’s Report of 2010 concluded that the risk for heart attack drops sharply just one year after smokers quit. Review of quitting techniques by the Cochrane Collaboration  ĂĽFOUNDĂĽTHATĂĽUNASSISTEDĂĽQUITĂĽRATESĂĽAREĂĽ depressingly low at 2-3%, with brief advice from a health professional adding 1-3% to this ďŹ gure. Australian researchers found that most smokers who quit do so without any assistance. Exercise Patients advised of high CVD risk often decide to “exercise and get ďŹ tâ€?. While there is ample evidence that markers of risk, such as blood pressure and LDL can be improved with exercise, and the quality of life beneďŹ ts are very real, the evidence that this translates to lower heart attack and stroke rates is not so clear. The latest Cochrane update (2016) concludes that exercise-based cardiac rehabilitation reduces the risk of cardiovascular mortality but not total mortality (and it is unclear whether the exercise components of the cardiac rehabilitation programmes examined were the reason for the improvement). The question of how much exercise is clouded by recent reservations that extreme endurance exercise may not be beneďŹ cial. The observational studies on the optimal amount of exercise shows a U or J shaped curve, with increasing CVD

30 | JULY 2016

risk with extreme exercise patterns. Current US guidelines recommend 40-minutes of moderate-to-vigorous intensity physical activity, 3 to 4 times weekly. Unused gym memberships are not only embarrassing, they also demonstrate how difďŹ cult it can be to follow advice. Weight loss The Framingham studies did not show that increased body weight as an adult increased cardiovascular risk. Hence, weight is not included in most risk calculators. It may have been different if waist measurement or waist hip ratio had been used, as more recent studies have shown that measures of abdominal obesity are more valid indices of cardiovascular risk than simple weight or BMI. Abdominal obesity is associated with the so called “metabolic syndromeâ€? and a risk of type II diabetes, dramatically improved by correcting abdominal obesity. Weight loss beneďŹ ts cardiovascular risk factors but effects on cardiovascular events and mortality, while widely assumed, remain unproven. Well-designed studies of intentional weight loss have not shown a clear beneďŹ t, with a 2009 meta-analysis concluding that the available evidence does not support solely advising overweight or obese individuals who are otherwise healthy to lose weight as a means of prolonging life. The latest Cochrane collaboration report (2016) conďŹ rms this. Low fat diet The beneďŹ ts of diet in preventing CVD is controversial. The decades-long advice to avoid excess intake of saturated fats is undergoing re-examination. Fifty years on, the strong correlation between high saturated fat intake and heart disease established in the classic Seven Countries studies, has come under heavy attack for incomplete

The Mediterranean diet has been widely embraced, and the famed Lyon Diet Heart Study from the late 1990’s had a big inuence, but a recant careful meta-analysis of the totality of evidence for the Mediterranean diet showed only improvements in risk factors but no convincing effect on cardiovascular outcomes. Multiple risk factor intervention It was recognised decades ago that targeting individual risk factors may not reduce overall risk, and a more global approach may be more logical and effective but multiple risk factor interventions are a challenge. The seven-year Multiple Risk Factor Intervention trial (MRFIT) in over 12,000 men without known cardiovascular disease conducted INĂĽTHEĂĽS ĂĽWASĂĽDISAPPOINTING ĂĽWITHĂĽNOĂĽ beneďŹ cial effect on CHD mortality compared with the usual care group. Since then, efforts to demonstrate a beneďŹ t of multiple risk factor intervention on cardiovascular mortality for primary prevention (now totalling 14 trials and 139,256 participants) have failed – the pooled odds ratio for total mortality stands at 1.00 and 0.99 for CHD mortality. Cardiac rehabilitation for secondary prevention The picture for patients with known cardiovascular disease (secondary prevention) is more encouraging. The clinical and emotional support and associated exercise that forms the basis of cardiac rehabilitation has been shown to reduce cardiovascular mortality by 26%, and the OVERALLĂĽRISKĂĽOFĂĽHOSPITALĂĽADMISSIONSĂĽBYĂĽĂĽBUTĂĽ have no effect on total mortality, risk of MI or revascularisation. It is difďŹ cult to identify which component of the exercise-based cardiac rehabilitation delivers the beneďŹ t. A recent randomised trial that did not include a large exercise component failed to demonstrate any improved outcomes.

MEDICAL FORUM


Clinical Opinion

Summary of the evidence Table 1: Effectiveness of lifestyle modification Lifestyle modification

Observational evidence

Clinical trials onducted?

Randomised Clinical Trial evidence Primary Prevention

Secondary Prevention

Smoking cessation*

Very strong

No

None available

None available

Exercise

Strong

Yes

Neutral

Effective as a component of cardiac rehabilitation

Weight loss

Strong

Yes

Neutral

Neutral

Low fat diet

Strong but being re-examined

Yes

#6åEVENTSå 

Neutral

Mediterranean diet

Strong

Yes

Neutral

Neutral

Multiple risk factor intervention Strong

Yes

No effect

Exercise based cardiac rehabilitation CV mortality -26%

The % estimates of benefit are drawn from Cochrane meta-analyses (references available). * RCT’s not justified – with all other modifications, more research is needed.

Implications for Clinical Practice Many of the lifestyle modifications in the primary and secondary prevention of cardiovascular disease lack clinical trial proof of benefit. When the strictest arbiter, reduction of events in randomised clinical trials, is applied to weigh the evidence, the widely assumed benefits of smoking cessation, regular exercise, maintenance of normal body weight, and a low saturated fat diet are far from proven beyond doubt. Calling our efforts in clinical practice and health promotion a ‘waste of time’ is not justified. First, lack of evidence is not evidence against. Second, conducting lifestyle modification trials has many difficulties including high dropout rates that may distort results. Third, risk factor changes achieved in trials may not have been sufficient to impact on outcomes. Finally and most importantly, randomised trials conducted over several years may not be the best way to evaluate the benefits of a lifetime of healthy living. Nevertheless, the lack of hard evidence for the benefits of lifestyle modifications has implications for the way we recommend changes. The following suggestions may help. 1. Set realistic goals Over-zealous lifestyle modification can be difficult to justify on the above evidence and unrealistic goals can be discouraging. The difficulties in achieving consistent wins with smoking, exercise, weight loss and dietary change are well known, and patients should be encouraged to obtain overall risk reduction through incremental changes in multiple risk factors. 2. Target our efforts better Working with at-risk groups is more likely to be effective, particularly if supported by GPs. The Australian Absolute Cardiovascular Risk Calculator (www.cvdcheck.org.au) takes little time to input risk factors to estimate

MEDICAL FORUM

risk of a cardiovascular event over the next five years. (Missing from this and all international CVD risk calculators is an index of weight or abdominal obesity, physical inactivity, family history and indigenous status, all of which should be considered.) In my experience, small improvements in risk profile are achievable and can dramatically improve cardiovascular health and the risk of future heart attack and stroke: for example, a normotensive middle age non–diabetic smoker can reduce their five-year risk from 26% to 16% by becoming a non-smoker, and to 10% with modest reductions in blood pressure and cholesterol.

3. Smarter ways to deliver advice The selective use of modern communication technology can achieve good results by improving the delivery of lifestyle advice. This includes telephone support in the Australian developed COACH programme in risk factor management, and text messaging.

References: Available on request

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Thinking Haematology & Oncology? Think Hollywood. WE’RE BIG IN HAEMATOLOGY & ONCOLOGY ([/VSS`^VVK7YP]H[L/VZWP[HS^LVɈLYV\[Z[HUKPUN medical and surgical treatment across a wide range of cancers and provide access to the latest treatments, world-class facilities and outstanding care. We have a team of specialists who provide cancer management services including curative care, palliative care and pre-operative tumour reduction. Our comprehensive chemotherapy treatments include: ࠮ intravenous chemotherapy ࠮ monoclonal antibodies ࠮ targeted therapies Our haematology services treat malignant haematological conditions such as: ࠮ leukaemia ࠮ lymphoma ࠮ myeloma

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For contact details of Hollywood Haematologists & Oncologists, visit the specialists section of our website hollywoodprivatehospital.com.au MEDICAL FORUM


Meet our Haematologists & Oncologists

Dr Bradley Augustson

Prof Ross Baker

Dr Tony Calogero

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MEDICAL FORUM

JULY 2016 | 33


WE ARE PLEASED TO ANNOUNCE HeartCare Western Australia has been granted early access to the Abbott Vascular bioresorbable Absorb scaffold for privately insured patients through selected health funds. The Absorb stent is a bioresorbable vascular scaffold that is designed to dissolve over a 2-3 year period. To date, data from over 13,000 patients from clinical trials are promising however more data are required to determine the superiority of the these stents compared with current generation metal stents. Although you will start seeing more of your patients with this type of stent, it will not affect management decisions related to the duration of their antiplatelet therapy.

BASE BA SELI SE LINE LI N NE

YEAR YE AR 2

YE EAR 5

REPAIRS stenosed vessels1

RESTORES vessel function2

RENEWS vessel wall structure2

ALL HEARTCARE WA INTERVENTIONAL CARDIOLOGISTS ARE EXPERIENCED IN THE IMPLANTATION OF THE ABSORB SCAFFOLD

Dr Alan Whelan

Dr Donald Latchem

Dr Randall Hendriks

Dr Allison Morton

*Small platinum markers at scaffold edges remain. OCT images courtesy of RJ van Geuns, Erasmus Medical Center, The Netherlands; De Bruyne B. ABSORB Cohort B 5-year, TCT 2014. Sources: 1. Serruys, P, et al. Lancet. Sept. 2014; http://dx.doi.org/10.1016/S0140-6736(14)61455-0. 2. Serruys PW et al. ABSORB Cohort B Presentation. TCT 2015.

heartcarewa.com.au 34 | JULY 2016

As part of GenesisCare and HeartCare Western Australia’s commitment to evidence-based clinical practice we have implemented the GenesisCare Percutaneous Coronary Interventional (PCI) database. The PCI database captures details of PCI procedures to enable a better understanding of patient conditions, with continued follow-up of patients to ensure quality outcomes and guideline adherence. With over 6,700 patients who have completed a 12 month follow up our results compare favourably with the US National Cardiovascular Data Registry (NCDR). A MEMBER OF THE

NETWORK MEDICAL FORUM


Clinical Opinion

Guidelines for menopausal HRT Evidence-based guidelines for HRT have recently released by the Endocrine Society in Washington DC. In Australia: the average age of menopause is 51 years; three-quarters of women experience some symptoms that include hot ushes, sweating, sleep disruption, mood changes, and poor concentration; symptoms can last for ďŹ ve to six years (>10 years in 25%); and 1 in 5 have moderate to severe symptoms that could affect work performance. In 2002, the Womens’ Health Initiative QUESTIONEDĂĽTHEĂĽSAFETYĂĽOFĂĽ(24ĂĽINĂĽ ĂĽ “healthyâ€? post-menopausal females, claiming that the risk of cardiovascular disease and invasive breast cancer outweighed the beneďŹ ts. This study had serious aws: volunteers were recruited without reference to symptoms; mean age was 63, two-thirds were overweight or obese and half were ex-smokers. Oestrogen protects females in their reproductive years from vascular disease but age increases the risk, as does the marked change in the lipid proďŹ le after the menopause. After the WHI report the use of (24ĂĽFELLĂĽBYĂĽ HRT according to symptom severity It is now agreed that the severity of symptoms determine if HRT is indicated. Recent

studies show that beneďŹ ts exceed risks for the majority of symptomatic women under the age of 60 or within 10 years of the menopause. The net effect on all-cause mortality is neutral or even favourable. The experts recommend that the diagnosis of menopause is made on symptoms, and if necessary measures of estradiol and FSH. Lifestyle issues should be addressed including smoking, alcohol, diet and exercise. Bone health should be assessed. For moderate to severe symptoms, oestrogen is advised for hysterectomised women; and if the uterus is retained, oestrogen plus progesterone. The lowest effective dose should be used. All patients require screening for CVD, thrombosis, and breast cancer risk. Where athero-thrombosis risk is present, trans-dermal HRT is preferred. On oestrogen alone, there is a linear increase in breast cancer incidence related to the length of therapy but the ďŹ ve–year risk is considered to be small. With combined oestrogen and progesterone, the risk for breast cancer is increased (risk ratio 1.25 to 1.34), and regular mammography is essential. Vaginal oestrogen therapy is advised for genitourinary symptoms including urinary frequency and for the prevention of vulvo-

Dr Tim Welborn Endocrinologist

vaginal atrophy. There is minimal systemic absorption. Non-hormonal remedies for menopausal symptoms are of lesser beneďŹ t and include SSRIs and SNRIs used at a quarter to half the normal antidepressant dose, and also low dose clonidine, pregabalin and gabapentin. Therapies containing plant oestrogens (e.g. soy products, chick peas, lentils and axseed) are used without clear evidence these help. The authors re-emphasise that all postmenopausal women should be encouraged to embrace appropriate lifestyle measures. References 1. Stuenkel CA, Davis SR, Gompel A et al. Treatment of symptoms of the menopause: Endocrine Society clinical practice guidelines. J Clin Endocrinol Metab 2015; 100: 3975-4011 2. Manson JE, Kaunitz AM. Menopause management – Getting clinical care back on track. New Engl J Med 2016; 374: 803-805

Author competing interests: no disclosures. Questions? Contact the author on timwelborn@iinet.net.au

Clinical Update

Pitfalls in dermatology – Part I In the diagnosis and treatment of skin diseases there are many pitfalls, especially for those unaccustomed to seeing many skin diseases. Treatment of eczema Eczema is a common inammatory skin condition that can have marked pruritus. Establishing the correct diagnosis is the key. Exclude a dermatophyte infection as this can often be hard to pinpoint clinically and all dry scaly lesions theoretically should be scraped to exclude a fungal infection. Tinea incognito can look like a steroid resistant dermatosis but closer examination for an annular border can provide the clinical clue. Exclusion of an allergic contact dermatitis is important. This may be clinically obvious e.g. sharp cut off at the wrist due to gloves. The site of the dermatitis may give a clue to cause. Currently there is an epidemic of allergic contact dermatitis due to wet wipes containing methylisothiazolinone, which are commonly used to wipe and clean the skin,

MEDICAL FORUM

By Dr Alan Donnelly Dermatologist West Leederville

and this should be considered for persistent dermatoses. The best mechanism is to arrange for patch testing. There are other rare conditions such as mycosis fungoides, which can present as eczema and can cause confusion because of its initial response to topical steroids. Pruritus tends to be less of a problem and diagnosis is obtained by repeated biopsies. Scabies infestation is common and can result in eczematous changes. It is important to examine the skin for typical burrows on the hands, ďŹ ngers and ďŹ nger web spaces as well as genitalia of the male and on breasts of the female. These patients often ďŹ nd the itch to be worse at night. Secondary infection with Staph aureus often requires treatment as well. Herpetic infection is often under diagnosed in atopic eczema. Mild cases may be treated as ordinary secondary Staph infection and can remit spontaneously but more severe cases have the typical herpetic picture with

grouped vesicles and scabbing. Diagnostic conďŹ rmation is with PCR testing. Treatment of pityriasis versicolor Pityriasis versicolor is due to a yeast organism malassezia furfur. It does respond to topical azoles as well as systemic azole treatments. Treatment with griseofulvin or terbeniďŹ ne will not have any beneďŹ cial effect for pityriasis versicolor, as they are not active against it. Treatment of acne Acne treated with systemic antibiotics should not be treated with topical antibiotics at the same time. Use of topical retinoids or benzyl peroxide preparations are beneďŹ cial with systemic antibiotics. Author competing interests: no relevant disclosures. Questions? Contact the author on 9380 9690

JULY 2016 | 35


Close-Up continued from Page 21

Where Are They Now? “Some days are better than others but I think everyone has days at work when they wonder what they’re doing. It’s quite natural to question your choice of career at times but I’m deďŹ nitely looking forward to applying for GP training next year.â€? J Dr Kyle Fairclough A Rural Bonded Scholarship allowed Kyle to pursue a medical career and he is loving every minute of it. “I’ll be heading back to the country in about four years’ time, hopefully to Denmark where I grew up or maybe Albany which is quite close. I’m working in the ED at Fiona Stanley, which is fantastic! The consultants are wonderful and it’s a great environment to work in.â€?

“The experience I’m getting will be a useful preparation for my GP training.â€? “Sometimes it’s a bit tough. On my last shift a patient arrested in the ďŹ rst two minutes of me starting, on another occasion we had to tell a bubbly 53-year-old woman that she had a metastatic brain tumour. That was pretty difďŹ cult.â€? “The scholarship allowed me to do medicine because my family wouldn’t have had the money to pay my way through medical school.â€?

By Peter McClelland

Curing Hepatitis C – Now the Province of GPs PBS-funded, GP initiated prescriptions for direct-acting antivirals (DAAs) to treat chronic hepatitis C have been available since March 2016. 7ITHĂĽCUREĂĽRATESĂĽOFĂĽĂĽĂĽFORĂĽMOSTĂĽCOMMONĂĽGENOTYPESĂĽINĂĽ!USTRALIA ĂĽTHISĂĽ represents an invaluable opportunity for GPs and primary health care providers to prevent chronic liver disease, hepatocellular carcinoma and liver transplants, and decrease hepatitis C transmission in the community by reducing the background prevalence of infection. Nearly one half (46%) of Medical Forum survey respondents reported having 1-5 patients with chronic hepatitis C in their practice and 19% HADĂĽĂĽĂĽAREĂĽINTERESTEDĂĽINĂĽPRESCRIBINGĂĽ$!!SĂĽFORĂĽHEPATITISĂĽ#ĂĽ3URVEYĂĽ respondents identiďŹ ed the following enablers to DAA prescribing: Access to specialist advice/mentoring

21%

Clear referral pathway

19%

Access to a specialist to approve my prescriptions

19%

Face-to-face training



Multi-disciplinary support for patients taking these drugs*

13%

On-line training

9%

Prof Donna Mak Communicable Disease Control Directorate WA Health

The Silver Book (Guidelines for managing STI and BBVs ww2. health.wa.gov.au/Silver-book) includes revised hepatitis C referral pathways and ‘remote consultation request for initiation of hepatitis C treatment’ in .rtf formats compatible with most GP practice software. Hepatologists and infectious diseases physicians in metropolitan and regional hospitals have endorsed these to facilitate specialist approval of GP-initiated prescriptions. The same approval from hepatologists and infectious diseases physicians in private practice can be obtained by GPs through personal arrangement. Many GPs have recently attended face-to-face training organised by public hospitals and WA Health. Free online training is at http://hepatitis.ecu.edu.au/ In March-April 2016, 6503 new patients started hepatitis C TREATMENTĂĽĂĽINĂĽ.37 ĂĽ6ICĂĽORĂĽ1LD ĂĽWITHĂĽONLYĂĽĂĽFROMĂĽ7!ĂĽDESPITEĂĽ high patient interest in, and demand for, treatment. Hepatitis WA informs patients about treatment (www.hepatitiswa. com.au/treatments) and lists GPs and pharmacies involved in hepatitis C treatment. Email csmanager@hepatitiswa.com.au if you want to be added to the list.

* Common hepatitis C genotypes in Australia (90% are types 1 and 3) can be successfully treated without interferon, which means side effects are fewer and should be able to be managed via a GP-led chronic disease management plan.

Working up a patient with chronic hepatitis C prior to treatment ü #ONlRMüCHRONICüHEPATITISü#üIEü(#6üANTIBODYüPOSITIVEüANDü(#6ü2.!üPOSITIVEüONüüSEPARATEüOCCASIONSüüMONTHSüAPART 2. Does patient have hepatitis B, HIV, cirrhosis, hepatocellular carcinoma or renal disease, or is she pregnant? If yes, refer to a specialist. 3. Review previous HCV treatment 4. Review patient’s current medications and potential for drug-drug interactions 5. Investigations HCV genotype

Creatinine

HCV RNA level

eGFR

ALT

Haemoglobin

AST

Platelet count

Bilirubin

INR

Albumin

Upper abdo US

AND

Assessment of liver ďŹ brosis APRI (AST to Platelet Ratio Index), use on-line calculator www.hepatitisc.uw.edu/page/clinical-calculators/apri OR Hepascore (available from PathWest) OR FibroScanÂŽ (EchoSens, Paris), no MBS rebate

6. The specialist will need access to the above information before approving a GP-initiated prescription. The best way of predicting adherence with treatment is to discuss treatment options with the patient over two consultations and if they attend both appointments conduct a pre-treatment work-up at the third consultation. Patients who attend all three appointments as scheduled are likely to complete treatment successfully even if they are not totally abstinent from alcohol and/or other drugs.

36 | JULY 2016

MEDICAL FORUM


Clinical Update

Aching wrists: role of surgery Wrist pain can occur with osteoarthritis, rheumatoid arthritis, post traumatic arthritis and acute injury. The most commonly performed elective surgical procedures are wrist arthroscopy, ulna shortening osteotomy, ligament reconstruction, limited intercarpal fusion, resection or replacement of carpal bones and full wrist arthrodesis. Wrist arthroscopy is useful to both evaluate and treat the painful wrist. Even with MRI scanning, certain pathologies (e.g. triquetro lunate instability, ulnocarpal abutment and scapho lunate ligament tears) are not adequately seen or diagnosed. Arthroscopy improves the understanding of these, including making cartilage damage more obvious. At arthroscopy, triangular fibrocartilage tears can be trimmed, resected or repaired and some forms of ganglion can be resected at their origin within the joint. Sometimes a more definitive procedure (e.g. open ligament repair or an osteotomy to shorten the ulna) needs to follow. Restoring stability. Ligament or cartilage injuries can lead to instability and a painful

wrist. Surgery usually involves repairing the torn ligaments but may, in more chronic situations, involve ligament reconstruction (e.g. tendon or ligament grafting/transfer in situations like scapho-lunate dissociation, triquetro-lunate instability and distal radial ulna joint instability, improve pain by improving stability and strength of the wrist). Partial fusion. Degeneration may be limited to one part of the wrist such as in scapho-trapezo arthritis. Fusing can provide considerable pain reduction and can be combined with carpal bone resection. Whilst fusion reduces the range of wrist motion as a trade-off for relieving pain, retaining some wrist mobility benefits patients. Other examples are radio-scaphoid fusion, triquetro-lunate fusion and four corner fusions with scaphoid excision – all part of treating some arthritis either related to long-standing ligament disruption, severe trauma or normal patterns of degeneration. Bone resection. The most common form of carpal bone resection arthroplasty is trapezium excision for carpal arthritis. A reliable procedure with a good success rate, it is sometimes combined with ligament transfer to improve stability.

Varicose veins are a sign of venous reflux, a pathological condition.

After

Osteotomy. Ulna shortening osteotomy is useful in different situations. This includes the ulna abutment syndrome where a positive ulna variance and pressure on both the triangular fibrocartilage and ulna side of the lunate causes degeneration. It also becomes a handy option to relieve ulna sided pain following a fractured radius with associated shortening. It may be helpful in tightening up structures when there is some mild laxity in the distal radial ulna joint. Full wrist arthrodesis is considered a last resort in many situations. The procedure involves applying a plate across from the radius bone to the metacarpals. The success rate here is reasonably good but one loses motion in return for relief of pain.

Author competing interests: no relevant disclosures. Questions? Contact the author on 9481 1990.

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JULY 2016 | 37


Fertility, Gynaecology and Endometriosis Treatment Clinic

When your patient’s family plan isn’t going to plan... Fertility North can help. zCycle Tracking z Timed Intercourse z Artificial Insemination zOvulation Induction zIn-vitro Fertilisation (IVF) zIntra-cytoplasmic Sperm Injection (ICSI) zPregnancy Monitoring zDonor Services zSperm / Egg Freezing zOncology Fertility Preservation zEgg Freezing for Social Reasons zSemen Analysis

Dr Vince Chapple

Dr Jay Natalwala

Dr Santanu Baruah

Dr Gian Urbani

Dr Megan Byrnes

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Fertility Specialist Qualifications

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Qualifications

Qualifications

MB, BS (London) FRANZCOG MRepMed

MB, BCh (UK) DRCOG FRANZCOG MRepMed

MBBS, MRCOG (UK) CCT (UK), CGES FRANZCOG

MBCHB, MMEd(O&G) FRANZCOG MRepMed

BMedSci, MBBS FRANZCOG MRepMed

MBBS, DRACOG FRACGP MRepMed

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 38 | JULY 2016

MEDICAL FORUM


Clinical Update

Self-ďŹ xing mesh in open inguinal hernia repair

By Dr Peter Smith, Endocrine, General & Oncological Surgeon, Subiaco

ProGripTM mesh is the only self-gripping, semi resorbable, light weight mesh available for a variety of hernia repairs, including open inguinal hernia repair where it advances the ‘gold standard’ Lichtenstein tension–free operation. ProGripTM, developed in France and available in Australia since 2010, attaches by means of “velcro likeâ€? hooks that are micro grips made from polylactic acid (PLA). These hooks provide immediate tissue integration and slowly dissolve once the woven component of the mesh (monoďŹ laments of polyester) become embedded in scar tissue. The hydrophilic nature of the polyester is said to improve tissue integration and reduce foreign material inammatory reaction. As no sutures are required to anchor the mesh, post-operative pain levels are very similar to laparoscopic hernia repair without the increased levels of serious complications that can occur with laparoscopic repair (e.g. bowel perforation, bladder perforation, vessel injury, signiďŹ cant haemorrhage and port site HERNIAS ĂĽ4HEĂĽLIGHT WEIGHTĂĽMESHĂĽISĂĽGMĂĽ before PLA resorption and after, reduces weight by 50%.

Trimmed mesh

oblique, with the velcro like hooks attaching into internal oblique, the medial edge of rectus fascia, down over the pubic tubercle and rolling up the inguinal ligament.

nerve; and 1.5% ongoing pain. There were no recurrences, no returns to theatre for any reason, no DVT/PE, and no cardiac events. Median pain scores day one post– operation were 5/10, and on day seven 2/10. SigniďŹ cantly higher pain levels were experienced by workers compensation insured patients on day one. Time taken before resuming normal activities RANGEDĂĽBETWEENĂĽ ĂĽDAYSĂĽMEDIANĂĽĂĽ days). &URTHERĂĽDATAĂĽFROMĂĽOVERĂĽĂĽ0RO'RIPTM inguinal hernia repairs is being analysed, but we have had no returns to theatre for bleeding, haematoma, sepsis, or chronic pain. There have been 0.4% recurrences. There have been no serious complications such as DVT/PE, MI, CVA, vessel injury, bladder or bowel perforation. Patients are not operated on as day cases due to the 10% incidence of urinary retention.

Mesh before and after resorption

Surgical technique

Some results

A 5-6 cm skin incision (which varies with the amount of body fat) runs parallel to the lower part of the inguinal ligament.

!MONGSTĂĽĂĽPATIENTSĂĽWITHĂĽĂĽHERNIAS ĂĽ reported by a single surgeon at the Adelaide International Hernia Conference (2011): 60% were unilateral, 19% were bilateral, 21% had another surgical procedure, and 9% were NONĂĽRESPONDERSĂĽĂĽWEREĂĽMALEĂĽAND ĂĽĂĽ privately insured, 9% were WC insured, 6% public patients, and 4% DVA.

Subcutaneous fat, Scarpa’s fascia, then external oblique are divided. The spermatic cord is dissected free from the attachments of the cremaster to the pubic tubercle and the ďŹ bres of internal oblique. The area around the inguinal canal must be cleared medially so that the fascia of anterior rectus sheath is EXPOSED ĂĽANDĂĽSUPERIORLY ĂĽFORĂĽĂĽTOĂĽĂĽCMĂĽABOVEĂĽ the deep inguinal ring. The mesh is manufactured as side speciďŹ c (i.e. left or right), then trimmed to ďŹ t by the surgeon before being placed under external

MEDICAL FORUM

References are available on request. Competing interests: the author was contracted in 2011 by Covidien to teach ProGrip™repair of inguinal hernias.

Short Term Complications (days 1-90 post-op) reported were 24.5% diminished sensation II nerve; 10% urinary retention requiring a catheter; and 3% suture line infections. Long Term Complications (at 3 months) reported were: 3% diminished sensation II

JULY 2016 | 39


Clinical Update

Minimally invasive bunion surgery

By Dr Matthew Scaddan Orthopaedic Surgeon Claremont

Bunion surgery Operative photo Open vs MI

Minimally invasive (MI) hallux valgus surgery is an option in the patient with a correctable deformity. About 50% of hallux valgus surgery could be performed this way. The method, in use in France for over 15 years and in Australia for five years, has a low complication rate with proper patient selection (similar to the open procedure) as well as due to improvements in technique, training and the types of screws used.

Arthritis of the great toe (MTP) should be excluded clinically and with X-ray, as these patients are better treated with fusing the MTP joint. Other examination findings such as instability of the first tarso-metatarsal joint, second metatarsalgia (‘painful knuckle’), lesser toe deformities and pre-operative numbness should also be noted. Ideally, patients undergoing MI surgery should have hallux valgus that is correctable during

Procedure points MI hallux valgus correction is usually performed under GA using a specialised burr which does a controlled cut of the bone to allow the osteotomy to shift. Typically, there are six small five-millimeter skin incisions: two for the osteotomies to the metatarsal (Chevron) and phalanx (akin); three for the insertion of the percutaneous screws; and a one for release of tight lateral soft tissue (MTP joint). Post operatively the foot is bandaged for two weeks and the patient weight bears as tolerated; a postoperative Darcot shoe is provided, aiming to transition to a loose sneaker after 2-3 weeks. Comparatively, an open hallux valgus correction uses a 10cm medial incision; osteotomies are performed using a saw; and more extensive soft tissue releases and balancing can be achieved but at the expense of more prolonged swelling and stiffness.

Pros and Cons Pros of MI surgery så ,ESSåPAINåANDåSWELLING så ,ESSåSTIFFNESS så 1UICKERåRETURNåTOåFOOTWEARå å åVSååWEEKS så 1UICKERåRETURNåTOåWORKååVSååWEEKS Bunion surgery Xray photo Open vs MI

Patient selection Who is a candidate? First, the patient must have pain to qualify for surgery, perhaps manifest as discomfort with footwear. The operation is not performed for cosmetic reasons. If conservative treatments fail, surgery is indicated. With any surgery on the foot it is important that pulses and sensation are present.

40 | JULY 2016

examination because MI surgery relies more on shifting the bone than it does changing soft tissues. To say it another way, a fixed bunion that cannot be corrected passively out of valgus will potentially have better results with an open release of tight lateral structures and tightening up of medial joint capsule and ligament.

Cons of MI surgery så )NCREASEDåRADIATIONå (intra-operative X-rays) så 4ECHNICALLYåMOREåDIFlCULT så (IGHERåRECURRENCEåRATEå (in wrong patient) så ,ONGERåOPERATINGåTIME

Author competing interests: no relevant disclosures. Questions? Contact the author on 9230 6333

MEDICAL FORUM


Clinical Updates

Monoclonal antibody use and risk of infection Biological disease modifying antirheumatic drugs (bDMARDs) such as anti-TNF-α monoclonal antibodies (infliximab, adalimumab, certolizumab pegol, golimumab), fusion antibody proteins (etanercept) and other agents (ustekinumab, natalizumab, vedolizumab) are increasingly being used in a range of conditions. However, they can lead to a significant increased risk of infections. Since 2003 in Australia, they have been prescribed for Crohn’s disease and ulcerative colitis to improve the clinical course of the disease and prevent long term complications, particularly by minimising or stopping chronic corticosteroid use. They have also revolutionised the management of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis and dermatological conditions such as plaque psoriasis, atopic dermatitis, and vasculitides.

By Dr Astrid Arellano Infectious Diseases Physician Palmyra

These drugs are often used for years, if not lifelong, and the problem of significantly increased risks of infection is often not appreciated by the patient or the general practitioner. The risks vary between agents – from infliximab at the most serious end, to adalimumab and etanercept at the least serious end of the spectrum. The overall risk of serious bacterial infections is at least 1.5 to 3 times that of baseline, increasing up to 15 times for elderly patients with co-morbidities such as diabetes, chronic renal failure and concomitant steroid use. The most common infections are septic arthritis (prosthetic knees and hips in particular), Staphylococcus aureus soft tissue infections especially after surgery and opportunistic infections such as Listeriosis, Legionella pneumoniae and Pneumocystis

jirovecii (PCP) pneumonia. Patients are at risk of reactivation of tuberculosis with dissemination, and reactivation of viral infections such as Hepatitis B with fulminant hepatitis, CMV colitis and herpes zoster infections. Management Patients considering biological therapies should be informed about the risks of infection. They should have screening tests (see table 1.) and receive preventive therapy for latent tuberculosis and Hepatitis B (HBsAg positive individuals). Their immunity to vaccine preventable conditions should be checked and subsequent vaccination administered if not immune. Annual boosters for influenza and five-yearly boosting of pneumococcal and meningococcal vaccines should be standard.

Table 1. Screening and Management Prior to Biological Treatments Disease

Diagnostic Test

Action

Management

TB

Quantiferon Gold

If Positive Quantiferon or CXR evidence of old TB refer to TB service or infectious diseases specialist

Rule out active TB. Treat with preventative therapy for at least 1 month prior to biological agent starting.

Hepatitis B

Anti-HBs, HBsAg, Anti-HBc, liver enzymes, HBV DNA if carrier or chronic disease

Evidence of past infection or carrier: Refer to viral hepatitis specialist

Monitor LFTs, HBV DNA. Treatment with antiviral agents often required prior and during biological agents.

Hepatitis A

History of illness or vaccination

Hepatitis A serology

Vaccinate if not immune

Hepatitis C

Risk factors, history of jaundice, abnormal LFTs

Hepatitis C Ab and if positive PCR Refer to viral hepatitis specialist

Monitor

Varicella, MMR, Diphtheria and Pertussis, Pneumococcal pneumonia, Meningococcal meningitis

History of illness or vaccination

VZV, MMR serology

Vaccinate if not immune (5 year boosters for pneumococcal and meningococcal infections)

HPV

History of vaccination

Strongyloides

History of illness

Influenza

History of illness or vaccination

Vaccinate if not immune Strongyloides serology

Treat if positive Annual vaccination

ED. We have been getting press releases from the Copenhagen conference of the European Haematology Association highlighting the value of various monoclonal antibodies against relapsing multiple myeloma, acute lymphoblastic leukaemia, and Hodgkin lymphoma – the genetics and pharmacology of monoclonal antibodies has researchers understandably excited, so this is not the end we will see of this class of drugs.

Use of Your Registration Fees Our December 2015 edition carried an article outlining the Medical Board and AHPRAs unsuccessful attempts to deregister a WA general practitioner. Just before this article, we outlined how only 9 of the 33 recommendations of the Snowball report into national registration and accreditation would be adopted. Improved communication and timeliness were two, about which people MEDICAL FORUM

had complained vehemently, including to a Victorian Parliament Senate investigation. We thought our case report brought out some precedents at law. Not so, according to Dr Elizabeth Brophy, a barrister and advanced mediator with the Victorian Bar. After a cursory look she explained, as did the lawyer involved with the case, that there is no legal precedent as each case turns on its facts.

However, we know that regulatory bodies such as AHPRA build ‘corporate knowledge’ that influences their decisions. They hopefully listen to comment such as this article and the Doctors Drum on AHPRA and the Medical Board (March 2015), where both outlined the delay and apparent secrecy during investigations.

JULY 2016 | 41


Clinical Update

Knee arthroscopy in the over 50s Knee arthroscopy in middle aged and elderly patients has come under increased scrutiny. Prospective randomised trials comparing knee arthroscopy to differing control groups have shown either improvement in the surgery group, a temporary benefit, or no benefit. A metaanalysis published in the BMJ in 2015 that attracted media attention (generally negative) concluded, “interventions that include arthroscopy are associated with a small benefit and with harms; the benefit is inconsequential and of short duration”.

to the presence of osteoarthritis. It recognises the limitations of arthroscopy in degenerate knees, and outlines evidence based situations where arthroscopy can be useful. The vast majority of orthopaedic surgeons agree that indiscriminate arthroscopy for osteoarthritis is not indicated. Exceptions would include mechanical locking, and significant mechanically unstable meniscal tears with appropriate clinical signs.

The BMJ meta-analysis included nine randomised trials, noting significant bias in eight. It pooled data from studies on both arthritic and non-arthritic knees, and was unable to stratify the results for the presence or absence of mechanical symptoms (one of the most significant factors in deciding to arthroscope a patient’s knee). What is the evidence? The Australian Knee Society and Australian Orthopaedic Association have reviewed the literature and released a position statement on knee arthroscopy with particular reference

Fig 1: Horizontal/oblique tear posterior horn medial meniscus in an 80-year-old female – unlikely to need surgery.

Not all meniscal tears need debridement (figure 1). About one third of over 50s have MRI evidence of meniscal damage, two thirds of whom are asymptomatic. According to the AKS position statement “in medial meniscal tears, in the absence of traumatic onset, locking or a repairable meniscal tear the majority do not require arthroscopic medial meniscectomy and will respond to non-operative measures”. Arthroscopy is appropriate, when there is a mechanically significant tear (figure 2) or non-operative treatment fails. Clinical guidelines Patients more likely to benefit from

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MEDICAL FORUM


såA/Prof Kevin Pfleger, from the Perkins Institute, has won the Novartis Prize for his body of published work on body receptors that are the target of many commonly used medicines. It follows a recent ARC linkage grant of $499,000 for his and Dr Karl Rosengren’s (Uni of Qld) work on technologies to monitor multi-molecular complexes.

By Dr Sani Erak Orthopaedic Surgeon Subiaco

arthroscopy are generally those with a shorter duration of symptoms or history of trauma, mechanical symptoms such as locking and pain, and tenderness localised to a joint line consistent with a meniscal tear (e.g. with twisting, positive McMurrays’s sign). Imaging evidence of significant meniscal tear (particularly with displaced meniscal fragments or flaps), large unstable chondral flaps or absence of severe (bone on bone) arthritic change supports arthroscopy.

såDr Michael Gannon, AMA WA president, was elected the national AMA president at the national conference. He was also inducted into the Roll of Fellows. Victorian GP and outgoing president of the Victoria branch, Dr Tony Bartone, was elected Vice President. Former WA Vice-President Dr Andrew Miller is now President of the local AMA branch. såProf Mike Daube was presented with the World Health Organization Director-General’s Special Recognition certificate at the World No Tobacco Day 2016 Awards.

Other conditions, particularly subchondral stress fractures that can resemble a symptomatic meniscal tear, would only be detected on MRI. My preference is to perform an MRI prior to arthroscopy.

såMs Anne Foyer has won the Public Health Association of Australia (PHAA) National Immunisation Achievement Award for her work in the Wheatbelt of WA.

Most middle aged to elderly patients with symptoms of arthritis or degenerate meniscal tearing can be managed with non-operative measures (analgesia, low impact exercises, injections, etc.). Arthroscopy in selected patients remains a valuable tool. References available on request

Author competing interests: no relevant disclosures. Questions? Contact the author on 6489 1755

såCatholic Health Australia has appointed SJGHC chair Mr Tony Howarth as chair of its board. Fig 2: Displaced meniscal fragment medial meniscus in a 60-year-old male with medial knee pain – more likely to improve with arthroscopy.

såEllen Health has won the Excellence in Professional Services Award at the Fremantle Chamber of Commerce business awards.

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MEDICAL FORUM

JULY 2016 | 43


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By Dr Clare Matthews

MoodPrism Clinical Usefulness

Ease of Use

Its purpose and who developed it. MoodPrism for smart phones has been deveoped by Monash University with funding from BeyondBlue. The App is designed to be used to track a users’ moods over time and support their mental health and wellbeing.

Pluses sĂĽ !NĂĽINNOVATIVEĂĽWAYĂĽOFĂĽ collecting de-identiďŹ ed data for researchers.

Details Free app, 5MB of space on Apple or android smart phones with iOS üORüLATERü$ESIGNEDüFORüADULTSü)TüCLAIMSüTOüBEüSUITABLEüFORüANüI0ADü or tablet; moodprismapp.com explains the App but is not part of the app’s use.

sĂĽ -AYĂĽBEĂĽUSEFULĂĽASĂĽAĂĽ-OODĂĽ History to help a patient gauge improvement in their mood following interventions by the GP such as referral to psychology or medication.

Overview Look and feel. The App uses numbers, colours and emoticon faces to feedback your moods. It is simple to use but rather time consuming in that it requires a questionnaire that takes approximately 20 mins at the start and ďŹ nish and about 5 mins per day. Frustratingly, for those of us without perfect eyesight the font size changes to very small half way through the daily questions. What assistance does it offer? To grade a person’s mood and demonstrate changes over time. However, daily mood tracking is asked for by the designers who say daily sampling is a more reliable indicator of how someone is travelling. The App does highlight useful websites and other Apps such as BeyondBlue and Smiling Mind. It directs those with more anxiety or depression to more appropriate websites, and suggests seeing your GP if symptoms are concerning but otherwise does not link to a doctor or require their input.

sĂĽ 3IMPLEĂĽTOĂĽUSE

Minuses sĂĽ 4IMEĂĽCONSUMING ĂĽ especially the ďŹ rst and last questionnaire. sĂĽ )ĂĽWASĂĽUNABLEĂĽTOĂĽGETĂĽTHEĂĽ!PPĂĽ on my iPad. sĂĽ 3OMEĂĽWILLĂĽBEĂĽCONCERNEDĂĽ about giving an unknown third party access to their data about social media and music usage. sĂĽ 4HEĂĽCHANCEĂĽTOĂĽWINĂĽONEĂĽOFĂĽ four $100 prizes at the end of nine months seems rather stingy considering the potentially large amount of time and effort required to provide this data to researchers. Is this sufďŹ cient carrot to keep users involved?

The promotional media release Medical Forum received said “Mood tracking apps like MoodPrism aim to prevent mental illness and decrease psychological distressâ€? so we were curious whether this app was about helping researchers or helping affected people. The website said “this research is about gathering the evidence to conďŹ rm that such an app works and will help people in the way intendedâ€? and “music use, physical activity and social network – each has been associated with changes in mental health risk.â€? Given our confusion, we asked the team leader, Adjunct Assoc/Prof Nikki Rickard, a registered psychologist, clinically relevant questions. Do people with signiďŹ cant mood disturbance have the wherewithal to use apps like this?

well as encouraging improved social connections, exercise and positive emotions. Its model promotes positive functioning, as important as preventing negative psychological functioning.

She said yes. Simplicity of use and the usefulness of other similar apps were proffered. She agreed that the app surveys (initially and a month later) were a bit time-consuming, but the daily questions were simple and straightforward. The feedback provided by users could improve engagement and insight – often barriers to seeking help.

How does this app improve someone’s access to mental health services?

Is the app overkill for those with minor mood disturbance and wouldn’t its use “medicalise� mood disturbance? The app is not a clinical tool, she said, but encourages positive psychological functioning by providing mental health information as

MEDICAL FORUM

She said it links to BeyondBlue mental health services, and if particular answers to questions indicate a risk of depression or anxiety, triggers recommendations to contact a GP or a mental health support service. As well, links to further information include mental health organisation websites (like Headspace and BeyondBlue), positive psychology sites, and various apps that can support positive health behaviours – links rotate over time, so users can access different support services and see which suits them. She pointed out that an estimated 1 in 2 people experiencing depression do not currently seek help from mental health professionals, so this app helps ďŹ lls that gap and encourages them to seek help by enhancing awareness of their emotional state, as well as their mental health literacy – a means of beginning the journey.

JULY 2016 | 45


Surfing

t s e n The Fi s d n e i of Fr Dr Hans Stampfer, left, Dr Fabrizio Goria, Dr Colin Parker and James McLay

Music as relaxation is a common thread for a lot of medical professionals but for a bunch of medicos from Joondalup, it has become a recording passion.

It was a steep learning curve for a bunch of medicos when they stepped into a recording studio to record their first CD. They may have had the benefit of some ‘real’ musicians, but it was a psychiatric nurse James McLay calling the shots.

singer went on to bigger and better things. But I still had all these songs bouncing around in my head. So I said to (psychiatrist) Hans Stampfer who plays lead guitar, banjo and ukulele on the CD, ‘let’s keep going and see where all this leads’.”

James works at the ED at Joondalup Health Campus but somewhere finds the time and inspiration to write and record music. Finest of Friends CD is living proof.

Fitting music-making into busy professional lives wasn’t easy with the entire process taking nearly three years.

“It was basically a bunch of mates doing something we love! The whole process was a joy and learning how to put an album together is a skill of its own and a very different thing to playing live,” he told Medical Forum. “I was in a cover band with a bunch of medical people, the guitarist Fabrizio Goria went off to a job at Bunbury Hospital and the lead

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“It all comes down to money and time. I worked out that two days working in the locked ward roughly equates to one day in the studio. Yes, I’ve suffered for my art! And working as an ED psych nurse in the Meth Capital of Australia is always going to be interesting. I’ll never be out of a job and it’s where I’ve met most of the guys in the band.” “It begs the question why so many medical people are into music? I guess it’s the fact that they’re interesting people who like doing interesting things.” James concedes that the nature of his work is changing, and not always for the better. “It gets pretty confronting at times and there have been some noticeable changes. There are a huge number of young people now, some in their early teens and we weren’t seeing that a decade ago. The ED can be interesting but I think some of the more troublesome patients look at me and decide I’m too old to bother taking a swing at!” “Some of the lyrics in my songs draw on those experiences but generally I try to separate the two. Playing music is my escape from all that!” Finest of Friends has a real ‘Commitments’ feel to the music with James on vocals, keyboards and guitar. “It’s a good thing that people won’t hear the songs without the technical assistance of the studio machines. It actually sounds like I’m singing in tune!” “One of the best things was the camaraderie within the group. We threw Alistair Vickery in at the deep-end on piano and plundered his very fine cellar into the bargain. When Hans was about to launch into a guitar solo we’d hit the talk-back button and say ‘remember, we’re all judging you!’.”

MEDICAL FORUM


Finest of Friends album

“We used a session musician, Carl Mackey on saxophone. I put myself through nursing school playing really bad sax and I wasn’t going to inict that on anyone.â€?

cover

And future plans for the Finest of Friends? “I’ve got lots of material, I’d like to do an album with a Country feel and there’s a real freedom in not being tied to any commercial outcomes.â€? “Music is a nice vehicle to express the way you’re feeling and there’ll deďŹ nitely be more on the way.â€?

For Sale

Medical Forum caught up with red-hot lead guitarist Hans Stampfer, which is a role that seems a million miles away from treating patients struggling with mental illness. “Music is a great circuit-breaker from work. James likened the studio sessions to occupational therapy for all of us and he was right! We’re all part-time musos with day-time jobs and the CD was great fun to make.� “James is absolutely irrepressible and wakes up every morning with a new idea.� Karrinyup Health Professionals

Like James, the catalyst for Hans’s musical dalliances was sparked by his medical experiences. “Fabrizio was my registrar at the Mental Health Unit and we formed a band called the Side Effects for a fundraiser. There were a couple of doctors, some nurses and an amazing singer called Paula who went on to ďŹ nish runner-up in The Voice.â€? “But my passion for music goes further back than that. I started with a Perth folk group, the Twilighters and we were the ďŹ rst act ever SIGNEDĂĽTOĂĽ#HANNELĂĽĂĽ3OĂĽWHENĂĽ*AMESĂĽGAVEĂĽMEĂĽTHEĂĽOPPORTUNITYĂĽTOĂĽLETĂĽ loose on my Fender electric I jumped at it.â€? “Everything is highly audible in the recording studio so you have to be on top of your game to get it right. James has got a great talent for writing songs and there are some subtle, edgy lyrics on the CD. it was all great fun!â€?

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JULY 2016 | 47


Philanthropy

A Vision Splendid

John Fawcett has worked tirelessly for 30 years helping doctors to restore the site of the disenfranchised in Bali. John Fawcett AM’s name is synonymous with curing preventable blindness and facial birth deformities amongst local Balinese. This West Australian has lived there for ages but how he got there is another story and an unusual connection with the medical profession. “Donors who have given signiďŹ cant amounts to speciďŹ c activities – say, upwards of $1000 – are sent a report on those activities, complete with photographs. We always welcome people visiting our Foundation’s base in Bali – going out with the Mobile Eye Clinic on one of the screening/operating programs is the best way to get a real feel for what we are doing and the signiďŹ cance of our assistance,â€? John said. There is no doubt that the ‘bang for the buck’ is extraordinary. sĂĽ &ORĂĽAĂĽSTART ĂĽONLYĂĽĂĽOFĂĽDONATIONSĂĽGOESĂĽ in administration (2015 ďŹ gures) and JFF is an Australian tax-deductible foundation !".ĂĽĂĽĂĽĂĽ  sĂĽ 7HILEĂĽ!5ĂĽRESTORESĂĽSIGHTĂĽTOĂĽSOMEONEĂĽ affected by cataracts (using small incision cataract surgery), $2500 brings a two-day screening/operating bus to an outlying village in Bali where about 500 locals are screened, glasses and eye drops given to about 300 people, and 10 people receive sight-restoring operations. Satisfying results indeed!

Mobile operating theatre loads transport airforce into| anJULY 48 2016

Transferring medical technology to Bali has been the cornerstone of the foundation’s work. The ďŹ rst mobile theatre bus arrived by Australian Hercules transport plane over 25 years ago. For facial corrective surgery, initially it was WA’s Dr Harold McComb, and over the last 15 years, plastic surgeon Dr Tim Cooper has been visiting Bali each year to conduct surgical training sessions in cleft lip and palate surgery, as well as other corrective surgical techniques. Training of local people has been part of their modus operandi. The Sight Restoration and Blindness Prevention Project led to the teaching of Balinese ophthalmologist Dr Wayan Gede Dharyata to do cataract removal, and lens implants by Australian ophthalmologists including Dr Peter Graham FROMĂĽ7!ĂĽ$RĂĽ$ARYATAĂĽHASĂĽDONEĂĽABOUTĂĽ ĂĽ sight restoring operations for the foundation over the past 25 years. “Over the past 15 years a close relationship has developed between JFF and the Centre for Ophthalmology and Visual Science UWA, The Lions Eye Institute and the Perth Eye Hospital. This has now blossomed into a formal agreement between the University of Udayana Bali, including the professional ophthalmic body and RANZCO fellows interested in ophthalmic technology transfer in Bali and the John Fawcett Foundation.â€?

Dr Peter Gra ha m discus a patient with Dr Dini ses Dharmawidia rini

John Fawcett with one of the many people he has helped.

In Indonesia, three million people are needlessly blind from cataracts, causing a huge drain on the economy, not to mention personal distress. JFF’s team go into the villages to screen people with eye problems, issue standard plus/minus glasses to those who need them, distribute eye drops to those with infections, and identify those who are blind with cataracts. The foundation’s mobile eye clinic accompanies the team and the cataract patients are operated the same day, returning the following morning for a post-op check. All JFF’s services are for the poor and are free of charge to the patients. Since the project BEGANĂĽINĂĽ ĂĽAROUNDĂĽ ĂĽPEOPLEĂĽHAVEĂĽ received sight-restoring operations, and nearly 1 million people have been screened for eye problems. “I would like to ask WA doctors to assist JFF ďŹ nancially – in whatever way this can be done. Funding is a huge issue for the continuation of our work. JFF is tax-deductible in Australia and JFF is a WA-based organisation.â€?

By Dr Rob McEvoy ED. Cheques made to ‘John Fawcett Foundation’ and sent to The John Fawcett Foundation, PO Box 1101, Nedlands WA 6909, or EFT to Westpac BSB 036-304 Account number 162 847 (Swift code: WPACAU2S), or by credit card online at http:// johnfawcett.org/donate-now/

Dr Gordon Bougher teaches in th the wet lab at JFF

Dr Jea n-Louis DeSousa on a post-op patient advised MEDICAL FORUM


Wine Review

in

Zonte’s Footsteps

By Dr Louis Papaelias

Survival in today’s wine market calls not only for commitment to quality but also innovation and air. Australian winemakers are facing competition from increasing numbers of wellpriced imports that are thriving on the value of the weak Aussie dollar. Zonte’s Footsteps is one winery that has risen to the challenge by cherry picking from premium South Australian locations to offer a quality range of reds and whites that will more than hold their own in the world wine stage. The cool Adelaide Hills region is the inspiration behind the crisp aromatic whites while McLaren Vale and Langhorne Creek are

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1. 2015 Doctoressa di Lago & 2015 Excalibur Both these wines are sourced from the Woodside sub-region of the premium, elevated Adelaide Hills area and are made from Pinot Grigio (Pinot Gris) and Sauvignon Blanc respectively. Excalibur is the seafood wine of the range, showing aromatic citrus and grapefruit aromas with a crisp and lively mouthfeel. It’s a refreshing change from the many cheap and clumsy New Zealand Sauvignon Blancs currently ooding the market. Doctoressa di Lago is a lovely food wine. Floral peach aromas, a generous melony texture on the palate and a pleasing crispness makes this example of pinot grigio a perfect companion to any number of dishes. 2. 2014 Chocolate Factory & 2014 Lake Doctor Both these deeply coloured wines are Shiraz based and come from McLaren Vale and Langhorne Creek respectively. I may well have been inuenced by the name but I could really detect a rich dark chocolate aroma on the McLaren Vale wine. Rich and velvety are apt descriptors of the sensations invoked in the mouth.

the backdrop for the classic shiraz styles for which South Australia is justly famous. There is also a pleasing trend away from labelling wines purely on varietal terms. Names like “Doctoressa Di Lagoâ€? and “Z-Forceâ€? lend an air of mystery and romance which has to be good for attracting and enticing the jaded consumer. The name Zonte’s Footsteps is inspired by a 19th century zante currant vineyard. ViniďŹ cation is skilful and respectful of the vineyard and grape variety and the wines, accordingly, demonstrate a varietal purity and a pleasing depth of avour.

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3. 2013 Z-Force This premium offering is composed of McLaren Vale Shiraz with 15% Petite Sirah (Durif). Selected parcels REVIEWER'S of grapes from the 1920s planted in the Seaview sub-region form the base of the wine. It is named in honour of the Australian heroes who served in the elite Z Force commando unit of World War II. A portion of the sales of this wine goes toward supporting the charitable organisation Legacy South Australia.

PICK

The wine itself is as heroic as its name suggests. Fermented in open vats with minimal use of sulphur and natural malolactic secondary FERMENTATION ĂĽITĂĽHASĂĽSPENTĂĽĂĽMONTHSĂĽINĂĽNEWĂĽANDĂĽUSEDĂĽOAKĂĽCASKSĂĽ4HEĂĽ colour is deep and dark with purple edges with concentrated aromas of spice, red fruits and jam mixed with attractive oak. A rich, full palate with lush avours of fruit and ďŹ ne soft-balanced tannins. A very good wine that does justice to the acclaimed Seaview area.

Lake Doctor 2014 comes with a number of gold medals festooned on the label and it’s not hard to see why. The 5% Viognier in the blend lends an aromatic whiff of intrigue to the earthy palate of berry and spice. Fruit and tannins lend a suppleness to the mouthfeel which lingers long on the ďŹ nish.

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Wine Question: What has inspired the name Zonte’s Footsteps?

Email Please send more information on Zonte’s Footsteps offers for Medical Forum readers.

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

#OMPETITIONĂĽ2ULESĂĽ/NEĂĽENTRYĂĽPERĂĽPERSONĂĽ0RIZEĂĽCHOSENĂĽATĂĽRANDOMĂĽ#OMPETITIONĂĽOPENĂĽTOĂĽALLĂĽDOCTORSĂĽORĂĽTHEIRĂĽPRACTICEĂĽSTAFFĂĽONĂĽTHEĂĽMAILINGĂĽLISTĂĽFORĂĽ-EDICALĂĽ&ORUMĂĽ#OMPETITIONĂĽCLOSESĂĽPM ĂĽ*ULYĂĽ ĂĽĂĽ4OĂĽENTERĂĽTHEĂĽDRAWĂĽTOĂĽWINĂĽTHISĂĽMONTHgSĂĽ$OCTORSĂĽ $OZEN ĂĽRETURNĂĽTHISĂĽCOMPLETEDĂĽCOUPONĂĽTOĂĽg-EDICALĂĽ&ORUMgSĂĽ$OCTORSĂĽ$OZENg ĂĽĂĽ(AWKERĂĽ!VE ĂĽ7ARWICKĂĽ7!ĂĽĂĽORĂĽFAXĂĽTOĂĽĂĽĂĽ

MEDICAL FORUM

JULY 2016 | 49


n– i ns of my ow I have opinio – but I don't strong opinions with them. always agree

BEST OF ARJ BARKER

ush - George W. B

I’m trying to feel terriďŹ ed and alone. And regret every decision I’ve ever made, drenched in a cold sweat. It’s called going to sleep. Maybe you’ve heard of it. I'm coming back. And when I get back, then we'll be together forever – forever and ever and ever – until death. Even beyond – beyond death: two souls enmeshed as one soul! One soul oating for all of eternity in the great abyss; the aftermath; that which remains unknown to all who dwell in the trappings of mortal esh until the ďŹ nal passing! Anyway, that's what I left on her answering machine. She hasn't called back yet. I deserve someone who likes me for who I am pretending to be. I was in a real conservative area just outside of Chicago recently. And this guy's like, 'Hey, Arj, you're from San Francisco. Are you in favour of gay marriage?' I was like, 'Well, I'd like to get to know you a little bit better ďŹ rst. I don't know what ever happened to buying a guy a smoothie and seeing what happens. That's how we do it back home.' Google is ridiculous. Everyone uses Google, and that's why Google has such an attitude. Because it's so popular, it's conceited. I mean, it has a serious attitude. Have you tried misspelling something lately? See the tone that it takes? 'Um, did you mean...?' A woman is a highly developed, deeply intelligent, inďŹ nitely complicated being. And it needs to be carefully tricked into doing things. )ĂĽJUSTĂĽGOTĂĽAĂĽNEWĂĽI0ODĂĽ)TSĂĽGOTĂĽĂĽGIGABYTESĂĽ"ECAUSEĂĽ)ĂĽLIKEĂĽTOĂĽJOGĂĽFORĂĽTHREEĂĽWEEKSĂĽATĂĽ a time and I do not want to hear the same song twice. She said I was moving too fast... I think it was a nice gesture to give her owers on the ďŹ rst date. Perhaps the 'Bless This Family' plaque could have waited. Nobody can ever learn our military's secrets – unless, you know, they happen to have the Discovery Channel. Then, it's pretty easy, just tune in for a few minutes. It’s too difďŹ cult to convey tone in electronic communication. And we can solve this, my friends. All we need is some new fonts. ‘Great party, Arj. Best party ever.’ What a jerk! ‘How do you know he wasn’t being sincere, Arj?’ ‘Because he wrote it in Sarcastica! If he had enjoyed himself, he would have used Good Times Roman.’ It’s gotten to the point where I think my friends would rather hang out with their own kids than hang out with me. And I’m like, "All right, but where’s the loyalty, man. I’ve known you for 25 years. How long have you known your baby, like, a month?" My general rule of thumb is, once something is a ride at Disneyland, I assume that it is no longer a threat in real life, which is why I don't expect to get attacked by a giant tea cup anytime soon. The last time I smoked pot and drove a car I ended up getting pulled over by a street cleaner. Marijuana has been scientiďŹ cally proven to distort one’s perception of depth and distance. So driving’s a terrible idea. 'Cuz you’re in your car, like, ‘Oh man, I got a small steering wheel. Well, I am a magical gnome‌so that’s pretty cool.’ ‘Maybe I’ll pull over by that pine tree and take a hike... oh wait, that’s the air freshener!’"

Credit Quickmeme Memegenerator Classical Art Memes Classical art memes Del Stewart

50 | JUNE 2016

MEDICAL FORUM


Music

d e s a e l P

h c n u P

as

The Punch Brothers come to Perth next month as relative unknowns but they hope to leave with a whole swag of new fans. Five young musicians from the USA pumping out a style that’s loosely described as ‘Bluegrass’ doesn’t do full justice to the eclectic brilliance of the Punch Brothers. They’re a band that punches above their weight and Perth audiences will be able to hear that for themselves at the Convention Centre next month. “That’s one thing I don’t particularly like about classifications and ‘genres’,” says Paul Kowert, bass player in the all-male band. “It can turn out to be a rather unhelpful shortcut in trying to capture just what the music sounds like. And, all too often, it can be a very short-cut!” “Punch Brothers is influenced by so many different kinds of music – it’s hard not to be in the age of iTunes – and it all seeps in somehow or other.” The band formed in 2006, largely at the instigation of mandolin player and leadsinger Chris Thile. They began life as How to Grow a Band, which morphed into the Tensions Mountain Boys a year later and then settled into Punch Brothers. “There’s a literary connection, the name comes from a Mark Twain short-story in which an earworm jingle gets stuck in the main character’s head. There’s something in there relating to the mantra of railroad conductors but I won’t go into that.” “Suffice to say they came up with the current name before my time and I like it just fine.” There’s a strong New York ‘flavour’ to the band’s makeup but, like all-things Punch Brothers, there’s a twist in the tail.

MEDICAL FORUM

“New York City is full of transient people. None of us is actually from there and none of us live there right now but we were there together for around eight years. When I joined the band in 2008 we all wanted to live in the same town and New York was the place.” Putting the ‘bluegrass’ tag to one side, Paul agrees there’s a weird quirkiness to many of their songs. How to Grow a Woman from the Ground is a classic example. “I can’t take any credit for the language in our songs because Chris writes most of the lyrics. However, he can’t take credit for that one either because it was written by a friend of ours. How to Grow a Woman is a nice vehicle for the band to interact and improvise.” “All our music is pretty collaborative even though five guys writing at the same time is rather a lot. But I think we’ve nailed down our individual roles and that ends up making music we’re all really happy with.” “We tend to have week-long writing retreats and they’re happily collaborative. There’s no juicy drama to share because it doesn’t happen. There’s no real angst attached to our audiences either. They’re noticeably quiet during our concerts and I guess they’re people who really like to listen to the music. Although I have to say that it makes me happy to see any kind of sign that everyone’s having a good time.” “I’m always interested in connecting with people. Life’s way more interesting that way.”

The Punch Broth

ers

The current tour itinerary ranges far and wide from California and Washington to Tokyo, Perth and Brisbane. “Well, how could we turn down the chance to go to Tokyo for a few days? And I’m looking forward to seeing Perth. I love your boxing kangaroos! This certainly isn’t a typical tour for the Punch Brothers.” Paul says that there should be at least one song in the show that will resonate with medicos. “One of our most popular songs is Rye Whiskey and yes, I do know about a ‘healthy limit’ when it comes to the consumption of alcohol. I also know a fair bit about doctors so I’ll just say that we all have ample health insurance.” “I hope that everyone who comes along enjoys the show and leaves with the feeling that they’d like to come to another one.” By Peter McClelland

JUNE 2016 | 51


Musical Theatre

g n i d FFereenzy

l Brent Hil It’s one of the liberating things about the performing arts that a musical comedy about a human flesh eating plant planning to conquer the world can elicit standing ovations night after night. But that’s what happens at the conclusion of Little Shop of Horrors thus cementing its cult status in the theatrical firmament.

"RENTåGRADUATEDåFROMå7!!0!åINååHAVINGå schooled at St Mark’s in Hillarys and Curtin University, so heading to Perth next month with a hit show is an exciting time for him – and his mum.

Rock of Ages and A Funny Thing Happened on the Way to the Forum performing alongside Geoffrey Rush, Shane Bourne and Magda Szubanski, as well as nominations for a couple of Helpmann Awards along the way.

“Mum is ecstatic. It’s always fun to come back home with a show.”

Comedy runs strongly through his CV.

#REATEDåINååBYåCOMPOSERå!LANå-ENKENå and writer Howard Ashman for an offBroadway release, it quickly turned into a hit stage show that spawned a film starring Rick Moranis, Steve Martin, Ellen Greene and Bill Murray.

As well as a chance for family and friends to see what Brent does for a living, he hopes to catch up with his mentors at WAAPA who have prepared him as well as possible for the highs and lows of a show biz life.

The stage show is heading West next month and Medical Forum spoke to Perth-born and trained Brent Hill, who plays the lead, nerdy down-at-heel florist Seymour Krelborn. “It’s a macabre comic classic. It’s a dark and funny show and the music is incredible. It’s a perfect storm when everything comes together so well – it’s great to be a part of it,” he said.

“I’ve had some wonderful opportunities over the past eight years to do great work and to work with great people but there are ups and downs. People often say how great it is I’ve worked so consistently. I have, of course, but there have also been some down times where it’s been about preparation for the next thing or finding the next thing. It’s all about trying to keep momentum.” He has caught the eye of his peers having won two Green Room awards for his role in

“I learnt all my comic instincts from training with the team at The Big Hoo Haa at the Brisbane Hotel in Perth. While I’m not terribly interested in pure stand-up I love theatrical comedy.” And to underscore that, he said he has composed a couple of musicals that have been produced for the stage. “I love music and write a lot of my own – there's something in it that really clicks with me and it seems to be where my career is heading. But I’m not sure where it will go next.” With 19 songs in Little Shop of Horrors, Brent is in his element!

By Jan Hallam

Sing it Loud and Proud in a Choir Perth Symphonic Chorus is calling for extra members for two special performances later in the year. The choir will be performing the exquisite Rachmaninoff’s Vespers for unaccompanied choir at Government House on September 25. And, of course, there’s its annual performance of Handel’s Messiah in December at the Perth Concert Hall. Director Margaret Pride said the choir was particularly interested in hearing from doctors who had musical training during their school and post-school years though previous choral

52 | JULY 2016

experience is not really necessary but a musical education is helpful. “Perth Symphonic Chorus is a great ensemble that cares about its music and achieves rave reviews while having fun along the way,” she said. “We hope new singers can join us. You provide the voice and we’ll provide the wonderful music, excellent choral and vocal training and professional orchestras!” Contact Margaret on 0416 120 662 or email mjpride@it.net.au

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Entering Medical Forum’s competitions is easy!

Competitions

Simply visit www.medicalhub.com.au and click on the ‘Competitions’ link (below the magazine cover on the left).

Dance: Tango Fire German Cornejo’s renowned dance troupe The Tango Fire Company of Buenos Aires sizzles with sensuality, while being accompanied by the unforgettable music and song of the great Tango masters, including Piazzolla, Pugliese and Gardel. Regal Theatre, July 28-31

Movie: Free State of Jones Based on the true story of Newton Knight (Matthew McConaughey), the film portrays the disillusionment of a band of Civil War soldiers who battle their comrades to create a free safe haven for deserters and slaves alike.

FEATURE

COMP

In cinemas, August 18

Movie: Absolutely Fabulous: The Movie

Music Drama: Rolling Thunder Vietnam

Edi and Patsy (Jennifer Saunders and Joanna Lumley) leave the little screen behind and invade the silver screen with their usual flamboyant style. Having despatched supermodel Kate Moss to the bottom of the Thames, accidently of course, they set off to wreak havoc on the French Riviera.

Personal stories of young Vietnam War soldiers are told alongside the music of such ’60s greats and Steppenwolf, Joe Cocker, Buffalo Springfield, Creedence Clearwater Revival, Santana Gladys Knight, Billy Thorpe and Paul Simon.

In cinemas, August 4

Crown Theatre, August 17-20

Musical Comedy: Little Shop of Horrors This cult classic returns to Perth with a new cast and a bigger and hungrier Audrey II, built by master puppetmakers Erth. Seymour is an unassuming florist who plants the seed that grows into the rapacious powerhungry plant Audrey. Great songs, great fun. His Majesty’s Theatre, from 4 August

Music: Punch Brothers Grammy-nominated Bluegrass quintet Punch Brothers will be bringing their unique sound to Perth for the first time. They combine mandolin, guitar, bass, banjo and violin for an inspiring sound that will captivate. Riverside Theatre, PCEC, August 8, 7.30pm

Doctors Dozen Winner The winner of the Turkey Flat Doctor’s Dozen was doubly pleased with his good luck. Dr Brian Hutchison was in the Scottish Highlands when we let him know that he was a ‘secondtime’ winner. (Brian won 12 bottles in mid-2006 – he still has the same winning smile). His holiday drinking has been reduced to fairly ordinary supermarket wine and he’s looking forward to removing a screw-cap or two from the Barossa Valley’s finest.

Winners from the May issue Movie – Hunt for the Wilderpeople: Ms Maria Oshea, Dr Alarna Boothroyd, Dr Palan Thirunavukkarasu, Dr Eng Gan, Dr Ed Olszewski, Dr Hertha Collin, Dr Diana Fakes, Dr Kamlesh Bhatt Movie – Money Monster: Dr Paul Laidman, Dr Anthony Ooi, Dr Andrew Siegmund, Dr Pippa Warren, Dr Indrani Saharay, Dr Jenny Tu, Dr Andrew Christophers, Dr Evelynne Wong Shame Game t Labiaplasty Demand t Sugar Tax & Obesity t E-Poll: Revalidation; PHNs; Over-testing; Doctors Drum t Clinicals: Women’s Libido; Bladder; EC; Pelvic Scans & More… t Travel, Comps, Wine & Shows

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May 2016

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Movie – Independence Day Resurgence (3D): Ms Sara Shelton, Dr Astrid Valentine, Dr Bill Thong, Dr Max Traub, Dr Crystal Durell, Dr Kathleen Bleeker-Sauzier, Dr Lawrence Chin, Dr Cathy Kan Movie – Ice Age 5: Collision Course (3D): Ms Lynda Vis, Dr Christine Lee-Baw, Dr Wei Chua, Dr Helen Slattery, Dr Michael Bray, Dr Linda Wong, Dr John Williams, Dr Simon Machlin Theatre –Angels in America Part 1: Dr Dovida Hickey Music – Behzod Abduraimov Play Prokfiev: Dr Luciano Marino

MEDICAL FORUM

JULY 2016 | 53


88

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BALCATTA 201 Jones Street Modern purpose built Day Surgery with operating theatre & Medical Rooms 362sqm available, fully furnished/ equipped Lots of parking, ambulance access Long Lease available, rent neg. Russell White of Park Property 0419 903 598 russell@parkproperty.com.au parkproperty.com.au PERTH Sessional rooms available at our Travel Doctor TMVC clinic in Perth CBD Fully furnished and fitted out ideal for medical specialists and allied health practitioners. Shared reception, waiting room and facilities. Close to public transport facilities Contact: Rebecca 08 6467 0900 or Rebecca.Hultink@traveldoctor.com.au NEDLANDS Hollywood Medical Centre 2 Sessional Suites. Secretarial support available. Phone: 0414 780 751 FREMANTLE Medical practice for lease in Wray Ave, Fremantle. Fully adapted heritage building with four treatment rooms plus reception/ waiting area. 108 m2. Fully renovated with medical grade wiring, new roof, polished boards etc. Great location, exposure, parking and access. Available June. Please call 0411 155 309 or e-mail achieve@iinet.net.au for more details. MURDOCH Medical Clinic SJOG Murdoch Specialist consulting sessions available. Email: gcford56@gmail.com MOSMAN PARK Large consulting room available for sessions Monday, Tuesday & Friday. Flexible terms and dedicated waiting area. Secretarial support available if required. On train line. Free on-site parking. Contact fiona.wong@westerneye.com.au AUBIN GROVE Consultation room available in our GP Practice in Aubin Grove. Please contact Rachel Pollexfen at frmcrachpoll@iinet.net.au MURDOCH Wexford Medical Centre consulting rooms available for lease. Modern and well lit. Secretarial support and IT system use available if required. Please contact Ai on 0410 786 007 or email aptran@jointswest.com.au

JOONDALUP Serviced Specialist Consulting Rooms Available Within new, purpose built, commercial property in Joondalup CBD, housing other medical tenants. Reception, typing, billing support as required. Please contact Penny Fegan 0420 385 418 for further information

EAST FREMANTLE “Richmond Quarter” : 126 sqm : Approval for Medical : Blank space : Toilet : Prime Position : Carpark/Disabled bays Contact: Gail 0449 129 771

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SHOALWATER Sessional and/or permanent rooms available at our brand new Shoalwater Medical Centre. Fully furnished and fitted out ideal for medical specialists and allied health practitioners. Full secretarial support if required. Fully equipped treatment room and procedure areas available. Experienced and friendly nursing and admin team. Located near both the Waikiki Private Hospital and Rockingham hospital. Please phone Rebecca on 08 9527 2236 Email manager@shoalwatermedicalcentre.com

MT HAWTHORN Sessional medical/allied health suites with ultrasound, uroflowmetry and secretarial support if required Contact: Elayne 0422 234 540 or email eooi@swanurology.com

SUBIACO 316 CHURCHILL AVE MEDICAL/DENTAL ROOMS FOR LEASE 190 sqm at $390psqm plus 4 car bays each $190pcm 4 consulting rooms, large sterilisation room, office area/ patient discussion area, staff room/kitchen Great location, elegant refurbishment. Email thre3times@gmail.com or call John Hearne 0407 442 660 NEDLANDS Hollywood Specialist Centre. Two large furnished suites available with secretarial support. Available on a sessional basis Monday to Friday. Phone: Leon 0421 455 585 or Gerry 0422 090 355

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SOUTH of RIVER Great opportunity to own your practice. A unique opportunity now exists for a motivated GP to take over an existing viable practice in an under-serviced community south of the river. Please call 0412 839 977 or 043 998 410 for further information.

MURDOCH New Wexford Medical Centre – St John of God Hospital Brand new medical consulting room available: t TRN t DBSCBZ For further details contact James Teh Universal Realty 0421 999 889 james@universalrealty.com.au

OSBORNE PARK Medical consulting suites on ground floor available for lease. Located at Osborne City Medical Centre on Scarborough Beach Road. Highly visible, easy access and ample free onsite parking. Flexible terms available and suitable for GP, specialist consultants or allied health. Pathology, podiatry, psychologist and dietitian are all onsite with radiology practices within close proximity. Multiple reception and waiting room facilities. Please call Michael on 0403 927 934 or michael@duncraigmedicalcentre.com.au

FOR SALE WANT TO BE A PRACTICE OWNER? Would you like a stress-free entry to starting out with your own practice? Then don’t miss this opportunity. Email your interest to: owningpractice@gmail.com

FOR SALE – Plastic Surgery Practice and Minor Day Surgery closing down. Office and theatre equipment along with furniture available. All items are in very good condition and need to all go. Please ring Ruth for further details on 0418 909 142 or email srchan@iinet.net.au

FOR SALE 3 x Midmark 604 Examination Beds For Sale. Only 3 years old. Are in excellent condition and good working order - $1250ea Neg. Please call Lincoln 0417 456 996 for further details. FOR SALE - Molemax 2 - $5000 ono Macro and Dermoscopy cameras with additional ELM attachment Cables in perfect order. Stand and Unit approx 10yo. Screen about 4yo. Software works perfectly Only issue is needs to be re-booted if not used for a while. Have upgraded and no space to keep Old Faithful! Contact angie@thewoodsmedical.com.au or 0403 313 882

RURAL POSITIONS VACANT TREENDALE – Time for a Tree change? * F/T GP Required * Small friendly & established Medical Group with 3 Locations in the South West * Brand New location in Treendale * Fully computerized and accredited modern practice with nursing and admin support * Well equipped treatment room * 10 minutes to Bunbury * 65 – 70% of billings depending on experience * DWS Area Please forward CV and enquiries to Kylie Wilson manager@harveymed.com.au

URBAN POSITIONS VACANT REDCLIFFE Ascot Medical Group Part-Time VR GP Wanted for friendly General Practice Non-Corporate Practice with Mixed Billings Accredited and Fully Computerised Sessions available: Afternoon’s and Saturday Morning (Alternate) Please contact Dr Cheng, Dr Hadi or Practice Manager on 9332 5556 WILLETTON VR-GP required part time Hours negotiable Non-corporate 0412 346 146

AUGUST 2016 - next deadline 12md Tuesday 12th July – Tel 9203 5222 or jasmine@mforum.com.au


medical forum 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

MAIDA VALE Seeking an enthusiastic VR GP (female) for a PT/FT position. Our friendly practice is located in the Kalamunda Hills region. Purpose built, fully accredited and private billing. Excellent patient profile with full admin and nursing support. Contact Peter for a confidential discussion on 9454 4544 or Email CV to: office@hillsfamilymedical.com.au and we will contact you within 24 hours

KWINANA General Practitioner with full AHPRA registration required for an immediate start. In the heart of Kwinana is Infinitive Health Wellness Centre, a new modern computerised rapidly growing family owned practice. Excellent location at shopping centre, free parking, plus full support from allied health within centre and diagnostics close by. Flexible hours and 70% of billings. Please contact 6558 0570 or email drk.black@infinitivehealth.com.au ROLEYSTONE Roleystone Family Medical Centre F/T or P/T Female VR Well – Established team, Accredited and fully computerized Please email: practicemanager@roleystonefmc.com.au Phone: (08) 9397 7122 BATEMAN Seeking VR GP for friendly, accredited, mixed billing, computerised (Medical Director) and long established practice. Contact: 0402 046 166 MUNDARING Mundaring Medical looking for VR (Female) GP for both FT/PT for long established busy, efficiently run 6 doctor practice. Fully computerised and accredited modern practice in DWS area nestled within Mundaring shopping centre, complete with excellent nursing and support staff, comprehensively equipped 4 bed treatment area and x1 procedure room. We are predominately a private billing practice and can offer excellent career opportunity, equity available to the right candidate. Ideally GP will have a particular interest in women’s health. Please forward CV and enquiries to Jane Smith at mundmed@iinet.net.au or 08 9295 1988

WEST LEEDERVILLE Full time/part time GP required for privately owned well established practice in West Leederville. Extremely busy clinic. Consultations are bulk billed but procedures are charged privately. Onsite pathology, nurse, podiatrist, physio, dietitian & specialist physician. Excellent earning potential. Contact: sanjaykanodia2000@yahoo.com SERPENTINE VR GP Required for practice only 2 years old, located in an ASGC-R2 location east of Perth. This practice is the perfect opportunity for a GP to work in the inner regional area of Perth located approximately 45 mins from the CBD. This large community busy practice is located next door to a pharmacy and can accommodate 2 full time GP’s. Admin and nursing services are provided along with onsite pathology and podiatrist/ Dietitian. Excellent remuneration is offered. For more information please call 0419 959 246 or 0401 091 921 BUTLER Butler Boulevard Medical Centre is looking for a Full Time or Part Time GP, 70% gross billing. Full Time or Part Time position also available. DWS welcome. New, state of the art medical centre, Great facilities, Fully-computerised. Flexible hours and billing, NOR, Non-Corporate, Onsite nurse. Onsite Pathology, Physiotherapist, Dietitian, Podiatrist and Psychologist. Excellent Remuneration Call Practice Manager on 08 9305 3232 or Email resume to: shentonavenuemedical@outlook.com WEST LEEDERVILLE Doctor required for busy long established family practice. Part time (up to full time) VR GP invited to join. Computerised and accredited, on-site pathology, non-corporate, opportunity to 100% private bill, excellent support staff, lots of flexibility with six females and one male colleague. Email Monica at glenstreetpractice@iinet.net.au or call 08 9381 7111 for more details

SHOALWATER F/T or P/T VR GP required for our modern state of the art medical centre located in Shoalwater (DWS), Offering modern surrounds and fully computerised clinical software. We are a friendly, privately owned and run centre. A full complement of nursing staff and administration team as well as onsite allied health, specialists and pathology. generous remuneration offered. Please phone Rebecca on 08 9527 2236 or Email CV to manager@shoalwatermedicalcentre.com

SEVILLE GROVE Seville Drive Medical Centre is seeking a hardworking and enthusiastic VR F/T or P/T GP to join our friendly professional team. Our centre see’s 200-250 patients per day; we also have an onsite pharmacy, pathology, allied health and visiting specialists. Full complement of GP’s, clinical staff and administration. Percentage of billings based on experience, with annual percentage increase. Please phone Rebecca or Debbie on 08 9498 1099 or Email CV to manager@sevilledrivemedical.com

ROCKINGHAM Read Street Medical and Skin Centre F/ T VR GP. DWS Location. Privately owned, private billing practice. Well established with existing patient base. Special interests encouraged. Fully computerised, excellent support staff. Onsite pathology available. Easy access to major shopping centre and public transportation. Contact us at pracman101@gmail.com Tel 08 9527 4976 HAMILTON HILL A female GP required for a clinic in a DWS and AON area 5 minutes drive from Fremantle. 3 Doctor GP Practice. Part time or Full time doctor considered Fully computerised practice. Rates negotiable Contact Eric on 0469 177 034 or Send CV to eric@hamiltonhillfamilypractice.com.au

KARRINYUP St Luke Karrinyup Medical Centre Great opportunity in a State of art clinic, inner-metro, Normal/after hours, Nursing support, Pathology and Allied services on site. Privately owned. Generous remuneration. Please call Dr Takla 0439 952 979

GOSNELLS Busy GP practice in Gosnells For a VR GP who is looking to do few sessions a Week including Weekend, a position is available @ Corfield Doctors Surgery. Session rates Negotiable. Contact PM on 04 4 967 915 for a Confidential discussion or e mail to corfield.doctors@gmail.com

VICTORIA PARK Dr required for Saturdays at a wellestablished clinic. DWS status available. Non VR’s with level 3 welcome to apply. Fully computerised and admin support available. Contact: g_vinu@yahoo.com

89 FREMANTLE INTERESTED IN WOMEN’S HEALTH? Fremantle Women’s Health Centre requires a female VR GP one day pw. It’s a computerised, private and bulk-billing practice, with nursing support, scope for spending more time with patients, provides sessional remuneration, superannuation and generous salary packaging. FWHC is a not-for-profit, community facility providing medical, nursing and counselling services, health education and group activities in a relaxed friendly setting. Phone 9431 0500 or email Dawn Needham clinical-manager@fwhc.org.au BULL CREEK MetroGP Part-Time VR GP Wanted for friendly General Practice Non-Corporate Practice with Mixed Billings Accredited and Fully Computerised Sessions available: Monday, Thursday and Saturday Morning (Alternate) Please contact Dr Cheng, Dr Hadi or Practice Manager on 9332 5556

BANKSIA GROVE North of the River Family Practice is seeking a VR GP. Well-established team, accredited and fully computerised. Please Email: jags@perthgp.com.au

Seeking expressions of interest from motivated VR GPs wanting to take the next step in your career. Ever dreamed of owning your own practice but don’t want the stress of set up? We are seeking both GPs looking for partnership opportunities and those looking to enjoy work a state of the art, fully supported and modern built for purpose medical centre 10 mins from Perth CBD. Flexible working conditions with excellent remuneration in a private billing and fully privately owned centre. For an entirely confidential discussion please email reception@forummedicalgroup.com

ALL AREAS VRs and NonVRs needed urgently. DWS and area of need. Supervision available if required. Pearsallmedical.com.au Hockingmedical.com.au Alkimosmedical.com.au Good income with initial guarantee. Additional income from Mole Scanner, Aesthetic Clinic & Travel Clinic. Chronic Disease Clinics with excellent admin and nursing support Good doctor/nurse ratio. In house Physio, Podiatry, Psychology, Dietician. Enquiries to Dr Ben Banwait banwaitben@gmail.com or 0416 893 131

AUGUST 2016 - next deadline 12md Tuesday 12th July – Tel 9203 5222 or jasmine@mforum.com.au


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OSBORNE PARK GP required for Osborne City Medical Centre. Flexible hours Monday to Thursday with optional afterhours. Excellent remuneration / $150 - $200 per hour. Predominantly private billing practice. Modern fully computerised practice with nursing support. Please call Michael on 0403 927 934 DUNCRAIG Duncraig Medical Centre requires a Female GP for immediate start. Fulltime patient load available. However, flexible with Monday to Friday hours. Excellent remuneration / $150 - $200 per hour. Predominantly private billing practice. Modern fully computerised practice with full time nurses. Please call Michael on 0403 927 934 or michael@duncraigmedicalcentre.com.au JOONDANNA We are seeking a VR GP to join our friendly team on a part-time or full-time basis. New, state of the art medical centre. Flexible hours and billing. Percentage negotiable. Fully-computerised. Nursing support for CDMP. Please call Wesley on 0414 287 537 for further details.

BENTLEY Rowethorpe Medical Centre is a nonprofit, friendly practice seeking a part time GP to provide visits to our onsite residential aged care facilities. Practicebased consultations are also available. t 'VMMZDPNQVUFSJTFE t /FXMZSFOPWBUFEQSFNJTFT t .PEFSOFRVJQNFOU t 0OTJUFQBUIPMPHZ t )PVSTUPTVJUZPV For enquiries, please contact Jackie on 6363 6315 or 0413 595 676 THORNLIE Thornlie Medical and Skin Cancer Clinic (DWS) is seeking a VR GP to help our friendly growing multicultural practice. Mixed billing, accredited, fully computerised with full-time nursing support. Computerised dermoscopy. Please email: thornliemedicalcentre@hotmail.comor Call 0403 009 838 CANNING VALE Canning Vale (DWS) requires weekend or part-time VR GP urgently. Rates negotiable. Privately owned practice - fully computerised, huge consulting rooms, spacious treatment room with FT RN , and on-site pathology with other health alliances in the complex. Phone: Julie 9456 1900 or Email: jphyo@nicholsonmedical.com.au

BICTON Full-time and Part-Time VR GPs positions available for our well established Accredited, Privately Owned, Friendly Family Practice in Bicton. The practice has a well-established patient base, and offers an exciting opportunity for an enthusiastic practitioner to join our practice, with potential to own. t 0OTJUFQBUIPMPHZBOE1SBDUJDF/VSTF support, Radiology available across the road. t 6OJRVFNFOUPSJOHPQQPSUVOJUJFT available, and excellent support staff and facilities t 8FVTF#FTU1SBDUJDFTPGUXBSFBOEBSF mostly a Private Billing practice. t 73XJUIFYQFSJFODFJOXPNFOTIFBMUI preferred, but not required. t -FBSONPSFBCPVUVTBU http://bictonmedicalclinic.com/ t "MMBQQMJDBUJPOTDPOTJEFSFE Contact Dr. Sam Messina on 9339 1400 Email: smess@iinet.net.au

BYFORD VR GP Female/ Male GP Required Full – Time or Part -Time Under New Management Privately owned well established modern practice located in Byford, 30 mins from CBD, DWS and area of need. Full admin, nurse and practice manager support Onsite Pathology, Podiatrist, Dental and Pharmacy Fully computerised accredited Practice Excellent Remuneration Please email: byfordfp@gmail.com

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

Metro Area GP positions available VR & Non – VR Dr’s are welcome to apply. Send applications to hr@betterhealthcare.com.au

Fantastic lifestyle – rewarding medicine Full-time general practitioner | KUNUNURRA Join a thriving practice and work in an amazing multidisciplinary team led by Indigenous GP, Dr Stephanie Trust. Live near iconic attractions including the Bungle Bungles and El Questro and take part in local events including the Gibb River Challenge, Lake Argyle Swim, Pentecost Big Barra Fishing and the Ord Valley Muster. A generous remuneration package is offered including 65 per cent of billings (approximately $250-300k), generous salary packaging and a housing allowance. This exciting position offers the following: z z Supportive team environment Full-time nursing support z z Brand new, state-of-the-art facility No on-call work Contact Rural Health West to find out more

T +61 8 6389 4500 | E recruit@ruralhealthwest.com.au

www.ruralhealthwest.com.au AUGUST 2016 - next deadline 12md Tuesday 12th July – Tel 9203 5222 or jasmine@mforum.com.au


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Join a growing team of visiting specialists to the south coast. Think Albany, Think Amity Health. We combine experience and efficiency in Albany’s newest purpose built health care facility to deliver: • Full administration, billing and reception support • 12 consulting rooms • Excellent access for clients • Excellent parking • Referral pathways to Amity Health’s team of allied health professionals • Collegial environment • Central location

Amity Health is a not for profit organisation. For more information, call Sian Bushell on 9842 2797

GENERAL PRACTITIONERS REQUIRED DWS positions available in 4 locations! Bunbury: Brecken Health Care - Join a team of 20 GPs Albany: St Clare Family and Occupational Practice – Join a team of 3 GPs Busselton: New site opening soon

7 Day Medical Centre We invite GPs and specialists to join our award-winning multi-disciplinary team in Fremantle. We are proud of our reputation for excellence in health care, and enjoy a comfortable and happy environment. Doctor-owned and managed, Ellen Health offers an instant referral base with our established general practice, with the ease and comfort of fully serviced new rooms. We are building our occupational health services.

Eaton: New site opening soon Special interests are encouraged! Skin cancer

Enquiries to Dr Catherine Douglass www.ellenhealth.com.au Ph 9239 0200 M 0421 520767

Antenatal/postnatal care Walk in/urgent and after hours care Occupational Health Travel Medicine Procedural work encouraged Chronic disease management All our sites are fully accredited with AGPAL. Nurses, admin & allied health support as well as pathology on site. FRACGP or equivalent highly regarded but not essential. Flexible hours, Full time or Part time available.

For Further information please contact Dr Brenda Murrison 0418 921 073 or brenda.murrison@breckenhealth.com.au

FOR LEASE 5 SHUFFREY ST FREMANTLE Do not miss out on this! POA A wonderful opportunity exists to lease a brilliant property that is approved for service professionals. Ideal for Accountants, Architect, Engineer, Lawyer and Medical Practitioners. 7 rooms, separate kitchen, bathroom and back room. Quality fit out, pre-cabled, ready to go. This is a rare opportunity. Don’t delay. Call Greg Isaac on 0413 206 206 to arrange an inspection.

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medical forum Sessional Rooms available Full practice management Sessional Rooms are available at the St John of God Murdoch Medical Clinic. * full-time/part-time/sessional * medical systems and secretarial support * adjacent to Fiona Stanley Hospital

MIDLAND VR General Practitioner for long established and busy DWS and non-DWS Medical Practice Work Type: Both FT & PT ŔAccommodating patients of recently retired GP (full books) ŔExcellent Remuneration ŔExcellent Nurse Support This is an excellent opportunity for an experienced VR General Practitioner to join a very established and busy family practice in Midland. We are dedicated to providing exceptional patient care. With an established local patient base, the new GP will be starting with full books to replace a recently retired doctor. Hours are flexible. The practice boasts great and social co-workers, exceptional support staff and nurses. We offer ŔWalk in Service ŔTravel Medicine ŔIV Therapies ŔMental Health Clinic ŔWork place Injuries

ŔFamily Medicine ŔChronic Care ŔSkin cancer clinic ŔCosmetic Medicine

Essential Criteria ŔMust be an Australian Citizen or Permanent Resident ŔMust have Full AHPRA Registration as a Medical Practitioner (Specialist Registration) ŔVocational Registration status

AHG Super Clinic Contact Person: Val Reeve Phone: 0415 322 790 Email: val.reeve@australasianhealth.com

More information phone: 9366 1802 or email: diane.car@sjog.org.au

Apollo Health is seeking local Dr’s with an interest in : - Skin cancer - General family medicine - Walk in /Urgent care For our practices in Armadale, Cockburn and Joondalup FRACGP required, Relocation incentives available

If you would like to join our dynamic team please contact office@apollohealth.biz

Solo rural GP required An opportunity has arisen for an experienced general practitioner (GP) to operate their own practice in a thriving wheatbelt community. The GP is required to provide on-call services to the local hospital and a onceweekly clinic in a nearby town. The practice will operate as your own business but with considerable Shire and other support. Turnover is circa $550-$600k with low overheads. Practice premises, house, maintained car and generous ongoing business support is provided. A comprehensive information package is available for suitable candidates. Vocationally registered GPs are preferred but remote supervision and support may be possible. Visa support is available if required. Contact Rural Health West if you would like to find out more: T +61 8 6389 4500 | E recruit@ruralhealthwest.com.au

www.ruralhealthwest.com.au AUGUST 2016 - next deadline 12md Tuesday 12th July – Tel 9203 5222 or jasmine@mforum.com.au


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Lockridge Medical Centre VR GPs or Subsequent Registrar PT / FT

WANTED Expressions of interest from doctors who hold a Fellowship in Pain Medicine to work with Dr Stephanie Davies in her Painless Clinics in Cottesloe, Duncraig and Bunbury and shortly in Murdoch.

To work at our modern, independent, accredited, innovative, teaching and award winning practice.

Painless is committed to providing multidisciplinary management of patients with persistent pain including traditional options in conjunction with GPs and treating specialists. Painless continues the two-day STEPS and STEPS2WORK program (Version 2), and engage people with pain with co-care strategies. We are now seeking the above qualified Doctors to establish a second hub at Murdoch to continue Painless Clinic’s multidisciplinary management, with targeted procedural interventions. Expressions of interest plus CV should be sent to stephanie.davies@painless.clinic

FOR LEASE 57 ELLEN ST FREMANTLE

A friendly and supportive work environment offering full computerisation, full time practice nursing support from open to close, nurse led chronic disease clinics, onsite pathology, psychology and physiotherapy services available. Offering flexible working hours combined with efficient practice systems in place to support chronic disease which assists the remuneration package. The practice is located in an outer metro suburb on the edge of the Swan Valley, 30 minutes to the hills or 30 minutes to the beach. The practice is not located in an area of district workforce shortage (DWS). With exciting building plans for a purpose built practice on the horizon, before you make up your mind - Our practice is definitely worth a visit. If you are interested we would be keen to speak with you! Please phone Natalie Watts on 08 6278 2555 or Email natalie.watts@lockridgegp.com

Rare opportunity to lease POA Opposite Fremantle Park and playing fields. Features verandah, hallway, polished floorboards, 4 offices, conference room, renovated kitchen, bathroom, staff room and rear courtyard. Land use is classified as “Service Professionals” and would be ideal for accountants, architects, engineers, and medical professionals or other.

St John is seeking experienced doctors to work in our new Urgent Care Centres. Relevant experience in urgent care, rural general practice or similar will be highly regarded. Full or part time. Attractive salary package.

Call Greg Isaac on 0413 206 206 to arrange an inspection.

If you would like to join our dynamic team please contact office@apollohealth.biz

GP West Requires VR GP’s to our state of the art medical centers in AON and DWS locations Harrisdale Medical Centre HARRISDALE

Wattle Grove Medical Centre WATTLE GROVE

Mundaring GP Super Clinic MUNDARING

GP Owned, 9 Consult rooms, 3 Minor Surgery bays

We also require VR GPs for

All allied health, pathology, pharmacy& Dental

Okely Medical Centre, CARINE Newpark Medical Centre, GIRRAWHEEN New Gumnut Medical Centre, WANNEROO Woodlake Village Medical, ELLENBROOK

70 % of billings, Partnership opportunities Non VR GPs are also welcome

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

or visit www.gpwest.com.au AUGUST 2016 - next deadline 12md Tuesday 12th July – Tel 9203 5222 or jasmine@mforum.com.au


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Lockridge Medical Centre VR GPs or Subsequent Registrar PT / FT

WANTED Expressions of interest from doctors who hold a Fellowship in Pain Medicine to work with Dr Stephanie Davies in her Painless Clinics in Cottesloe, Duncraig and Bunbury and shortly in Murdoch.

To work at our modern, independent, accredited, innovative, teaching and award winning practice.

Painless is committed to providing multidisciplinary management of patients with persistent pain including traditional options in conjunction with GPs and treating specialists. Painless continues the two-day STEPS and STEPS2WORK program (Version 2), and engage people with pain with co-care strategies. We are now seeking the above qualified Doctors to establish a second hub at Murdoch to continue Painless Clinic’s multidisciplinary management, with targeted procedural interventions. Expressions of interest plus CV should be sent to stephanie.davies@painless.clinic

FOR LEASE 57 ELLEN ST FREMANTLE

A friendly and supportive work environment offering full computerisation, full time practice nursing support from open to close, nurse led chronic disease clinics, onsite pathology, psychology and physiotherapy services available. Offering flexible working hours combined with efficient practice systems in place to support chronic disease which assists the remuneration package. The practice is located in an outer metro suburb on the edge of the Swan Valley, 30 minutes to the hills or 30 minutes to the beach. The practice is not located in an area of district workforce shortage (DWS). With exciting building plans for a purpose built practice on the horizon, before you make up your mind - Our practice is definitely worth a visit. If you are interested we would be keen to speak with you! Please phone Natalie Watts on 08 6278 2555 or Email natalie.watts@lockridgegp.com

Rare opportunity to lease POA Opposite Fremantle Park and playing fields. Features verandah, hallway, polished floorboards, 4 offices, conference room, renovated kitchen, bathroom, staff room and rear courtyard. Land use is classified as “Service Professionals” and would be ideal for accountants, architects, engineers, and medical professionals or other.

St John is seeking experienced doctors to work in our new Urgent Care Centres. Relevant experience in urgent care, rural general practice or similar will be highly regarded. Full or part time. Attractive salary package.

Call Greg Isaac on 0413 206 206 to arrange an inspection.

If you would like to join our dynamic team please contact office@apollohealth.biz

GP West Requires VR GP’s to our state of the art medical centers in AON and DWS locations Harrisdale Medical Centre HARRISDALE

Wattle Grove Medical Centre WATTLE GROVE

Mundaring GP Super Clinic MUNDARING

GP Owned, 9 Consult rooms, 3 Minor Surgery bays

We also require VR GPs for

All allied health, pathology, pharmacy& Dental

Okely Medical Centre, CARINE Newpark Medical Centre, GIRRAWHEEN New Gumnut Medical Centre, WANNEROO Woodlake Village Medical, ELLENBROOK

70 % of billings, Partnership opportunities Non VR GPs are also welcome

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

or visit www.gpwest.com.au AUGUST 2016 - next deadline 12md Tuesday 12th July – Tel 9203 5222 or jasmine@mforum.com.au


Medicalforumwa 0716 Public Edition  

Western Australia's Independent Monthly for Health Professionals