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Two Sides, Many Stories t t t t t

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Don’t Disrupt Me, I’m Creating Words are the most intriguing of things. In their pure form they are abstract; stick them on a wall or in a book or magazine and they can morph into anything the reader wants them to be. So we come to the current buzz-word, ‘Disruption’. In a simpler time, this was the signal for the naughty kid in the class to step outside to reflect on his behaviour (I can’t help but be gender specific, it was usually a boy. Things may have changed there too). Now we read that disruption and disruptors are welcome in the highest circles. At the GP16 conference in Perth at the end of September, the members’ forum was entitled Revalidation and Digital Disruption. Everyone understands the implications of revalidation, but digital disruption? Should we be thrilled or terrified? Or, perhaps, both at the same time? So I did what I always do when life throws me a curve ball, I practised what I now know as a little disruptive behaviour. I googled! Forbes Magazine, the epitome of capital and, one expects, almost certainly brimming with disruptors, offered this as an explanation: “People are sometimes confused about the difference between innovation and disruption. It’s not exactly black and white, but there are real distinctions, and it’s not just splitting hairs. Think of it this way: Disruptors are innovators, but not all innovators are disruptors — in the same way that a square is a rectangle but not all rectangles are squares.” ‘Good grief!’ were the words that spontaneously disrupted my thoughts, but a sense of fairness prevailed to the innovators (or disruptors) out there, so I read on. “Innovation and disruption are similar in that they are both makers and builders. Disruption takes a left turn by literally uprooting and changing how we think, behave, do business, learn and go about our day-to-day. Harvard Business School professor and disruption guru Clayton Christensen says that a disruption displaces an existing market, industry, or technology and produces something new and more efficient and worthwhile. It is at once destructive and creative.” The article then proceeded to list the most disruptive names in business, many of whom, no doubt, spent a good part of their education out in the school corridor reflecting on their behaviour.

The gloves are off. Forget the old-school charm of reform – that offers too much freedom to resist; too much chatter; too much debate. What the health system needs is a good dose of disruption. Tip over the bucket and see what floats. The only trouble with that theory can be summed up by the old, yet elegant, aphorism – don’t throw the baby out with the bathwater. Disruption, be it digital or systemic, risks depletion and denudation of the health system’s core strengths (most certainly its workforce) unless there is some sense of explanation, consultation and education. Our friends at Forbes perhaps don’t look at human capital in the same light as the medical profession. Not to put too fine a point on it, disruption is also a way for some businesses and individuals to make a killing. While Guru Clayton talks in warm and comforting terms of creating “something new and more efficient” what is not said is that destruction creates a vacuum that needs be filled, most probably by the disruptors. And it will be an era where big will rule because the little guy will simply not be able to afford to play the game. It puts into perspective the strategic positioning within the health sector by the country’s biggest communication provider, not so very long ago owned by the Australian public. There are still a lot of words to be bandied about but it is worthwhile for all of us to remember that while the Ms Jan Hallam playing field may be changing shape, it is still owned and maintained by the people of Australia. And they can be quite disruptive, particularly at certain crucial moments in an election cycle. Time to practise a little disruption of your own! By Jan Hallam

While on the surface this seems like a jumble of junk, if you think about it more deeply it does explain a lot of what’s been going on in the health sector.

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FEATURES 20 Supporting Solo Rural GPs 24 Head-gear in Sport 28 Health Care Homes 46 Land of the Hobbits NEWS & VIEWS 1 Editorial: Don't Disrupt Me, I'm Creating 4

12 14 14

Ms Jan Hallam Letters to the Editor Revalidation: No Compelling Case Dr Aniello Iannuzzi Surgeons Support Proposals Dr Philip Truskett No More ‘Big Brother’ Dr Philip Morris PSA Teamwork Needed Dr Tom Shannon Prostate Education Key Prof Anthony Lowe Dying Laws Should Stay Dr John Hayes Children out of Detention Dr Sarah Dalton Have You Heard Laughter Best Medicine Beneath the Drapes

16 18 22 23 31 37 41 42 45

Clinics in Calcutta Dr Lin Arias Work of FoodBank 50 Years of Busselton Study State of the Workforce Hope for the Homeless State Endoscopy Services Cancer Registries Internet OCD Therapy Windows 10 Privacy Tips

LIFESTYLE 48 The Land of the Hobbits Dr Rob McEvoy 48 Funny Side 49 Wine Review: Harewood Estate 50 51 52 53

Dr Louis Papaelias Social Pulse SJG Subiaco and Murdoch Hospitals Party Snugglepot & Cuddlepie Tallis Scholars Competitions




Clinical Contributors


Dr Jonathan Grasko 'What is the Ultimate Elixir of Sport?'


Dr Tim Gattorna Arrhythmias in Primary Care


Dr Carmel Goodman Dilemmas in Managing Athletes


Dr Sandra Mejak Back Pain in Young People


Dr Brendan Ricciardo Acromio-Clavicular Joint Separation


Dr Donna Mak The Clap is Back


Dr Peter Honey Tendon Injuries of the Elbow


Dr Arjun Rao Treatment of Chronic Tendinopathy

Training Standards Doing Us No Favours

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Guest Columnists


Dr Lisa Wood Homelessness Linked to Poor Health


Dr Louise Naylor Fitness vs Fatness


Mr Greg Mount-Bryson Hard Core Tee-Ball


Flt Lt Ray Werndly Tough Love Saves Lives

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 OCTOBER 2016 | 3

Letters to the Editor

has measurably improved patient outcomes because of the introduction of ‘revalidation’. Professional regulation, like clinical medicine must be evidence based.

No compelling case for revalidation Dear Editor, The Medical Board of Australia needs to provide convincing evidence that where implemented, the imposition of so-called ‘revalidation’ on busy doctors has led to a significant and measurable improvement in the outcomes for patients. In 2014 in the MJA, Monash University’s Prof Kerry Breen said: “the medical regulator and medical profession might be wiser to first more clearly identify what the problem is that revalidation is trying to fix and then examine what methods might best suit that aim.” “It seems illogical and unnecessarily costly to introduce an additional layer of assessment of all doctors when there is general agreement that most doctors strive to maintain and enhance their knowledge and skills and are rarely the subject of complaint. This is even more problematic without an evidence base to indicate that revalidation will achieve its stated aim.” The Australian Doctors Fund believes ‘the problem’ has still not been defined. The argument that any area of the health system can be made safer with more compliance always needs close evaluation as it is a very open-ended claim. Currently under national law, AHPRA is able to assess the performance of any individual doctor. AHPRA has enacted mandatory reporting of doctors and other nationally registered health professionals. These are major powers which were granted to AHPRA to ensure public safety. Now we are being told it’s not enough. Australia should not blindly follow bureaucratic process from the UK. The NHS is a one-system employed doctor health delivery service that does not match Australia’s public and private sector split.

Australian doctors do not need any more boxes to tick and Australian senior doctors do not need to be vilified as targets by any regulatory system simply because of their senior years. It’s time for a reality check. The growing compliance burden being imported into Australia is counter-productive to productivity and evidence-based professional leadership. It’s time for the profession as a whole to decide the issue and not simply have it imposed by a select group, namely AHPRA or the MBA. Dr Aniello Iannuzzi, Director, Australian Doctors' Fund ........................................................................

RACS supports proposals Dear Editor, Re: What Revalidation Might Look Like (September edition), there is much in the Expert Advisory Group’s report that needs the profession’s support. It is consultative, fit for purpose and reflective of the practitioner’s scope of practice. There is a clear understanding of the complexities of the Australian health sector and significant differences from the United Kingdom and other countries. RACS will strongly engage in this consultation at multiple levels. It is most important that the profession takes strong ownership of selfregulation of standards. Our formal response will be submitted before the deadline of the consultation, which is 30 November 2016.

We are yet to see any evidence that the NHS

A lie gets halfway around the world before the truth has a chance to get its pants on. Sir Winston Churchill

Dr Phil Truskett, president, Royal Australian College of Surgeons ED: RACS President Dr Truskett attended the first meeting of the Medical Board of Australia’s Consultative Committee on revalidation in Melbourne on August 16 to discuss their interim report.


No more ‘big brother’ Dear Editor, It seems if you are male, or 'old', or in solo practice, or from 'some' overseas countries you will be targeted for being ‘at-risk’. Who decides who will be targeted? Will medical colleges refer or notify certain of their members to the Medical Board police? On what basis? Population screening to find 'cases' (i.e. bad doctors) only works effectively if the base rate of 'abnormality' is reasonably high. We are not told what the base rate of 'bad' doctors is in Australia. If it is very small (which I suspect) the screening of whole populations of targeted doctors will be a waste of resources and will just be a bureaucratic assault on the profession. The process will require additional resources – Medical Board doctors, policemen and policewomen – and will grow the Medical Board bureaucracy requiring additional registration fees. The board will outsource the process to the medical colleges (via 'strengthened CPD’) and the colleges will welcome the opportunity to charge their members additional membership subscriptions. Public sector and other employed doctors will have less of a burden as they can tell their employer that compliance with the revalidation process will need to be done during paid work hours. The compliance costs for private practitioners will be onerous and an unfair burden. There is a lot of 'opinion' from bureaucratic stakeholders, who might benefit, that revalidation is a 'good idea', but so far little supported argument that persuades me. I would be open to be convinced otherwise by robust evidence. The Medical Board website notes there will

continued on Page 6

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Major Sponsor: Clinipath Pathology

'What is the Ultimate Elixir of Sport?'

By Dr Jonathan Grasko MBBCh, FRCPA, PDip (Med Tox) Consultant Chemical Pathologist and Toxicologist, Clinipath Pathology

In 1889, Dr Charles-Édouard BrownSĂŠquard, a world renowned physiologist and neurologist, who ďŹ rst described a syndrome that bears his name, published in The Lancet, a paper based on a number of experiments done on animals and humans (including himself). It involved injecting an elixir derived from blood from the testicular artery, semen and uid extracted from freshly crushed animal testicles. He concluded â€œâ€Śgreat dynamogenic power is possessed by some substance or substances which our blood owes to the testicles.â€? and “I can assert that the ‌ given liquid is endowed with very great power.â€? The inherent belief that human performance can be improved by the addition of an elixir can be traced to ancient Greece. Athletes and warriors ingested berries and herbal infusions to improve strength and skill. The intrinsic risk attached to these substances has always been appreciated. Scandinavian mythology mentions Berserkers (ancient Norse warriors) who would drink a mixture called "butotens", to increase their physical power at the risk of insanity. They would literally go berserk (where the modern meaning of the word arises) by biting into their shields and gnawing at their skin before launching into battle, killing anything in their path. This desire to out-compete rivals at any cost seems to be branded into the human psyche. The willingness to partake of substances that may inevitably be detrimental even to the point of death has been repeatedly demonstrated. Thomas Hicks, an Americanborn athlete won the 1904 Olympic marathon having received multiple injections of strychnine by his trainer. Hicks survived his ordeal but never raced again. An attempt at understanding the extent of this risk-taking behaviour was undertaken by physician Dr Bob Goldman. In his research involving elite athletes he presented a scenario where success in sport would be guaranteed by the ingestion of an undetectable substance, however, with death the inevitable outcome after ďŹ ve years. He concluded that approximately half the athletes would take the drug. This scenario has been dubbed the “Goldman's dilemmaâ€?. A more recent repeat of this study yielded a lower correlation. During World War II soldiers on both sides were given amphetamines to counteract fatigue, elevate mood and heighten endurance. Following the war these drugs – nicknamed “La bombaâ€? and “Atoomâ€? by Italian and Dutch cyclists – started to enter the

sporting arena with the intention of minimising fatigue.


In the 1950s, there was the perception in the USA that the success of the Russian weightlifting team was solely due to the use of performance-enhancing drugs. Dr John Ziegler, in collaboration with CIBA Pharmaceuticals and under FDA approval, developed the ďŹ rst oral anabolic steroid, methandrostenolone, which US Athletics gave its entire Olympic weightlifting team. Zeigler was later quoted when discovering that athletes were taking 20 times the recommended dose: "I lost interest in fooling with IQs of that calibre. Now it's about as widespread among these idiots as marijuana."


It came to a head at the 1960 Olympic Games where Danish cyclist, Knud Enemark Jensen, collapsed and died while competing in the 100km race. An autopsy revealed the presence of amphetamines and nicotinyl tartrate in his system. In the 1967 Tour de France, world renowned British cyclist Tommy Simpson died during the 13th stage after consuming excessive amounts of amphetamines and brandy. Simpson’s motto was allegedly "If it takes ten to kill you, take nine and win!" Simpson's death created pressure for sporting agencies to take action against doping. This ultimately led to the formation of The World Anti-Doping Agency (WADA) in 1999 as an international independent agency composed and funded equally by international sports associations and governments. Every year WADA publishes an updated list of banned drugs, which fall into three groups:

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sĂĽ -ĂĽ'ENEĂĽ$OPING Gene doping involves the use of gene transfer to alter gene expression and protein biosynthesis of a speciďŹ c human protein. This is done by injecting the gene carrier into the athlete using a viral vector or by transfecting the cells outside the body and then reintroducing them. WADA has invested signiďŹ cant resources to detect this process. Currently there is no evidence that this is common practice. In addition to the traditional incentives such as fame, honour and power, the past 60 years has brought with it the most potent of drivers – money. The ďŹ nancial incentives to both sporting institutions and athletes are profound with some authorities claiming almost a 250% increase in revenue with the introduction of industrial scale performanceenhancing drugs. The supplements industry has already exceeded a value of $60b a year. The combination of primal ambition and ever improving designer performance-enhancing modalities makes the future of professional sport, I believe, the realm of the highest bidder. Anti-doping agencies, with the help of technology, will need to ďŹ nd increasingly more creative ways of testing to stand any chance of success. References available on request.

Letters to the Editor continued from Page 4 be specific attention directed to ‘at-risk’ and ‘poorly performing’ practitioners. Who determines who are in these categories? Maybe you are one if you have blue eyes, or some age-related or physical or racial or religious characteristic or if you get social media attention from groups with a barrow to push. I hope not. But this aspect demands close scrutiny. There is little evidence or support in the Medical Board’s media releases or information provided about revalidation that would justify any additional bureaucratic ‘bigbrother’ regulation of the medical profession. The existing CPD programs of the medical colleges and GP and specialist societies are sufficient. Prof Philip Morris, Treasurer, Australian Senior Active Doctors Association (ASADA) ........................................................................

PSA teamwork required. In response to letters from Drs Frank Jones and Gerry Cartmel (August edition): As we transition from the divisive for and against positions towards a consensus view on the early detection of prostate cancer, it is inevitable that those who have taken strong stances in the past will try to defend them. As doctors, we are fundamentally scientists. When we make decisions based on science, we are free to change our minds when the evidence to support it changes. Much of the disagreement that has occurred has been due to the fact that clinicians dealing with prostate cancer are aware of information

before the trials can be conducted that prove what is clinically known. Every day, we make decisions based on the best available evidence, not all of it from a randomised prospective clinical trial. The consequences of prostate cancer are significant in our community and it is important that the evidence is robust before proceeding with a screening program that, by its nature, will be aimed at people of average risk. PSA testing has been held to the highest level of scrutiny, one I would doubt will ever be applied to breast cancer. Detractors will use the fact that no screening program is recommended to suggest that PSA testing does not work, nor save lives. This is not the case. With such a common and complex cancer it is essential that there is a framework for primary care physicians to have the tools to discuss and manage PSA testing. These guidelines provide this. They are a comprehensive, independent, multidisciplinary evidence-based guide that now has the endorsement of all stakeholders. The contents are not my personal opinion, even if they echo my position over many years. Despite what Dr Jones has written, the recommendations do not align with the RACGP position as stated in the ‘Red Book’ and do not state that PSA testing is unreliable and not recommended. The guidelines clearly recommend testing of informed asymptomatic men, starting at a young age if there is a risk higher than average. Most doctors are able to understand the complexities of prostate cancer in order to improve the health of their male patients, and have been more aligned with these new recommendations than the ‘red book’ for some time. It is time to end the division by becoming familiar with the contents of this important

document. Both the Red Book and The PSA Consensus Guidelines are easily available online and I would encourage everyone to read them to make their own informed decision. Dr Tom Shannon, Urologist, Nedlands ........................................................................

Prostate education is the key Dear Editor, A recent landmark Australian clinical trial published in The Lancet has shown that there is no significant difference in the outcomes achieved by robotic-assisted and standard open prostate cancer surgery at 12 weeks post-operation. These findings demonstrate the importance that doctors provide patients with balanced advice regarding their treatment options for prostate cancer. While patients who underwent roboticassisted surgery experienced less blood loss and pain in the first week following the procedure in comparison to open surgery, these differences levelled off 12 weeks postoperation. The study has some limitations, however, the take-away message is patients who cannot afford to undergo a robotic-assisted procedure should not be disheartened or feel they will be worse off if they opt for open surgery. Practitioners need to be in a position to discuss treatment options with their patients and ensure they are aware of all factors – continued on Page 8

Curious Conversations

I Love Living the Rural Life Albany GP Airell Hodgkinson is very happy living in the Great Southern. The nightly news is… often one horror after another. It’s sad that the media search for sensationalism, blood and gore when so many positive things happen every day. I prefer to scan the news headlines online now. Alain de Botton's book, The News - a User's Guide, provides some interesting insights. One of the best nights in the theatre I’ve ever had was… Matilda, in London. It’s a great musical – funny, terrific performances with excellent stage and props. The fact that it was written by our own Tim Minchin made it even more special. My saddest moment in medicine was… telling two children who’d been in a car accident that their parents had died in the crash. Neither

6 | OCTOBER 2016

of the adults was wearing a seat-belt. The children were, and sustained only minor injuries. It was such a tragic and pointless loss of life with devastating consequences for the family. I love living in Albany because… it’s a large country town with a strong sense of community. It allows me to practise a wide variety of medical skills while providing wonderful resources to engage in hobbies and interests. If only the weather were a little warmer! One thing I’d really love to do before I get too much older is… do more long hikes and bush walks through our spectacular scenery before my knees give up.



Arrhythmias in Primary Care

"CPVUUIFBVUIPS Arrhythmias in the primary care setting are a common presenting complaint. Symptoms can include palpitations, dizziness, blackouts, chest pain, breathlessness, fatigue, anxiety and panic. This broad range of symptoms and the intermittent nature of episodes can make diagnosis challenging and frustrating. In general, palpitations have a benign prognosis, although recurrent episodes can lead to signiďŹ cant impairment in the patient’s quality of life, anxiety, frequent presentations to health professionals and risk of adverse clinical events in those with pathological causes. Work-up: A thorough history and examination is vital to guide the diagnostic and therapeutic strategy and can assist in risk-stratifying patients. 1. Accurate history -

Symptoms in patients own words. DeďŹ ne “dizzinessâ€?, “palpitationsâ€?, for example


Frequency, duration, onset, offset


If palpitations, ask the patient to tap out the beat: regular, irregular


Syncope or presyncope


Associated symptoms (breathlessness, chest pain)


Co-morbidities (including history of cardiac disease)

Initial investigations The initial diagnostic pathway is generally guided by the history and examination. It should include a 12-lead ECG in all patients and a pathology screen including FBC, EUC and TFT. An ECG at the time of symptoms is the gold standard but even in the absence of symptoms it provides valuable prognostic information. An abnormal ECG may point to the diagnosis, for example, hypertrophic cardiomyopathy, long QT syndrome, and ventricular pre-excitation. Other Investigations (secondary care setting) The key to making the diagnosis is recording the rhythm at the time of symptoms. The frequency of symptoms determines the best method of recording and includes: sĂĽ !MBULATORYĂĽMONITORINGĂĽnĂĽIFĂĽSYMPTOMSĂĽAREĂĽ frequent (24-hour Holter) or Event Monitor (1 week) if less frequent sĂĽ ,OOPĂĽRECORDERĂĽnĂĽIFĂĽRECURRENTĂĽSYNCOPEĂĽANDĂĽ diagnosis unclear sĂĽ %CHOCARDIOGRAPHYĂĽnĂĽINĂĽPATIENTSĂĽWITHĂĽ a history of heart failure, an abnormal examination including murmurs, an abnormal ECG, syncope or for the exclusion of structural heart disease sĂĽ %XERCISEĂĽSTRESSĂĽTESTĂĽnĂĽIFĂĽEXERCISE INDUCEDĂĽ symptoms or suspected coronary artery disease

2. Any family history – unexpected deaths, drowning, or epilepsy


3. Any contributing factors – triggers, relieving factors, relationship to exercise, drug/medication list, alcohol, caffeine

Features of the history or results of further investigation may prompt an urgent referral (see tables below).

4. Examination – patient's general state, particular attention should be paid to tremor or symptoms of thyroid disease. Assessment of heart rate, rhythm and BP, and auscultation of the heart.


Conclusion Primary care has a major role to play in the recognition, diagnosis and management of arrhythmias. The key elements include an accurate history, examination and appropriate referral.

Refer to Cardiology with urgency








AF is the commonest arrhythmia and is associated with increased morbidity and mortality. The condition is often asymptomatic and undiagnosed. Therefore, case identiďŹ cation with simple screening via manual pulse palpation is particularly important. A 12lead ECG is required to conďŹ rm the diagnosis and should be followed up by stroke risk assessment, rate control and follow-up.

Refer to Cardiology



Role of Primary Care in Atrial Fibrillation (AF)

Low Risk Manage in Primary Care


Dr Tim Gattorna graduated from the University of Sydney and completed his cardiology training at Royal Prince Alfred Hospital (Sydney) where he also underwent further subspecialty training in electrophysiology and pacing. His areas of interest include diagnosis and management of cardiac arrhythmias, including catheter ablation, and implantation and management of cardiac devices (pacemakers, implantable defibrillators and biventricular devices). He is involved in a number of multicentre, international clinical trials and is active in the training and education of medical students from the University of WA. Tim is a consultant cardiologist and electrophysiologist at Fiona Stanley Hospital. He consults with Western Cardiology at Subiaco, Midland, Northam and Kalgoorlie.










From PCCJ, Wolff and Cowan 2009

7JTJUXXXXFTUFSODBSEJPMPHZDPNBV 16 Cardiologists, together with Ancillary Staff, provide a comprehensive range of private Adult and Paediatric Services

Main Rooms: St John of God Hospital, Suite 324/25 McCourt Street, Subiaco 6008 5FMt$PVOUSZ'SFF$BMM 6SCBO#SBODIFT Applecross, Balcatta, Duncraig, Joondalup, Midland & Mount Lawley Regional: Busselton, Geraldton, Kalgoorlie, Mandurah & Northam MEDICAL FORUM


OCTOBER 2016 | 7

Letters to the Editor continued from Page 6 including potential side effects and cost – as they go through their decision-making process. This includes discussing the appropriateness of active surveillance and radiation therapy as alternatives to surgery. Outside of the GP and specialist office, there needs to be ongoing patient education to ensure men affected by prostate cancer have all the tools to research all treatment options. There is much emphasis placed on supporting research projects about prostate cancer. The same emphasis needs to be placed into developing new, accessible patient education resources. Prostate Cancer Foundation of Australia (PCFA) is supporting the launch of an innovative online and mobile application, Advanced Prostate Cancer Xplained, which makes information about advanced prostate cancer more accessible and easier to understand. The app is an interactive tool that uses storytelling and illustrations to deliver information about the diagnosis, treatment and ongoing management of the disease. By offering a variety of resources to men and their families, it will encourage them to seek out information about prostate cancer treatment, especially those men who might not normally take the first step in seeking more information. A/Prof Anthony Lowe, CEO, Prostate Cancer Foundation of Australia .......................................................................

The laws don’t need changing Dear Editor, When Andrew Denton appeared on National Television ( Q+A: Facing Death) last November, he passionately supported assisted suicide for the elderly, the mentally ill and "anyone who is suffering", i.e. people with chronic diseases or pain. Denton also praised the Belgian system where anyone "tired of living" can request to be euthanased. Now, none of these groups qualify and euthanasia will be limited to the

"terminally ill" in his view! His policy reversal is staggering and politicians have every reason to be sceptical. A year ago, euthanasia campaigner Dr Nitschke was praising the "rational suicide" of 45-year-old depressed man Nigel Brayley. His views have not changed. Speaking on Sunday Night, (Crossing the Line), Nitschke supported assisted suicide for healthy people over 50 "tired of living" with no age limit for anyone with an illness, such as Mr Brayley. Assisted dying of the terminally ill under the "double-effect" provisions is already accepted medical practice and is supported by the AMA. It does NOT require any change in the law. Many GPs, however, are unaware of these provisions and are reluctant to use adequate pain-relieving medications. Clearly this needs to better publicised. Dr John Hayes, Consultant Physician, West Leederville ........................................................................

We must be better than this Dear Editor, We didn’t need more evidence of the terrible harms of detention, but the revelations in the incident reports leaked to The Guardian are horrifying, shocking, but not surprising. Not to the hundreds of doctors and other healthcare workers who have seen the evidence of the harms of immigration detention over and over again. Not to those of us who have repeatedly voiced our concerns about the extreme risk to physical and mental health posed by conditions in the Nauru detention centre. “Bring them here.” The popular social media catchcry that all asylum seekers on Nauru and Manus Island be brought to Australia is an echo of what the Royal Australasian College of Physicians has been saying for years. Why? Because immigration detention harms the health of every single person there – adult and child – in both the short and long term. In 2½ years, there were seven reports of sexual assaults and 59 reports of physical assault against children in the Nauru centre. Threats of sexual violence and incidents of self-harm are even more common. The RACP understands from the UN refugee agency UNHCR that the Nauru centre sees rates of post-traumatic stress disorder and depression among the highest recorded in medical literature anywhere in the world. My fellow paediatricians and other brave health professionals – risking jail time for speaking out on the impact of detention on the health of their patients – are once again asking the question: when will our warnings be heeded?

but for us it is clear: children are suffering unspeakable abuse and harm in immigration detention, right now. Quite possibly, they will suffer the physical and mental health effects for the rest of their lives. We have repeatedly warned that the conditions for children in the Nauru detention centre pose devastating health risks and we have offered the solution: bring them here. In Australia paediatricians can properly treat our young patients, we can discharge them from hospital knowing we will see them again, and we can fulfil our legal and ethical requirements to ensure we are not sending these children back into harm’s way. The offshore detention of children prevents us from doing these things. The system that we have created in Australia will not allow paediatricians to fulfil our most basic function; to promote and protect the health and wellbeing of children. Are we really the kind of society that turns away when we hear of young children being hurt, assaulted and abused? How many Royal Commissions do we need before we finally say, “Enough!” We don’t need any more reports or horrifying news headlines to tell us what we already know. Children are being harmed, abused and traumatised, and it must stop. Now. We are better than this. We must be. Dr Sarah Dalton, RACP Paediatrics & Child Health Division President ED: On August 10, The Guardian Australia released leaked incident reports totalling more than 8000 pages from the Nauru detention centre, dubbed The Nauru Files. The reports (from May 2013- October 15) reveal the assaults, sexual abuse, self-harm attempts, child abuse and living conditions endured by asylum seekers held by the Australian government. The news site’s analysis revealed that children were over-represented with 51.3% of those reports involving children. ........................................................................

We welcome your letters and leads for stories. Please keep them short. Email: (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

Paediatricians, physicians, psychiatrists, nurses – we all speak from an evidencebased perspective. Yes this is a highly emotive issue in a politically charged environment,

8 | OCTOBER 2016


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Homelessness Linked to Poor Health Having somewhere to call ‘home’ is an important component of integrated health care, suggests A/Prof Lisa Wood. It wouldn’t come as a surprise to most health professionals that people experiencing homelessness are less likely to access primary care. Consequently, they’re much more likely to engage with the acute and more costly end of the health service spectrum. New research released by the UWA Centre for Social Impact has demonstrated that there are enormous savings for the health system when people struggling with homelessness are provided with public housing. The study, undertaken with colleagues Professor Paul &LATAUåANDå3HANNENå6ALLESI åISåTHEålRSTåINå Australia to link hospital and health service data with public housing and homelessness statistics. Within just one year of their entry into public housing, the 3383 participants in the study who were previously homeless showed a marked reduction in ED presentations, hospital admissions and length of stay coupled with a reduced number of bed-days in psychiatric units and ICU. This equated to a combined annual cost-saving of $16.4m for the WA health system. The most dramatic reduction in the use of health services was observed among people who received support from a National Partnership Agreement on Homelessness (NPAH) program. This is a joint federal and state/territory government initiative that couples access to public housing with targeted support. Unfortunately, it’s only funded until 2017.

There were nearly 1000 study participants in the NPAH program and the average reduction in health service use equated to a potential saving of $13,273 a year for each individual. An even larger cost saving was observed among those public housing tenants who had been part of a NPAH program where housing support workers provide assistance to people exiting a mental health service. The cost saving in the latter case equated to an average of $84,135 per person, largely attributable to the significant drop in psychiatric admissions once people were established in stable housing. The study also surveyed some of the public housing tenants and the results reinforced a strong relationship between housing and health. It was obvious that precarious housing circumstances exacerbate stress and mental health issues for many people, making it more difficult for them to commit to health-related behaviour changes. Conversely, there were reports of positive changes in mental and physical health among surveyed tenants once they were living in a place they called ‘home’. These are compelling findings for the health and medical sectors. They reinforce the fact that the revolving door between homelessness and poor health can actually be addressed, and that doing so can save the health system money. Most critically, the health sector savings far outweigh the cost of providing support for homeless people to access public housing.

This confirms the merits of prevention and early intervention, a public health policy much espoused at the moment. Just as importantly, the study findings support the merits of more fully integrated models of health care. See feature Page 31

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Have You Heard?

MBS item shake-up

Consumer watchdog sanctions DNA test The ACCC has sounded a warning to DNA ‘retailers’ that they are watching them – closely. It fired a shot over Chemart’s bow when the watchdog told the retailer that the promotion for its myDNA test was misleading. The material in Chemmart’s catalogues, television infomercials and in-store brochures made claims about the effectiveness of the test in identifying an individual’s response to certain drugs. It “risked conveying a false or misleading impression regarding the usefulness of the genetic test, and the consumers for whom it may be appropriate,” says the ACCC. It went on further to say consumers trusted pharmacists and the information they provide … “Consumer are entitled to expect that products and services…are promoted in a way that is clear and accurate, and explains both [their] benefits and limitations." The ACCC accepted an administrative undertaking by Chemmart to withdraw the offending material.

Early in September the MBS taskforce handed down it interim report and it didn’t take long for it to alienate thousands of doctors. The president of the RACGP, Dr Frank Jones, was less than impressed. "The federal government is running an inequitable campaign against general practice and GPs, which is not based on best evidence," he told media. The big offence is this oddly termed ‘administrative’ GP consult. Frank smells a rat with the report being leaked to The Australian newspaper before its release and that coverage focuses on ‘wasteful’ GPs. Leaving that to one side, the report’s Appendix A should be mandatory reading for all docs. Here the clinical committees report their deliberations. We heard a little about the Imaging team’s talk during the election but ENT, Gastroenterology, Obstetrics and Thoracic medicine have also offered up their obsolete item numbers. The interesting recommendation from the ENT team is for the fee differential between GPs and specialists doing the same procedure to be scrapped. And that message is reiterated by the Obstetrics committee for ectopic pregnancy. Download the report

Faster help for FASD kids In August, we spoke to Telethon Kids’ Prof Carol Bower about the FASD project at Banksia Hill Juvenile Detention Centre and she announced then that the long-awaited diagnostic tool was ‘close’. That day has arrived and it is now ready for practitioners


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12 | OCTOBER 2016

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Have You Heard?

who have patients at high-risk to download. Carol said the tool would allow clinicians to make an early FASD diagnosis using the national standardised diagnostic criteria and instrument and provide the foundation to improve rates of diagnoses of FASD in Australia. “Unfortunately…FASD is a condition that is under diagnosed in Australia. We hope this national tool will improve those rates.” You can download here http:// Australian-FASD-Diagnostic-Instrument

Razors at the ready In July, we spoke to HBF boss Rob Bransby who was pushing for an overhaul of the prostheses pricing list when he discovered the difference in prices being charged for prostheses in public and private hospitals. He would be welcoming the Health Minister Sussan Ley’s announcement of a new Prostheses List Advisory Committee (PLAC) in mid-September, led by cardiologist Prof Terry Campbell, who is an academic at 5.37åANDåHEADåOFåMEDICINEåATå3Tå6INCENTSå Hospital in Sydney. He has also been a longtime member of the PBAC. The minister has tasked the committee not only to improve affordability and access for consumers but to reduce duplication in the TGA's assessment processes. She also promises improved transparency of the PLAC’s deliberations.

Health insurers brace for reform Reform fever has struck health insurers with the Minister announcing, you guessed it, yet another committee! Distinguished

public servant Dr Jeffrey Harmer is the chair of the Private Health Ministerial Advisory Committee. He will soon be joined by appointees from the Consumers Health Forum, COTA, the AMA, RACS, Allied Health Professionals Australia, Private Healthcare Australia, the NFP group HIRMAA, Australian Private Hospitals Association, Catholic Health Australia, Day Hospitals Australia, the Medical Technology Association of Australia and an independent private health insurance industry expert. High on the reform agenda is the development of user-friendly policies and premiums.

Sponsor truth doesn’t hurt a bit Well the world didn’t implode with the first reporting of payments and transfers of value to doctors on the Medicines Australia website on August 31. In fact it was a little underwhelming and not very sexy at all. The amounts were modest and often for attendances to interstate meetings – gone were the thoughts of hoola girls and Bollinger. And given the public statement by Medicines Australia, you’d never know they resisted the changes like ornery mules. Now MA and its members are “leading the way in providing greater transparency for consumers”. Payments, it said, were for doctors to share their expertise and knowledge with pharmaceutical companies or leading medical education for other healthcare professionals. Doctors who appear on the register have automatically given consent for their interactions with drug companies to be made public. According to MA, nearly two out of three healthcare professionals agreed

to have their names reported; so that leaves a third whose dealings remain secret. We know that meals under the value of $120 don’t have to be reported.

Counting the heart beats We see a lot of reports and a lot of statistics, but hands down, the Heart Foundation’s Australian Heart Maps is the best fun we’ve ever had playing with stats. Log onto http:// australian-heart-maps and mouse over the states for their individual ASR for all heart admissions (WA is 47 per 10,000); click on a state to have the stats broken down even further, and again to refine the figures into local government areas, which is then compared against the national average and ranked. Of course, it has more than entertainment value. Using data from hospital admission rates the foundation says it will be a valuable tool for health professionals, health services, local governments, researchers and policy makers as the maps also highlight the association between socioeconomic disadvantage and remoteness to heart health outcomes. It also breaks down admissions for heart attack (both STEMI and NonSTEMI), heart failure, and unstable angina.

“Everyone in rural WA is doing great work, however, I’m humbled to be singled out and recognised by my peers.” Dr Michael Comparti 2016 award winner

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Laughter Really is the Best Medicine There’s nothing quite like a spot of amateur dramatics to get a community laughing and enjoying life together, according to Albany doctors Andrew Wenzel and Airell Hodgkinson. tripping over. We also needed people who are actually funny in a Monty Python kind of way.”

It was four months of rehearsals three times a week for Albany’s Dr Andrew Wenzel before Spamalot hit the stage. Andrew played the hapless King Arthur in the Albany Light Opera & Theatre Company production and he was ably assisted by actors, singers, dancers, musicians and back-stage staff. It was a community effort and the end result was hilarious!

“There was a good medical representation in the production with a physiotherapist as my offsider, a dentist and a couple of nurses with lots of singing and dancing. There was also plenty of dialogue for King Arthur!” “This sort of thing is terrific for a small regional community. We got great feedback, and I don’t think that’s just people being kind! Theatre such as this promotes a great sense of community connection and it’s a wonderful opportunity to see people revealing hidden skills.”

“It was a lot of work and plenty of fun, although it didn’t feel like work until after the final performance and then we all realised just how tired we were. We played every Friday and Saturday night for a month, so 10 performances in all and the majority were sold out.” “There are always new people who come out of the woodwork and just blow you away with their skills. A local teacher revealed his talents as a master of amusing accents!” “And another Albany medico, Dr Airell Hodgkinson made his debut as a director for this production.” Spamalot was a long time coming, but the actors can’t be blamed for that! “We had to delay the opening for just over a year because of asbestos in the roof at the Port Theatre. It’s an historic old building and the theatre space is actually a renovated cold-

Dr Rohan Gay and Dr Brenda Murrison

såBayswater GP Dr Rohan Gay is the 2016 WA GP Supervisor of the Year. The RACGP also named Dr Mary Wyatt, of the Ranford Medical Centre, WA Registrar of the Year. Bunbury’s Brecken Health Care, established by Dr Brenda Murrison is the WA Practice of the Year. Also honoured in the awards were Dr Jane McCulloch who won the Edward Gawthorn Prize for her (2015.2) results and Dr Hilaire Dufour for her 2016.1 results. The RACGP WA Faculty Legend is Dr Sean Stevens. såThe WA Government has announced the first Healthway board under the new legislation which it passed earlier this year. The seven-member board will be chaired

14 | OCTOBER 2016

Dr Andrew Wenzel as King Arthur

storage facility that now seats around 200 people.” Andrew’s passion for theatre goes right back to his school-days. “I did drama as one of my matriculation subjects in South Australia and I’ve been involved with the theatre ever since. Spamalot is the third show that Airell and I have worked on together. Everyone, including me, has to audition in front of a panel because we need to make sure that people can hold a tune and move their feet without

by Prof Bryant Stokes, who is currently chair of the NMHS board. Others on the board are: Ms Fiona Kalaf, CEO of Youth Focus; Mr Nathan Giles, ED of Perth Public Art Foundation; Adj/Prof Terry Slevin, Director of Education and Research at the Cancer Council WA; Mr Steve Harris, CEO of the Brand Agency; Dr Roslyn Carbon, a Combat Sports Commissioner and a clinical consultant for athletes and the general public; and Ms Ricky Burges, CEO of the WA Local Government Association. Healthway has an appropriation of $23.3m in the 2016-17 state budget.

“Having the manager of a major building company up on stage in tap shoes made it all worthwhile. It’s a real delight to go along to the theatre and see your friends make fools of themselves, in the nicest possible way of course!” “Airell and I couldn’t resist a bit of fun on April Fool’s day. We put out a press release saying that we’d fallen out over artistic differences and we’d secured the services of Hugh Jackman to play King Arthur.” “We were quite surprised when one person asked for a refund, even after we announced that the entire thing was a joke!”

By Peter McClelland

in Armadale, Murray and SerpentineJarrahdale. The region was launched on September 30. såThe national Mental Health Commission has appointed Dr Peggy Brown as its CEO replacing Mr David Butt.

såProf Jonathan Carapetis and Dr Tom Snelling from the Telethon Kids Institute were finalists in the leadership categories of the Eureka Prize. såMs Stephanie Buckland has replaced Mr Ray Glickman as CEO of aged care NFP Amana Living. såMr Milton Catelin is the new CEO of Medicines Australia. He takes over the reins from interim CEO Mr Lee Hill. såMs Sheila-Anne MacLeod is the Regional Manager for the latest WA NDIS region

såProfessor Alistair Forrest (above) from the Perkins Institute has won a 2016 Australian Museum Eureka Prize for international scientific collaboration for his work with the FANTOM5 project, which involves researchers in 20 countries. The genetics project started in Japan.


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OCTOBER 2016 | 15

Guest Column

Helping to Make a Difference Overseas With children almost grown, Wembley GP Dr Lin Arias decided to take her medical skills to Kolkata and writes here about the inspirational clinical work being done there. As doctors, we share a passion for helping people. We want to use our brains, our hands and our compassion to relieve suffering. We enjoy making people better. We are also a privileged lot and we like to challenge ourselves, inside and outside of medicine. There are amazing people doing wonderful, life-changing work whose stories never make it into the media. One such person is Dr Jack Preger, a doctor from the UK, who came to India in 1979 to help the slum dwellers of Calcutta, or Kolkata as it is now called, and started the NGO Calcutta Rescue (CR) more than 30 years ago. CR is no longer just Dr Jack and his doctor’s bag. It operates three standing clinics with doctors and allied staff; a street doctor van, which visits the slums; and two schools to help the children grow up healthy, and educationally robust enough to be able to enter the government school system.

pharmaceutical education sessions for the clinic doctors, who are paid a token fee for their work and who therefore earn their living outside of their sessions with CR.

CR also runs programs that teach craft skills to disabled workers. These men and women produce handicrafts, which CR sells, earning the workers an income and improving their chances of gaining other employment. The sewing group, for instance makes school uniforms. All their products are Fair Trade certified.

My latest visit eventuated after a vigorous email exchange with Deputy Medical Officer Dr Ghosh. She idenitifed that the nurse and doctors who provided maternal and child health care could benefit from education and support. Having a DRACOG and a lot of experience in antenatal care at KEMH, this sounded like a role I could fill.

Patients waiting to be seen by the Street Doctor, Instruction packet for taking medicine.

For two weeks I sat in with nurse Sheila as she saw the antenatal and postnatal women. She assessed infants and toddlers who had been identified as malnourished and who were on the supplemental feeding program CR runs. Sadly, sometimes the children don't gain weight. In one instance, the father was taking the milk for himself or selling it.

Dr Ghosh, nurse Sheila and Dr Lin Arias at the main clinic

A Governing Council oversees the work of a dedicated staff. CR is supported by international groups, which raise money for its work and send volunteers, mainly allied health workers, to help and train local staff. To ensure sustainability, it is all run and managed by locals. Outsiders, like myself, primarily help in a teaching role. Pharmacists from Germany teach local pharmacists (who don’t have training) about the medicines they stock and dispense to the clinics. They also run

16 | OCTOBER 2016

6ISITINGåTHEåVARIOUSåCLINICSåYOUåMUSTåBEå prepared to see anything from accident trauma, coughs and colds, rashes, worms to pneumonia, major trauma and leprosy. Clinic and outreach staff are always on the lookout for white patches of skin and persistent cough, signs of leprosy and TB, respectively. These patients are educated about the need for hospital review and CR uses its vehicles to take them to the hospital clinic for care on the day as a matter of urgency. One morning clinic was devoted to following UPåANDåDISPENSINGåMEDICINEåTOå()6åPOSITIVEå patients, many of whom were teens and young adults. All clinic patients are required to attend an educational session each time they visit the clinic. They are also provided with a simple breakfast and their travel expenses as some come from over an hour away.

Postnatal patients waiting for Sheila’s clinic to start.

to fight for the rights of the poor to access health care and it’s humbling to see what he’s achieved against so many odds. To participate even in a small way is a privilege. I’ve been to India several times, it's an exhilarating place full of movement, colour, fantastic food, smells, beauty, and changing scenery. I find it enthralling. No, I don’t like the pollution, the garbage, the congestion, the spitting, and the poverty. However, rarely is it overpowering and it’s not hard to find 10 minutes out of the hustle and bustle to find some peace and quiet, collect my thoughts and equilibrium then get back out on the streets of Kolkata again.

Now in his 80s, Dr Jack Preger continues


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OCTOBER 2016 | 17

News e s & Views e s

Downturn Hits Families Hard The demand on the resources of FoodBank is the litmus test for hard times in the community and right now there are thousands out there hurting. It’s a disturbing fact of contemporary life that an increasing number of West Australians are falling into the category of the ‘working poor’. Greg Hebble, the CEO of FoodBank WA, spends his days exploring the supply-line to divert food surplus to those in need of assistance. “It’s a real concern that every week more than 18,000 children in WA, from Kalumburu to Esperance, go to school without eating breakfast. FoodBank runs Australia’s biggest breakfast program and we’ve had positive outcomes such as increased attendance rates, particularly in regional areas.” “We also offer lunches because we know that some children won’t get an evening meal. We do worry about what happens on the weekends, but we’re not here to be the food police.” FoodBank is a conduit between ‘surplus’ and ‘need’ and Greg has the perfect experience to link the food industry with charities and relief organisations. 'Working poor' included “I spent around 30 years in the grocery industry and then I was on the YMCA Board in Sydney for a decade. FoodBank needed someone in Perth with retail food experience and a strong commitment to community. FoodBank will be providing more than five million meals this year and around half that much again in our ‘Food for All’ Breakfast program. I’ve been here just over seven years and thoroughly enjoying it.” FoodBank doesn’t fall within the ambit of a frontline charity. “We don’t have the general public coming to our door and we don’t do any vetting of potential clients. The people we see are sent to us from frontline charities such as the Salvation Army, Mission Australia and Anglicare. There’s an undeniable increase in

18 | OCTOBER 2016

the demand for their services and, sadly, I don’t see that diminishing anytime soon.” “A lot of people out there who have two jobs are really struggling. They’re the ‘working poor’, often with two or three children, a hefty mortgage and lots of bills to pay. The problem of not having enough to eat cuts across a broad demographic and it’s not just pensioners, the homeless or those on Centrelink.” Strains on families, some turned away “It could be the person next door who needs a hand-up. There’s about 10% of the population in WA who are currently at risk of falling into a food crisis and will need some help from us.” “It’s a tough time at the moment and a family could be on $60,000 a year and still be struggling.” “The majority of the product we get is from food manufacturers and retailers. It’s often getting close to its ‘Best Before’ date but we all know from experience that many foodstuffs are absolutely fine well beyond that time-period. Obviously that doesn’t apply to anything in the ‘Use By’ category, such as perishables like milk.” “But this food can’t legally be sold, so instead of going into a hole in the ground we ‘rescue’ and distribute it.” “We have a strong focus on fresh fruit and vegetables, some of which is still hanging on the tree or sitting in the ground. Sometimes it just doesn’t meet ‘market grade’ standard and we’ll get volunteers from the corporate sector to come and pick the fruit as a teambuilding exercise.” In spite of the activities of organisations such as FoodBank, Greg maintains that a lot of work remains to be done.

Greg Hebble

community. We put out a Hunger Report every year that embraces more than 450 charities across the state and the findings are disturbing. More than 53,000 West Australians are being fed by these agencies every month and roughly 7000 are being turned away.” Topping up supplies “We often have to purchase staple food items such as rice, flour and tinned products so that there’s a good balance of products available in our food distribution centres. Apart from our Perth base we’ve got five in regional areas – Geraldton, Kalgoorlie, Mandurah, Bunbury and Albany.” “The downturn in the resource sector has seen a big increase in demand for our services in the Peel region. There are a lot of people living down there who used to be FIFO workers and they’re out of work now.” Keeping the service up and running is demanding according to Greg and he’s keen to spread the word, particularly within the medical fraternity. “The majority of our funding is provided by the state government and we do get support from Telethon and the corporate sector. We’re on our way to building a self-sustainable model but we’re not quite there yet.” “It’s important to let GPs know that there are organisations out there that may be able to help any of their patients who might be struggling. I’m sure that doctors have these conversations all the time in their surgeries.” “In fact, we’d welcome any group of doctors to come out and have a look around. You can’t get a real appreciation of the scale of FoodBank until you see it in operation. There’s a WOW factor, that’s for sure!”

By Peter McClelland

“There’s a ‘hunger crisis’ out in the



OCTOBER 2016 | 19


Support for Remote Solo GPs Retaining the services of GPs working ng solo in small rural and remote towns is vital to the health and welfare are of the entire state. Help is at hand. The unique pressures experienced by GPs working in rural and remote regions, often as solo practitioners, if not addressed can have serious consequences for the doctors involved, their families and their patients. The workforce issues that have hit the headlines in the past few weeks overlook the fact that 55% of the WAâ&#x20AC;&#x2122;s rural and remote doctors have overseas qualiďŹ cations. So how best to support them and the host of Australian-trained doctors practising in the bush? Rural Health West in July launched the Strengthening Solo General Practice Project, which over the next 18 months will focus and strengthen strategies to help 35 solo GPs in rural and remote towns of between 800 and 1200 people in ways that city doctors often take for granted. Ultimately, it aims to create a more stable and sustainable medical service in small country towns. As the map shows, the Wheatbelt has the greatest reliance on solo GP practices in Western Australia and Australia, so it was a logical place to start this pilot. Emphasis on practicalities Project coordinator Beth McEwan and Workforce Services Manager Laura Hartnett told Medical Forum that it was important to recognise that remote solo GP work was tough and so the project would focus on problem areas that if not addressed could lead to frustration, burn out, family stress and mental health issues for the doctor and a community without a doctor. It will look to: sĂĽ (ELPĂĽSOLOĂĽ'0SĂĽTOĂĽMAINTAINĂĽTHEĂĽAPPROPRIATEĂĽ clinical skills to do their jobs conďŹ dently and competently. In many cases, the solo GP is on-call 24 hours a day, not only in their practice but at the local hospital as well.

Narabeen GP Dr Peter Lines with Governor Malcolm McCusker

He told Medical Forum that from his perspective, the round-the-clock responsibilities could take its toll. Pressures of 24/7 depends on local help â&#x20AC;&#x153;That is probably the biggest potential source of stress and it depends on how much conďŹ dence you have in your local nursesâ&#x20AC;&#x2122; abilities to deal with issues on their own without needing to ring you for every little thing. A good team of nurses make a huge difference so the culture of local hospitals is important because staff must feel supported,â&#x20AC;? he said.


â&#x20AC;&#x153;In my case, weâ&#x20AC;&#x2122;ve brokered an agreement where I am only disturbed overnight if it is very serious problem. The evening is not a problem if Iâ&#x20AC;&#x2122;m at home, and I am on-call one weekend in three but it is good to know that there are times when Iâ&#x20AC;&#x2122;m not going to get disturbed.â&#x20AC;?

sĂĽ &ACILITATEĂĽ'0ĂĽTOĂĽ'0ĂĽMENTORING ĂĽESPECIALLYĂĽ from GPs who have long-term rural experience and understand the difďŹ culties of going solo. A number of GPs have already formed a reference group to counsel colleagues.

â&#x20AC;&#x153;I donâ&#x20AC;&#x2122;t drink alcohol so that aspect is not a concern for me but other doctors might value time when they can have a drink and relax, which, of course, is problematic when it comes to a hospital callout.â&#x20AC;?

sĂĽ 3UPPORTĂĽFORĂĽSPOUSESĂĽANDĂĽCHILDRENĂĽTOĂĽHELPĂĽ them settle in the community. sĂĽ ,OGISTICALĂĽSUPPORTĂĽFORĂĽDOCTORSĂĽSETTINGĂĽUPĂĽ practice, incorporating support from the local government and community groups to welcome the GP and their family. Narembeen GP Dr Peter Lines has run his own practice in the town for about 16 years after leaving Yorkshire in 1998 to experience rural practice in WA.

20 | OCTOBER 2016

One of the big positives of being the only GP in town is that you are an intrinsic part of a community. Positives outweigh the negatives but... â&#x20AC;&#x153;We see multi-generations of the same family and it is the ultimate in continuity of care. I really am following people throughout their health adventures and that is very satisfying. I really look forward to my job and the

experiences are more than dollars can buy,â&#x20AC;? Peter said. â&#x20AC;&#x153;I deďŹ nitely feel an important part of the communityâ&#x20AC;&#x2122;s life and am genuinely fond of pretty much all my patients, hopefully they feel good about me.â&#x20AC;? But there is another side to that commitment to patients. â&#x20AC;&#x153;You can feel slightly guilty if you need to take a day off to attend your own appointments or matters though patients tend to be understanding. But thereâ&#x20AC;&#x2122;s also the work waiting for you when you get back â&#x20AC;&#x201C; you know you are going to be busier catching up. So I donâ&#x20AC;&#x2122;t tend to take that much time off because it seems easier for me to plod along and keep turning up to work. Thatâ&#x20AC;&#x2122;s ďŹ ne though because I enjoy my work.â&#x20AC;? â&#x20AC;&#x153;Iâ&#x20AC;&#x2122;m lucky that I love living in a really small town and I hate going anywhere else. It is not a sacriďŹ ce to me. If I go to Perth once a year itâ&#x20AC;&#x2122;s once too often. I take an annual two weeksâ&#x20AC;&#x2122; holiday where the family and I tend to go overseas and during that period the surgery is closed as itâ&#x20AC;&#x2122;s generally felt that two weeks is not long enough to organise a locum.â&#x20AC;? â&#x20AC;&#x153;It seems to work fairly well. I donâ&#x20AC;&#x2122;t think my family feel they are imprisoned against their will. This is their home.â&#x20AC;? Locums and payments The availability of locums is a particular focus of the solo GP project and while Peter doesnâ&#x20AC;&#x2122;t usually call on one, he does have views on how the system works.



“I think it is a little unfair that a GP is expected to employ somebody to do his work in his place when it is likely to cost him money as often patients prefer to wait until the normal GP returns. It seems perverse that you are shelling out thousands of dollars a week and ensure the locum has accommodation and access to a vehicle and you may not get any of that money back.” “It would be better if it were agreed that locums would not bring in any income for the GP but nor would they cost him anything. Cost neutrality would be much better.” Does it take a special kind of person to take up a solo rural general practice? “You do have to feel confident in dealing with matters based on your own knowledge and experience, particularly given that you have little in the way of immediate support either from more experienced colleagues or ready access to services such as imaging and pathology,” Peter said. GP skills, better access, family needs “I probably do a lot more on clinical grounds than some of my city colleagues. They are able to send a patient off for a CT scan or a blood test and everyone feels better about it. I have to weigh up the pros and cons of sending someone on a logistically big trip to Perth.”

professionals in a way that was impossible a decade ago. Skype consultations with specialists and Emergency Telehealth are commonplace, though Peter adds that he could do with a lot more Skype consults for his patients.

“Assuming you get the medicine right, it is reassuring and rewarding to use your brain rather than ticking a box on a form.”

While a GP might be solo in their work, Peter believes it’s important to share the personal journey.

Technology is also connecting isolated health

“I think it’s important you have a family

with you or you can feel very isolated and that makes it essential your family feels comfortable in this life that has been chosen. Luckily we have an excellent school here at Narembeen, had it not been so good, we may not have stayed so long. But it is good and we are happy to stay. This is home.”

By Jan Hallam

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OCTOBER 2016 | 21

News & Views

Busselton Releads the Way What started out as a rural GP’s vision to improve the health of his community has developed into a global treasure trove for researchers at the edge of science. The Busselton Population Health Studies celebrates 50 years next month and there would be few doctors who have not been touched by its work in some way – be it personal involvement or having used some of its research findings at medical school or in their practice. It’s like a faithful friend who’s always there but, at times, can be taken for granted. So in the golden glow of such a significant anniversary, it is fitting to remind ourselves what it has achieved and what it means to WA to have such a substantial and distinguished longitudinal population health study in our midst.

Among the discoveries are: så 4HEåDISCOVERYåOFåTHEålRSTåGENETICå association with asthma så $ElNINGåTHEåCLINICALåRELEVANCEåOFåGENETICå testing in haemochomatosis så .EWåGENEåDISCOVERYåANDåCONlRMATIONåOFå KNOWNåGENETICåASSOCIATIONSåWITHå#6$ å respiratory disease, lung function, obesity, sleep apnoea, diabetes, iron metabolism and thyroid disease And the list goes on but at the heart of it all is Kevin Cullen’s prime motivation – to demonstrate the health effects of the survey, or as Prof Welborn said in an oral history about the project: “No survey without Service”. The health care of the Busselton participants would be enhanced by their involvement. After a period in the 1980s and 1990s when there were some widening survey gaps, the past decade has seen renewed and reinvigorated work on the longitudinal study owing in part to a permanent presence in the town.

Dr Kevin Cullen and Prof Tim Welborn

It’s certainly come a long way since Busselton GP Kevin Cullen pushed the idea in 1966 for a cross-disciplinary study of community health that would not only help to improve care but also provide research opportunities for undergraduates and post-graduates in the social sciences and medicine. His ideas were music to the ears of young Perth-based researchers, endocrinologist Prof Tim Welborn, epidemiologist Dr Michael McCall, biochemist Dr David Curnow and CSIRO biostatistician Dr Norman Stenhouse. And with a lot of hard work and forthright exchanges of opinion, the first health survey of 3394 Busselton adults took place in November 1966 with 1614 Busselton children surveyed the following year. The surveys have changed shape as the population of Busselton has grown and become more mobile – from 6000 in 1966 to 36,000 in 2016 – and research focuses have changed reflecting worldwide clinical demand. Data and biosamples from the 20,368 Busseltonians who have participated have contributed to more than 400 local and international scientific papers across a broad range of chronic diseases.

22 | OCTOBER 2016

The Busselton Population Medical Research Institute (BPMRI) has been established with survey centre director Dr Michael Hunter leading a core staff and overseeing the annual collection Dr Michael Hunter of data. Between 2005 and 2008, surveys have been conducted into the respiratory health of 4268 adults and children, sleep studies for 793 and obstructive lung disease. In 2008-09 the focus was diabetes and from 2010 the surveys have looked into healthy ageing and currently until 2020, the health of Baby Boomers. The eyes of the world are on Busselton. “A lot of our research is presented to international conferences and the conversation and topic is Busselton. Particularly over the past 10 years, the data set has allowed us to be a part of large international collaborations exploring genetic causes for a range of diseases,” Michael said. “Busselton is the first stop for many researchers because the data is here. The Busselton studies have really put WA medical

research on the map. Local researchers such as Prof Fiona Stanley, who was involved in the study as a student collecting samples, to Nobel Laureate Prof Barry Marshall, who used data collected in Busselton to study the transmission rates of helicobactor pylori, have mined what Prof Stanley describes as a treasure trove. “It is a unique resource and as technology and scientific knowledge expands, the importance of the results from the past 50 years has become invaluable,” Michael said. “The explosion of genetic technology over the past 10 years has seen researchers all over the world use DNA samples that were collected 30 years ago in the 1994-95 survey as they have moved from genome association studies to genomic location of a disease to genome sequencing.” “The only way you can do these types of studies is to have a really well phenotyped population like Busselton with DNA samples available and the willingness of the community to take part. This is an irreplaceable resource.” Research funding is tricky at the best of times, in fiscally constrained times even harder and Michael said the challenge is to keep the study and the work of the institute at the fore of public consciousness. But like many other research institutes, the competition for NHMRC grants is intense. The BPMRI’s activities are partly supported by State Government grants and custodial arrangements of the database and the biospecimen collection exist with UWA and Pathwest. However, to maintain this 50year resource and fund ongoing surveys a relatively modest $750,000 a year secured funding would ensure its future. “With the permanent presence of the study in Busselton, the past 10 years have seen the community re-engage and we are starting to achieve exceptional participation rates that match the earlier surveys. We are building momentum. Staff are trained and the people of Busselton are enthused. To lose that headway, or shut down survey activity would take a lot of time, resources and money to build back up again.” ED: As part of the 50th anniversary an online publication and a hard copy history of the work of the Busselton Population Health Study is at http://


News & Views

IMGs and GPs for the Bush The issue of Australia’s reliance on International Medical Graduates is never far from the surface. The debate rages once again with strong rural-urban differences. Medical Graduates in Rural WA 2010



























Source: Rural Health West * Australian Medical Graduates A few weeks ago, The Australian newspaper released an unpublished Health Department submission to the Government’s review of Immigration’s Skilled Occupation List (SOL) – and 41 health jobs were on the hitlist to chop, among them GPs, resident medical officers, surgeons and anaesthetists. The cuts were supported by the AMA and the Rural Doctors Association of Australia. The RACGP had made a similar call back in May. Their arguments were based on the increased number of local medical graduates finding it difficult to secure training places and internships. However, the CEO of WA’s largest rural recruiter, Rural Health West, has cautioned against any hasty decision to halt the supply of IMGs until effective strategies were in place to attract and retain Australian-trained graduates to rural and remote locations. CEO Tim Shackleton said while recent strategies to draw Australian graduates into these areas was proving successful, Rural Health West was currently seeking candidates for 90 GP vacancies in rural and remote locations across the State – the highest number of vacancies on record. “This high number of vacancies and the significant proportion of IMGs working in rural WA demonstrates that, at present, the increased number of locally-trained medical graduates are not yet making their way to more rural and remote locations,” Mr Shackleton said. Don’t underestimate IMGs rurally “The contribution of IMGs to the rural WA medical workforce should not be understated.” The most recent census of WA’s rural general practice workforce (as of 30 November 2015) showed that of the 897 GPs working bush, 493 (55%) had obtained their basic medical qualification overseas and that proportion had not changed much since 2008. Last year, a report from Rural Health West showed that the largest proportion of IMGs had gained their basic medical qualification in the UK (19.5%); followed by Pakistan (8.5%) and Nigeria (7.3%).

(19.5% in 2015 compared to 25.6% in 2012),” the report said.

difference creating a “mismatch” in some rural communities.

Medical Observer opened a comment line on the issue of the SOL and, of the 320 respondees, two thirds wanted a stop to IMGs coming to Australia. The arguments ranged from the need to give the increasing number of local graduates a job to stopping what some described as poor-calibre IMG candidates practising in Australia.

However, he was also critical of the apparent lack of interest by Australian graduates in obtaining rural practice experience.

Is it just about standards? Criticism of the clinical standards of some IMGs has continually dogged all overseastrained doctors. However, the Medical Board’s criteria is rigorous. Rural Health West requires recruits to have a minimum of three years’ experience after graduation (the MBA, two years), though the perceptions still prevail. Medical Forum spoke to one rural GP who thought some IMGs were perhaps not prepared for rigours of rural practice. He said that in some instances poor English skills were a barrier to clear communication with patients as well as body language and cultural

For Lease

Locals lack of interest “International students are the ones keen to do a four-week rotation in the country. They seem much more prepared to come and see what it’s all about out here. Australian students just seem to want to stay in the city.” More GP registrars, recruited by WAGPET, are heading to the bush – in 2015, 25 who completed their specialist training through the RACGP or ACCRM, elected to take up positions in rural WA, the highest ever. However, as MF reported last year, federal funds for the vocational GP training program dried up as of December 2015. Perhaps the government needs to review that decision in the light of the evidence.

By Jan Hallam See e-poll page 26

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Perth 441 Murray Street s¬ West end of CBD s¬ Various areas available s¬ 4 star NABERS rating Ross Skelton – JLL 0418 926 430 Mitchell White – JLL 0411 055 544 Colin Gilchrist - CBRE 0410 336 241

“While the UK continues to be a significant source of new GPs, the proportion of doctors who initially trained there is declining annually


OCTOBER 2016 | 23


Using Your Helmet … Not Your Head Those who are ruled by evidence say the jury is out when it comes to the efficacy of helmets in sport. It’s a different matter if you ask the players.

Western Force prop Pekka Cowan, above, sports his colourful headgear and, below, Hockeyroo goalie Rachael Lynch suited up for battle.

instructor with a long-standing involvement in water sports. “It’s compulsory for all kitesurfing organisations with a teaching licence to make sure every student wears a helmet and a lifevest. But it’s also interesting to note that the majority of people, once they’ve completed the course, choose not to wear them.” “They’re much more likely to be worn by elite surfers in big waves, particularly if they’re near a shallow reef. Obviously, there’s a much greater chance of hitting your head in challenging conditions.” It would seem that male vanity plays a part, too. Some kite-surfers are pretty keen to look like Formula 1 drivers. Hockeyroo goalie Rachael Lynch is one player who needs protective gear. What about the others?

The general consensus is that not even a revamped protective helmet would have saved Australian Test batsman Phillip Hughes. His death in November 2014 was a ‘freak accident’ but as one pundit put it, ‘one freak accident too many.’ Helmets and headgear are worn in a range of sports at both junior and senior level despite the fact that their usefulness remains contentious. It’s worth taking notice when Sports Medicine Australia, our most high-profile sports science organisation, sees fit to remind us that there is no good clinical evidence to support the argument that wearing protective headgear will prevent concussion. And there’s always that

24 | OCTOBER 2016

old ‘increased risk-taking’ chestnut implying that any form of artificial ‘protection’ may encourage individuals to place themselves in harm’s way. Wind on water and rocks Kitesurfing is a boom sport in WA mainly due to the fact that we have some of the strongest, most consistent sea-breezes in the world. The ‘Fremantle Doctor’ not only drops the temperature 10-15 degrees in a matter of minutes but also provides plenty of aerial thrills for those strapped on to one end of a powerful expanse of colourful nylon. Michael Oliver is an experienced kitesurfing

“There are a number of different models around varying in price from around $90 to $300. For some people it’s as much about aesthetics and ‘looking good’ as any concern about safety,” Michael said. “But it’s important to remember that you’re attached to a giant and very powerful kite. If you lose control, things can go wrong very quickly. There was a tragic accident at Cottesloe a few years ago when a guy died after getting slammed into rocks.” Rugby’s impact zones Rugby at the elite level is not for the fainthearted. Pekka Cowan, former Wallaby and current Western Force player, wears some of the most spectacular headgear you’re ever likely to see on a football field. “It was funny how that came about, I’d split




Kitesurfer at play

my head just before I did an on-camera interview so I was all bandagedup. Putting on some headgear made me look a bit more presentable. After that I decided to wear it all the time so I chose the loudest and proudest model I could ďŹ nd!â&#x20AC;?

Senior Medical Practitioner Emergency Medicine

â&#x20AC;&#x153;The company that makes it ended up giving me a contract and they send me a whole pile of kidsâ&#x20AC;&#x2122; sizes and I throw those into the crowd after the match.â&#x20AC;?

WA Country Health Service is seeking four highly motivated Senior Medical Practitioners to join the team based in Geraldton.

Pekka has a short and informed response to Sports Medicine Australiaâ&#x20AC;&#x2122;s claim regarding a paucity of evidence supporting headgearâ&#x20AC;&#x2122;s efďŹ cacy against concussion. â&#x20AC;&#x153;Well, theyâ&#x20AC;&#x2122;re not the ones running onto the ďŹ eld! I havenâ&#x20AC;&#x2122;t been concussed since wearing headgear and Iâ&#x20AC;&#x2122;ve deďŹ nitely avoided cuts and lacerations. I wouldnâ&#x20AC;&#x2122;t mind seeing their evidence because it gets pretty interesting when two guys each weighing 120kg run into each other on purpose.â&#x20AC;?

The suitable applicant will have previous experience in emergency departments within Australia and is a Fellow of the Royal Australia College of General Practitioners (FRACGP) or have extensive relevant experience and/or hold post graduate qualifications in Emergency Medicine. Appointment is based on skills and experience with a minimum of 12 years relevant experience. In this role you will work as part of a multidisciplinary team, providing a high standard of medical care to patients under the supervision of Emergency Consultants.

â&#x20AC;&#x153;If thereâ&#x20AC;&#x2122;s protective equipment around, then Iâ&#x20AC;&#x2122;m all for it. I love the game but itâ&#x20AC;&#x2122;s good to minimise the risks.â&#x20AC;? Hockeyâ&#x20AC;&#x2122;s round missile can create havoc In terms of padding and protection, the goalie is the most fortunate player on the ďŹ eld, says Hockeyroo goalie Rachael Lynch. â&#x20AC;&#x153;Impacts from the ball are a lot more common that youâ&#x20AC;&#x2122;d think, especially in training. I still feel the thump if it gets me in the face-mask. It often gets dented and the entire thing has to be replaced.â&#x20AC;? â&#x20AC;&#x153;There was a very sad case several years ago in Perth where a young woman was killed when the ball deďŹ&#x201A;ected off her stick and hit the back of her head.â&#x20AC;?


â&#x20AC;&#x153;The ball is hit at upwards of 100km/h off a drag-ďŹ&#x201A;ick on a short corner. The players on the ďŹ eld are standing right next to me and charging out so they need to be brave. One of the girls got a fractured eye socket and trained in a modiďŹ ed foam mask but you canâ&#x20AC;&#x2122;t wear protection like that in a competitive game.â&#x20AC;? â&#x20AC;&#x153;The ofďŹ cials are very aware of any piece of protective equipment that might actually injure an opposition player.â&#x20AC;? â&#x20AC;&#x153;In a World Cup match a couple of years ago I got hit in the face by another playerâ&#x20AC;&#x2122;s knee. It knocked my helmet off and the rest of that game was a bit of a blur. You see plenty of bruises in this sport!â&#x20AC;?

dĹ˝Ä&#x201A;Ć&#x2030;Ć&#x2030;ĹŻÇ&#x2021;Ç&#x20AC;Ĺ?Ć?Ĺ?Ć&#x161;Í&#x2014; Ç Ç Ç Í&#x2DC;Ç Ä&#x201A;Ä?ŽƾŜĆ&#x161;Ć&#x152;Ç&#x2021;Í&#x2DC;Ĺ&#x161;Ä&#x17E;Ä&#x201A;ĹŻĆ&#x161;Ĺ&#x161;Í&#x2DC;Ç Ä&#x201A;Í&#x2DC;Ĺ?Ĺ˝Ç&#x20AC;Í&#x2DC;Ä&#x201A;ĆľŃ&#x2026;Ç Ĺ˝Ć&#x152;ĹŹ Ç Ĺ?Ć&#x161;Ĺ&#x161;ĆľĆ?Ń&#x2026;ĹľÄ&#x17E;Ä&#x161;Ĺ?Ä?Ä&#x201A;ĹŻÄ?Ä&#x201A;Ć&#x152;Ä&#x17E;Ä&#x17E;Ć&#x152;Ć?Ń&#x2026;ĹľÄ&#x17E;Ä&#x161;Ĺ?Ä?Ä&#x201A;ĹŻÇ&#x20AC;Ä&#x201A;Ä?Ä&#x201A;ĹśÄ?Ĺ?Ä&#x17E;Ć?

By Peter McClelland


OCTOBER 2016 | 25

October e-Poll

Training Standards Doing Us No Favours It seems doctors are are suffering poll fatigue! We had a smaller than expected expe anonymous response and the lion’s share of our 86 responses within 10 days were General Practitioners (42%) and Other Specialists (52%) with the remainder made up of Doctors in Training and ‘Other’. Not unexpected, gender breakup was predominantly Male (67%) who made up most Other Specialists (82%) - we have indicated where gender appears to have affected results.


e-Pober ll

Erosion of the medical profession’s image


Should we ask the community about the performance of new medical graduates?

Do you think the Medical Profession currently has an image problem because of the bad behaviours of a minority?

Yes No Uncertain

35% 50% 15%

A sizeable majority of doctors were not surprised by our revelation about teachers being reticent to fail students. The next question might be, ‘Is this going to impact doctors adversely?’


You answered ‘Yes’ so is the image bad enough to do something about it?

Yes No Uncertain


80% 7% 13%

ED. Among those who thought an image problem existed, 80% said it was bad enough to do something about it. This response was strongest amongst ‘Males’ and ‘Other Specialists’ by a factor of about two-to-one. This comes on the back of our last E-poll results, taken up by The West Australian, showing male doctors were being impacted by the media handling of child abuse reports.

Yes No Uncertain


Generally speaking, is it going to improve how we tackle community health problems if consumers determine more what doctors do?

Yes No Uncertain

20% 65% 15%

ED. Consumers do not know best when it comes to tackling community health problems, according to 65% of doctors. Interestingly, GPs felt this stronger than ‘Other Specialists’ (81% vs 51%) with nearly three times more of the latter being ‘Uncertain’ of their position. There were no significant gender differences on this question.

Who is responsible for ‘bad eggs’?


Overall, are new medical graduates adequately trained to work in our community?

Yes No Uncertain

26 | OCTOBER 2016

33% 41% 27%

While you were studying at medical school did another student, in your view, need either serious counselling or ‘weeding out’ because of their beliefs or behaviour?

Yes No Uncertain

50% 44% 6%

ED. Both sexes gave similar answers to the three questions. A minority of doctors (37%) thought they should ask the community about new medical graduates while a third (33%) of respondents felt new graduate doctors were inadequately trained to meet community needs. Maybe doctors have the answers already as exactly a half (50%) said they knew of someone during their training at medical school, who they thought should be weeded out. This latter view was held more strongly by ‘Other Specialists’ (58% vs 36% of GPs).

Are teachers responsible somehow?


Who has the best fix?


37% 42% 21%

Would it surprise you to learn that some teachers of trainees (medical students or specialist trainees) are wary of failing students because of legal consequences, student expectations, or student appeals?

Yes No Uncertain

26% 72% 2%

ED. A sizeable majority of doctors were not surprised by our revelation about teachers being reticent to fail students. The next question might be, ‘Is this going to impact doctors adversely?’

Is overseas training up to scratch?


Do some overseas trained doctors seem to repeatedly underperform, for whatever reasons, when doctoring in some locations?

Yes No Uncertain

65% 9% 26%

ED. A high proportion (26%) were ‘Uncertain’, so someone needs to look into this. Compared with GPs, Other Specialists held this view more strongly (69% vs 58%) and GPs were more uncertain of their position (31% vs 24%), perhaps reflecting their differing experiences. Interestingly, more female doctors answered ‘Yes’ than males (75% vs 62%).


October e-Poll

Inadequate training positions or training, or both?


Do you think the profession will be increasingly faced with a lack of quality training positions?

Yes No Uncertain


69% 21% 10%

During your undergraduate training do you recall a teacher who harassed or bullied students in ways you found detrimental to learning?

Yes No Uncertain

Comments by WA doctors. We asked, Any comment on anything to do with ‘Training and ‘Dud’ Doctors’? and about 20 doctors offered comment (direct quotes below). A question of student attitude? ‘Dud’ says that we recognise that the doctor in question is not up the task required. It is often a question of insight, and understanding, rather than knowledge. In some cases it is cultural. Attitude is important. We have all seen trainees who perform when observed by teachers/superiors, but completely change their behaviour, and performance, when on their own. Dud Doctors have a common fault which is lack of ethics and respect for patients. This needs to be part of their training and if failure to comply with ethical behaviour, they need their registration cancelled. A need to do it differently? I teach in a med school and am increasingly concerned about how scared the uni is of student appeals and legal challenges. It is almost impossible to prevent unsuitable or underperforming students from graduating eventually and then when they do they cause problems in their workplace but by then it is too late. The idea of training is to bring these people up to a standard, which I think is done reasonably well at every level. I do get concerned that universities are letting people past the barriers (exams) when they are ‘borderline’, and have experienced this as a sixth-year examiner.


During your time studying medicine do you remember a teacher whom you regarded as 'very poor' in getting across practical or theoretical teaching?

ED. The issue of poor quality training positions concerns most doctors (69%), particularly male non-GPs. But maybe a closer look at teachers are required with harassment or bullying by teachers that was detrimental to their training mentioned by a half of doctors, particularly GPs over Other Specialists (61% vs 47%) and females over males (58% vs 45%). Furthermore, 71% of doctors said they were exposed to ‘very poor’ teachers.

51% 47% 2%

The biggest problem is there is no objective metric to measure and identify problems with insight, enthusiasm and attitude. We (as teachers/trainers) recognise a problem when we see it. If you dare to comment today, you are likely to be labelled and harassed by HR as a bully.

university that ‘trained’ that person.

I had asked my mentors and teachers how they decided who got onto the training programme. The answer was simple. “Pick the people you like. Pick the person you would be happy to marry your child.” They may have been right. If you like them, they are likely to have a similar set of values and mindset, a decent work ethic, and are likely to get on with others (which is becoming increasingly important).

The dud trainers and the dud students are a tiny minority.

Doubling the number of students junked the degree…The cream is undoubtedly still there but very significantly diluted by inadequate performers…[who] will not be practising medical practitioners in 20 years. The universities are the problem and adding a new problem in Perth is an insane waste of taxpayers’ money. The public need protecting from duds. The medical colleges/ AMC will do that as they are responsible for training and quality control. The universities will not as they are responsible for turning a profit. The undergraduates are poorly trained on emergence from university such that specialist primary examination pass rates have plummeted from high 80% to under 50% in a mere five years resulting in the termination of specialist training of increasing numbers because they are unable to pass the examinations. Personally, I have had to terminate specialist training and they now need to find a different career. The Australian taxpayer has been ripped off again by the

To hear what the Doctors Drum panel and audience had to say on the vital issue of training, don’t miss the November issue of Medical Forum WA.


71% 26% 3%

Yes No Uncertain

The current framework that inhibits us from failing a student when we feel appropriate and the fear of reprisals from the students let us pass far too many students who should not be let out in the community.

Present deficit of training positions, which will be exacerbated by the creation of yet another Medical School (Curtin). An insane decision by the previous Minister of Health. Honest talk and more? My pathway to specialty was difficult and, in the end, I had to work it out for myself. I still resent that someone had not pulled me aside earlier and said ‘this is not good enough’ and then perhaps pointed me in the right direction. I walked several paths until I stumbled on the right one. Some do this sooner than others. This ability can't be measured, but is clearly identifiable when you see it in a prospective trainee…Perhaps if they do not reach the standard, we need to be stricter in allowing them to proceed. It is time to not be afraid to protect the public and our professional reputation. Medical Board tolerates too many underperforming doctors. This is dangerous to the public and is detrimental to the profession’s image. We need to be less tolerant of people who are under performing (incompetent, personality disorders, criminal behaviour, drug/alcohol dependence, etc.). If the practice embraces accreditation properly and it is done well you address some of the issues and can implement behavioural change.

Breakfast sponsored by…

OCTOBER 2016 | 27


Asking GPs? Itâ&#x20AC;&#x2122;s Time to Listen The starterâ&#x20AC;&#x2122;s gun has gone off and primary care reform is becoming a reality. So what is happening?

While it may be hard for GPs not to develop a siege mentality given the almost daily headlines that affect their practice, itâ&#x20AC;&#x2122;s also important to know what the institutions set up to support their work are doing. If, as the RACGP suggests, the government is playing politics with its agenda-shaping leaks to key media â&#x20AC;&#x201C; the latest MBS taskforce report a case in point â&#x20AC;&#x201C; at least the Health Minister Sussan Leyâ&#x20AC;&#x2122;s August 24 announcement of the 2017 trial sites for the Health Care Homes returns the reform agenda to somewhat ďŹ rmer outcome-driven ground. So what is going on? Well quite a bit, as we discovered. The Minister announced that 200 general practices nationally, involving 65,000 patients, in 11 Primary Health Networks, (PHN) would take part in the Health Care Home trial and that the Perth North PHN would be WAâ&#x20AC;&#x2122;s only site. Thatâ&#x20AC;&#x2122;s due to start on July 1, 2017. The Commonwealth has not conďŹ rmed the number of practices in the WA trial but given the relatively small number nationally and the tight budget, the size of which has drawn criticism from both the College and the AMA (see breakout), it would seem not that many. While detail out of Canberra to the media has been sketchy, Chris Kane, Strategy and Policy Manager at the government-funded WA Primary Health Alliance, said the Perth North PHN will have responsibilities to support the process (which is now being called State 1 Implementation). The Commonwealth Chris Kane will establish a Regional Coordination Advisory Committee with both PHN and State Health representation.

28 | OCTOBER 2016

However, PHNs across the country have not been idle in the interim. Chris told Medical Forum that WAPHA, along with a number of other PHNs in other states, has been working on GP engagement strategies that are separate from and yet complementary to the Commonwealthâ&#x20AC;&#x2122;s Health Care Home model. In WA, that strategy is called Comprehensive Primary Care and has focused on intensive GP engagement around care for patients with chronic and complex health conditions. â&#x20AC;&#x153;We started this process when it became evident from government policy and particularly the PCHAG Better Outcomes report that the landscape of general practice was going to transform to these patientcentred medical home-based models of care,â&#x20AC;? Chris said. â&#x20AC;&#x153;After our discussions with RACGP and WAGPET we established innovation hubs with about 20 GPs, so we could start talking about what this medical home model could look like in WA and how we as the PHNs could approach that.â&#x20AC;? Leading the march The WentWest PHN in Sydneyâ&#x20AC;&#x2122;s West has been developing such a model for nearly a decade, long before the Health Care Home became government policy and Chris said its work has inspired a lot of discussion here in the West. In a nutshell, the WAPHA plan is to have the three WA PHNs work intensively with a small number of general practices in identiďŹ ed hotspots with a signiďŹ cant number of patients with chronic complex co-occurring conditions. They will provide practices with support to achieve the outcomes everyone hopes the Health Care Home model will achieve â&#x20AC;&#x201C; keeping these patients out of hospital, especially Emergency Departments. WAPHA recently held a workshop on the patient-centred medical home model for GPs in these patient hotspots to listen to their concerns and to explore what they would need in their individual practices to make

the medical home model of care work for their complex patients. The meeting was held at WAPHAâ&#x20AC;&#x2122;s Rivervale ofďŹ ces in early September with places for 41 GPs â&#x20AC;&#x201C; the demand was so great an extra half dozen were squeezed in with a waiting list of many more. About 30 practices were represented from hotspot areas identiďŹ ed in WAPHA's needs assessments. Such is the hunger for information and guidance in this new era. Leading discussion Some of the questions that were raised for discussion were around: sĂĽ 0ATIENTĂĽMANAGEMENTĂĽnĂĽUSEĂĽOFĂĽ#AREĂĽ0LANS ĂĽ Reviews, GP Management Plans and Team Care Arrangements; sĂĽ 4EAMĂĽMANAGEMENTĂĽACROSSĂĽSPECIALISTĂĽ medical practitioners, nursing, pharmacy and allied health services; sĂĽ 5SEĂĽOFĂĽ-"3ĂĽCHRONICĂĽDISEASEĂĽMANAGEMENTĂĽ items; PIP; sĂĽ 5SEĂĽOFĂĽCLINICALĂĽDATAĂĽANDĂĽOUTCOMEĂĽ measures; sĂĽ 5SEĂĽOFĂĽRISKĂĽSTRATIlCATIONĂĽTOĂĽIDENTIFYĂĽHIGH needs patients sĂĽ $ETERMININGĂĽOPTIMALĂĽPRIMARYĂĽCAREĂĽANDĂĽTHEĂĽ challenges; sĂĽ 2EVISEDĂĽFUNDINGĂĽMODELSĂĽIEĂĽCOMPLEXITYĂĽ payments, bundled payments) â&#x20AC;&#x153;Practice selection for the project will be based on expressions of interest but the work of the PHNs goes on around this,â&#x20AC;? Chris said. â&#x20AC;&#x153;When WentWest began the process, they were working with 30 practices engaged in integrated care and now theyâ&#x20AC;&#x2122;re working with eight in the intensive Primary Care Medical Home transformation program. The lesson for us at this point is to work with practices intent on transforming to this model and to provide support incrementally and not in a prescriptive fashion.â&#x20AC;? GPs speaking up â&#x20AC;&#x153;One of the comments that came up at a GP workshops was â&#x20AC;&#x2DC;these models are just going to be imposed and we are just going to



have to conformâ&#x20AC;&#x2122;. The whole point of the GP engagement was to invite practices to work with us on mutual terms to make things work. We donâ&#x20AC;&#x2122;t want to impose anything.â&#x20AC;? â&#x20AC;&#x153;We want to work with GPs who want to explore how to provide patient-centred, teambased integrated care thatâ&#x20AC;&#x2122;s underpinned by some science, informed by data and has patient and provider measures. If they do then we take the next step together.â&#x20AC;? Chris said that in the initial stages of the Comprehensive Primary Care plan WAPHA would concentrate on delivering assistance to practices around the ďŹ rst four of Bodenheimerâ&#x20AC;&#x2122;s 10 building Blocks of High Performing Primary Care, namely: sĂĽ %NGAGEDĂĽ,EADERSHIP sĂĽ $ATAĂĽ$RIVENĂĽ)MPROVEMENTĂĽANDĂĽHEALTHĂĽ records linkage);

cashed out of Medicare,â&#x20AC;? he wrote in the Medical Observer. â&#x20AC;&#x153;A cynical observer may suggest this is not a genuine investment in the Medical/Health care home trial, merely a shift in existing expenditure.â&#x20AC;?

PENNY PINCHING The outgoing President of the RACGP, Dr Frank Jones questioned the governmentâ&#x20AC;&#x2122;s commitment to the Health Care Home trial given the $120m â&#x20AC;&#x2DC;investmentâ&#x20AC;&#x2122; was not new money but rather redirected from other Medicare GP payments. â&#x20AC;&#x153;In reality it is $21.3m from the PIP redirected to infrastructure, training and evaluation, and $93.3m for some MBS chronic disease management items being


He went on to say that the College had calculated that for an appropriately funded trial, a practice would require $100,000 on average a year in addition to current funding for chronic disease management items and other MBS items. The College is arguing strongly for the slow and steady route of meaningful activity followed by rigorous evaluation, saying that a rushed job at this stage of transformation could compromise the entire agenda. But does general practice have the luxury of time?

sĂĽ 4EAM BASEDĂĽCAREĂĽINĂĽTHEĂĽPRACTICEĂĽ â&#x20AC;&#x153;The support offered to these GPs will be informed by the conversations we have with each of them. It will be what they want and need for their practice. I would expect that would entail some education on population management, continuity of care and datadriven improvements and ehealth records linkage.â&#x20AC;? Help along the way â&#x20AC;&#x153;WentWest has explored this in more detail â&#x20AC;&#x201C; providing some leadership and change management coaching for practice principals. We donâ&#x20AC;&#x2122;t want to mirror exactly whatâ&#x20AC;&#x2122;s been rolled out elsewhere before we have these

CORPORATES & PRIVATE HEALTH INSURANCE WAPHA consultations so far have been mainly conďŹ ned to small to medium general practices but WAPHAâ&#x20AC;&#x2122;s Chris Kane said corporate practices couldnâ&#x20AC;&#x2122;t be excluded though it would require work to establish how their structure could ďŹ t with the WAPHA process. At a recent IPN dinner at which Queensland GP and chair of the PCHAG Dr Steve Hambleton was keynote speaker, and those guests from the PHNs were left with a strong feeling that the corporates were moving into the health care home space â&#x20AC;Ś and quickly. â&#x20AC;&#x153;I donâ&#x20AC;&#x2122;t think we can, given our nature of our remit as PHNs, say if youâ&#x20AC;&#x2122;re a corporate we are not going to include you in the process, but we are very conscious of keeping a watching brief on what the corporate practices are doing independently,â&#x20AC;? Chris told Medical Forum.


intensive conversations with local practices to determine what they need and want.â&#x20AC;? â&#x20AC;&#x153;We are certainly not saying how you should run your business because different practices will approach this in different ways. Solo practices will have different methodologies and needs than a big general practice.â&#x20AC;? Chris believes there is a growing acknowledgement among GPs that transformational change is on its way, but it should be made surely and steadily if the nation is to achieve a fully collaborative health system.

â&#x20AC;&#x153;There is a long way to go and weâ&#x20AC;&#x2122;re cautious about general practiceâ&#x20AC;&#x2122;s level of acceptance of everything thatâ&#x20AC;&#x2122;s on the horizon. Thatâ&#x20AC;&#x2122;s why engagement and consultation is so important. We are conscious of the issues that GPs face in the care of their patients and of their business outcomes.â&#x20AC;?

By Jan Hallam

â&#x20AC;&#x153;The future will be about collaboration and at some point corporate practices will need to be brought into the hub at both state and commonwealth levels. Weâ&#x20AC;&#x2122;ve made sure we maintain good relationships with corporate practices because the ultimate end of all of this work is the health of these vulnerable patients.â&#x20AC;? The government has also indicated to the PHNs that they should explore the work being done by private health insurers where it concerns the medical home models of care. â&#x20AC;&#x153;The commonwealth is conscious of including private health insurers in discussions but there are clearly considerations around universality and access to quality care. Weâ&#x20AC;&#x2122;re fortunate in WA that we have really only two major health insurers working here and we can keep the channels of communication open,â&#x20AC;? she said. â&#x20AC;&#x153;However, we have not involved insurers speciďŹ cally in our Comprehensive Primary Care practice transitioning program.â&#x20AC;?

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OCTOBER 2016 | 29

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The Road to Recovery Having a roof over your head can be life changing but so can outside help with finances and lifestyle, not to mention healthcare! The slide into homelessness often begins slowly and for many different reasons. When mental illness is a causal factor, life on the street becomes doubly difficult. Kevin Newton's story is a case in point. He was living in the UK during the early 1980s and managing a chain of about 20 pubs. “I was working 18 hours a day so cocaine was a pretty attractive option. I have a history of drug abuse that I’m not proud of but it was hard to resist because drugs were so cheap in West London,” he said. “My problems really began when my mother, sister and best friend all died within a short period of time. I slipped into severe depression and spent nearly five months in a mental hospital in England. The NHS looked after me really well. I reckon it’s a good system.” After he was discharged Kevin decided to come to Perth to look after his ageing father. After completing an Aged Care III course, he became his father’s full-time carer in 2009. Circumstances pile up “I started to develop osteoarthritis and they said I couldn’t look after him properly so he ended up going into aged care. Then I had some issues with the Public Trustee regarding power of attorney and I went into a downward spiral. One night I just walked out of my rented flat, walked to North Beach and threw my phone into the ocean. I was going to kill myself.” “Thankfully, someone came along and called an ambulance. That was the start of another long period of mental illness that included times when I was homeless.” “I ended up at Bentley Hospital but couldn’t leave there because I had nowhere to go. I’d walked away from my flat with nothing, no money, no clothes, no furniture. Eventually I was sent to Tate St Lodge, which was awful. I was paying $500 a fortnight out of my Centrelink allowance and I couldn’t walk up the stairs to the kitchen. I survived on sandwiches from the local service station.” “I walked away from there, homeless once again, and took an overdose.”

Mr Kevin Newton, centre, with UWA researchers and the CEO of St Bartholomews, Mr John Berger.

arms and living rough. I’d find somewhere to sleep during the day and roam around at night. Drugs are so available on the street if you know where to look.” “I was referred to St Bartholomew’s House, a fantastic organisation and the views from the sixth floor are amazing! I had my own room and there’s a communal kitchen so, with my chef background, I was pretty popular. There’s a graded transition at St Bart’s where you learn to become more independent and after that I went onto the Street to Home program.” Help was at hand

Another stint at Bentley stabilised Kevin’s depression, albeit briefly. Unfortunately, it wasn’t long before a combination of illegal drugs and a few poor choices saw Kevin’s life reach crisis point.

“I was transferred to St. Bart’s in Midland, a nice duplex with people on both sides and really good support. Someone would come out once a week and make sure I was all right.”

Spiralling out of control

“It was great to get some help to manage my finances and they also gave me some introductions to other professional health care services.”

“I started taking methyl-amphetamines and it was the biggest mistake I’ve ever made. To make matters worse, I got involved with some bad people and was actually couriering the stuff for a while. I was lucky I didn’t end up in prison.” “By mid-2014 I was self-harming, cutting my


public transport and hospitals. My neighbours are a mixed bunch, some are pretty old and others have health problems.” First-hand experience with the public mental health system will inevitably shine a light on some of its deficiencies. Nonetheless, Kevin is more than happy to throw a few bouquets. “The people at Osborne Park Hospital have been brilliant! Dr Helen Ward and Natalie Fairclough have helped me get back on the straight and narrow, they’ve been terrific. And so has my GP, Dr Christine KuhlmannJackson.” “I still have some bad days but I reckon I’m on the road to recovery. It would be good to have a bit more social interaction but I need to be careful because there are some people I need to stay away from. I don’t want to return to my old way of life.”

By Peter McClelland

“In November 2015 I was allocated a house through Homeswest and now live in a duplex in Karrinyup. It’s great to be near the shopping centre and there’s good access to

OCTOBER 2016 | 31


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Guest Column

Fitness vs Fatness Where does science sit in this age-old debate? Dr Louise Naylor from UWA says that mobility and keeping ďŹ t is the most crucial part of the life equation. Thereâ&#x20AC;&#x2122;s no question that obesity is linked with poor health outcomes. So, too, are low ďŹ tness levels and the integral part they play in the causal chain leading to T2DM and heart disease. Somewhere in the mix is the â&#x20AC;&#x2DC;Fit but Fatâ&#x20AC;&#x2122; theory, arguing that cardiovascular ďŹ tness attenuates the risk of disease and premature mortality independent of BMI. Put simply, being overweight or obese doesnâ&#x20AC;&#x2122;t really matter as long as you perform regular exercise. Or so the story goes. Fit but Fat, popularised in the late 1990s, is based on evidence from large cohort studies showing that, after adjusting for other risk factors, the â&#x20AC;&#x2DC;health beneďŹ tsâ&#x20AC;&#x2122; of being lean are limited to ďŹ t men and that a general level of ďŹ tness may also reduce the inherent hazards linked with being obese. More recent studies have provided compelling evidence that disputes this argument. In late 2016 a group of Swedish researchers using data from 1.3m men revealing that those who were unďŹ t with normal weight had a 30% lower risk of early death from any cause compared with â&#x20AC;&#x2DC;ďŹ t and fatâ&#x20AC;&#x2122; individuals. Fit and fat debunked!

We can conďŹ dently say that exercise confers critically important beneďŹ ts. Another study examined the associations between physical activity and all-cause mortality and asked the question slightly differently â&#x20AC;&#x201C; does fatness modify these associations? The participants were followed for 12 years and the ďŹ ndings revealed that if obesity were avoided, the number of deaths would be reduced by 3.66%. There are, of course, ongoing issues with how we measure obesity. Body Mass? BMI? Waist Circumference? Percentage Body Fat? Nonetheless, what is crucially important is the distribution of fat on the body. It is now generally accepted that central, abdominal obesity is linked with a constellation of metabolic abnormalities. Itâ&#x20AC;&#x2122;s also important to appreciate the importance of lean muscle mass because it is increasingly evident that changes in the metabolic function of muscle plays a direct role in the development of insulin resistance.

by Medical Director PROF JOHN YOVICH

There has been research at UWA for more than a decade looking at the beneďŹ ts of exercise for individuals with, or at risk of developing, cardiometabolic disease. Results consistently show that exercise training confers cardiovascular and metabolic beneďŹ ts, independent of changes in total body weight. We can conďŹ dently say that exercise confers critically important beneďŹ ts. We now also know that these improvements are beyond the manipulation of the traditional RISKĂĽFACTORSĂĽLINKEDĂĽWITHĂĽ#6ĂĽANDĂĽMETABOLICĂĽ disease, with evidence suggesting that a large proportion (~40%) of the beneďŹ t of exercise cannot be attributed to changes in traditional risk factors alone. Regular exercise increases lean muscle mass, REDUCESĂĽTHEĂĽRISKĂĽOFĂĽDEVELOPINGĂĽCANCER ĂĽ#6$ ĂĽ improves metabolic health and directly impacts the vascular system. Itâ&#x20AC;&#x2122;s also linked with improved ageing, improves bone health, general mood and reduces the risk of dementia and Alzheimerâ&#x20AC;&#x2122;s disease. There are many beneďŹ ts linked with regular physical activity. One of them is, hopefully, avoiding becoming an obesity statistic because the Fat but Fit argument isnâ&#x20AC;&#x2122;t looking all that attractive anymore.



)6& )#3)ĂĽSPLITĂĽINSEMINATIONĂĽSTUDY â&#x20AC;Ś reveals beneďŹ ts of ICSI even when DFI low Intracytoplasmic sperm injection (ICSI; see ďŹ gure) has been applied INĂĽ)6&ĂĽPROGRAMSĂĽSINCEĂĽ'IANPIEROĂĽ0ALERMO ĂĽOFĂĽ"RUSSELS ĂĽlRSTĂĽPUBLISHEDĂĽ his ďŹ ndings in 1992. Working at the prestigious New York Cornell-Weill CENTREĂĽHEĂĽEXTENDEDĂĽTHOSEĂĽSTUDIES ĂĽONEĂĽINVOLVINGĂĽAĂĽ0)6%4 PIONEEREDĂĽ APPLICATIONĂĽnĂĽTHEĂĽADJUNCTIVEĂĽUSEĂĽOFĂĽPENTOXIFYLLINEĂĽĂĽ ĂĽOPENINGĂĽUPĂĽ)6&ĂĽ TOĂĽMALEĂĽINFERTILITYĂĽ6IABLEĂĽEMBRYOSĂĽCOULDĂĽBEĂĽGENERATEDĂĽWITHĂĽSCARCEĂĽ sperm. Azo-ospermic men, anejaculatory cases, men with spinal injury and those with retrograde ejaculation can be assisted by combining testicular sperm recovery (best undertaken by microsurgical techniques) with ICSI. )6&ĂĽHASĂĽEXTENDEDĂĽFROMĂĽ4UBALĂĽANDĂĽ-ALE FACTORĂĽINFERTILITYĂĽTOĂĽUNKNOWNĂĽ causes. However, even when the male has a normal semen analysis, a small proportion demonstrates poor (<50%) or complete fertilisation failure (CFF). To identify such cases, tests for sperm DNA fragmentation have been developed. The Halo test recently replaced THEĂĽ3#3!ĂĽSPERMĂĽCHROMATINĂĽSTRUCTUREĂĽASSAY ĂĽMETHODĂĽATĂĽ0)6%4ĂĽSEEĂĽ August edition). Current advice is to avoid ICSI unless required. Published reports NOW AT 2 LOCATIONS PERTH & BUNBURY


INDICATEDĂĽ$&)ĂĽLEVELSĂĽUPĂĽTOĂĽĂĽASĂĽACCEPTABLEĂĽ0)6%4ĂĽSTUDIESĂĽREVISEĂĽTHISĂĽ ďŹ gure. Applying a prospectively randomised allocation of oocytes to a SPLITĂĽ)6& )#3)ĂĽMODEL ĂĽTHEĂĽCUT OFFĂĽSHOULDĂĽBEĂĽĂĽWHEREĂĽ#&&ĂĽWOULDĂĽBEĂĽ reduced from 7.9% of cases to zero and poor fertilisation from 28.9% to 2.6%. The study of 585 oocytes from 38 couples showed that the low level of CFF could not be reduced further even when DFI levels were rated <5% except by ICSI where both CFF and poor fertilisation RATESĂĽWEREĂĽZEROĂĽ0)6%4ĂĽ CURRENTLYĂĽOFFERSĂĽ)6& )#3)ĂĽ split to all new cases. This can deďŹ ne who needs ICSI and avoid failed fertilisation. Fig: Oocyte with ďŹ rst polar body (MII stage â&#x20AC;&#x201C; meiosis II suspended at metaphase) about to be injected with single spermatozoon.

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Guest Column

Hard Core Tee-Ball The natural evolution of junior sport requires a ďŹ&#x201A;exible approach to rule-making suggests Chief Umpire Greg Mount-Bryson from Tee-Ball WA. Tee-Ball made its ďŹ rst appearance in WA in 1974, a modiďŹ ed version of baseball designed for younger players. Hard-core, leather bound balls â&#x20AC;&#x201C; baseballs, in fact â&#x20AC;&#x201C; were used and it was critically important that helmets were worn by batters and baserunners. The young kids, understandably enough, were prone to some pretty wild hits and throws and it wasnâ&#x20AC;&#x2122;t uncommon for a player to be hit on the head with a ball. Formal rules were drawn up and one related to the introduction of a new ball made of a cork or wool-bound centre with a rubber coating and much softer than a standard baseball. Consequently, helmets only became compulsory for the 10-11 year-old age group who still used the hard ball. A further rule modiďŹ cation was the introduction of helmets with ear guards and a face guard, and chest plates for the pitcher â&#x20AC;&#x201C; the closest person in the batterâ&#x20AC;&#x2122;s ďŹ ring line! The game increased in both pace and sophistication and, while there didnâ&#x20AC;&#x2122;t seem to be a signiďŹ cant increase in the number of head injuries, ofďŹ cials began to look more closely at this issue. Of particular concern were the State Championships where the

We decided that:

A young player had been hit on the head by the ball and his father approached me objecting to the coachâ&#x20AC;&#x2122;s decision to remove his son from the game. sport was being played at an elite level. There was also an increasing reluctance on the part of some parents and coaches to follow the Tee-Ball codeâ&#x20AC;&#x2122;s recommendation to remove players from the game if they have been struck on the head. I distinctly remember a game in 2010 in which I was the chief umpire. A young player had been hit on the head by the ball and his father approached me objecting to the coachâ&#x20AC;&#x2122;s decision to remove his son from the game and send him to the ďŹ rst-aid post, and also wanted to sign a waiver absolving the TeeBall Association of any legal liability. This sort of thing was completely unacceptable so we modiďŹ ed the rules again.

sĂĽ (ELMETSĂĽSHOULDĂĽBEĂĽCOMPULSORYĂĽFORĂĽALLĂĽAGEĂĽ groups using tee-balls or baseballs. sĂĽ !NYĂĽPLAYERĂĽRECEIVINGĂĽAĂĽHITĂĽTOĂĽTHEĂĽHEADĂĽWITHĂĽ a ball or falling to the ground hitting their head must be removed from the game. sĂĽ .OĂĽFURTHERĂĽPARTICIPATIONĂĽSHALLĂĽBEĂĽALLOWEDĂĽ until the player has been assessed by St John Ambulance ofďŹ cers. Should they be concerned with the playerâ&#x20AC;&#x2122;s health, a Doctorâ&#x20AC;&#x2122;s certiďŹ cate must be produced before the player can resume playing. Serious injury is a reasonably rare occurrence in our sport and thatâ&#x20AC;&#x2122;s reďŹ&#x201A;ected in our player insurance premiums. which are among the lowest of any team sport in Australia. Tee-Ball is speciďŹ cally designed to introduce young children to diamond sports. We teach and accredit hundreds of parents each year to become coaches and umpires and itâ&#x20AC;&#x2122;s incumbent upon us to demonstrate a high level of safety practices. The Four Fs of Tee-Ball are Fun, Fair Play, Fundamental Skills and Family Involvement. Player safety underpins all of the above.






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Guest Column

Tough Love Saves Lives In the tough world of aviation failing a trainee can save lives, says Flt Lt Ray Werndly. Is there a lesson here for medicine? The military pilot’s work environment conjures up some pretty harsh adjectives – competitive, combative, exhausting, complex and dangerous. It’s no surprise that the training process aims to produce pilots who are not just technically competent but who can also cope with tricky ‘grey’ areas in difficult and dynamic circumstances. At the sharp end of a military aircraft you need both good judgement and flexible decision making. You also have to be able to ‘recover’ a situation when things turn pear-shaped.

Currently, the trainee pilot failure rate…sits at around 30-40%. There are some distinct and important differences between military pilots and their commercial counterparts. The highly regulated automation in an Airbus or Boeing cockpit doesn’t offer much assistance when you’re hovering above the pitching deck of a navy frigate on a dark night. Consequently, some essential elements need to be built in to the military aviation training regime. They come at a price, but it’s a price worth paying. Currently, the trainee pilot failure rate (‘attrition rate’) sits at around 30-40%. This may appear wasteful but it’s highly cost-effective compared with an aircraft accident caused by ‘human factors’. And we’ve learnt that lesson the hard way. Running in parallel with this ‘tough love’ is the rather less tangible aspect of ‘subjective assessment’. This is more nebulous, almost akin to an ‘art’.

By Mr Peter Ammon Foot Ankle & Knee Surgery

Surgery for Heel Pain Heel pain is a frequent problem that presents to the general practitioner. Plantar fasciitis is the most common cause of under the heel pain. Most patients will improve with non-operative treatment but not all. Surgery is a very effective form of treatment for this condition in patients with long standing refractory symptoms. Before being considered for surgery patients should undergo at least six months of non-operative treatment that includes the following (in the appropriate order): så 2EST åAVOIDANCEåOFåACTIVITY så .3!)$S åSTRETCHING exercise program så /RTHOTICSåOFFåTHEåSHELF or custom så #ORTISONEåINJECTION (one only) så 3HOCKWAVEåTHERAPY

Plantar fascia origin

Surgery can be open or endoscopic. The principle part of the procedure is release of the plantar fascia near its origin on the heel. Historically only the medial half was released but recent literature supports more complete release. Open surgery is performed through a 3cm incision in the proximal arch and allows not just plantar fascia release but also decompression of the tarsal tunnel and Baxters nerve which is often implicated in heel pain.

Here’s a breakdown that may prove illuminating and have some useful applications within the world of medicine. så Trust – military flying instructors take ‘time out’ from operational flying to train new pilots and the latter are well aware of this. This breeds ‘trust’ – the instructor/trainee relationship nourishes both that bond and the broader fellowship within professional aviation. The trainee knows that their own welfare sits near the top of the pyramid. This makes things considerably simpler if a training exercise warrants a ‘fail’. så Kinship – teaching another individual a complex set of skills generates a strong sense of kinship, an affinity within a professional fellowship. This is particularly so in the initial stages of training when both student and teacher need to exhibit courage and commitment. It’s not easy putting your head on the chopping block, figuratively or literally. There wouldn’t be too many military pilots pinning on their brand new ‘wings’ who hadn’t had their confidence shaken or asked themselves, ‘is all this worth it?’ s Feedback Loop – when an accident occurs all members of the military aviation community feel it deeply. The victim’s former instructors will search their souls for something they may have missed. Poor training can come back to bite, and hard! This makes it a little easier to fail a student who is just not making the grade. Ideally, a reciprocal relationship based on respect and professionalism exists between instructor and student. If that’s the case, and the latter is consistently struggling, they are much more likely to come to a mature acceptance that this particular career may neither be in their best interests nor of those who place their trust in them. ED: Flt Lt Ray Werndly is an experienced RAAF flying instructor. The opinions expressed are those of the author and may not necessarily represent the views of the Royal Australian Air Force.


Endoscopic plantar fascia release is indicated for those without nerve compression symptoms and is done through a much smaller incision using a camera assisted cutting device much like a carpal tunnel release. Both open and endoscopic releases are performed as day cases and require approximately two weeks on crutches. Recovery is slightly quicker for endoscopic patients as you would expect. Patients can expect an 80-90% chance of a good result from surgery. Complications are rare.

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OCTOBER 2016 | 35


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Clinical Update

Dilemmas in managing athletes

By Dr Carmel Goodman Sports Physician CMO WAIS

Whether dealing with an Olympic or professional athlete, a talented school athlete or a dedicated triathlete, we have all needed to tailor advice depending on the situation. As a Sport and Exercise Physician, I frequently hear patients say: "I understand that the correct medical advice is... however, I still intend to play in the grand final, be in contention for final selection or complete the event I spent the last 12 months training for!" While never complicit in allowing the athlete to compete if I genuinely feel the risk/benefit ratio is unreasonable, it is often a very grey area. Real examples An Australian hockey team (Hockeyroos) member recently sustained a traumatic, comminuted orbit and maxilla fracture during training. Maxillofacial advice recommended immediate surgery to prevent deformity. However, if performed she would not recover in time to play at the Rio Olympics. After discussion with the athlete, her husband and the coaches, we decided that as she was one of the team’s best players and this was to be her last Olympics, we would give her the best possible chance to play. She clearly understood the risks, including that delayed surgery would not provide as good a cosmetic result as immediate surgery. We set about sourcing, fashioning and modifying appropriate facial masks in an attempt to protect her face from further damage. (See image). At the time of writing, she had successfully negotiated full training sessions with the mask and played three games at the Olympics. The recreational ultra-marathon runner commonly presents just before the 90km Comrades marathon run in South Africa, with overuse injuries such as tibia or fibula stress fractures, tendon injuries, or knee pain. The 50-60 year olds present with synovitis of ankle, knee or hip joints, from running 100-120km a week on arthritic joints. When launching into the negative consequences of running on arthritic joints or stress fractures, the reply is invariably; “You are a runner doc; you know how important it is and withdrawing is not an option!”

Special face mask devised for a Hockeyroo who has sustained traumatic, comminuted orbit and maxilla fracture during training.

They return to Perth post-marathon, slightly worse for wear, agreeing to appropriate management such as decreasing/ceasing running until pain free, physiotherapy rehabilitation exercises and footwear/orthotic intervention – until next year. I draw the line at young athletes with injuries, whom I advise to rest and undergo appropriate management even though parents protest how important it is for their children to continue to train and compete. In these situations I advise the coaches, as well as the parents, of the potential damage that can be done by continuing to train. A classic example is the young gymnast with pars stress fracture, which, if untreated, can result in permanent pathology and pain. Always attempt to “first do no harm”, but recognise patient autonomy and holistic management temper this decision. Author competing interests: no relevant disclosures. Questions? Contact the author on 9387 8166.

Streamlining endoscopy services There are over 11,000 patients waiting for a colonoscopy or gastroscopy at a WA public hospital and with the expansion of the National Bowel Cancer Screening Program and the ageing population, demand for endoscopy services is expected to grow over the next few years. WA Health is coordinating a WA Adult Gastrointestinal Endoscopy Services (WAGES) project to streamline the endoscopy referral process, improve the quality of referral information and reduce inappropriate referrals. These strategies include a new electronic referral form and pathway via the Central Referral Service and the introduction of WA Health guidelines on the referral and triage of endoscopy referrals. The department, in collaboration with the WA Primary Health Alliance, will be contacting hospitals and GP practices to provide more information. Further details on the project can be found at gastro.cfm


We are located close to the Swan River and offer a variety of specialties. Southbank Day Surgery has established an excellent reputation in the community for its high commitment to customer service, patient care and quality improvement. We have undergone major refurbishments which include six theatres, CSSD and Dermatology and consisting of three procedural theatres. These are specifically designed to meet all Moh’s (Microscopically controlled surgical technique to remove skin cancers) patient needs. These have been designed to cope with the growing needs of the hospital and community.

Any queries please contact Bronwyn Grant on 0429 368 730 38 Meadowvale Ave, South Perth WA 6151 PH: 0893687344 WEB:

OCTOBER 2016 | 37

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Clinical Update

Back pain in adolescents and young adults

By Dr Sandra Mejak Cricket Australia State Medical Officer WA, Sport and Exercise Medicine Physician, Karrinyup

Lumbar spine stress fractures are important to consider in any physically active adolescent or young adult who presents with back pain. It is a slow to heal stress fracture, not unlike a navicular stress fracture.

(widened fracture line, rounding of edges). Sclerotic fracture margins are also a described feature of chronicity but in my experience this is often normal in elite athletes exhibiting higher extension / lateral flexion load, such as fast bowlers, whose pars regions physiologically adapt to this load over time.

Risk factors include the skeletally immature spine, sports where repeated extension and or lateral rotation occurs, such as cricket fast bowlers, gymnasts and tennis players, but they can occur in any sport. Too much or too rapid an increase in the amount of extension / lateral flexion load is often the triggering factor, but biomechanical and technique factors are also important. Stress fractures typically occur in the pars interarticularis region of the lower lumbar vertebrae, and less commonly in the nearby pedicle. They often occur on one side at one level, particularly if diagnosed early, but can occur bilaterally and at multiple levels. How problems present Pars stress fractures present much like other stress fractures, with pain initially during the aggravating activity such as fast bowling or tennis serving. As the problem progresses, the pain takes longer to settle between triggering activities and is felt with lesser stimuli such as running. As the fracture progresses further, there can be rest and night pain. Clinical assessment There is pain with lumbar spine extension or extension with lateral flexion (quadrant test). Sometimes, there is pain with flexion as well - but painful flexion alone makes a stress fracture very unlikely. There is often (but not always) focal tenderness over the affected pars site or sites. Occasionally there are no clinical signs at all, but only pain with the aggravating activity, although this is uncommon. Lack of clinical signs in the presence of a stress fracture is more likely due to failure to examine into the patient’s full extension / quadrant range. Diagnosis requires imaging Imaging should be done early if there is high suspicion of a stress fracture because continuation of the aggravating activity can cause an early healable stress fracture to progress to a chronic non-united stress

DMD Drug cleared by FDA Murdoch University’s Prof Steve Wilton and Prof Susan Fletcher heard the good news late September that the US Food and Drug Administration (FDA) had approved their drug eteplirsen making it accessible to patients with Duchenne Muscular Dystrophy.


It is important to note that any stage of stress reaction or fracture on imaging can also be asymptomatic, so imaging findings must match clinical findings. Asymptomatic fractures at one site can be present when there is a symptomatic fracture at another site – making it important these patients are referred to a doctor experienced in treating them. Treatment includes prevention VIBE MRI of a L4 pars stress fracture (arrowed).

fracture. Chronic non-unions at worst lead to chronic pain, and can lead to disc and facet degeneration over time. An X-ray is never the test of choice - it will miss stress reactions and smaller fractures and involve a relatively high dose of radiation. The test of choice is an MRI. Newer higher resolution MRIs will demonstrate bone oedema in the affected pars region with very high sensitivity, and standard T1 views often demonstrate the fracture. Newer 6IBEåORå4HRIVEå-2)åSEQUENCESåBOTHåHIGHå resolution volume capture techniques) are better at resolving the fracture than a standard T1 sequence and can replace a CT scan for visualising a fracture at certain imaging centres. They should be specifically requested on the order form but do not incur an extra fee. When MRI is not practical, a regional bone scan with SPECT views will also demonstrate an active stress fracture and stress reaction, but must be followed by a separate high resolution CT to visualise the fracture anatomy. Both a bone scan and CT involve radiation at a vulnerable age, which is not ideal if repeat imaging is indicated. Prognostic findings on imaging that are poor include bilateral fractures, multilevel fractures, and fracture anatomy that suggests chronicity

US clinical trials indicated that treatment with the drug reduces the severity of the disease. “Through the trials we’ve seen the progression of these kids doing things they would not ordinarily be doing. Boys who would normally be in wheelchairs are instead running around playing football, jumping into cars,” Steve said.

Treatment of stress reactions and fractures with the potential to heal involves rest from the aggravating activity for a prolonged period, which does not mean no activity at all. For example, simple non-painful exercises which are performed well should be performed to maintain or increase lumbopelvic strength and control. Stationary cycling is appropriate as cross-training as long as there is no pain and the spine is maintained in a neutral position. Typically this can be started at low intensity within the first month. Regular review by a good musculoskeletal physiotherapist experienced in sport and pars stress fractures is important, as well as by the treating doctor. Any contributing factors that increase extension / lateral flexion load can be addressed early e.g. leg length discrepancy, increased lumbar lordosis, and poor dissociation between hip and lumbar spine movements. Return to progressed running and extension activities should only occur after resolution of symptoms and signs, resolution on imaging, correction of alterable biomechanics, and progression through staged loading, including resistance exercises. Achieving all these factors reduces the likelihood of recurrence, which is made easier by access to the above mentioned resources. Correcting technique faults can be difficult and must involve coaches if attempted. Time to return to full sport is months.

Author competing interests: no relevant disclosures. Questions? Contact the author on 9245 1011.

“Having the drug approved by the FDA means more to Sue and I than any award we have ever received. Now for the first time our research will directly impact on the lives of young DMD sufferers worldwide.”

OCTOBER 2016 | 39

Practice by day.

Clinical Update

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Clinical Update

Acute acromio-clavicular joint separation in sport

By Dr Brendan Ricciardo, Orthopaedic Surgeon, Claremont

Acromio-clavicular joint (ACJ) separation, typically from a direct blow to the tip of the adducted shoulder (e.g. ‘driven into the turf’ in a tackle), accounts for about 10% of all shoulder injuries. The majority of ACJ injuries can be managed non-surgically with excellent outcome. Controversy exists regarding the management of high-grade ACJ injuries, which involve complete disruption of both the ACJ capsule/ligament and the coracoclavicular ligaments. Clinically there is tenderness and deformity over the ACJ (usually superior prominence of the lateral clavicle). This deformity may or may not be reducible (with downward pressure on the lateral clavicle and upward pressure beneath the elbow). An x-ray will confirm dislocation of the ACJ (superior, posterior or very rarely inferior). Posterior dislocation is best diagnosed on clinical exam and axillary lateral x-ray. When is surgery indicated? Surgery is usually recommended in acute high-grade ACJ separations with marked displacement of the lateral clavicle where deformity is not reducible. The ACJ is not reducible if the lateral clavicle ‘button-holes’ posteriorly through the trapezius muscle, if there is interposition of the delto-trapezial fascia between the acromion and the lateral clavicle, or (rarely) if the lateral clavicle becomes ‘locked’ under the coracoid. Managing reducible high grade ACJ separation remains controversial. The vast majority will become pain free (after 4-6

Cancer registers expand Legislation will be introduced to establish a National Cancer Screening Register to replace the eight separate State and Territory cervical cancer registers and the fragmented bowel screening system. In her announcement, the Health Minister Sussan Ley said that 80% of women who currently have a diagnosis of cervical cancer have not been screened nor had regular screening. Changes to the National Cervical Cancer Screening Program from 1 May 2017 WILLåINTRODUCEåTHEåHUMANåPAPILLOMAVIRUSå(06 å test to replace the two-yearly Pap test. Regarding the expanded free National Bowel Cancer Screening program, at home bowel cancer screening kit will be sent to Australians aged 50 to 74 years every two years by 2020. Telstra Health will be the service provider and it will be required to comply with all legal and legislative requirements around data security.


Fig 1. AP x-ray demonstrating high grade ACJ separation

weeks in a sling) and return to full sports function by three months. Early surgical fixation may offer benefit in those returning to sports with repetitive overhead activity and/ or throwing (basketball, volleyball, tennis). If return to contact sport is anticipated (rugby, AFL), then surgery is usually not recommended due to the high risk of reinjury/failure of fixation. Optimal timing of surgery If surgery is chosen, they are best fixed early (within four weeks) when the biological healing response is greatest. Surgery may involve using a plate or repair/reconstruction of the ligaments using synthetic material or hamstring tendon. In the acute ACJ separation, which is initially managed without surgery, a small percentage will report ongoing pain, shoulder weakness and/or lateral clavicle instability beyond three months. These symptoms may prevent

Fig 2. AP x-ray following ACJ reconstruction

a return to sport. Results from delayed reconstruction are nearly comparable to early surgery and yield high rates of return to sport. All ACJ separations are associated with an increased risk of developing post-traumatic ACJ arthritis. This typically manifests as ACJ pain and crepitus several years later. Surgery to excise the arthritic joint with or without stabilization of the lateral clavicle (depending on the degree of lateral clavicle instability) can be considered. References available on request.

WHEN IS EARLY SURGERY CONSIDERED? Severe deformity Irreducible deformity Young overhead athlete Author competing interests. Nil relevant disclosures. Questions? Contact the author on 9230 6333

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OCTOBER 2016 | 41

Clinical& Update News Views

OCD therapy goes online An online therapy for Obsessive Compulsive Disorder (OCD) in young people aged between 12 and 18 years who suffered mild to moderate symptoms has been trialled and evaluated by a team of researchers at Curtin University’s School of Psychology and Speech Pathology with some positive results. Lead author A/Prof Clare Rees and her team looked at the effectiveness of the OCD Not Me! program – an internet cognitive behavioural therapy (iCBT) intervention and found the cohort demonstrated significant reductions in symptoms and severity following the completion of the trial. OCD Not Me! is an eight-stage self-guided iCBT therapy based on exposure and

response prevention. Its accessibility means that young people can address and alleviate some of their symptoms outside of the mental health system. Clare told Medical Forum, the next research step was to compare the program to a faceto-face version of CBT therapy. “Our program consists of an automated initial assessment, which means that it is truly selfguided. Other self-guided internet treatments exist through the treatment phase but still involve a therapist at the initial assessment stage. In future research we will compare the effectiveness of having a clinician or no clinician at this assessment phase.”

Gonorrhoea on the Rise in Perth Clinicians in metropolitan Perth need to be aware that gonorrhoea cases have more than doubled since 2010, with a steep increase since the beginning of 2016. Once largely confined to Aboriginal people and men who have sex with men (MSM), gonorrhoea has now spread to heterosexual, nonAboriginal women and men in Perth. In the first half of 2016, there were over 600 gonorrhoea notifications among heterosexual women and men – double that of MSM, and people aged 20-39 account for the vast

“In this model, low-intensity and least-invasive treatment options are primarily designed for people who have symptoms at the mild level. By providing help early when symptoms are emerging, it is possible to prevent a worsening of the problem.” “If the participant doesn’t respond to the lower-intensity treatments, they can then be offered more intensive treatment such as seeing a clinician face-to-face. While our program was aimed at people with fairly mild symptoms, we also had young people who had quite severe levels of OCD and quite significant comorbidity. The results suggest the program may also be effective for more severe cases of OCD.”

Prof Donna Mak Communicable Disease Control Directorate WA Health majority of cases (see link to realtime data below). Thankfully, antimicrobial resistance is not a significant factor. The recommended empirical treatment of azithromycin 1g oral and ceftriaxone 500mg IMI (dissolved in 2 ml 1% lignocaine) is still effective. While the cause(s) of this increase are not clearly understood, the implications for clinical practice are clear:

Gonorrhoea is asymptomatic in 80% of women and the vast majority of men with throat and rectal infections, so it is important to be pro-active and offer testing for gonorrhoea to sexually active women and men. Many people engage in oral and anal sex, so routinely offer throat and rectal swabs for PCR testing in addition to the first void usual urine or cervical/vaginal specimens. If there is a purulent discharge, take a swab in charcoal or agar transport medium for culture and antimicrobial sensitivity testing (essential for surveillance of antibiotic sensitivity).

Comprehensive antenatal STI testing includes testing for gonorrhoea åCHLAMYDIA åSYPHILIS åHEPATITISå"åANDå()6å at the booking visit, and in high-risk women again in the third trimester. It is concerning that 11% of women delivering at public maternity hospitals in Perth last year were not tested for gonorrhoea or chlamydia when treatment during pregnancy prevents sight-threatening gonococcal ophthalmia neonatorum. Have a high index of suspicion for gonorrhoea e.g. young males presenting with UTI symptoms or testicular pain (gonococcal urethritis/epididymo-orchitis), females presenting with lower abdominal pain suggestive of appendicitis (pelvic inflammatory disease), septic arthritis (disseminated gonococcal infection), conjunctivitis (direct contact between genital secretions and the eyes during oral sex).

For real-time gonorrhoea notification data see

42 | OCTOBER 2016

Encourage patients to test by displaying The Clap is back poster in your waiting room – from Silver-book/Notifiableinfections/Gonorrhoea which also provides added information about the clinical management of gonorrhoea

The Clap is back... Gonorrhoea cases are on the rise in Perth

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Patients with gonorrhoea need to advise their sexual partners to get tested and treated; see for tips on how to do this, including SMS and email notification options. For assistance with tracing and notifying partners, contact your closest public health unit au/Articles/A_E/Contact-details-for-population-publichealth-units


Clinical Update

Tendon injuries of the elbow and forearm Tendon pathology around the elbow may present after an acute injury (e.g. tendon tear), a period of intense activity (acute inďŹ&#x201A;ammation) or as a chronic problem (tendinosis without inďŹ&#x201A;ammation). If history suggests a possibly signiďŹ cant tendon tear, early imaging and referral is appropriate. In chronic problems, imaging is not as helpful.

Medial and lateral epicondylitis

Bicep tendon injuries

Acute non-speciďŹ c tendinopathy is presumed (as it is rarely biopsied) to be a stage of tendinitis in some individuals. In an acute presentation, treatments for inďŹ&#x201A;ammation (ice, anti-inďŹ&#x201A;ammatory medication) may beneďŹ t. Tendinosis (chronic degeneration and breakdown of the tendon origin without inďŹ&#x201A;ammation) is more common.

The commonest biceps tendon problem is a partial or complete tear with a history of a sudden onset of pain, as the elbow moved from fully extended to ďŹ&#x201A;exed position under load. With complete tears there is usually a palpable defect, in partial tears, the hook test is helpful.

Initial diagnosis is by history and examination. Look for tenderness over the involved area and aggravation of pain by forceful contraction of the involved muscles. Without inďŹ&#x201A;ammation and no true healing, imaging cannot differentiate between current or past epicondylitis.

The examinerâ&#x20AC;&#x2122;s index ďŹ nger is hooked around the medial side of the biceps of the ďŹ&#x201A;exed elbow, and pulled laterally. This test is more accurate than MRI scanning in diagnosing partial thickness tears and distal biceps tendinitis. Early referral and repair is indicated

There are many non-operative treatments. They provide symptomatic relief without any one being superior to others or to no treatment. After 12 months most have signiďŹ cantly improved regardless.

Acute triceps tendon tears do occur but insertional tendinitis in a throwing athlete is more common. Rest, NSAIDs and staged return to sport are usually sufďŹ cient treatment.

sĂĽ !VOIDINGĂĽACTIVITYĂĽGENERALLYĂĽREPETITIVEĂĽWRISTĂĽ ďŹ&#x201A;exion and extension with some angular deviation of the wrist) that provokes symptoms, is helpful. sĂĽ -ODALITIESĂĽULTRASOUND ĂĽETC ĂĽAREĂĽREPORTEDLYĂĽ helpful but seem to work in studies just as well with the machine turned off.

By Dr Peter Honey Orthopaedic Surgeon West Perth

sĂĽ "RACESĂĽCANĂĽBEĂĽDESIGNEDĂĽTOĂĽRESTĂĽTHEĂĽJOINTĂĽ (a wrist extension splint) or alter the forces acting across the tendon origin (elbow counterforce brace). They provide some symptomatic relief without inďŹ&#x201A;uencing long-term prognosis. sĂĽ 0ASSIVEĂĽSTRETCHINGĂĽANDĂĽECCENTRICĂĽ strengthening exercises seem better than transverse (Cyriax) massage. sĂĽ )NJECTIONSĂĽREGARDLESSĂĽOFĂĽWHATĂĽISĂĽINJECTED ĂĽ seem to help. Cortisone injections reliably provide 4-6 weeksâ&#x20AC;&#x2122; pain relief but do not affect the ďŹ nal outcome. Dry needling, percutaneous release, whole blood injections and PRP injections reduce the duration of symptoms, presumably by introducing the cellular and chemical responses to injury that are lacking in tendinosis. Referral for surgical treatment is appropriate for those symptomatic after 12 months. No one surgical treatment has been found to reliably give superior results, and are all effective in most patients. Author competing interests- no relevant disclosures. Questions? Contact the author 9481 2856

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Clinical Updates

Tenocyte injections for recalcitrant tendinopathy The cellular response to tendinopathy depends on the stage of pathology. Tendons have a speciďŹ c capacity to withstand load. A normal tendon response to load is to become stiffer. If that tendon is given an appropriate amount of load and sufďŹ cient recovery time, it adapts to the demand placed on it and copes. If too much load and/or insufďŹ cient recovery time is placed on a tendon, it goes through stages of cellular and tissue changes considered pathological. In the latter stages of tendon degeneration, there is intra-substance tearing and cellular depletion within the central aspect of the tendon as well as collagen/extracellular matrix breakdown. It becomes unable to induce an appropriate repair, so called â&#x20AC;&#x153;fatigue healingâ&#x20AC;? i.e. the tendon is fatigued and unable to heal. In earlier stages of this pathology continuum, which deďŹ nes and provides rationale for various treatments, the tendon can often repair itself (see Fig 1). Some adjunct treatment may be required to 'kick start' the 'healing' process such as the mechanical induction of repair and obliteration of neovessels via exercise/tendon loading. Once this fatigue healing stage is reached, it does not really matter how much you load the tendon or pump it full of corticosteroid, blood products, or PRP etc. If there are no cells local to the tear site to proliferate and produce the required intra-tendon repair tissue, the tendon will not heal. Injecting tenocytes to promote healing Tenocytes have the capacity to proliferate and can easily be acquired with a known lineage. They are both autologous and homologous.

Treatment Algorithm PATHOGENESIS Over-use

Avoid re-injury Mechanical induction of intrinsic repair

Degenerative change of tendon cell & matrix

Control of pain



Matric breakdown & fatigue healing

Sunstitution of tendon progenitor cells for tendon repair


Structural and mechanical failure

Correction of biomechanics & decompression


Figure 1 (Reproduced kind permission of Professor Mingh Hao Zeng Centre of Translational Orthopaedic Research, UWA)

A translational process from proof of concept through to animal studies and clinical trials has been undertaken at the Centre for Translational Orthopaedic Research, UWA. In essence a 14G tru-cut biopsy is taken from the patellar tendon. The cells are cultured in the laboratory for a period of 4-6 weeks and then injected into the site of central tearing under ultrasound guidance. A pilot prospective study on 18 patients with recalcitrant common extensor tendinopathy demonstrated a dramatic reduction in pain and improvement in function after ATI over a period of 3-12 months, which was maintained at 4½ years. There was good correlation with MRI. These ďŹ ndings were further supported by a two-year prospective study on the gluteal tendon. The early results are certainly promising and have instigated the commencement of randomised control trials.

Racism is like cricket â&#x20AC;&#x201C; it was invented here, but perfected in Australia. â&#x20AC;&#x201C; Nish Kumar


WHO SHOULD BE CONSIDERED FOR ATI AND WHOM SHOULD THEY BE REFERRED TO? sĂĽ ,ONGSTANDINGĂĽ ĂĽMONTHS ĂĽ symptoms and dysfunction not responding to other conservative measures. sĂĽ 0ERSISTENTĂĽPROBLEMSĂĽAFTERĂĽPRIMARYĂĽ surgical repair sĂĽ 2EFERRALĂĽISĂĽCROSS DISCIPLINARYĂĽEGĂĽ specialist GPâ&#x20AC;&#x2122;s, sports physicians, orthopaedic surgeons, radiologists) and largely dependent on patient demographic.

Author competing interests â&#x20AC;&#x201C; the author has consulted for Orthocell. Questions? Contact the author by email

References available on request

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In a way Iâ&#x20AC;&#x2122;m quite pleased by Brexit. I wish Iâ&#x20AC;&#x2122;d been here before Britain joined the Common Market because, from what I hear, it must have been an absolute paradise. You got to work three days a week... Let's hope we can all live through that again in the very near future. â&#x20AC;&#x201C; Henning Wehn


AngioďŹ broblastic hyperplasia


Just because I donâ&#x20AC;&#x2122;t know the literal meanings of things, donâ&#x20AC;&#x2122;t treat me like an idiom. â&#x20AC;&#x201C; Phil Nichol

Funnies from Edinburgh Fringe 2016

Dr Arjun Rao Sports Physician Inglewood.

A lot of people say, "A stranger is just a friend you haven't met yet." But I've been mugged four times and I haven't kept in touch with any of them. â&#x20AC;&#x201C; Chris Stokes I recently learnt that being in the vegan club is the exact opposite of being in Fight Club, in that the ďŹ rst rule of vegan club is: tell everyone about vegan club; and the second rule of vegan club is: tell everyone about vegan club; and then the third rule is: don't eat meat. â&#x20AC;&#x201C; Tez Ilyas My stepfather doesn't like it when I call him my "fake-dad". He prefers "faux-pa". â&#x20AC;&#x201C; Glenn Moore

I'm not like most men, and I know that because there was a survey in a magazine, and the question was "what is your ultimate fantasy?" And apparently most guys said "being with two women at the same time" which I thought was really weird because I said "being a wizard". â&#x20AC;&#x201C; Peter White Apparently one in three Britons are conceived in an IKEA bed which is mad because those places are really well lit" â&#x20AC;&#x201C; Mark Smith My dad is Irish and my mum is Iranian, which meant that we spent most of our family holidays in customs. â&#x20AC;&#x201C; Patrick Monaghan Did you know Kinder Surprise is German for "unwanted pregnancy?" â&#x20AC;&#x201C; Adam Hess When I was a kid I asked my mum what a couple was and she said: 'Oh, two or three'. She wondered why her marriage didn't work. â&#x20AC;&#x201C; Josie Long

OCTOBER 2016 | 45

Left Intentionally Blank to comply with Medicines Australia Code


f o d n a L s t i b b o the H

The modern sheep and cattle, plus the 4WD, stand in stark contrast to the working Mill on the lake and Dragon Inn, both with properly thatched roofs using local lake reeds.

n I t o N s I The World d Books. n A s p a M r You . e r e h T t u It Is O

e, for s on this trepples were m lu p ’ ic t n s o th e a ed ‘a uthe They need cording to the book, s to suit. filming ac ith plu ms a nd leave replaced w

Most film sets are demolished when the filming stops – down comes the polystyrene, pretend this-and-that, and the actors go home. Well Sir Peter Jackson is from New Zealand and he has The Lord of the Rings and The Hobbittrilogies as his flagship productions, like them or not. Most people like them, so much so that about 50,000 people visit the Hobbiton movie set every year to take a closer look at the 39 Hobbit Holes on the 6ha Shire set, along with The Mill and the welcome roaring fire in the Green Dragon Inn by the natural lake – all rebuilt to last in 2009 when The Hobbit was filmed near the Bay of Plenty on NZ’s north island. Each few seconds in the film have been

46 | OCTOBER 2016

The a ncient a re hollow a solid wooden colu mns but you a re nd not so a ncient difference. flat out telling the

This Hobbit Hole is ‘to size’ and like the others has an indoors that connect windows to the main door.

lovingly maintained since, just as they were in the film, by a team of gardeners. Middle-Earth and Bag-End has never looked so good and for those who have even caught glimpses of the movies or read Tolkein’s books, déjà vu is alive and well.

on display (except for the potatoes). And there were frogs introduced that became too noisy for filming and had to be removed, and the sheep that looked like modern merinos and had to be swapped for those with more colourful wool.

Your guide will take your picture in the entrance to a Hobbit Hole, tell you whether each has been manufactured to 60% or 85% of actual size for filming purposes, and relate how the moss on the fences has been stuck on using look-alike materials, not to mention the artificial leaves tied to the tree at the top of the hill and each leaf sprayed a colour that matched the story.

You can take a night tour from Matamata or park nearby at Brock’s Place and a catch the first tour in the morning. The last filming of The Hobbit trilogy was in November 2011 and even though key actors have gone home – Sir Ian McKellen (Gandalf), Elijah Wood (Frodo), Sean Astin (Sam), Ian Holm (Bilbo Baggins) and Martin Freeman (young Bilbo Baggins) – the memories linger. For those with olfactory memories there is scented smoke from a Hobbit Hole’s chimney.

Many things are for real though, like the thatching on the Inn and Mill and the vegies


The lichen on the fence was contrived and pasted on, and the tree on the top of the hill had artiďŹ cial painted leaves but everything else is real, including scented smoke from the chimney!


OCTOBER 2016 | 47

I don't know

why we are here, but I'm that it is not pretty sure in order to e njoy ourselv es.

- Ludwig W

Honest Brand Slogans

clerk asked for my birthdate.

Hallmark: â&#x20AC;&#x153;When you care enough to give a card mass-produced by a corporation.â&#x20AC;?

I said, 10-3-60.

Ritz crackers: â&#x20AC;&#x153;Tiny, edible plates.â&#x20AC;?

What are My Options?

CliffsNotes: â&#x20AC;&#x153;Theyâ&#x20AC;&#x2122;re still going to know you didnâ&#x20AC;&#x2122;t read the book.â&#x20AC;?

Scene: Me using the Siri app on my iPhone.

Gillette: â&#x20AC;&#x153;Weâ&#x20AC;&#x2122;re just going to keep adding blades.â&#x20AC;? ChapStick: â&#x20AC;&#x153;Youâ&#x20AC;&#x2122;ll misplace it before the tubeâ&#x20AC;&#x2122;s empty.â&#x20AC;?

Her next question: â&#x20AC;&#x153;Is that 1960?â&#x20AC;?

Me: Siri, call my wife. Siri: Samantha McLaughlin is not in your contacts. Me: Samantha Gibbs is my wife.

Real Excuses Tenants Gave for Not Paying Rent

Siri: Iâ&#x20AC;&#x2122;ve added Samantha Gibbs as your wife.


Siri: Which wife?

sĂĽh9OUĂĽAREĂĽTOOĂĽWRAPPEDĂĽUPĂĽINĂĽTHEĂĽWHOLEĂĽ concept of â&#x20AC;&#x2DC;money â&#x20AC;&#x2122;. â&#x20AC;?

An irate patient called our pathology group, demanding that I explain every lab test on her statement.

sĂĽh3OĂĽxĂĽYOUREĂĽTALKINGĂĽTOĂĽMEĂĽONLYĂĽBECAUSEĂĽ the rentâ&#x20AC;&#x2122;s not paid? Is that all I am to you? A tenant?â&#x20AC;? Actually, I'm a Time Traveller

Me: Call my wife. Urine Trouble Now


There is No Such Thing as a Dumb Question, Except for These: sĂĽ)ĂĽWORKĂĽINĂĽ)4ĂĽ!ĂĽCUSTOMERĂĽASKEDĂĽMEĂĽIFĂĽTHEĂĽ string of numbers Iâ&#x20AC;&#x2122;d read off was upper- or lowercase. Another customer rang to tell me she was having trouble making her modum work. I asked her to go to her computer and she interrupted and said â&#x20AC;&#x153;I donâ&#x20AC;&#x2122;t have a computer, I only have a modum.â&#x20AC;? sĂĽ3OMEONEĂĽONCEĂĽASKED ĂĽh)SĂĽTHISĂĽTHEĂĽ museum?â&#x20AC;? I work at a pool. sĂĽ!ĂĽFEWĂĽOFĂĽTHEĂĽTHINGSĂĽCUSTOMERSĂĽHAVEĂĽASKEDĂĽ for at our art-supply store include disco balls, trees and cruciďŹ xion wood. sĂĽ)MĂĽAĂĽBUTCHERĂĽ!ĂĽWOMANĂĽASKEDĂĽĂĽIFĂĽSHEĂĽCOULDĂĽ sleep in our freezer to test out a heavy-duty sleeping bag before a trip to the Himalayas.

â&#x20AC;&#x153;Of course,â&#x20AC;? I said. I brought up her bill: â&#x20AC;&#x153;Number one, urinalysis â&#x20AC;Śâ&#x20AC;? She interrupted me: â&#x20AC;&#x153;Iâ&#x20AC;&#x2122;m a what?!â&#x20AC;?

When I bought beer at the grocery store, the

Windows 10 Privacy Tips With Windows 10, Microsoft have incorporated a lot of new features and functionality that users will ďŹ nd beneďŹ cial. However, there are a lot of "ET phone home" additions undesirable to businesses, from a security and privacy perspective, as well as Internet bandwidth. The new Windows 10 anniversary update has a few more settings to go through to disable most of the unwanted features.

Change settings as depicted (see screenshot) to ensure your PC doesnâ&#x20AC;&#x2122;t start sending updates to everyone over the Internet and bogging your connection. Unfortunately, it is not possible to turn off all

By Mr Jerome Chiew

the telemetry and data collection functionality in Windows 10, but following the tips above will help ensure your privacy is more secure and your Internet connection isnâ&#x20AC;&#x2122;t slowed down.

Firstly, access â&#x20AC;&#x153;All Settingsâ&#x20AC;? by clicking on the Action Center icon (i.e. the speech bubble icon), which is next to the date & time at the bottom of the screen. Now click â&#x20AC;&#x153;Privacyâ&#x20AC;? and turn everything OFF except SmartScreen Filter (see screenshot). Click on â&#x20AC;&#x153;Manage my Microsoft advertising and other personalisation infoâ&#x20AC;? at the bottom of this screen and turn off â&#x20AC;&#x153;Personalised ads in this browserâ&#x20AC;? (and â&#x20AC;&#x153;Personalised ads wherever I use my Microsoft accountâ&#x20AC;? if youâ&#x20AC;&#x2122;re signed in using a Microsoft account). Now close the web browser. Back in the â&#x20AC;&#x153;Settingsâ&#x20AC;? window, click Feedback & Diagnostics and change â&#x20AC;&#x153;Windows should ask for my feedbackâ&#x20AC;? to Never. Also set â&#x20AC;&#x153;Send your device data to Microsoftâ&#x20AC;? to Basic. Click the back arrow on the top left and then click â&#x20AC;&#x153;Update & securityâ&#x20AC;?, followed by â&#x20AC;&#x153;Advanced optionsâ&#x20AC;?, then â&#x20AC;&#x153;Choose how updates are deliveredâ&#x20AC;?

48 | OCTOBER 2016


Wine Review

Taste the Skill and Knowledge In 2003, NSW-born James Kellie made a life-changing decision by purchasing Harewood Estate from local Denmark farmer Keith Graham. With wife Careena and ďŹ ve children on board he also took the plunge and built a winery on the property. He had arrived ďŹ ve years earlier to work as winemaker at Howard Park. The initial intention was to learn more of his trade from Howard Parkâ&#x20AC;&#x2122;s John Wade and then move on to Tasmania. At the time, Howard Park was making wine under contract for many growers giving James the opportunity to appreciate and understand the various microclimates scattered around the Great Southern Wine Region. Making wine for Harewood, he was very well aware of the excellent cool-climate fruit coming off the Scotsdale Rd property By Dr Louis Papaelias

The vineyards are a small part of the Harewood Estate farming property, which is located in the PICTURESQUEĂĽ3COTSDALEĂĽ6ALLEY ĂĽWESTĂĽOFĂĽTHEĂĽ$ENMARKĂĽTOWNSHIPĂĽ#LIMATEĂĽISĂĽMARITIMEĂĽWITHĂĽSIGNIlCANTĂĽCOOLINGĂĽ due to proximity to the south coast. The topography is undulating hills with lush green pastures most of the year. Majestic stands of 200-year-old Karris welcome the visitor at the propertyâ&#x20AC;&#x2122;s entrance. Soils are gravelly and the Denmark property is planted to Pinot Noir, Chardonnay, Sauvignon Blanc and Riesling. The Great Southern is also represented at Harewood with Mt Barker, Frankland and the Porongurups sub-regions contributing Cabernet Sauvignon, Shiraz and Riesling. Quality fruit selection and winemaking is paramount. This property has an impressive wine show career perhaps best summed up by winning this yearâ&#x20AC;&#x2122;s John Gladstoneâ&#x20AC;&#x2122;s trophy for the â&#x20AC;&#x153;Best and Most Distinctive Regional Characterâ&#x20AC;? at the WA Qantas Wine Show.





1. 2016 Denmark Riesling RRP $23 Rieslings from Denmark are not commonly found. Stylistically they are delicate with ďŹ ne refreshing acidity more akin to the Porongurups than to the more robust examples from Mt Barker. This 2016 made from free-run juice and tank fermented shows beautiful crisp aromas hinting of citrus and ďŹ&#x201A;owers. Fruit ďŹ&#x201A;avours on the palate are pristine and balanced without any phenolic hardness. Lovely drinking even now but will keep for years. Great value. 2. 2015 Denmark Chardonnay RRP $27.50 Entirely estate grown, this is a restrained cool-climate chardonnay. Careful oak handling has allowed the whistle clean ďŹ&#x201A;avours of peach and grapefruit to emerge and blend with hints of spicy oak and vanilla. Well-balanced and attractive it needs about a year or two extra in the bottle to show its best. The reputation of Denmark-grown chardonnay is on the rise.

WIN a Doctorâ&#x20AC;&#x2122;s Dozen! Name Phone


3. 2014 Cabernet RRP $21 The label states that this is a blend of Great Southern Cabernet. Matured for 18 months in French oak casks in the Bordeaux tradition, this wine is deep red with purple edges. Cassis, plum and berry ďŹ&#x201A;avours mixed skilfully with spice and vanillan make for an attractive presence in the mouth. A full-bodied wine showing good balance with ďŹ ne tannins and a persistent aftertaste. This can take 5-10 years bottle age.



.. or online at

4. 2015 F Block Pinot Noir RRP $27.50 This wine comes from estate-grown fruit from a northfacing gravelly slope. Three different clones of Pinot make up the blend (115,114,777). This wine has the sought after â&#x20AC;&#x2DC;sour cherryâ&#x20AC;&#x2122; character seen in good pinot noir. It has a fragrant aroma and is medium-to-light bodied. Good fruit concentration and acidity. Subtle SPICYĂĽBACKGROUNDĂĽWITHĂĽGOODĂĽPERSISTENCEĂĽ6ERYĂĽWELLĂĽ made and lovely drinking at present.

Wine Question: Which Harewood Estate wine is grown on a gravelly slope?

Email Please send more information on Harewood Estate's offers for Medical Forum readers.

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

Competition Rules: One entry per person. Prize chosen at random. Competition open to all doctors or their practice staff on the mailing list for Medical Forum. Competition closes 5pm, October 31, 2016. To enter the draw to win this month's Doctors Dozen, return this completed coupon to 'Medical Forum's Doctors Dozen', 8 Hawker Ave, Warwick WA 6024 or fax to 9203 5333.


OCTOBER 2016 | 49

Social Pulse

The Name is Bond St John of God Murdoch Hospital partied in James Bond-style at its Annual Gala Ball at the Crown Perth. The evening featured a 007-themed room, a martini bar, an Aston Martin on display. Staff, doctors, and guests were greeted by a posse of paparazzi followed by a night of sophisticated fun. A raffle and silent auction raised money for Compassionate Friends WA. 1

Dr Andre and Lily Chong


Dr Krishna Epari and Emelyn Lee



Dr Peter, Pauline and Jonathon Bremner



3 The St John of God Subiaco Hospital held its annual ball in August where more than 500 doctors, nursing and admin staff all had a chance to dress up and party. 1

Dr Darragh Waters, Dr Peter Rogers, Joe Rossi and Jemma Koios


Dr Roisin McManus and friends


Dr Soo In Lim and the pharmacy crew


Dr Stuart Patterson, Gemma Clarke, Kate Laird and Kathryn Graves

$Rå6INITAå2AJADURAI å(AYDENå Gloudemans, Meg Smith and Grace Kurniawan

3 50 | OCTOBER 2016


St John of God Subiaco





Kids Theatre

s t e u q u o B & s t u n m u G

May Gibbs’ gumnut and blossom babies have stood the test of time and technology. The expectations of putting one of the country’s most beloved children’s stories on stage should not be underestimated. May Gibbs’ Snugglepot and Cuddlepie has been referenced by big and small for near a century since its brilliantly successful debut in 1918. Every nuance of the characters, from the chubby, rosy cheeked gum blossom babies to the sinister sibilance of Mrs Snake, is known and anticipated by all those in the audience. So no, pressure! The latest production, which is touring nationally, arrives in Perth in November with a truckload of charm and some home-grown talent in the shape of actor Nicholas Hiatt who plays Snugglepot. Apart from the thrill of leading this adventurous romp with Thomas Pidd as Cuddlepie, Nicholas told Medical Forum it was a wonderful thing to see a new generation of children discover Gibbs’ wonderful landscape. “I was born in South Perth and lived in May Gibbs territory until we moved to Kalamunda when I was nine. My teacher at St Columba’s primary school read us Snugglepot and Cuddlepie and then took us to the South Perth historical society’s display of her life and work. The story is on everyone’s periphery, even in 2016.” “What I love about the book and why I think it has stuck around for so long is that for generations Australian kids have been able to read the story and then step out


into their backyards to see the very things that inspired it.” “So often after a show, I leave the theatre and hear school groups talk about what they’ve seen. Teachers will tell their kids they’re off to the real Botanic Gardens next, where perhaps they will see the real Snugglepot and Cuddlepie. This recognition of landscape really taps into kids’ imaginations.” Of course, the other necessary ingredient for any children’s entertainment to be truly successful is the ‘scream factor’. And May Gibbs tapped into that perfectly with the Big Bad Banksia Men and Mrs Snake. “There are screams every show – not so much terrified screams, as hysterical rollercoaster screams,” Nicholas said. “At first we were a little worried that we were terrifying the kids a bit too much, but they revel in the villains. The character I find really scary is Mrs Snake … she’s malevolent and a lot scarier that any of the others.” The aesthetics of Gibbs’ bushland have been brought to life by costume designer Matthew Aberline, who has been inspired by the flash but grimy Sydney underworld of the 1920s. There is a nostalgia about the way the production looks, referencing Gibbs’ own time, but when all’s said and done, it’s about those naughty but nice gumnut babies. “As Snugglepot, I get to lead us on the adventures while Cuddlepie is the cautious one who would be happy to lie

Nicholas Hiatt, Tho

mas Pidd, Heid

run Lohr

on a branch all day. In real life, the tables are reversed. Tom is the one who always wants to jump in. I’m much more wary,” Nicholas said. “But I am enjoying being the hero at least for an hour a day.” One thing he’s not afraid of is hard work. Prior to being accepted into NIDA, Nicholas spent 2010 working as a singer on a cruise ship plying between ports in the Adriatic and Aegean. “I saw some amazing places but it was hard work. A two-week itinerary would see us do 10 main shows, everything from a concert version of Oklahoma to a Rock n Roll gala (I am so not rock n roll) and I would also do a bit of late-night cabaret. I even had my own cabaret show in one of the upstairs bars.” “I performed almost every day for eight months but I developed a lot of discipline which made NIDA, when I was eventually accepted in 2011, a little easier.” For the NIDA-trained 28-year-old, the six months touring (or as he described it, living the vagabond life) as Snugglepot will come to an end after the Perth season when it will be back to Sydney to work on the next project. “I’m looking forward to coming home in a show. It will be the first time since I graduated that I have performed in front of a home crowd and the first time I’ve performed at the Heath Ledger Theatre.” By Jan Hallam

OCTOBER 2016 | 51

Choral Music


PERFECT SOUND The Tallis Scholars return to Perth to remind us all how close to the angels music can take an audience. Peter Phillips has an extraordinary talent. For 43 years, he has had a special sound rattling around in his head that finds its outward expression in the heartstoppingly beautiful music produced by his choral group, Tallis Scholars. For Peter, who founded the group in 1973 when he was an organ scholar at St John's College, Oxford, the polyphony of Renaissance vocal music is ever-present and very precise. He knows exactly the sound he wants to hear from his singers. “The sound is so distinctive that over the years, yes, I suppose it’s fair enough to describe it as a brand, it certainly has been widely imitated,” he told Medical Forum from Lisbon where he had been holidaying before embarking on a tour of China, later to be followed by a national tour of Australia including Perth. The challenges of keeping that sound pure over the decades has been no mean feat as singers come and go but, surprisingly, maintaining that sound has been getting easier as the Tallis Scholars discography gets bigger. “The thing that never changes is the ideal sound that I have in my head. That’s what we’re all working towards. It was there in 1973 and it hasn’t changed. What’s changed is our ability to approximate and hit that sound more often than not when we’re standing on a concert stage, battling, as we do so often, with jetlag.” Peter said.

400 Years of Laughs Tartuffe – or The Hypocrite and even some versions as The Imposter – is the enduring story of a vagabond, who disguises himself as a priest and ingratiates himself into a wealthy household, caused an uproar when INåPREMIEREDåINå åTHOUGHå,OUISå8)6åISåSAIDå to have loved it. Such was and perhaps still is

52 | OCTOBER 2016

And when it comes to talent renewal, well, that’s getting easier too. “Young people who are coming into the group have grown up with our sound in their minds. Earlier on I had to indicate to people what was in my mind which was hard because I can’t sing very well. If I could sing I’d be singing in the group but I can’t. I even get asked to stop humming!” “Singers these days have very good technique and training so you know immediately if they will make the grade. I have just had a 22-yearold countertenor do his first job for us and I have never heard a countertenor of any age sing as well as he did. It is heartening and exciting.” Peter says he never auditions singers but rather accepts them on trusted recommendations and once they are in the fold the music rules. “That’s one of the interesting things about Renaissance music – all parts are equal in the polyphonic web.” While much of the Tallis Scholars’ repertoire is sacred music, Peter says it is not a religious group. “We make our living in concert halls as much as churches. The one thing that binds us together is an appreciation of how good this music is. Part of its wonder is its ability to take people out of their busy lives to where things are much calmer and more relaxed. If you want to call that god, call it god.”

the tensions between state and church! Black Swan State Theatre Company is staging this classic satire as its finale to a successful 2016 season and Artistic Director Kate Cherry’s swansong before departing the company to become head of National Institute of Drama Art in Sydney. Justin Fleming is responsible for this adaptation of “thumping English

As the mastermind of the ensemble, there is the challenge to keep the sound fresh and that has led to some collaboration with contemporary composers over the past few years. “I should point out the repertoire is 95% Renaissance – 15 years ago it was 100% and even now our sound is Renaissance. When we have collaborated with modern composers, we have asked them for a sound that will suit the Tallis Scholars and fit in with our Renaissance program.” “That’s interesting in itself but the sound world doesn’t change much. The audience still gets to journey through different pieces of music with the same basic instrument, because I see the group as an instrument, like an organ or a harpsicord, where the sound is fixed.” American Composer Eric Whitacre took up such a challenge in 2013. “I know it was a challenge for him, I was there!” Peter said. “It took a couple of goes but Eric took the trouble to conduct the ensemble so he could get the sound ‘under his fingers’ and write the music knowingly, which he did. I was really pleased about that.” In Perth, the Tallis Scholars will perform in the tranquil airiness of St Mary’s Cathedral on November 8 in a program that includes Tallis, Pärt and Tavener. In Tallis’s Spem in Alium, the Scholars will sing with members of the Perth Chamber Choir trained by Dr Margaret Pride.

By Jan Hallam

verse” (so says the publicity spiel), so not a drop of wit will be spilt. Medical Forum readers have a chance to win tickets to this production on Saturday, October 22, at the Heath Ledger Theatre. Email before October 16.


Entering Medical Forumâ&#x20AC;&#x2122;s competitions is easy!


Simply visit XXXNFEJDBMIVCDPNBV and click on the â&#x20AC;&#x2DC;Competitionsâ&#x20AC;&#x2122; link (below the magazine cover on the left).

Movie: Robinson Crusoe This limited release animated ďŹ lm revamps the 18th century tale of shipwreck and survival and gives it an Ice Age/Lion King twist with the fauna of the exotic tropical island lending a sassy hand to the hapless Robinson Crusoe. One of those kids ďŹ lms that offers something for everyone. In cinemas from October 27 for two weekends only

Movie: Hacksaw Ridge Directed by Mel Gibson, this ďŹ lm, which was shot in Australia, tells the true story of medic Desmond Doss who, in Okinawa during the bloodiest battle of WWII, saved 75 men without carrying a gun. Doss was the ďŹ rst conscientious objector awarded the Congressional Medal of Honor. In cinemas, November 3

Movie: I, Daniel Blake 6ETERANĂĽDIRECTORĂĽ+ENĂĽ,OACHĂĽWONĂĽTHEĂĽ0ALMEĂĽDg/RĂĽATĂĽTHEĂĽ Cannes Film Festival this year with this story of Daniel Blake who at 59 ďŹ nds himself out of work for the ďŹ rst time and needing help from the State. He crosses paths with a single mother of two in the story of social isolation. In cinemas, November 17

Music: The Tallis Scholars This internationally acclaimed vocal ensemble, dubbed the rock stars of Renaissance vocal music by The New York Times, returns to Perth after wowing festival crowds back in 2007. Under the direction of founder Peter Phillips they will sing a selection of works by Tallis, Taverner and Clemens among others. St Maryâ&#x20AC;&#x2122;s Cathedral, November 8, 7.30pm

Kidsâ&#x20AC;&#x2122; Theatre: Snugglepot and Cuddlepie The colourful world of May Gibbsâ&#x20AC;&#x2122; Snugglepot and Cuddlepie springs to life on stage for children aged 5-10 (and their adults) in a new action-packed Australian adaptation with all the favourites â&#x20AC;&#x201C; Mr Possum, Mr Lizard and Mrs Snake helping or hindering our favourite Gumnut Babies.


COMP Movie: The Light Between Oceans WA writer M.L. Steadmanâ&#x20AC;&#x2122;s international bestseller is now a movie with some serious talent attached. Michael Fassbender, Alicia 6IKANDERĂĽANDĂĽ2ACHELĂĽ7EISZĂĽSTARĂĽINĂĽTHISĂĽTALEĂĽOFĂĽAĂĽLIGHTHOUSEĂĽKEEPERĂĽ on a remote island of WA and his wife who rescue a baby adrift in a rowboat. Gripping and moving. In cinemas, November 3

Doctors Dozen Winner Dr Christine Troy, a GP who works in the area of anaesthetics, takes home the Doctorâ&#x20AC;&#x2122;s Dozen carton of Little Creatures beer. Christine celebrates a signiďŹ cant birthday in the hot month of January so a couple of cooling ales are sure to be part of the celebrations.

Heath Ledger Theatre, November 9-14

8JOOFST from the August issue Music â&#x20AC;&#x201C; WASO Schubert & Bartok: Dr Lyn Minsker Musical Theatre â&#x20AC;&#x201C; The Sound of Music: Dr Ivan Lee Movie â&#x20AC;&#x201C; Italian Film Festival: Dr Gordana Cuk, Dr Farah Ahmed, Dr Clyde Jumeaux, Dr Sally Price, Dr Donna Mak Child Health

Movie â&#x20AC;&#x201C; The Beatles: Dr Eric Khong, Dr Ioana Vlad, Dr Paul Oâ&#x20AC;&#x2122;Hara, Dr Kon Kozak, Dr Catherine Keating Movie â&#x20AC;&#x201C; David Brent Life on the Road: Dr Suzette Finch, Dr Christina Wang, Dr Ade Kusumawardhani, Dr Sue Martin, Dr Bill Thong, Dr Richard John, Dr Murray Nixon, Dr Stephen Rodrigues, Dr Andrea Piesse, Dr Tony Connell

t Engaging Adolescents t FASD Management t Courting Mental Health t Property & Performing t Clinicals: Allergy; Skin; Child Growth; Kidsâ&#x20AC;&#x2122; Bones & Moreâ&#x20AC;Ś

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Movie â&#x20AC;&#x201C; Captain Fantastic: Dr Bibiana Tie, Dr Lynette Spooner, Dr Leanne Heredia, Dr Lawrence Chin, Dr Michael Woodall, Dr Linda Wong, Dr Brett Baird, Dr Michael Bray, Dr Chong Kwah, Dr Sue Bant August 2016

OCTOBER 2016 | 53

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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

EAST FREMANTLE Consulting rooms available in a new medical clinic on the ground floor of the â&#x20AC;&#x153;Richmond Quarterâ&#x20AC;? on Canning highway. Includes minor procedures operating theatre. Various options available from room use only, up to comprehensive secretarial, IT and promotional packages. Contact Rick 0404 758 182 or email


MT HAWTHORN Sessional medical/allied health suites with ultrasound, uroflowmetry and secretarial support if required Contact: Elayne 0422 234 540 or email SUBIACO Sessional Suites available at brand new specialist consulting rooms in Subiaco. Fully furnished and fitted out, ideal for medical specialists and allied health practitioners with the option for reception and secretarial support. Located near SJOG Hospital Subiaco. All enquires to or 0413 767 562

URBAN POSITIONS VACANT 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

FREMANTLE Medical practice for lease in Wray Ave. Fully adapted heritage building with four treatment rooms, reception, waiting area, kitchen and toilet. High ceilings, medical grade wiring, new roof, polished boards etc. Optional store. 107 to 114 m2 Great location, exposure, parking and access. Call Susannah 0407 938 678 fremantle/124-wray-avenue

NEDLANDS Fantastic opening for a PT VR GP who seeks work life balance. Looking for GP to do afternoon sessions 5 days a week. Next to UWA and Swan River in a busy shopping centre. Mixed billing. Full accredited. Pathology onsite. FT Registered Nurse Allied health services next door. Call Suzanne on 08 9389 8964 or Email: DIANELLA Dianella Family Medical Centre - seeking a VR GP to join our practice working part time. Fully computerised, non-corporate, flexible billing with 70% gross remuneration. Physio, dietician, podiatrist, Clinipath & pharmacy within the practice. Call Practice Manager on 9276 3472 or Email resume to

MURDOCH Medical Clinic SJOG Murdoch Specialist consulting sessions available. Email:

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

SOUTH WEST WA GPâ&#x20AC;&#x2122;s Required t &YDFMMFOU0QQPSUVOJUZUPKPJO expanding Medical Group in the beautiful South West WA t &TUBCMJTIFENFEJDBMHSPVQJO)BSWFZ & Waroona with 2 new locations t #SBOEOFXMPDBUJPOTJOOFX development areas Treendale & Dalyellup t 'VMMZDPNQVUFSJTFEBDDSFEJUFE modern practices with nursing & admin support t PGCJMMJOHTEFQFOEJOH on experience t %84BOE"P/ Please email CV to

MURDOCH New Wexford Medical Centre â&#x20AC;&#x201C; 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 NEDLANDS Fully furnished consulting suite available for sessional use. Monday - Friday at Hollywood Medical Centre. Please contact Jade on 0433 123 921 or

BYFORD VR GP Female/Male GP required Full time or Part time Privately owned well established modern practice located in Byford, 30 minutes from CBD, DWS and area of need. Full admin, and practice nurse support. Onsite Pathology, Podiatrist, Dental and Pharmacy. Fully computerised GPA Accredited Practice. Excellent remuneration, high billing from start, takeover existing patient base. Please email: or Phone Dr Naga 0434 049 767

91 AUBIN GROVE General Practitioner required F/T for our Medical Practice in Aubin Grove. Please forward resume to BENTLEY Rowethorpe Medical Centre is a non-profit, friendly practice seeking a part time GP to provide visits to our onsite residential aged care facilities. Practice-based 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 DUNCRAIG Duncraig Medical Centre requires a Female GP for immediate start. Fulltime patient load available. However, flexible with Monday to Friday hours. Excellent remuneration / $135 - $200 per hour. Predominantly private billing practice. Modern fully computerised practice with full time nurses. Please call Michael on 0403 927 934 or MOUNT LAWLEY Long established After Hours clinic Looking for a VR GP to work after hours shifts Flexible with hours Fully computerised and AGPAL accredited Private billing only Contact Gina on 0412 760 871 for further details OSBORNE PARK RAPHA CENTRE is dedicated to Womenâ&#x20AC;&#x2122;s Health specialising in Bio-Identical hormone optimization. Private billing, non-corporate, fully computerised, friendly team. Suitable for VR GP for rewarding experience in treating the root cause of most diseases with combination of nutritional and hormone balancing and more. Email: for confidential enquiries. Mentorship provided. 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: Afternoonâ&#x20AC;&#x2122;s and Saturday Morning (Alternate) Please contact Dr Cheng, Dr Hadi or Practice Manager on 9332 5556

NOVEMBER 2016 - next deadline 12md Thursday 13th October â&#x20AC;&#x201C; Tel 9203 5222 or


medical forum

MYAREE GP full-time or part-time required For inner south of river practice. Modern, non-corporate, fully accredited training practice Dr well supported by RN and other Dr’s. 65% remuneration. School holiday cover. Mon – Fri. No after-hours. Ph – 9317 8882 or email – CLAREMONT Growing GP practice located in the trendy suburb of Claremont. 78% of billings. Looking for VR GPs with unrestricted provider number on a part-time/full time basis for weekdays evening sessions (3pm to 8pm). Fully computerised with on-site pathology and RN support. Located in a modern complex with access to the gym and pool. For further information please contact Dr Ang on 9472 9306 or Email:

MAIDA VALE We are 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. Please contact Peter for a confidential discussion on 08 9454 4500 or email your CV to: and we will contact you within 24 hours.

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

YOKINE Part-Time VR GP required for a small privately owned practice in Yokine. Two male, two female GP’s on site working part time. Family friendly practice with nursing support and a lovely team of receptionists. Our GP’s have full autonomy. Private billing. Fully computerised. Accredited. On-site pathology. Allied health rooms attached next to the practice. Excellent remuneration is offered to the right applicant, but we are not in a DWS area. Please contact Jess or Dr Peter Cummins for further information.

WEST LEEDERVILLE & KINROSS FT/PT GP required for privately owned these 2 bulk billing practices. Procedures are billed privately. Excellent earning potential at both centres. Onsite pathology, nurse, Psychologist, podiatrist, physio, dietitian, specialist physician & Geriatrician. Contact CURRAMBINE We are seeking a full time or part time VR or non VR GP to join our friendly team at new state of the art premises. We have onsite pathology, physiotherapist and psychologist and pharmacy. Open 7 days with extended week day hours. Please contact Jackie on 9304 1424 or email for more information.

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:

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

BYFORD VR GP Required Accredited, busy, modern, non- corporate, mixed -billing practice. Full nursing support and friendly admin staff. Onsite Pathology, Dietician, Physiotherapist, Psychologist & Podiatrist. Phone Practice Manager on 0429 346 313 or email

SECRET HARBOUR Secret Harbour Medical Centre VR GP wanted. 65-70% offered. A generous relocation fee may also be offered. Brand new, modern and computerised. Contact: Dr Jagadish Krishnan Dr Vishnu Gopalan

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

SOUTH LAKE Dynamic VR / Non VR GPs required for a new practise in South Lake WA. High percentage offered. DWS available. Fully computerised. Registered nurse on site every day. Friendly and supportive team. Allied Health and pathology on site. Great location. Please email latest CV to:

VICTORIA PARK Unrestricted Dr required to service 2 x psychiatric hostels located in Vic park. Excellent remuneration available. Contact:

LEEMING Non-corporate General Practice presents an exciting opportunity for VR P/T or F/T GP to join our team. Well managed long established 3 doctor practice with comprehensive CDM program. This is an excellent opportunity for a GP who wants to be busy and work as part of happy and well managed team. Enquiries to Practice Manager on 0419 959 246 or

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.

ALL AREAS VRs and NonVRs needed urgently. DWS and area of need. Supervision available if required. 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 or 0416 893 131

SOUTH FREMANTLE VR GP required Fremantle area F/T P/T for Private Family Practice, Accredited, mixed billing, F/T Nurse support. 65% remuneration. Contact Practice Manager 9336 3665

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@

BUTLER Connolly Drive Medical Centre VR GP required for this very new, state of the art, fully computerised, absolutely paperless, spacious medical centre. Fully equipped procedure rooms and casualty, well-furnished consult rooms, pathology, allied health, RN support. Abundant patients, DWS, non-corporate. Generous remuneration. Confidential enquiries Dr Ken Jones on (08) 9562 2599 Tina (manager) on (08) 9562 2500 Email:

MADELEY VR & Non VR General Medical Practitioners required for Highland Medical Madeley which is located in a District of Workplace Shortage. Highland Medical Madeley is a non corporate practice with 5 male GPs, 3 Practice Nurses, 1 Chiropractor, 1 Physiotherapist, 1 Dietician, 1 Podiatrist and 1 exercise physiologist. Sessions and leave negotiable, salary is compiled from billings rather than takings. Up to 70% of billings paid (dependant on experience). Please contact Jacky on 0488 500 153 or E-mail to

Contact Jasmine, to place your classified advert

NOVEMBER 2016 - next deadline 12md Thursday 13th October – Tel 9203 5222 or

medical forum ASCOT 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

WHITFORD FT/PT Doctor required for friendly practice VR 70% of billings Non VR with general registration for weeknights and weekends from 65% Please contact Dr Michael Gendy Or Dr Rafik Mansour Phone: 08 9404 4400 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: or Call 0403 009 838 ROCKINGHAM Read Street Medical and Skin Centre F/T or P/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 Tel 08-9527 4976

JOONDALUP Full or part-time GPs required to join Candlewood Medical Centre. We are a busy multiple doctor family practice, mixed billing, accredited and fully computerised. Located close to pristine beaches with a wide range of amenities, providing for very attractive lifestyle choices. Please direct your resume or any enquiry to the business manager at Alternatively you can contact John Wong on 0414 981 888. MORLEY Full-time VR GP required. Centro Medical Centre is a non – corporate mixed Billing Practice situated in the Galleria Shopping Centre Morley. t 8FSFRVJSFBQFSNBOFOU(FOFSBM Practitioner (VR) to start as soon as possible t $POTVMUBUJPOIPVSTBSFOFHPUJBCMF t .PSMFZJTOPU%84 t 5IFQSBDUJDFJTGVMMZFRVJQQFEBOE computerised with nursing support For further information please contact Tina Fusco on 08 9375 2266 Or email OSBORNE PARK GP required for Osborne City Medical Centre. Flexible hours Monday to Thursday with optional afterhours. Excellent remuneration / $135 - $200 per hour. Predominantly private billing practice. Modern fully computerised practice with nursing support. Please call Michael on 0403 927 934 BELDON Full-time/Part-time VR GP required. Belridge Medical Centre is a non – corporate mixed Billing Practice t 8FSFRVJSFBQFSNBOFOU(FOFSBM Practitioner (VR) to start as soon as possible t $POTVMUBUJPOIPVSTBSFOFHPUJBCMF t #FMEPOJTOPU%84 t 5IFQSBDUJDFJTGVMMZFRVJQQFEBOE computerised with nursing support For further information please contact Margaret Chalk on 08 9307 0707 Or email


GP required for GP4YP program

The GP4YP program (General Practice for Young People) is a service aimed at youth up to the age 25. We require a GP with training in youth health to work 6-8 hours a week. The hours are flexible so can be done in one or more days between Monday – Friday and the GP will receive 100% of Medicare billing. For further information please contact Marina Trevino on either 9319 0555 or email

Lockridge Medical Centre VR GPs or Subsequent Registrar PT / FT To work at our modern, independent, accredited, innovative, teaching and award winning practice. 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

Doctors... Take Note! An exceptional opportunity has become available in a very successful practice. Dynamic VR / Non VR required in South Lake, WA Excellent earning potential and opportunity for the right candidate (Full Time/Part Time) + High percentage offered + Non VR Preferably with General Registration + Located south side of the river in Perth, in a DWS & AoN area

Metro Area GP positions available VR & Non – VR Dr’s are welcome to apply. Send applications to

+ Nurturing, friendly supportive team & working environment + Fully computerised with reliable administration support + Pharmacy around the corner

+ Registered Nurse on site everyday

+ Great location with ample car park

+ Allied health services and Pathology on site

+ Options for flexible hours available Please email your recent CV to or call 0466 210 369 for a friendly discussion.

NOVEMBER 2016 - next deadline 12md Thursday 13th October – Tel 9203 5222 or


medical forum

Olympic Medical Centre Full Time Female VR GP Required


Opportunity exists for a Female doctor to take over existing patient base.

DWS positions available in 5 locations!

Olympic Medical Centre in Canning Vale is privately owned medical practice with well-equipped treatment rooms.

Bunbury: Brecken Health Care - Join a team of 20 GPs Albany: St Clare Family and Occupational Practice – Join a team of 3 GPs

We use Best Practice Software and are as paperless as possible. Many allied health services are housed in the same complex creating a local Health Hub including pathology, physiotherapy, podiatry and psychologist.

Busselton: New site opening soon Eaton: Join a team of 3 GP’s Australind: Join a team of 5 GP’s

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

All our sites are fully accredited with AGPAL Nurses, admin & allied health support as well as pathology on site

ESSENTIAL REQUIREMENTS Vocational Registration Full AHPRA Registration

FRACGP or equivalent highly regarded but not essential.

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

For Further information please contact Dr Brenda Murrison 0418 921 073 or

Flexible hours, Full time or Part time available

DWS location If you are interested in this Full Time opportunity at Olympic Medical Centre please send your CV to Vishnu -

GP West Requires VR GP’s to our state of the art medical centers in AON and DWS locations Wattle Grove Medical Centre WATTLE GROVE

Egerton Drive Medical Centre AVELEY

New Gumnut Medical Centre WANNEROO

Okely Medical Centre CARINE

Newpark Medical Centre GIRRAWHEEN

Mundaring GP Super Clinic MUNDARING

Woodlake Village Medical ELLENBROOK

Harrisdale Medical Centre HARRISDALE

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

Please contact Dr Kiran Puttappa on 0401815587 or email

or visit

NOVEMBER 2016 - next deadline 12md Thursday 13th October – Tel 9203 5222 or

medical forum


Does your Home Loan rate start with a 3? Then call us a for a Free review of your current loans Choice: Less Stress: Service: Loans for:

we compare over 30 lenders for you we do all the paperwork & legwork for you we offer you a personal one on one service Home & Investment property, Business & Commercial, SMSF, Equipment & Vehicle

Call Dom Del Borrello on 0427 448 634 or e: Greenleaf Finance

ACL: 377 711 ACR: 482 358

ARE YOU LOOKING TO BUY A MEDICAL PRACTICE? As WA’s only specialised medical business broker we have helped many buyers find medical practices that match their experience. You won’t have to go through the onerous process of trying to find someone interested in selling. You’ll get a comprehensive package on each practice containing information that you and your advisers need to make a decision. We’ll take care of all the bits and pieces and you’ll benefit from our experience to ensure a smooth transition.

To find a practice that meets your needs, call:

Brad Potter on 0411 185 006

Join a growing team of visiting specialists to the south coast.

Suite 27, 782 - 784 Canning Highway, Applecross WA 6153 Ph: 9315 2599

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

FRANZCOG Opportunities Mandurah Obstetrics is a well-established local women’s health clinic that offers comprehensive services in Obstetrics and gynaecology. In 2017 we are seeing the services of a Fellow (new graduates welcome to apply) to take on the role of either part-time (with overnight on-call) services (3 days per week) or full-time Obstetric services. The opportunity to expand and develop a successful O&G service within an already existing clinic provides the support and business links within the Peel Region. Private and Public patient services at Peel Health Campus opens the door for a forward-thinking practitioner who would like to remain within a short distance from the CBD. Opportunities are limited and applicants are invited to submit expressions of interest to:

NOVEMBER 2016 - next deadline 12md Thursday 13th October – Tel 9203 5222 or


medical forum ality WKH e y client DOXHIRU

With a reputation built on quality of service, Optima Press has the resources, the people and the commitment to provide every client with the finest printing and value for money. 9 Carbon Court, Osborne Park 6017 } Tel 9445 8380

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 For enquiries to join our dynamic team, please contact us via E: or P: 9334 1451

WEMBLEY DOWNS VR GPs or Subsequent Registrar Part-Time /Full-Time


Venosan Diabetic Socks

An EXCELLENT CAREER opportunity exists for an experienced VR GP to work closely with a family oriented community. The practice is accredited by AGPAL and is an accredited teaching practice, which takes registrars in advanced and subsequent terms. We Offer • A modern facility with state-of-the-art equipment for both its Doctors and Staff. • Established patient base • Cosmetic Medicine • Onsite nursing, pathology and allied health services • Private Billing Practice • Great location • Great remuneration Essential Criteria • Must have FULL AHPRA Registration • Vocational Registration status

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

This opportunity should not be missed!


IF THIS SOUNDS LIKE YOU, please forward your resume to:

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


Keeps feet cooler in the summer and warmer in the winter

Comfort for The Patient

St John is seeking experienced doctors to work in our new Urgent Care Centres. Relevant experience in urgent care, rural general practice or similar will be highly regarded. Full or part time. Attractive salary package. For enquiries to join our dynamic team, please contact us via E: or P: 9334 1451


Soft-Spun Cotton - Ultra soft cotton


Fully cushioned foot and fully cushioned sock


Comfortable for arthritic patients

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

NOVEMBER 2016 - next deadline 12md Thursday 13th October – Tel 9203 5222 or

medical forum


GP Opportunities Available IPN Medical Centres 2 2 2 2

2 Wanneroo GP Superclinic 2 Wellard Family Practice 2 York General Practice

Baldivis Medical Centre Jindalee Medical Centre Parmelia Medical Centre Port Kennedy General Practice

Could we be the best option for you? If you explore what joining IPN entails, we think you’ll be pleasantly surprised. GPs across Australia choose to partner with IPN for good reason. We offer full practice support, security, autonomy with patient focus, flexibility and work life balance. Investigate for yourself why so many of your colleagues have joined and stayed with IPN. Dr Moayad Al Kaptan- Independent Practitioner - Perth

Contact Luke McLoughlin on 0472 822 745 or email

With IPN, you’ll be In Good Company.

Full Time or Part Time

VR GP WANTED Ŕ Busy non corporate practice requires Full Time or Part Time VR GP Ŕ On site Chemist, Pathology, Physiotherapist, Clinical Psychologist and Dentist Ŕ 6km from Perth CBD (opposite Belmont Forum Shopping Centre) Ŕ 65% - 70% of receipted billings Ŕ Excellent nursing support Ŕ Accredited and fully computerised Ŕ Guaranteed hourly income. Ŕ DWS doctors can apply for after hours and weekend sessions Ŕ See 40+ patients per day Ŕ 11 Consult + 4 Bay Treatment + 2 Bay Skin Procedure Rooms

$7000/= SIGN ON FEE PAID Please contact Preksha on 0433 583 972 or 0417 881 234 for more information

DWS GENERAL PRACTICE SKIN CANCER CLINIC | COSMETIC MEDICINE | OCCUPATIONAL HEALTH This is a rare chance to join a busy medical practice with a very large cosmetic medicine and skin cancer practice. Services Provided ŔWrinkle Relaxers ŔDermal Fillers ŔFace Lifts ŔThread Face Lifts ŔSkin Treatments ŔHair Transplant ŔBlepharoplasty ŔChronic Care Nurse ŔSkin Cancer Clinic ŔSkin Cancer Excisions ŔSkin Cancer Screening ŔFamily Medicine

ŔWomens Health ŔMens Health ŔOccupational Health ŔMultiple Nurses ŔNurse Practitioner ŔOn Site admin ŔWorkplace Injuries ŔFitness for Work ŔPre- Employment Medicals ŔDrivers Medical ŔGreat and fun team!

Essential Criteria ŔMust be an Australian Citizen or Permanent Resident ŔMust have Full AHPRA Registration as a Medical Practitioner (Specialist Registration) ŔVocational Registration status Remuneration ŔUp to 75% of receipts ŔEstimated yearly earnings $300,000+ ŔMinimum Retainer guaranteed AHG Super Clinic Contact Person: Val Reeve Phone: 0415 322 790 Email:

NOVEMBER 2016 - next deadline 12md Thursday 13th October – Tel 9203 5222 or

Medical Forum WA 10-16 Public Edition  

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