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Living Life to the Full t Passing On Values t Work Less, Give More t Travelling Broadens the Mind t Clinicals: Zika Virus; Traveller’s Kit; Anaemia; Glaucoma & More‌

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Editorial

Health Changes Must Deliver The coming weeks, with the impending state election, will see some interesting ‘solutions’ to problems in health. Will it all be smoke and mirrors? Fuel for the ďŹ re is the four-yearly election cycles decried as too short by serious health planners. Watch out for popular ďŹ xes, designed to get some elected and bring others wealth or inuence and maybe not deliver what’s promised in the long-term. The climate for change is ripe. The conservative risk-averse nature of the profession and government are too slow for rapidly growing consumer demand. The risk takers and innovators may be given their head (our ‘Trumpism’ if you like). As demand outstrips supply and the cake shrinks, the squeaky doors are getting squeakier. The basic problem is there is less oil (money) to make things run smoothly. To keep disquiet to a minimum, especially just before an election, we need efďŹ ciencies and we need them now! Amongst this noise, as people jostle for position, doctors and other health professionals with clean motives are best to stand up for vulnerable people who struggle to be heard – kids, the elderly, those in detention, etc. The dogged determination of these health professionals will be needed to counteract the slick PR machines, awards, celebrity champions, media manipulation, etc that almost every worthwhile cause and medical lobby group has these days. At Medical Forum the media release pace quickens before an election. Here’s a selection‌. sĂĽ h)FĂĽYOUĂĽMISSEDĂĽWATCHINGĂĽTHISĂĽIMPORTANTĂĽVIDEOĂĽLASTĂĽ week, don't miss it again. XXX is a 100% not-for-proďŹ t organisation and we [‌] want to help change the world for the better.â€? sĂĽ h2ESEARCHERSĂĽATĂĽ888ĂĽ5NIVERSITYSĂĽ888ĂĽAREĂĽAMONGĂĽAĂĽGROUPĂĽ of Australian scientists awarded $X million by the NHMRC to support a Centre for Research Excellence focusing on XX.â€? sĂĽ !CCORDINGĂĽTOĂĽONEĂĽNATIONALĂĽPOLLSTER ĂĽTHEĂĽh-ENTALĂĽ(EALTHĂĽ .URSEĂĽ)NCENTIVEĂĽ0ROGRAMĂĽISĂĽUNDERĂĽTHREATvĂĽSINCEĂĽFUNDINGĂĽ hWASĂĽTRANSFERREDĂĽTOĂĽ0RIMARYĂĽ(EALTHĂĽ.ETWORKSvĂĽ4HENĂĽITĂĽ lists percentage responses of those doctors surveyed to back its claims (and without giving absolute numbers). sĂĽ !(02!ĂĽRELEASESĂĽITSĂĽANNUALĂĽREPORT ĂĽPROCLAIMINGĂĽMOREĂĽ REGISTRANTSĂĽANDĂĽONLINEĂĽEFlCIENCYĂĽ)TĂĽHASĂĽAĂĽhMULTIĂĽPROFESSIONĂĽ approach to risk-based regulation with a clear focus on ensuring that Australians have a safe and competent

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MEDICAL FORUM

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

health workforceâ€?. This involves a 19.7% increase in complaints and closure of about half that number in a YEARĂĽnĂĽTHISĂĽhFOCUSvĂĽONĂĽCASEĂĽLONGEVITYĂĽISĂĽPOORĂĽCOMFORTĂĽFORĂĽ some wrongly accused doctors. sĂĽ #ANNABISĂĽHASĂĽBEENĂĽVERYĂĽNEWSĂĽWORTHYĂĽ"EHINDĂĽTHEĂĽLAYĂĽ media anecdotes, one media release announces an ASX company has received a TGA licence to import cannabis. !NOTHERĂĽ!38ĂĽCOMPANYĂĽISĂĽONĂĽTHEĂĽVERGEĂĽOFĂĽhBREAKINGĂĽ into the lucrative European skincare market with [‌] its cannabis-based cosmeticsâ€?. Meanwhile WA researchers reportedly say cannabis uses portrayed in the lay media – pain, spasticity, anticonvulsant action, weight gain, antiglaucoma – are alleged not proven. An AAPM e-news links to a story on Queensland’s facilitating of legalising legislation, saying Victoria is already there. A separate political media release announces the Commonwealth OfďŹ ce of Drug Control will start accepting applications for cannabis cultivation licenses. And so on. [Read the state’s head pharmacist Neil Keen’s update on P6]. )SĂĽALLĂĽCHANGEĂĽUSEFULĂĽ)TĂĽMAYĂĽBEĂĽBESTĂĽTOĂĽASK ĂĽFORĂĽWHOMĂĽ&ORĂĽ example, researchers used to list publications on their CVs. The longest list won. Now with the plethora of online journals wanting to publish and the explosion in numbers of researchers and PhD students, each author, scientist or scholar has an H-index (or something like it) to show whether their published research is made more meaningful by being cited by others. Manipulation of this system is easily imagined. !NOTHERĂĽSCENARIOĂĽ57!ĂĽADOPTEDĂĽTHEĂĽ!MERICANĂĽSYSTEMĂĽTHATĂĽ resulted in the proliferation of professors (with ‘Winthrop professors’ indicating the ‘real ones’), some say to keep market share, a comment made about recent changes to THEIRĂĽ-$ĂĽCOURSEĂĽTHATĂĽINCLUDESĂĽCHANGEDĂĽENTRANCEĂĽCRITERIAĂĽ"UTĂĽ .OTREĂĽ$AMEĂĽWASĂĽTHEĂĽlRSTĂĽ5NIĂĽINĂĽ7!ĂĽTOĂĽAPPOINTĂĽAĂĽFULLĂĽPROFESSORĂĽ without the usual academic, teaching, or research pedigree. (AVEĂĽPROFESSORSHIPSĂĽBEENĂĽDEVALUED These are interesting times and change for the better, no matter the pain of change, is welcome.

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

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

DECEMBER 2016 | 1


December 2016

Contents

16

18

22

20

FEATURES 16å #LOSE 5På0ROFå$AVIDå&LETCHER 18 Values in Health 20 Doctors on Retirement 22 Helping Hand in Ethiopia NEWS & VIEWS 1å %DITORIALå(EALTHå#HANGESå-USTå$ELIVER 4 å å

å å å å

Dr Rob McEvoy Letters to the Editor Managing Poor performance Prof Piers Yates #ONSUMERSÃ¥)NTRINSICÃ¥2OLES Ms Pip Brennan $ELAYEDÃ¥.$)3Ã¥AÃ¥#ONCERN Ms Debbie Karasinski AM Resistance in RACFs Dr Lynne Weekes #ANNABISÃ¥7HATÃ¥ITÃ¥-EANS Mr Neil Keen 7!Ã¥3LOWÃ¥(EPÃ¥#Ã¥5PTAKE Dr Donna Mak )-'SÃ¥4RAINEDÃ¥ANDÃ¥3UPPORTED Ms Kelli Porter & Ms Tina Donovan !Ã¥3WEETÃ¥)NVESTMENT Mr Paul Callander

12 25Ã¥ 26Ã¥ 43 49 51Ã¥

Have You Heard /NÃ¥4IMEÃ¥ANDÃ¥/NÃ¥4RACKÃ¥Dr Paul Collin -EDICOLEGALÃ¥7EREÃ¥!LLÃ¥$OCTORSÃ¥(ERE Latest ED Figures Antibiotic Resistance 7INÃ¥4IPSÃ¥Mr Jerome Chiew

LIFESTYLE 52å 3OCIALå0ULSEå-OUNTå(OSPITALåTHå!NNIVERSARYåå å

53Ã¥ 54Ã¥ 55Ã¥ 56

"ETHESDAå%XPANSION 4RAVELLINGå!ROUND å"ONINGå5PåDr Simon Zilko -USICALå3INGINåINåTHEå2AIN 7INEå2EVIEWå'ILBERTSå7INES Dr Louis Papaelias Competitions

FIND US ON FACEBOOK & TWITTER! /medicalforumwa/

/medicalforumwa/

MAJOR SPONSORS 2 | DECEMBER 2016

MEDICAL FORUM


Clinical Contributors

7

Dr Smathi Chong Zika Virus

43

Dr Ken Thong Diabetes and ‘Fitness to Drive’

50

Dr Matthew Wright 4ESTSåFORå5NEXPLAINEDå Anaemia

51

Dr Kunal Thacker H.Pylori in Children

44

Dr Peter Burke Kits for Travellers

48

Dr Jason Lim Non-medical Management of Glaucoma

)TSåBEGINNINGåTOåLOOKåAåLOTå like Christmas… Christmas Greetings Feature, PPå 

Guest Columnists

11

Dr Astrid Arellano Curse of the Smartphone

39

Dr Ralph Longhorn Road Less Travelled (While Sober)

41

Mihaela Nicolescu Talking About Gambling

42

Dr Roger Paterson ‘Dud’ Doctor or a Mismatch

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 DECEMBER 2016 | 3


Letters to the Editor

Managing poor performance Dear Editor, )NĂĽHISĂĽARTICLE Tough Love Saves Lives (October edition), Flt Lt Ray Werndly suggests a number close parallels in military pilot training that may have useful applications INĂĽMEDICALĂĽTRAININGĂĽ)MPORTANTĂĽATTRIBUTESĂĽINĂĽ both professions are exible decision making, working though grey areas, and being able to recover situations when they go pear shaped. These clearly have close parallels in the skills desired in our training, especially in the surgical specialties and anaesthetics. He also underlines the importance of identifying those that are not going to make it. )NĂĽPOSTGRADUATEĂĽMEDICINE ĂĽOURĂĽTRAININGĂĽISĂĽSTILLĂĽ highly dependent on learning by experience and by observing the behaviour and professional standards of our supervisors. Factual knowledge and intelligence, like in aviation, is very important, and relatively easy to test, but what makes a good doctor is how we interact with our patients and make judgements that are not necessarily learned from a text book. Some of these areas are difďŹ cult to assess, but in the future, the assessment of doctors will become more formalised and, again, we will probably follow the example of methods used in aviation assessment and training including simulation training, revalidation, psychological testing etc. However, one of the biggest challenges for us in medicine is going to be how we manage poor performance when we do identify it, in order to correct or redirect trainees at the EARLIESTĂĽOPPORTUNITYĂĽ)FĂĽWEĂĽFAILĂĽTOĂĽBEĂĽEFFECTIVEĂĽINĂĽ this, then external bodies will become more and more involved in regulatory roles, which can only be detrimental to our profession. Prof Piers Yates, Co-Head of Orthopaedic Surgery, Fiona Stanley Hospital ........................................................................

$ELAYEDĂĽ.$)3ĂĽ decision a concern Dear Editor, Despite assurances that a decision would be made by the end of last month, a bilateral

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

agreement between the State and Federal governments is yet to be reached on how the .ATIONALĂĽ$ISABILITYĂĽ)NSURANCEĂĽ3CHEMEĂĽWILLĂĽBEĂĽ implemented in WA. Currently two trials are under way in WA nĂĽAĂĽ3TATE ADMINISTEREDĂĽ7!ĂĽ.$)3ĂĽANDĂĽAĂĽ #OMMONWEALTH RUNĂĽ.$)3ĂĽ Many organisations are ďŹ nding the extra adminstrative resources and attention required to meet the different funding models to be an unwarranted distraction from focusing on the delivery of vital services to people with disability. We had anticipated needing to manage two different payment systems, reporting structures and planning protocols throughout THEĂĽ ĂĽ.$)3ĂĽTRIALĂĽINĂĽ7! ĂĽANDĂĽWILLINGLYĂĽ carried this in anticipation of ultimately having the best system for people with disability in this State. When the trials were extended, we continued to manage the costs of duplication of systems with goodwill on the understanding that at the end of October we would have clariďŹ cation ONĂĽTHEĂĽlNALĂĽ.$)3ĂĽMODELĂĽ9ETĂĽTHEĂĽUNCERTAINTYĂĽ continues. We also know that the delay is causing anxiety among people with disability, particularly those who are not currently in a trial site and who just want to know when THEYĂĽWILLĂĽBEĂĽABLEĂĽTOĂĽACCESSĂĽTHEĂĽ.$)3ĂĽANDĂĽWHATĂĽ it will look like. We are calling for a decision to be made to bring an end to this uncertainty and allow the disability sector time to prepare for the transition to the full scheme rollout by July 1 2017. Ms Debbie Karasinski, chair National Disability Services WA State Committee ED: An agreement had not been reached between the State and Federal governments by the time we went to press.

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

Consumers' intrinsic roles Dear Editor, 2EĂĽDoctors Drum: Training and ‘Dud’ Doctors and Hello Consumer Directed Care (November EDITION ĂĽ4HEĂĽ(EALTHĂĽ Consumers’ Council acknowledges the wisdom of the saying from Patient Opinion #%/ĂĽ-ICHAELĂĽ'RECOĂĽh4HEĂĽEXPERTĂĽISĂĽONĂĽBOTHĂĽ The support of all advertisers, sponsors and contributors is welcome. Neither the publisher nor any of its servants will have any liability for the information or advice contained in Medical Forum. The statements or opinions expressed in the magazine reect the views of the authors. Readers should independently verify information or advice. Publication of an advertisement or clinical column does not imply endorsement by the publisher or its contributors for the promoted product, service or treatment.

ends of the stethoscope.â€? The lived experience of the patient needs to play an essential role in health service planning, delivery and review. Medical training is the obvious starting point and the opportunity in transformation is to have consumers both co-designing and delivering training. There is nothing more transformative than a well-told story, as the WA Clinical Senate consistently proves through its inclusion of a consumer presentation for each debate topic. "EINGĂĽABLEĂĽTOĂĽCOMMUNICATEĂĽTHEĂĽVITALĂĽ IMPORTANCEĂĽOFĂĽTHEĂĽQUESTIONSĂĽSUCHĂĽASĂĽhWHATSĂĽ MOSTĂĽIMPORTANTĂĽTOĂĽYOUvĂĽANDĂĽhWHATSĂĽYOURĂĽ UNDERSTANDINGĂĽOFĂĽYOURĂĽCONDITIONĂĽRIGHTĂĽNOWvĂĽ uncovers the information that only the patient can provide, and unlocks the opportunity for a positive and safe health care episode. Another key opportunity in training is to plant the seeds of the well-performing team – doctors do not work in a vacuum in the hospital setting. The danger with our current medical training and indeed all our health professions’ training is that people are trained to work in their discipline, but not across disciplines. The opportunity to increase inter-disciplinary training and activities will support a safer, more patient-focused health service. )NĂĽREGARDSĂĽTOĂĽCONSUMERĂĽDIRECTEDĂĽIN HOMEĂĽCAREĂĽ for the elderly, it seems counter-intuitive that a health consumer advocacy agency would be anything other than positive about consumerdirected reforms. November’s Medical Forum was full of the importance of moving from a regimented, service-directed orientation to one where the consumer is at the centre. All of it is exciting and positive. However, what happens when the consumer is in a vulnerable position, unable to make INFORMEDĂĽDECISIONSĂĽ Self-praise is no recommendation, but what else will consumers have to go by other than each organisation’s information about their services, which is hardly going to be DISINTERESTEDĂĽ Can we be sure there will be no aged care equivalent of the travesties that occurred in the TRAININGĂĽSECTORĂĽWHENĂĽTHISĂĽWASĂĽPRIVATISEDĂĽ(OWĂĽ are consumers able to know with conďŹ dence THATĂĽTHEIRĂĽCHOICEĂĽISĂĽTRULYĂĽBEĂĽTHEĂĽBESTĂĽOPTIONĂĽ How will it work if a commitment has been made with a provider, the relationship has crumbled and the consumer is faced with fees ORĂĽCHARGESĂĽINĂĽMOVINGĂĽONTOĂĽANOTHERĂĽPERSON These important questions will need answers. Ms Pip Brennan, ED Health Consumers Council WA continued on Page 6

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

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Letters to the Editor continued from Page 4

#ANNABISĂĽWHATĂĽ it means to you Dear Editor, Cannabis-based PRODUCTSĂĽ#"0 ĂĽ were reclassiďŹ ed as Schedule 8 substances (controlled drugs) on November 1, 2016, following changes to Commonwealth LEGISLATIONĂĽ)TĂĽISĂĽNOWĂĽLEGALĂĽFORĂĽAĂĽSPECIALISTĂĽ medical practitioner to prescribe, and a PHARMACISTĂĽTOĂĽDISPENSE ĂĽ#"0ĂĽINĂĽ7!ĂĽ While there is literature to support the use of #"0SĂĽINĂĽSELECTEDĂĽCONDITIONS ĂĽTHEĂĽEVIDENCEĂĽ ISĂĽLIMITEDĂĽANDĂĽOFĂĽVARIABLEĂĽQUALITYĂĽ5NTILĂĽNOW ĂĽ strict Commonwealth and international PROHIBITIONĂĽLAWSĂĽSURROUNDINGĂĽ#"0SĂĽHASĂĽLIMITEDĂĽ RESEARCHĂĽINĂĽTHISĂĽlELDĂĽ)TĂĽISĂĽHOPEDĂĽTHATĂĽBYĂĽTHEIRĂĽ reclassiďŹ cation, higher quality research into the efďŹ cacy and safety of these products will emerge. There is moderate-quality evidence to SUPPORTĂĽTHEĂĽUSEĂĽOFĂĽ#"0SĂĽINĂĽTHEĂĽTREATMENTĂĽ of chronic pain and spasticity. To date, there is low-quality evidence for their use in sleep disorders, nausea and vomiting due TOĂĽCHEMOTHERAPY ĂĽANDĂĽWEIGHTĂĽGAINĂĽINĂĽ()6ĂĽ infection. There is also low-quality evidence for the use OFĂĽCANNABIDIOLĂĽ#"$ ĂĽINĂĽSEIZUREĂĽDISORDERSĂĽ 4HEĂĽMANUFACTUREĂĽOFĂĽUNREGISTEREDĂĽ#"$ĂĽ products is subject to the recent legislative changes, but where containing less than 2% tetrahydrocannabinol (THC) they are classiďŹ ed as Schedule 4 prescription substances, rather than controlled drugs.

of medications where therapeutic beneďŹ ts and long-term side effects are uncertain. 4OĂĽPRESCRIBEĂĽAĂĽ#"0 ĂĽAĂĽSPECIALISTĂĽMEDICALĂĽ practitioner must obtain approval from the TGA under the Special Access Scheme or the Authorised Prescribers Pathway. Permission must also be sought from the WA $EPARTMENTĂĽOFĂĽ(EALTH ĂĽWHEREĂĽAĂĽ#"0ĂĽ%XPERTĂĽ Advisory Panel will assess individual requests. )NĂĽTHEĂĽSETTINGĂĽOFĂĽLIMITEDĂĽEVIDENCEĂĽONĂĽEFlCACYĂĽ and safety, informed patient consent will be essential. A specialist medical practitioner may also wish to apply to appoint a GP as a co-prescriber, however, all treatment decisions surrounding product and treatment dose will remain at the direction of the specialist. Once approved, a patient will be able to present their script to any pharmacy in WA for dispensing, but supply is still likely to be difďŹ cult for many months. To date, there are no Australian products available though it is anticipated that they will become available in 2017. &ORĂĽNOW ĂĽTHEĂĽPRESCRIPTIONĂĽOFĂĽ#"0SĂĽSHOULDĂĽ proceed with caution, and only when all other TREATMENTĂĽOPTIONSĂĽHAVEĂĽBEENĂĽEXHAUSTEDĂĽ)TĂĽISĂĽ hoped that the changes in Commonwealth legislation will enable medical research to solidify the evidence for the therapeutic proďŹ le OFĂĽ#"0S ĂĽANDĂĽTHATĂĽSAFE ĂĽEFFECTIVEĂĽANDĂĽRELIABLEĂĽ products will become available.

of urinary tract infections. Excessive antibiotic use—in the context of asymptomatic bacteriuria—may be contributing to the high prevalence of multidrug-resistant E. coli seen in this group. )NĂĽAGED CAREĂĽFACILITIESĂĽWHEREĂĽTHEREĂĽISĂĽAĂĽHIGHĂĽ prevalence of asymptomatic bacteriuria, DIAGNOSINGĂĽSYMPTOMATICĂĽ54)ĂĽREQUIRESĂĽ assessment of new presenting signs and symptoms. The patient’s existing medicines and conditions should also be considered. Patients with advanced dementia are of particular concern as they may have factors associated with harbouring antibiotic-resistant bacteria (such as faecal incontinence or skin ulcers). These patients also require signiďŹ cant assistance with activities of daily living and this can contribute to the spread of antibioticresistant bacteria to healthcare workers due to poor infection control. Current evidence supports treating asymptomatic bacteriuria with antibiotics for those at risk of complications or who are to undergo procedures that involve the bladder or urethra. Among other populations where asymptomatic bacteriuria is common, such as women aged over 60 years, catheterised patients in hospitals, people with diabetes and the elderly, a clinical beneďŹ t of antibiotic treatment is not evident. Dr Lynn Weekes, CEO, NPS MedicineWise

Mr Neil Keen, WA Chief Pharmacist

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WA slow hep C uptake

AM resistance in RACFs

Common adverse events in the short term use OFĂĽ#"0SĂĽINCLUDEĂĽDIZZINESS ĂĽDRYĂĽMOUTH ĂĽNAUSEA ĂĽ fatigue, disorientation and hallucination. A recent systematic review and meta-analysis INTOĂĽ#"0SĂĽFORĂĽMEDICALĂĽUSEĂĽFOUNDĂĽTHATĂĽTHEREĂĽ were no studies evaluating the long-term sideeffects, even when searches were extended to include lower-levels of evidence.

The article, Resistant Gram negatives – a growing threat (November) highlights the importance of judicious antibiotics use among residents in aged care facilities. Antimicrobial resistance is a growing concern.

#"0SĂĽREMAINĂĽUNREGISTEREDĂĽTHERAPEUTICĂĽGOODSĂĽ and, as such, the role of Government is to ensure a robust process for the prescribing

One area where NPS MedicineWise believes progress can be made is in the management

GPs can now initiate new hepatitis C treatments without specialist authorisation. WA Health urges doctors to inform their patients about the effectiveness (>90% cure rate with a 12- 24 week treatment course) of direct acting antiviral hepatitis C treatments and the fact that these oral treatments have very few side-effects. continued on Page 8

Curious Conversations

It's a Big, Wide World It’s a life of open roads and an open mind for Dr Angus Turner. If I had to write a memoir of my life so far the title would be‌ h"LUEü3KIESüANDü/PENü2OADSv One of my fondest memories of my school days is‌ rowing in the mist on the upper reaches of the Swan River near Guildford. The one dish I really like to cook is‌üKANGAROOünüHOTüANDüFASTü!NDü)ü love smoking any kind of food, too.

6 | DECEMBER 2016

If I could have 20 minutes with the WA Health Minister I’d say‌ thanks for doing a tough job and please remember that one third of the population live outside Perth. I’m very glad I chose medicine because‌ü)üCANüROLLüUPüMYüSLEEVESü anywhere from Australia to Africa and help people in need. And there’s always something new to learn!

MEDICAL FORUM


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By Dr Smathi Chong Clinical Microbiologist & Infectious Diseases Physician

Zika Virus The list of countries with endemic transmission of Zika virus continues to grow. First discovered in the 1940s in Uganda, it remained under the radar until fairly recently. Outbreaks in the South PaciďŹ c, Latin America and the Caribbean have occurred in recent years and now more than 60 countries have had reports of local transmission. In the last few months, many cases have been diagnosed in some South-east Asian countries including popular destinations for Australians like Singapore, Malaysia and Thailand. Zika virus is from the same family (Flavivirus) as dengue, Japanese encephalitis and yellow FEVERĂĽ)TĂĽISĂĽPRIMARILYĂĽTRANSMITTEDĂĽBYĂĽTHEĂĽSAMEĂĽ mosquito as dengue, chikungunya and yellow fever – the Aedes aegypti and Aedes albopictus mosquitos, which fortunately do not occur in WA but they are only in northern Queensland. All cases of Zika virus in Australia so far have been ‘imported’ FROMĂĽRETURNEDĂĽTRAVELLERSĂĽ5NLIKEĂĽDENGUE ĂĽ sexual transmission of Zika virus has also occurred, albeit uncommonly. Zika cannot be transmitted via casual contact.

Mosquito: Aedes albopictus

There have been more than 50 conďŹ rmed cases of Zika diagnoses in Australia so far this year. The top few destination countries INCLUDEĂĽ4ONGA ĂĽ&IJI ĂĽ3AMOA ĂĽ-EXICOĂĽANDĂĽ"RAZILĂĽ This is in contrast to dengue which has been diagnosed in about 1800 patients in Australia with about 500 of those from WA alone in 2016. All the WA dengue cases would have been acquired overseas. Zika co-infection with dengue and chikungunya is possible. Zika only causes a mild illness usually, and very few deaths, with incubation PERIODĂĽOFĂĽ ĂĽDAYSĂĽ&EVER ĂĽHEADACHE ĂĽ arthralgia, myalgia, a generalised macular or maculopapular rash and conjunctivitis are the common symptoms that usually only last a few days. Zika has been linked to 'UILLAIN "ARREĂĽSYNDROME ĂĽANĂĽINmAMMATORYĂĽ demyelinating neuropathy which can also be precipitated by other infections like #AMPYLOBACTERĂĽANDĂĽINmUENZAĂĽ4HEĂĽRISKĂĽOFĂĽTHISĂĽ syndrome after Zika infection is about 1 in 5000 cases of Zika. Asymptomatic infection is thought to be very common. The most concerning thing about Zika is its association with severe foetal outcomes including microcephaly when infection occurs during pregnancy. There is no speciďŹ c treatment or vaccine yet. Treatment is symptomatic. A person who has been infected with Zika is likely to be immune to further Zika infections.

In Pregnancy Women who are pregnant or plan to get pregnant should avoid travelling to countries where Zika transmission is on-going. The list of countries is constantly updated. Pregnant women suspected of Zika infection should undergo testing and be referred for specialist obstetrical care if infection is suspected or proven. Planning pregnancy The World Health Organisation (WHO) recommend safe sex for 6 months after return from endemic areas for both males and females. However current Australian Guidelines mention a minimum of 8 weeks for females and 6 months for males. Sex Any man, regardless of symptoms, who has travelled to areas where Zika transmission is ongoing, and whose partner is pregnant, should abstain from penetrative sex or correctly use condoms for every sexual intercourse throughout pregnancy. )TĂĽISĂĽRECOMMENDEDĂĽTHATĂĽANYĂĽMANĂĽWITHĂĽ conďŹ rmed Zika infection abstains from intercourse or uses condoms consistently for 6 months after resolution of symptoms. Testing All testing in WA is performed by the State viral reference laboratory on samples submitted by both private and public pathology collection centres. Tests to perform for suspected acute or RECENTĂĽ:IKAĂĽINFECTIONSĂĽ sĂĽ 3ERUMĂĽFORĂĽ:IKAĂĽANTIBODIESĂĽĂĽ0#2ĂĽTESTING

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sĂĽ 5RINEĂĽFORĂĽ:IKAĂĽ0#2ĂĽMAYĂĽBEĂĽPOSITIVEĂĽFORĂĽUPĂĽ to a month of symptom onset) sĂĽ &"%ĂĽLYMPHOPAENIA ĂĽLYMPHOCYTOSIS ĂĽ atypical lymphocytes), LFTs (may be mildmoderately raised), other similar infections e.g. serology for dengue, chikungunya, etc. Testing for asymptomatic individuals planning pregnancy Zika virus serology testing can be considered at least 4 weeks after leaving a Zika affected country (to enable enough time for detectable antibodies against Zika to develop). Zika virus testing on semen is not currently available in WA. There are many scenarios not covered by this brief article. Prevention Measures to prevent mosquito bites are recommended when travelling (also important to prevent other mosquito-borne diseases). )NFORMATIONĂĽABOUTĂĽEMERGINGĂĽINFECTIONSĂĽMAYĂĽ become out-of-date rapidly. The current list of countries affected by Zika virus may be obtained via the Commonwealth Dept. of Health website. Further information may also be obtained FROMĂĽWEBSITESĂĽOF sĂĽ !USTRALIANĂĽ#OMMONWEALTHĂĽ$EPTĂĽOFĂĽ(EALTHĂĽ sĂĽ 7!ĂĽ$EPTĂĽOFĂĽ(EALTH sĂĽ #ENTERSĂĽFORĂĽ$ISEASEĂĽ#ONTROLĂĽANDĂĽ Prevention (CDC) Google Zika Department of Health or Zika CDC


Letters to the Editor continued from Page 6 From October 1, 2016, GPs have been ABLEĂĽTOĂĽINITIATEĂĽ0"3 FUNDEDĂĽ3ĂĽHEPATITISĂĽ#ĂĽ treatments without specialist authorisation. Patients must be treated by a medical practitioner experienced in the treatment OFĂĽCHRONICĂĽHEPATITISĂĽ#ĂĽINFECTIONĂĽORĂĽINĂĽ consultation with a gastroenterologist, hepatologist or infectious diseases physician experienced in the treatment of chronic hepatitis C infection. 4HEĂĽ0"3ĂĽAPPLICATIONĂĽMUSTĂĽINCLUDE sĂĽ 4HEĂĽHEPATITISĂĽ#ĂĽVIRUSĂĽGENOTYPEĂĽANDĂĽ sĂĽ 4HEĂĽPATIENTSĂĽCIRRHOTICĂĽSTATUSĂĽNON CIRRHOTICĂĽ or cirrhotic). )TĂĽISĂĽNECESSARYĂĽTOĂĽRECORDĂĽINĂĽTHEĂĽPATIENTSĂĽ MEDICALĂĽRECORDS sĂĽ %VIDENCEĂĽOFĂĽCHRONICĂĽHEPATITISĂĽ#ĂĽINFECTIONĂĽ (repeatedly antibody to hepatitis C virus (anti-HCV) positive and hepatitis C virus RIBONUCLEICĂĽACIDĂĽ(#6ĂĽ2.! ĂĽPOSITIVE ĂĽANDĂĽ sĂĽ THEĂĽHEPATITISĂĽ#ĂĽVIRUSĂĽGENOTYPEĂĽ "ASEDĂĽONĂĽ0"3ĂĽDATAĂĽCOLLECTEDĂĽFROMĂĽ-ARCHĂĽTOĂĽ July 2016, WA is lagging behind in terms of treatment uptake, with only 7% of patients with chronic hepatitis C having been started on treatment, in contrast with 19% in the ACT ANDĂĽ ĂĽINĂĽ.37 ĂĽ1LD ĂĽ3!ĂĽANDĂĽ6ICTORIAĂĽ 4HEĂĽ3ILVERĂĽ"OOKĂĽ'UIDELINESĂĽFORĂĽMANAGINGĂĽ34)ĂĽ ANDĂĽ""6SĂĽWWHEALTHWAGOVAU3ILVER BOOK ĂĽ now includes a revised chapter on hepatitis C including a referral form. Online training resources in the new hepatitis C treatments can be accessed at the FOLLOWINGĂĽWEBSITES HTTPSLMSASHMORGAUĂĽ HTTPWWWNPSORGAUHEALTH PROFESSIONALS CPDACTIVITIESONLINE COURSESMANAGING hepatitis-c-in-primary-care HTTPHEPATITISECUEDUAU 4HEĂĽ!USTRALASIANĂĽ3OCIETYĂĽOFĂĽ()6 ĂĽ(EPATITISĂĽ and Sexual Health Medicine (ASHM) will provide free face-to-face training in WA and webinars in 2017. For more information email Sonja Hill at Sonja.hill@ashm.org.au Prof Donna Mak, Communicable Disease Control Directorate, WA Health ED: An update from an ongoing study by St George Hospital in Sydney has found that the majority of 114 hepatitis C patients who were put on direct-acting antivirals after PBS listing in March were being treated at a liver clinic. Only six were treated by GPs and a further 25 by specialists in private rooms. In a survey of 131 GPs about DAA therapy, other researchers from the hospital have found 29% feel they are up to date with Australian guidelines for managing non-cirrhotic patients. Just six of the GPs had prescribed DAAs and a further 37 planned to. The barriers reported by the

non-prescribers were unfamiliarity with the drugs (88%), uncertainty about the need for the treatment (45%) and uncertainty about whether pharmacies dispensed the drugs (28%).Only 51% of GPs were aware that cure rates with the new regimens were over 90%, and 21% were not aware that DAAs are oral medications.

career expectations of the applicant.

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

The pathway to medical registration depends on an individual doctor’s qualiďŹ cations and EXPERIENCEĂĽSEEĂĽ-EDICALĂĽ"OARDĂĽWEBPAGE ĂĽ!SĂĽ part of the registration process, applicants must demonstrate their English language COMPETENCYĂĽTHISĂĽMAYĂĽBEĂĽTHROUGHĂĽPROVINGĂĽ English is their ďŹ rst language, they have undertaken additional study in English or have achieved a set standard among other English language tests.

)-'SĂĽTRAINEDĂĽANDĂĽSUPPORTEDĂĽ 2E Doctors Drum Training and ‘Dud’ Doctors and the concerns about TRAININGĂĽOFĂĽ)-'SĂĽ (November edition) Rural Health West receives more than 900 applications from international medical GRADUATESĂĽ)-'S ĂĽ every year. About 20% of these applicants have relevant skills and experience and are reviewed by Rural Health West’s recruitment team to determine their suitability for rural general practice. This involves a clinical interview with a medical educator, a referee check and the completion of a self-assessment questionnaire. A small number of applicants are classiďŹ ed Category 1 as their post-graduate qualiďŹ cations are deemed to be equivalent to Australia’s Fellowship qualiďŹ cation. #ATEGORYĂĽĂĽDOCTORSĂĽAREĂĽTHOSEĂĽFROMĂĽTHEĂĽ5+ ĂĽ )RELAND ĂĽ#ANADAĂĽANDĂĽ.EWĂĽ:EALANDĂĽWHEREĂĽ both the medical training system and general practice are similar to Australia. These doctors typically adapt quickly and are highlysought after by practices. Category 1 doctors are not required to sit a clinical interview, however, we do contact referees and doctors need to complete a self-assessment. Non-category 1 doctors need to work towards attaining Fellowship, so new rural doctors are given information on the Rural Vocational Training Scheme and independent Fellowship pathways through RACGP and ACRRM. Rural Health West also manages the Additional Assistance Scheme on behalf of the Australian Government, which can provide mentoring, exam preparation and ďŹ nancial support while they work towards their Fellowship. Doctors deemed suitable for rural practice are matched against vacancies, considering both the requirements and skills desired by the practice, as well as the family make-up and

One can never have enough socks," said Dumbledore. "Another Christmas has come and gone and I didn't get a single pair. People will insist on giving me books.

We encourage all practices to complete their own interview to ensure the candidate is the RIGHTĂĽlTĂĽFORĂĽTHEIRĂĽTEAMĂĽ)FĂĽAĂĽJOBĂĽOFFERĂĽISĂĽMADE ĂĽ Rural Health West supports candidates through the medical registration and visa process.

All doctors new to rural practice in WA are offered a comprehensive orientation before starting work, which includes learning about Medicare, any relevant cultural practices and how to access support while settling into their NEWĂĽROLEĂĽ/NCEĂĽANĂĽ)-'ĂĽISĂĽIN SITU ĂĽTHEREĂĽISĂĽAĂĽ diverse range of support programs to help them attain Fellowship, upskill or integrate into their new community. Ms Tina Donovan, Recruitment Manager and Ms Kelli Porter, GM, Rural Health West ........................................................................

A sweet investment Dear Editor, ManukaLife, is developing the industry in WA to produce medical grade Manuka honey for supply globally. Manuka honey contains proven high level antibiotic activity through its methylglyoxal (MGO) and dihydroxyacetone (DHA) contents. We are seeking medical companies in WA to be involved in research and development of products for the medical and pharmaceutical industries. We also invite medical practitioners who have access to land to propagate Manuka trees on plantations in the South West, following our 2015 importation of eight high-quality genetic seed cultivars of Leptospermum scoparium (Manuka) from New Zealand. The intention is to grow these trees in WA and to market the honey to the medical, pharmaceutical and cosmetic industries. We have propagated and planted 400,000 seedlings across ďŹ ve different locations of about HAĂĽEACHĂĽINĂĽ3OUTHĂĽ7ESTĂĽ7!ĂĽ7EĂĽAREĂĽNOWĂĽ propagating seedlings for planting in 500ha in May 2017. Anyone in the medical ďŹ eld who would like to get involved with Manuka as an agricultural crop THATĂĽPROVIDESĂĽAĂĽVERYĂĽSOLIDĂĽECONOMICĂĽRETURN ĂĽ)ĂĽAMĂĽ AVAILABLEĂĽONĂĽĂĽĂĽĂĽ Mr Paul Callander, MD ManukaLife

Harry Potter and the Sorcerer's Stone by J.K. Rowling 8 | DECEMBER 2016

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Incisions

The Curse of the Smartphone Infectious diseases physician Dr Astrid Arellano suggests some strong ground rules in a doctor’s relationship with their smartphone, starting with the off button. After returning from a run, the phone showed three missed calls and half a dozen new email messages. My heart rate, already high, went up a notch.

Smartphones are beneďŹ cial for optimising efďŹ ciency but require management. They are a curse when trying to live a balanced life. Doctors are at greater risk of depression and anxiety with higher rates of suicidal ideation than other Australians. Phones cause mental fatigue, they make us disengage with family and friends and they cause constant anxiety. We feel anxious if we can’t get to the phone, anxious of what may be required when answering the phone, we ďŹ ddle with them when there is down-time and we are constantly interrupted by calls and notiďŹ cations. Most of us sleep with the phone by the bedside or under the pillow. Smartphones are more demanding that the worst child anyone has had to look after.

)ĂĽWASNTĂĽONĂĽCALLĂĽBUTĂĽCURSEDĂĽLEAVINGĂĽTHEĂĽPHONEĂĽ behind. Absurd given that nothing should be that urgent that an hour of disconnect is a PROBLEM ĂĽESPECIALLYĂĽONĂĽAĂĽDAYĂĽOFFĂĽ)ĂĽLISTENEDĂĽTOĂĽ the voicemail with the consequent to-do-list of tasks and people to call back. The anxiety about missed information and guilt for letting colleagues and patients down was hard to push back. Email was equally DEMANDINGĂĽSCHOOLĂĽPERMISSIONĂĽSLIPS ĂĽBANKINGĂĽ requirements, clinic referrals to triage, and SOĂĽONĂĽ)NĂĽANĂĽINSTANTĂĽTHEĂĽBENElTĂĽDERIVEDĂĽFROMĂĽ THEĂĽEXERCISEĂĽSEEMEDĂĽTOĂĽVANISHĂĽ)ĂĽWASĂĽBACKĂĽ to feeling stressed and annoyed at the interruptions on my day off.

The expectation of being available around the clock needs to change. We need to use @ABSENTĂĽMESSAGESĂĽMOREĂĽWEĂĽNEEDĂĽTOĂĽSTOPĂĽ checking the phone 80 times a day and we need to insist on uninterrupted blocks of time because to be effective in our interactions with patients, to digest difďŹ cult cases and to perform operations we need to be able to concentrate.

)NĂĽREALITYĂĽTHEĂĽCALLSĂĽANDĂĽEMAILĂĽHADĂĽONLYĂĽBECOMEĂĽAĂĽ SOURCEĂĽOFĂĽSTRESSĂĽBECAUSEĂĽ)ĂĽLOOKEDĂĽATĂĽTHEĂĽPHONEĂĽ 5NFORTUNATELYĂĽMUCHĂĽOFĂĽOURĂĽLIVESĂĽAREĂĽDRIVENĂĽ by stress, pressure and anxiety about the consequences of not doing something rather than the pleasure and satisfaction derived from a job well done. Smartphones are in the pockets of 80% of doctors and therefore schedules can be checked, clinic and theatre lists modiďŹ ed, x-rays and blood tests viewed ĂĽWITHĂĽTHEĂĽCONSEQUENTĂĽREQUIREDĂĽACTIONSĂĽ

Each time we read an email or check a blood test we are liable for our actions. Failing to act in a timely manner can lead to litigation. Texting is not conďŹ dential or secure, yet patient discussions regularly occur via text.

Most importantly, we need time to eat and go TOĂĽTHEĂĽTOILET ĂĽTOĂĽUNWINDĂĽANDĂĽEXERCISEĂĽANDĂĽTIMEĂĽ away from work and phones.

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Have You Heard?

Universities ready for action

In a Galaxy far, far away‌ @-AYüTHEü&ORCEPSü"Eü7ITHü9OUüANDüWITHüINVOCATIONüTHEüINAUGURALü3IM7ARSüWEREüKICKEDüOFFüATü RANZCOG’s annual ASM held in Perth recently. The team event was organised by Dr Katrina #ALVERTüFROMü&IONAü3TANLEYü(OSPITALüANDüINVOLVEDüTEAMSüFROMü/'üUNITSüFROMü1UEENSLAND ü.:ü and WA who competed in a live, real-time, on-stage simulation of an emergency. Also on hand were paramedics from St John Ambulance, midwifery, nursing and anaesthetic volunteers from King Edward Memorial Hospital, Osborne Park Hospital and Fiona Stanley Hospital, the acting TALENTSüOFüTHEü"ROOMEü(OSPITALüMEDICALüSTUDENTS üANDüSUPPORTüANDüEQUIPMENTüFROMü0EELüHEALTHü Campus. Katrina said it was fantastic to have had the chance to learn together, while showcasing WHATüSIMULATIONüCOULDüDO üANDüHAVEüFUNüINüTHEüPROCESSü4HEüVICTORSü4HEü"RISBANEüTEAM ü4HEü Mater Mannequin Muddlers, took out the People's Choice Award for the best overall team. The WINNERüOFüTHEü"ESTü$EBRIElNGü!WARDüWASüTHEü.EWü:EALANDüTEAMü4HEü+IWIü3TRIKESü"ACK üANDü WINNERüOFüTHEü"ESTü3IMULATIONü3CENARIOü0ERFORMANCEü!WARDüWASüTHEü7!üTEAMü4EAMü-OTHERSHIP 

The university sector is bracing for a huge ĂĽ#URTINĂĽ5NIVERSITYSĂĽ-EDICALĂĽ3CHOOLĂĽHASĂĽ been granted accreditation by the AMC which has given the school the green light to start its ďŹ rst year of training in February. The AMC go-ahead sparked renewed criticism from AMA president Dr Michael Gannon, who told The Medical Republic that the AMA would hold Curtin to all its undertakings, including the promise to take high school graduates from less-privileged areas. The Dean, Prof William Hart, said to date there had been 1506 applications for the 60 available places. "YĂĽ ĂĽTHEĂĽINTAKEĂĽISĂĽEXPECTEDĂĽTOĂĽRISEĂĽTOĂĽĂĽ a year – 110 domestic and 10 international STUDENTSĂĽ.EXTĂĽYEAR ĂĽTHEĂĽ5NIVERSITYĂĽOFĂĽ.OTREĂĽ $AMEĂĽMEDICALĂĽSCHOOLĂĽWILLĂĽJOINĂĽ57!ĂĽWITHĂĽAĂĽ NEWLYĂĽMINTEDĂĽ-$ĂĽCOURSEĂĽ57!ĂĽWILLĂĽLAUNCHĂĽANĂĽ undergraduate Medical Sciences major in 2017, which will enable students with this under their belt to be recognised for credits or exemptions when they commence the post-graduate MD. One program that is putting runs on the board ISĂĽ57!SĂĽ2URALĂĽ3TUDENTĂĽ2ECRUITMENTĂĽ0ROGRAM ĂĽ which this year (it’s 16th) sees 60 rural students from 22 country towns, including 17 from "UNBURY ĂĽGRADUATEĂĽnĂĽTHEĂĽBIGGESTĂĽNUMBERĂĽ of rural background doctors to graduate in a single year. The students are from towns INCLUDINGĂĽ!LBANY ĂĽ"RIDGETOWN ĂĽ"ROOME ĂĽ "UNBURY ĂĽ#ARNARVON ĂĽ#HRISTMASĂĽ)SLAND ĂĽ Denmark, Esperance, Geraldton, Kalbarri, Kalgoorlie, Karratha, Lake Grace, Mandurah, Manjimup, Moorine Rock, Narrogin, Northam, Oakford, Serpentine and Yallingup.

Kick off the new triennium with an unforgettable upskilling opportunity in Karijini National Park.

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Have You Heard?

HITWA 4HEĂĽ(EALTHĂĽ)NFORMATICSĂĽ3OCIETYĂĽOFĂĽ!USTRALIASĂĽ 7!ĂĽEVENTĂĽ()47!ĂĽLASTĂĽMONTHĂĽSAWĂĽANĂĽ impressive line-up of talent talking up digital disruption to like-minded people who will no doubt be leading the rest of us by the hand into the brave new world of eHealth. Dr Monica Trujillo head of Clinical and Consumer Engagement and Clinical Governance at the Australian Digital Health Agency not surprisingly talked up the My Health Record and announced the start of an online and face-to-face consultation process that would wrap up at the end of January. She said secure messaging was a key priority (see RACGP story below). The opt-out strategy employed at the trial sites in Queensland and NSW was producing high numbers of stayers. Dr Trujillo said there were 4.28m consumer REGISTRATIONSĂĽNATIONALLYĂĽĂĽWEREĂĽWOMENĂĽANDĂĽ representing 18% of the population) and 9299 providers have signed up.

RACGP leads secure messaging Those GPs who were at the GP16 member forum on digital disruption would have seen Melbourne GP Dr Nathan Pinskier’s wise digital head at work. And those who read last month’s snippet about the forum would know the kerfufe raised by the phasing out of faxes. News has just come through that Nathan will oversee the development of secure electronic messaging so doctors can prise their ďŹ ngers off the fax machine. Australian Digital Health Agency chief Tim Kelsey said interoperable secure messaging was the agency’s top priority. His choice of Nathan is strategic. Mr

Kelsey told a RACGP eHealth forum that the agency recognised that doctors had a hHISTORYĂĽOFĂĽDISAPPOINTMENTvĂĽREGARDINGĂĽDIGITALĂĽ health and they needed their conďŹ dence restored. Nathan, an outspoken critic of the Government’s former eHealth policies, said without secure point-to-point messaging, doctors would not join the eHealth train. Joining Nathan on the project are WA community representative Fiona Panagoulias and Dr Mal Thatcher, CEO of eHealth Queensland.

saw the evacuation of 77 patients and an awful mess to clear up after the ďŹ re brigade HADĂĽDOUSEDĂĽTHEĂĽmAMESĂĽ)NĂĽLESSĂĽTHANĂĽTHREEĂĽ weeks 24 patients were welcome back and the operating theatre, maternity, surgical, medical and rehabilitation wards were back INĂĽBUSINESSĂĽ!CTINGĂĽ#%/ĂĽ"ENĂĽ%DWARDSĂĽSAIDĂĽ the hospital’s medical consulting suites, SKG Radiology, Mercy Physiotherapy and St John of God Pathology were not impacted by the ďŹ re.

Rush is on at Midland

"UTĂĽWAITĂĽĂĽTHERESĂĽMOREĂĽFROMĂĽ3*'(#ĂĽ!FTERĂĽ losing out to Ramsay Health for the buy-out of the controversial government contract to run the Peel Health Campus (which by the way falls due in 12 months), and shelving plans for a private hospital just across the road from the existing campus – at least for the moment – the not-for-proďŹ t has ventured into the region once again, this time opening consulting suites in Mandurah for urology, orthopaedics, gastroenterology, ophthalmology, upper gastrointestinal and counselling.

The public-private partnership between St John of God Health Care and the WA Government at Midland celebrated is ďŹ rst anniversary on November 24 and by ofďŹ cial reports the public hospital has exceeded expectations, so much so, the Government has injected a 12% increase in funds for the coming year. The public hospital has TREATEDĂĽ ĂĽINPATIENTS ĂĽ ĂĽOUTPATIENTS ĂĽ  ĂĽ%$ĂĽPRESENTATIONS ĂĽPERFORMEDĂĽĂĽ procedures and delivered 1650 babies. And between the SJG Midland Public and Private Hospitals, about 161,000 patients have been through the doors. The hospital expects increased activity next year in the area of orthopaedics, general and plastic surgery and gynaecology.

Smooth return after ďŹ re Meanwhile, down the road at SJG Mt Lawley Hospital, November was a month of reallife ďŹ re emergency and high drama. A ďŹ re which started on November 1 in the kitchen

Specialist presence in Mandurah

Mysteries of Sarcopaenia )NĂĽTHEĂĽAGEDĂĽCAREĂĽEDITIONĂĽINĂĽ.OVEMBER ĂĽ Geriatrician Dr Rita Malik wrote about the need for growing awareness of the prevalence of Sarcopaenia in the over 65 COHORTĂĽ.OWĂĽTHEĂĽ5NIVERSITYĂĽOFĂĽ-ELBOURNEĂĽISĂĽ leading a push for more research into the muscle-wasting disease that affects one continued on Page 8

stiveshomecare.com.au MEDICAL FORUM

DECEMBER 2016 | 13


Have You Heard?

Scramble at the Rotto Ramble )TĂĽWASĂĽTHEĂĽTURNĂĽOFĂĽĂĽJUNIORĂĽDOCSĂĽANDĂĽMEDICALĂĽ STUDENTSĂĽTOĂĽHITĂĽ2OTTNESTĂĽ)SLANDĂĽTOĂĽTESTĂĽ their skills in a series of simulated medical emergencies including a near drowning, a snake bite, a stroke and a potential spinal injury. Rural Health West hosted the ďŹ rst 2OTTOĂĽ2AMBLE ĂĽANĂĽ@!MAZINGĂĽ2ACEĂĽSTYLEĂĽ medical wilderness challenge to help develop decision-making in emergency situations. The six teams had no idea of what medical emergency was around the corner but the creator of the Rotto Ramble SCGH EMERGENCYĂĽSPECIALISTĂĽ0ROFĂĽ4ONYĂĽ#ELENZA ĂĽ said the uniqueness of the wilderness event enabled the participants to use a wide range of skills. The event was sponsored by Rural Doctors Association WA (RDAWA) and the Stroke Foundation of WA.

sĂĽDr Lachlan Henderson who was CEO of St John of God Subiaco and Executive Director, Perth Northern Hospitals (Midland Public and Private, Mt Lawley and Wembley Day Surgery) will leave WA to take up the position of group CEO of Epworth Health Care in Victoria. sĂĽDr Neale Fong has been elected national president of the Australasian College of Health Service Management (ACHSM). He is currently WA president. sĂĽ#HIEFĂĽ/PERATINGĂĽ/FlCERĂĽ#AREĂĽFORĂĽTHEĂĽ3TĂĽ)VESĂĽ Group Michelle de Ronchi has been appointed to the inaugural board of Leading Aged Services Australia (LASA), which is the national peak body representing all age service providers.

Prof Jack Goldblatt

süPioneer of genetic services in WA Prof Jack Goldblatt has won the 2016 Minister for Health Award. Prof Goldblatt, who is retiring this year after 27 years leading the WA Health’s genetic services team. Also at the WA Health Awards, Rockingham General Hospital was recognised for its clinical engagement project and Solaris Care for its consumer and community engagement project. WACHS WA Trachoma program in

14 | DECEMBER 2016

the GoldďŹ elds was acknowledged and the East Metropolitan Health Service, Royal 0ERTHĂĽ(OSPITALĂĽANDĂĽTHEĂĽ(OMEĂĽ)NTRAVENOUSĂĽ Antibiotics Service took out the category of out-of-hospital health care. sĂĽProfs Eric VisserĂĽ5NIVERSITYĂĽOFĂĽ.OTREĂĽ$AME ĂĽ and Peter Drummond and A/Prof Philip FinchĂĽBOTHĂĽFROMĂĽ-URDOCHĂĽ5NIVERSITY ĂĽHAVEĂĽ received a $100,000 grant for a research program into chronic pain management from the Australian and New Zealand College of Anaethetists. sĂĽThe WA Government has awarded BroadspectrumĂĽAĂĽĂĽMILLIONĂĽCONTRACTĂĽ previously held by Serco to provide security and custodial services in the state. sĂĽ57!ĂĽSTUDENTĂĽRichard O’Halloran is a 2017 Rhodes Scholar. He will study for a Masters in Global Health Sciences and a Masters in 0UBLICĂĽ0OLICYĂĽATĂĽ/XFORDĂĽ5NIVERSITYĂĽ(EĂĽWILLĂĽ focus on improving health systems in rural and remote areas. sĂĽ4HEĂĽ,IONSĂĽ%YEĂĽ)NSTITUTEĂĽANDĂĽ57!SĂĽ#ENTREĂĽ for Ophthalmology and Visual Science HASĂĽBEENĂĽAWARDEDĂĽMĂĽINĂĽTWOĂĽ.(-2#ĂĽ grants. A team led by Prof David Mackey is developing treatments to target genetic eye diseases. Prof Dao-Yi Yu, Prof Stephen Cringle and Prof William Morgan will use their grant to develop new glaucoma surgery for clinical use and commercialisation. sĂĽRonan O'Connor, who worked with Australian Digital Health Agency (ADHA) CEO Tim Kelsey at the NHS England, has been appointed executive general manager of ADHA's Core Systems Operations division, which will oversee the functioning of the My Health Record system.

sĂĽ2ESEARCHERSĂĽATĂĽ57!SĂĽ#ENTREĂĽFORĂĽ Respiratory Heath are among a group of Australian scientists awarded $2.5 million by the NHMRC to support work into lung ďŹ brosis. Prof Geoff Laurent and A/Prof Yuben Moodley, are members of a multidisciplinary national consortium. sĂĽShane Solomon, the inaugural head and driving force behind Telstra's healthcare division, will retire as managing director in February. He will continue as an adviser to Telstra on the delivery of the National Cancer Screening Register and as chair of the project control board. sĂĽ57!ĂĽHASĂĽCREATEDĂĽ a new chair to recognise Prof Ian Constable’s contribution to ophthalmology. 4HEĂĽ)ANĂĽ#ONSTABLEĂĽ Chair in Discovery and Translational Ophthalmic Science Prof Ian Constable is being established with the ďŹ nancial support of the Australian Foundation for the 0REVENTIONĂĽOFĂĽ"LINDNESSĂĽ!&0" ĂĽANDĂĽPRIVATEĂĽ donations and will be based at the Lions Eye )NSTITUTE sĂĽLinear Clinical Research won the "USINESSĂĽ3ERVICESĂĽ!WARDĂĽATĂĽTHEĂĽĂĽ7!ĂĽ )NDUSTRYĂĽANDĂĽ%XPORTSĂĽ!WARDĂĽ sĂĽThe philanthropy category of Research Australia’s national awards was won by the McCusker Charitable Foundation for giving $50 million to a diverse range of health and medical projects in WA.

MEDICAL FORUM


Have You Heard? continued from Page 13 in three people globally over the age of 60. Prof Gustavo Duque says while it is common knowledge we lose muscle mass as we age, we don’t know how much is normal. He said Sarcopenia was to muscles what osteoporosis was to bones, but little is known of the disease. Current research is focusing on exercise, protein supplements and Vitamin D and Prof Duque is leading clinical trials into anti-myostatin antibodies which are found to curb muscle growth.

Cautionary tale from a GP Recently a GP wrote into Medical Forum’s lead hotline with concerns about the PACKAGINGĂĽOFĂĽ%LEVITĂĽPRODUCTSĂĽ(EĂĽWROTEĂĽ h)ĂĽTHOUGHTĂĽITĂĽREASONABLEĂĽTOĂĽTRUSTĂĽTHATĂĽ%LEVITĂĽ contains folic acid. There is a new product Elevit morning sickness relief which has NONEĂĽ)TSĂĽAĂĽBITĂĽCHEAPERĂĽ)TĂĽLOOKSĂĽVERYĂĽSIMILARĂĽ )TĂĽSHOULDĂĽBEĂĽSOLDĂĽASĂĽANĂĽADD ONĂĽBUTĂĽONEĂĽOFĂĽMYĂĽ PATIENTSĂĽBOUGHTĂĽITĂĽBYĂĽMISTAKEĂĽ)FĂĽTAKENĂĽALONEĂĽ through the ďŹ rst trimester – when sickness is most common – it will not reduce the risk of NTD as we expect Elevit should. The ingredients are not in themselves harmful, but please check that your pregnant patients are taking the right Elevit, or script folic acid. The risk is low but the consequence large. )ĂĽHAVEĂĽCONTACTEDĂĽ"AYER ĂĽBUTĂĽMEANTIME ĂĽ'0ĂĽ awareness could help.â€? We also contacted "AYERĂĽWHOĂĽRESPONDEDĂĽTHATĂĽITĂĽTOOKĂĽGREATĂĽCAREĂĽ when developing the packaging of products TOĂĽENSUREĂĽTHATĂĽTHEYĂĽhNOTĂĽONLYĂĽPORTRAYĂĽTHEĂĽ beneďŹ ts of the product but also provide clear advice on the ingredients and usageâ€?. The colour-coded packaging on Elevit Morning Sickness was designed to differentiate it from OTHERĂĽPRODUCTSĂĽINĂĽTHEĂĽRANGEĂĽANDĂĽITSĂĽh$IRECTIONSĂĽ for useâ€? information explained that the product was suitable for use in combination with Elevit Pregnancy Multivitamins. However, ITĂĽDIDĂĽWELCOMEĂĽTHEĂĽFEEDBACKĂĽADDINGĂĽh"AYERĂĽ monitors the packaging after launch to ensure it continues to perform in the manner in which it was originally designed.â€?

Review cracking down on fraud The Professional Services Review annual report was released last month and took a swipe at larger GP practices from where individual GPs had been picked up for -EDICAREĂĽRORTINGĂĽ)TĂĽSAIDĂĽANĂĽEMERGINGĂĽ issue was the extent to which the practice owner was responsible for ensuring that contracted practitioners did not engage in inappropriate practice. To date, no ofďŹ cers of bodies corporate have been referred to PSR for review. This is despite the fact that the practice may have beneďŹ ted to some extent while the individual doctor was asked

Art of healing ,ASTĂĽMONTHĂĽWEĂĽSAWĂĽARTISTSĂĽFROMĂĽTHEĂĽ"LACKĂĽ3WANĂĽ0RIZEĂĽFORĂĽ0ORTRAITUREĂĽHELPĂĽHARNESSĂĽTHEĂĽHEALINGĂĽ power of art with residents of Amana Living who have dementia. Last month artists took to the foyers of two St John of God hospitals in Subiaco and Midland for public portrait sittings with patients and visitors, while group CEO Dr Michael Stanford found time to sit for his portrait at 3*'ĂĽ-URDOCHĂĽ4HEĂĽ"LACKĂĽ3WANĂĽEXHIBITIONĂĽHASĂĽCONCLUDEDĂĽATĂĽTHEĂĽ!RTĂĽ'ALLERYĂĽOFĂĽ7!ĂĽBUTĂĽAĂĽSELECTIONĂĽ of works from the exhibition will be on display in salon showings at the three hospitals until early this month. TOĂĽREPAYĂĽALLĂĽTHEĂĽMONEYĂĽ)TSĂĽAĂĽLOOPHOLEĂĽTHEĂĽ032ĂĽ wants to close. The report also noted that nearly 54% of those doctors referred to the PSR for investigation were overseas-trained. One English graduate new to Australian GENERALĂĽPRACTICEĂĽPARTICULARLYĂĽWORRIEDĂĽ-"3ĂĽ ITEMSĂĽĂĽANDĂĽĂĽAROUNDĂĽCHRONICĂĽDISEASEĂĽ management) over 400 times in a year without proper documentation.

Unhappy Health Care Homes We have reported previously the RACGP concerns about the funding for the Health Care Homes model and it is now even more ‘disappointed’ regarding practice and patient eligibility, patient eligibility as well as payment systems revealed by the Government. During the past month, there’s been argy bargy about limiting non-chronic disease consultation for a registered patient to ďŹ ve visits a year. New College president $RĂĽ"ASTIANĂĽ3EIDELĂĽSMELTĂĽAĂĽRATĂĽWHENĂĽTHEĂĽ Government released details late on a Friday afternoon – known in a news room as the graveyard hour. The Government was obviously not up for another stoush with the college and dropped the proposal to cap GP visits. To save face they changed the wording OFĂĽTHEĂĽFACTĂĽSHEETĂĽTOĂĽSAYĂĽh%NROLLEDĂĽPATIENTSĂĽ can still access fee-for service episodes of care not related to a patient’s chronic

“Christmas is built upon a beautiful and intentional paradox; that the birth of the homeless should be ccelebrated in every home.�

CONDITIONSvü"UTüITSüSTILLüNOTüAüGOODüLOOKü4HEü !-!ü6ICEü0RESIDENTü$Rü4ONYü"ARTONEüSAIDü the government should consider delaying the Health Care Home trials in order to win OVERü'0SüCONlDENCEüASüTHEüREFORMüWASühTOOü important to fail�. That hasn’t had a reaction from the Minister leaving GPs until December 15 to register their interest in joining the trials.

CPD concerns a sign With revalidation talk heating up over the coming months, there has been grumpy talk from GP education providers about THEü2!#'0SüNEWü1)üü#0$üREGIME üWHICHü PROVIDERSüSAYüISüANTI COMPETITIVEü)NCREASEü in provider fees and the college’s decision to take a mandatory education component in-house have been the sticking points. The EXCHANGEüBOILEDüDOWNüTOühISüNOT üISüSOvüKINDüOFü talk but it is a promise of things to come and needs to be managed if the education and training sectors are to avoid the tangled mess that seems to be the byword of health reform these days.

You really, really love us This news may make it all worthwhile. According to independent social research COMMISSIONEDĂĽBYĂĽTHEĂĽ-EDICALĂĽ"OARDĂĽOFĂĽ Australia, doctors are the most trusted of the professions along with nurses and pharmacists. The research forms part of THEĂĽ"OARDSĂĽWORKĂĽONĂĽREVALIDATIONĂĽANDĂĽWASĂĽ designed to help it understand what the public expected doctors to do to demonstrate ONGOINGĂĽlTNESSĂĽANDĂĽCOMPETENCEĂĽ)TĂĽHASĂĽ APPARENTLYĂĽRULEDĂĽOUTĂĽ5+ STYLEĂĽREVALIDATIONĂĽANDĂĽ made it clear that doctors will not be required to re-sit their fellowship exams every ďŹ ve years. Merry Christmas and hold on to your hats in the New Year.

G.K. Chesterton

MEDICAL FORUM MED

DECEMBER 2016 | 15


News & Views Close-up

Having the Cutting Edge Surgeon Prof David Fletcher has never resiled from hard work and difďŹ cult decisions and his students know he’s always got their back. It’s no lofty tower where the Head of General Surgery at Fiona Stanley Hospital Prof David Fletcher clocks in for service each day. His ofďŹ ce is just another rather spartan square in the rubric cube that is this enormous hospital. Yet it suits this plain-speaking, no-frills clinician who ďŹ xes you with his sharp eyes and greets you with his steady handshake – both pretty important attributes for a surgeon. "UTĂĽDEEPERĂĽINTOĂĽTHEĂĽCONVERSATION ĂĽITĂĽISĂĽEVIDENTĂĽ David has worked in some interesting places. Take the time in his early days of medicine when he took a short-term job as a ship’s surgeon and found himself operating on a Greek seaman who had suffered a cerebral haemorrhage with a drill bit the ship’s engineer had fashioned for him. That was only after David played an integral part in the mid-sea patient transfer in big SWELLĂĽTHEĂĽLIKESĂĽOFĂĽWHICHĂĽ"EARĂĽ'RYLLSĂĽWOULDĂĽBEĂĽ proud. h4HEĂĽCHANCEĂĽOFĂĽHISĂĽSURVIVALĂĽWASĂĽONLYĂĽ ĂĽ but we got him to Singapore and put him in ANĂĽAMBULANCEĂĽ)ĂĽASKEDĂĽTHEMĂĽTOĂĽLETĂĽMEĂĽKNOWĂĽ HOWĂĽHEĂĽGOTĂĽONĂĽnĂĽ)DĂĽSPENTĂĽAĂĽWEEKĂĽOFĂĽMYĂĽLIFEĂĽ with the bugger, my wife Chrissy helped nurse HIM ĂĽANDĂĽWEĂĽNEVERĂĽHEARDĂĽAĂĽTHINGĂĽ)ĂĽWASĂĽAĂĽBITĂĽ pissed off to be honest,â€? he said. This knack to call a spade a shovel has at times put him at odds with system types who PREFERĂĽTOĂĽBEĂĽAGREEDĂĽWITHĂĽ"UT ĂĽASĂĽ$AVIDĂĽPUTSĂĽITĂĽ h)ĂĽGUESSĂĽITĂĽISĂĽHOWĂĽ)ĂĽWASĂĽRAISEDv Social conscience from the cradle h)ĂĽWASĂĽBORNĂĽINĂĽ7!ĂĽANDĂĽWEĂĽMOVEDĂĽTOĂĽ &REMANTLEĂĽWHENĂĽ)ĂĽWASĂĽTHREEĂĽ-YĂĽFATHERĂĽWASĂĽAĂĽ

ďŹ tter and turner at the local power station, my mother was a district nurse. She went on to be hospital almoner and then became the ďŹ rst social worker at Fremantle Hospital. The Old Man became the local MP and Chair of the &REMANTLEĂĽ(OSPITALĂĽ"OARDv The ‘Old Man’ was die-hard Labor man Harry Fletcher who held the seat of Fremantle for 18 years and his mother was Esme Fletcher who negotiated the establishment of a low-fee day nursery for children of distressed families so MOTHERSĂĽCOULDĂĽWORKĂĽ)TĂĽBECAMEĂĽKNOWNĂĽASĂĽTHEĂĽ Esme Fletcher Day Care Centre. She was to go on to become deputy mayor of the City of Fremantle. So not surprisingly David and his older brother, John, grew up handing out how-tovote cards and understanding there were many people in their community who needed a fair go.

16 | DECEMBER 2016

management training. The new boss was hard as nails but he went about the policymaking process democratically. However, once a decision was made you did it, or else. There was no arguing. He stood up and SUPPORTEDüHISüSTAFFüANDü)üLEARNTüAüBIGüLESSONü from that. You need to be a democrat and listen to people and try to get them to share your vision.� Research opens doors

h)TĂĽWASĂĽAĂĽFAMILYĂĽTRADITIONĂĽTOĂĽUSEĂĽWHATEVERĂĽ talents we had for the beneďŹ t of those around USĂĽ)FĂĽWEĂĽBELIEVEDĂĽTHEREĂĽWASĂĽAĂĽPROBLEM ĂĽITĂĽWASĂĽ our duty to ďŹ x it,â€? David said.

As a kid, David was inspired by Howard Florey and had thoughts of being a researcher UNTILĂĽHEALINGĂĽWITHĂĽHISĂĽHANDSĂĽTOOKĂĽOVERĂĽ"UTĂĽATĂĽ the Hammersmith he fell into research.

He put that creed into action as a junior hospital staff president in the early 1970s when he saw an injustice being done to a colleague.

h4HEREüWASüAüRESEARCHüBOFlNüINüEVERYü cupboard at Hammersmith and it was an EXHILARATINGüEXPERIENCEü)üBECAMEüINVOLVEDüINü endocrinology research for my MD (PhD) but when we were ready to return to Australia, )üWASNTüINVITEDüBACKüTOü0ERTHüBECAUSEü)ü HADüTRODDENüONüTOESü)üHADüTWOüJOBüOFFERSüINü Melbourne so that’s where we went.�

The cost of speaking up h)ĂĽGOTĂĽlREDĂĽBUTĂĽTHEYĂĽDIDĂĽMEĂĽAĂĽFAVOURĂĽINĂĽTHEĂĽ end.â€? The ‘favour’ was the push he needed to DECIDEĂĽTOĂĽHEADĂĽTOĂĽTHEĂĽ5+ĂĽĂĽAFTERĂĽ&ELLOWSHIPĂĽFORĂĽ advanced surgical training. h&ORĂĽTHEĂĽlRSTĂĽTHREEĂĽYEARSĂĽOFĂĽMEDICALĂĽSCHOOLĂĽ )ĂĽCONCENTRATEDĂĽONĂĽRUGBYĂĽANDĂĽMISCHIEFĂĽ"YĂĽ THEĂĽTIMEĂĽ)ĂĽGOTĂĽTOĂĽFOURTHĂĽYEARĂĽ)ĂĽSTARTEDĂĽTOĂĽ PAYĂĽATTENTIONĂĽANDĂĽITĂĽWASĂĽTHENĂĽ)ĂĽSAWĂĽ;0ERTHĂĽ SURGEON=ĂĽ.AZIRĂĽ!HMEDĂĽATĂĽWORKĂĽANDĂĽITĂĽINSPIREDĂĽ me. Everything he did had a logic and was DONEĂĽWITHĂĽTEXTBOOKĂĽPRECISIONĂĽSOĂĽ)ĂĽSETĂĽMYĂĽ sights on surgery.â€? David and Medical Scientist Chrissy, who married in 1970 in David’s intern year, established themselves in Fremantle where both worked. They welcomed their son in  ĂĽONĂĽTHEĂĽEVEĂĽOFĂĽTHEIRĂĽMOVEĂĽTOĂĽTHEĂĽ5+ĂĽONCEĂĽ surgical training was completed.

Prof David Fletcher with grandson Callan

Prof David Fletcher, a self-confessed rugby tragic, manages a half smile at the recent thrashing of the Wallabies by the All Blacks at Eden Park.

h)ĂĽKNEWĂĽ)ĂĽWASNTĂĽREADYĂĽANDĂĽNEEDEDĂĽFURTHERĂĽ EXPERIENCE ĂĽSOĂĽ)ĂĽWENTĂĽTOĂĽPRACTISEĂĽONĂĽTHEĂĽ 0OMSĂĽ)ĂĽLANDEDĂĽAĂĽJOBĂĽATĂĽTHEĂĽ(AMMERSMITHĂĽ INĂĽ,ONDONĂĽWHEREĂĽ)ĂĽWASĂĽĂĽ2ESIDENTĂĽ3URGICALĂĽ OfďŹ cer responsible for the junior staff. )TĂĽMEANTĂĽ)ĂĽSATĂĽONĂĽTHEĂĽEXECUTIVEĂĽATĂĽAĂĽTIMEĂĽ when the hospital was going through transition (1977-8) with the arrival of Prof Les "LUMGARTĂĽANDĂĽASĂĽAĂĽRESULTĂĽ)ĂĽACTUALLYĂĽGOTĂĽSOMEĂĽ

h)TĂĽWASĂĽHARDĂĽLEAVINGĂĽTHEĂĽ/LDĂĽ-ANĂĽBEHINDĂĽnĂĽHEĂĽ WASĂĽONĂĽHISĂĽOWNĂĽBYĂĽTHENĂĽ-UMĂĽHADĂĽDIEDĂĽFROMĂĽ a heart attack in 1977 – but a job at the Austin and research opportunities at Melbourne 5NIVERSITYĂĽWEREĂĽTOOĂĽGOODĂĽTOĂĽPASSĂĽUPĂĽ-YĂĽ interest after the Hammersmith experience was upper gastro-intestinal surgery and in 1987 when the department was planning its lRSTĂĽLIVERĂĽTRANSPLANT ĂĽ)ĂĽBECAMEĂĽPARTĂĽOFĂĽTHEĂĽTEAMĂĽ (1988 to 1994) – it was an innovative place.â€? h4HEĂĽBOSSĂĽWENTĂĽTOĂĽ&RANCEĂĽANDĂĽHAPPENEDĂĽ to witness one of the ďŹ rst laparoscopic cholecystectomies. We thought he was nuts but when he showed us the video, we change our minds and trained ourselves up. )NĂĽ&EBRUARYĂĽ ĂĽWEĂĽPERFORMEDĂĽTHEĂĽlRSTĂĽ laparoscopic cholecystectomy in the country. )TĂĽBEGANĂĽTHEĂĽBIGGESTĂĽSURGICALĂĽREVOLUTIONĂĽOFĂĽTHEĂĽ modern era.â€? Leading from the front h)TĂĽWASĂĽAĂĽWILDĂĽRIDEĂĽ4HEĂĽ#OLLEGEĂĽHADĂĽTHISĂĽ revolution on its hands and the dilemma of training 2000 surgeons across Australia and NZ in a technique that they had not seen done before. The College got us to produce the guidelines and we ran workshops town to

MEDICAL FORUM


Close-Up

and a complaints hotline the result.

town using pigs as models. When )üLEFTüTHEüDEPARTMENTüINü üTHEYü gave me a toy pig as a farewell gift.�

h4HISĂĽBEHAVIOURĂĽISĂĽNOTĂĽACCEPTABLEĂĽ Surgery is demanding and stressful and when you’re up to your neck in ’nure, you’ve just got to go on and you have to be conďŹ dent you will survive the challenges.â€?

The episode stirred a new passion in David – training – and he’s good at it, a fact acknowledged by his students and peers alike. This year he received the College’s 3UPERVISOR#LINICALü!SSESSORüOFüTHEü Year Award for WA.

h"UTüITSüNOTüABOUTü@IFü)üCANüDOüIT ü YOUüCANüDOüITüOR ü@IFüYOUüDONTüDOü it like me you won’t succeed’. That attitude is part of the problem and NOWüBECOMINGüTHEüPASTü)üWANTüMYü students to challenge and question THEüSYSTEMü)üDONTüWANTüTOüAPPOINTü AüCLONE ü)üWANTüTOüEMPLOYüSOMEONEü who asks questions and thinks @HOWüCANüWEüDOüITüBETTERv

He has worked doggedly and tirelessly to support his students in their endeavours to become competent and skilful surgeons and that sometimes has meant butting heads with the system. h4HEĂĽWORLDĂĽHASĂĽMOVEDĂĽONĂĽSOĂĽMUCHĂĽ that the ability to do everything has gone. The laparoscopic revolution made that very clear. We used to say in private those who wanted to be surgeons needed to operate on anything they could get their hands on ‌ and that is now the problem.â€? h9OUNGERĂĽSURGEONSĂĽAREĂĽBEINGĂĽFORCEDĂĽINTOĂĽ the private sector because there’s no work in the public sector to support them. That’s a real problem. You need full-time people in a hospital like this one but you also need part-timers too because it keeps everyone honest.â€? InefďŹ ciencies killing the system h4HEĂĽCURRENTĂĽMETHODĂĽOFĂĽSORTINGĂĽTHISĂĽOUTĂĽISĂĽ UTTERĂĽBULLSHITĂĽ4HEYĂĽAREĂĽTRYINGĂĽTOĂĽSQUEEZEĂĽMOREĂĽ out of the hospitals. We are overloaded and BEINGĂĽSQUEEZEDĂĽBECAUSEĂĽOFĂĽINEFlCIENCIESĂĽINĂĽ the system. My surgeons are saying they want to operate on the never ending ow of elective and emergency cases coming through the door.â€? Another valuable innovation, which David said was improving both patient safety and enhancing training was the development of THEĂĽ!CUTEĂĽ3URGICALĂĽ5NITĂĽ!35 ĂĽINĂĽ h)TĂĽGIVESĂĽTRAINEESĂĽBROADĂĽEXPOSUREĂĽANDĂĽTHEYĂĽ are well supported because it is Fellow and Consultant led 24 hours a day with a Consultant in the Hospital every day and one on call after hours. There is a growing problem of getting the training balance right. There is so much technical expertise to develop and you can’t know it all or do it all. 4HEĂĽ!35ĂĽPROVIDESĂĽTHATĂĽADDITIONALĂĽTRAININGvĂĽ

System change necessary h)MPROVINGüTHEüQUALITYüOFüANü individual patient’s life is extremely SATISFYING üITSüTHEüJOYüOFüSURGERYü impacting on many is even more satisfying. Those with knowledge of the system need to be involved in pursuing improvement. You can achieve a lot by changing the system.�

Getting away from it all

While David will put it on the line for trainees, he said he wouldn’t hesitate to fail someone during training if they weren’t up to scratch. h'OODüSUPERVISORS üWHOüTRAINüANDüASSESSüPROü bono, know early on if a trainee is going to be a constant performer.� Legal challenges cause headaches h4HEüPROFESSIONüNEEDSüTOüBEüTIGHTLYüREGULATEDü INüTERMSüOFüASSESSMENTüWEüACTUALLYüHAVEü TRAINEESüCHALLENGINGüDECISIONSüINüCOURTü)TSü a sad reality that the college, when it sought insurance it put tenders to 16 companies only four applied. We now have a $100,000 EXCESSü5NLESSüWEüDOCUMENTüTHEüAPPRAISALü extremely carefully and are able to justify everything, they can go to a lawyer.� h7EüHAVEüHADüAüCOUPLEüOFüCASESüINü7!ü where that’s happened but they got nowhere because we had been thorough. There is a lot of pressure on trainees but there is no room for poor performance and we’re not talking just technical expertise.� h4HATüSAID üTHEREüAREüSOMEüOUTSTANDINGü trainees and it’s our responsibility to pick the ONESüWHOüAREüGOINGüTOüBEüGOODü)üRECENTLYü witnessed a procedure being done by one of MYüFORMERü&ELLOWSü)üWASüBOTHüAMAZEDüANDü proud of what he was capable of.� "ULLYINGüANDüHARASSMENTüINüSURGERYüHAVEü been in the headlines and RACS was rapid in its response to the controversy with new guidelines, standards, education programs

"UTüPOLITICSüHASüAüHABITüOFüGETTINGüINüTHEüWAYü h&IONAü3TANLEYü(OSPITALüISüAüSPECTACULARüPLACEü and what’s in it, staff and equipment, are spectacularly good, but there are problems – political problems.� And those problems stretch back to the deviation from government planning which would have seen two tertiary medical hubs, FSH in the south and SCGH in the North, delivering complex care and secondary hospitals delivering care closer to where PEOPLEüLIVEü)TüWOULDüHAVEüPRODUCEDüBETTERü outcomes and less waste, according to David. h!NDüITüWOULDüHAVEüWORKEDüBUTüWEüAREüNOWü back where we started from in 2002 and it’s a tragedy that came about because of politics, votes and self-interest. We don’t build hospitals for those who work in them but for THOSEüWEüSERVEü)üDONTüTHINKüSOMEüPEOPLEü understand that.� h-YüJOBüNOWüISüTOüCONTINUEüTOüSTRIVEüFORüSYSTEMü change and to protect the staff so they can DOüTHEüJOBü)TüISüALSOüTOüCREATEüOPPORTUNITIESüFORü those who deserve it and we have some really great staff.�

By Jan Hallam

‘Problem Solvers’ of Pharmaceuticals We specialise in customised, compounded medicines BioHRT . Dental . Dermatology . Hospice . Nutrition . Paediatric . Pain . Sports

www.maylandscompounding.com.au

1/181 Guildford Rd, Maylands Phone: (08) 9370 4410 Fax: (08) 9471 7115 Email: info@maylandscompounding.com.au

MEDICAL FORUM

DECEMBER 2016 | 17


Feature

When Times Get Tough‌ So many health narratives are reduced down to a squabble over money, but what does that say about thee values of our health system? The Australian health system has undergone a year of conict, a volatile election, numerous taskforces and h reports, tough talk and back downs. With all that, the end point in political and art system terms is the same as the start ey in the point – there is not enough money one wants budget to do everything everyone to do in health.

Dr David Russell-Weisz

3O CAN YOU ASSESS VALUES !RE YOU GOING 3OüCANüYOUüASSESSüVALUESü!REüYOUüGOINGü to fail someone for not displaying as much EMPATHYüASüTHEYüSHOULD EMPATHY AS THEY SHOULD increasing Consumers are playing an increasin role in medical training – simulated, actors or the real thing. Consumer grou groups are urging medical schools sch to give students more exposure ex to actual patients early e so they can start developing developin qualities that in an older tim time were called bedside MANNER " MANNERü"UTüDOESüEVERYüSTUDENTü have to be b an Oprah Winfrey or a Dr 0HIL TO 0HILüTOüBEüAüCARINGüDOCTOR

E RECENT ()47! !TüTHEüRECENTü()47!ü ealth informatics health conference in Perth, the Director General of Health, Dr David Russell-Weisz, was aining the priorities explaining for the WA system in spending its annual budget of $8.6b – an amount that has doubled in just 10 years.

His ďŹ rst was safety and quality – and the nurturing of a culture that puts those things above all others. The second and third priorities were clinical performance and ďŹ nancial prudence. )NĂĽHISĂĽADDRESSĂĽTOĂĽAĂĽROOMĂĽFULLĂĽOFĂĽTECHNOĂĽWIZZES ĂĽ he kept it real. He acknowledged the serious MISMANAGEMENTĂĽOFĂĽTHEĂĽDEPARTMENTSĂĽ)#4ĂĽ procurement which saw millions squandered BETWEENĂĽĂĽANDĂĽĂĽ(OWEVER ĂĽTHEĂĽ experience had, he said, led to greater oversight and a more rigorous contract process. Spending on technical innovation in the new world order had to have clinical and safety outcomes or it would be an empty thing. )TĂĽISĂĽINEVITABLEĂĽnĂĽANDĂĽNECESSARYĂĽnĂĽTHATĂĽHEALTHĂĽ should be set within a ďŹ rm ďŹ scal framework but is that shorthand for cost and corner cutting in all the wrong places and the erosion of values enshrined in mission statements FRAMEDĂĽINĂĽHOSPITALĂĽFOYERSĂĽACROSSĂĽTHEĂĽNATION We spoke to three people involved in politics, training and the private hospital sectors to learn how values drove what they did and what they perceived as the greatest threats to a values-based health system. The Educator Public health physician Prof Donna Mak and Chair of the Population and Preventive Health $OMAIN AT THE 5NIVERSITY of Notre Dame has the responsibility of teaching values to medical students, a task she believes is absolutely possible given the right curriculum and support. Prof Donna Mak

and work. This form of learning is very inuential.�

h/URĂĽUNIVERSITYSĂĽMISSIONĂĽ is to graduate doctors

18 | DECEMBER 2016

Don Donna doesn’t think so. C Can you assess empathy?

with both clinical expertise and the values of values of compassion, respect and service but they are empty words unless they are implemented. The curriculum is shaped by the Australian Medical Council and in its requirements for medical school accreditation is the injunction to ensure medical graduates demonstrate professional values including commitment to high quality clinical standards, compassion, empathy, respect for all patients, integrity and honesty. h"UTüATüTHEüPOINTYüEND üWHEREüITüAFFECTSü students, is assessment. What do you assess THEMüONü#ANüYOUüASSESSüVALUESü(OWüDOü YOUüDOüITv h4HERESüANOTHERüINmUENTIALüELEMENT üWHICHü is less overt though inevitable, is the people you have teaching and working with students BECAUSEüSTUDENTSüABSORBüCULTUREü)FüYOUüHAVEü people in the education process who embody THOSEüVALUESüTHENüSTUDENTSüWILLüLEARNüIFüYOUü don’t, then regardless of how much you put it in teaching and assessment, it won’t work.� Learning is for life h'IVENüTHEüRAPIDüADVANCESüINüKNOWLEDGEü these days, we can teach students the best, most up-to-date technical knowledge and still be sure that most of it will change in a few year’s time. What doesn’t change is the need to teach students how to think and to understand the need to keep learning throughout their career, and that includes values and behaviour.� h)FüYOUüWEREüTOüASKüMEüANDüMANYüESTABLISHEDü doctors what we learnt in medical school that we still put into practice today, it wouldn’t be the factual or technical aspects of medicine, but rather our teachers’ approaches to life

h3TUDENTSĂĽINĂĽMOSTĂĽ!USTRALIANĂĽMEDICALĂĽ schools have patients involved in assessing students in clinical exams. Can you pass THEĂĽEMPATHYĂĽTESTĂĽBYĂĽACTINGĂĽ9ES ĂĽIFĂĽYOUĂĽAREĂĽ so good that patients don’t know, it may not matter as long as what you’re doing and the end outcome is beneďŹ tting people. And you might probably end up believing it yourself!â€? A recent article published in The Medical Republic BYĂĽ53ĂĽPHYSICIANĂĽ$RĂĽ,OUISĂĽ-ĂĽ0ROFETAĂĽ suggested that patients don’t care what’s happening in the lives of their doctors, what they are after is a smile, competence, reassurance and politeness and while a

If you were to ask me and many established doctors what we learnt in medical school that we still put into practice today, it wouldn’t be the factual or technical aspects of medicine, but rather our teachers’ approaches to life and work. This form of learning is very inuential.�

doctor on the day may not feel all those things, they can certainly do all those things, and in the mind of the patient it is enough. However, Donna sounds a cautionary note that doctors in small communities don’t have the luxury of anonymity after hours and if there is dissonance between the values on display in the surgery and in their private lives, that doctor could come unstuck.

MEDICAL FORUM


Feature

We all know medicine doesn’t exist in a vacuum. Societal and generational shifts of values permeate everything and it has always been thus. The emphasis placed on some values over others is a moveable feast and not all established values (such as bullying and harassment) should be left unchallenged. Earning of buying a degree As Notre Dame prepares next year to launch its MD program it does so in an environment where students are now consumers of an educational product rather than a more romantic notion of strivers for academic excellence. Hopefully the reality is a combination of both. This commercialisation of universities which has been building for a number of years has shifted the balance of responsibility and, it can be argued, changed the emphasis on SOMEĂĽVALUESĂĽ)FĂĽSTUDENTSĂĽAREĂĽNOWĂĽCONSUMERS ĂĽ it goes without saying, they have rights and after forking out close to $100,000 for a post graduate degree via HECS (double if university fees are deregulated and unspeakable if you are full-fee paying) do THOSEĂĽRIGHTSĂĽEXTENDĂĽTOĂĽINSISTINGĂĽONĂĽGRADUATING 5NLESSĂĽTERMSĂĽANDĂĽCONDITIONSĂĽAREĂĽCLEARLYĂĽSTATEDĂĽ at the commencement of such an educational contract, universities can ďŹ nd themselves in TRICKYĂĽLEGALĂĽWATERSĂĽ)FĂĽWEĂĽEXTRAPOLATEĂĽFURTHERĂĽ could it be possible for universities to accept some liability if a recently graduated doctor ďŹ nds himself or herself before the Medical "OARD

health care is about quality relationships and REPUTATIONü)FüWEüGOTüTHOSEüTHINGSüRIGHT üWEü would be successful.� h4REATINGüOTHERSüHOWüYOUüWOULDüLIKEüTOüBEü TREATEDüPUTTINGüYOURSELFüINüTHEüOTHERSüSHOESü E LOOKINGüAFTERüPEOPLEüBEINGüHONESTüDOINGüTHEü RIGHTüTHINGü)üCANüSTILLüHEARüHIMüSAYüTHATv Keeping legacies alive Those values are Paul Ramsay’s legacyy to ow he’s his highly successful company but now ME 7ELL

GONE ĂĽWHOĂĽISĂĽTHEĂĽPROTECTORĂĽOFĂĽTHEĂĽmAMEĂĽ7ELL ĂĽ or the it would seem everyone who works for company. AND h7EĂĽCALLĂĽTHEMĂĽTHEĂĽ2AMSAYĂĽ7AYĂĽVALUESĂĽANDĂĽ they are a part of all the orientation in all our hospitals but it’s up to us who have been around for a while to see that the culture of caring continues. Any organisation that wants to be successful needs to have a strong, positive culture and not just a bunch of words on the wall.â€? h!LLĂĽCOMPANIESĂĽHAVEĂĽVALUES ĂĽWHETHERĂĽTHEYĂĽLIVEĂĽ BYĂĽTHEMĂĽORĂĽNOTĂĽISĂĽANOTHERĂĽMATTER ĂĽBUTĂĽ)ĂĽBELIEVEĂĽ Ramsay does, which doesn’t mean you don’t make unpleasant or tough decisions, you do, every day, but it's the way you go about it.â€? h-UTUALĂĽRESPECTĂĽISĂĽCRUCIALĂĽANDĂĽFREEĂĽEXCHANGEĂĽ of ideas critical and, in tough ďŹ nancial times, that means being innovative. The best way to BEĂĽINNOVATIVEĂĽISĂĽTOĂĽENGAGEĂĽYOURĂĽPEOPLEĂĽ)FĂĽYOUĂĽ don’t have that trust and respect you don’t have that exchange of ideas either.â€?

These thorny questions are not for a dystopic future but for a complex present and answers are needed.

h4HEüINNOVATORSüAREüNOTüSENIORüMANAGEMENT ü they the people doing the work who know how to do it slicker.�

The Hospital Administrator

h)TSüNOTüROCKETüSCIENCEü)FüWEüTREATüEVERYONE ü regardless of roles, in accordance with our values of care and respect, people will respond positively.�

Kevin CassRyall is Operations Manager for Ramsay Health Care in WA and SA, the publicly listed company that in WA owns and operates the Hollywood Kevin Cass Ryall and Glengarry Private Hospitals, Attadale Rehabilitation Hospital, and has the state contracts to operate the Joondalup ANDü0EELü(EALTHü#AMPUSESü)TSüNATIONALüANDü international footprint is also large. The company was started by Paul Ramsay in Sydney in 1964 and now operates 220 hospitals and day surgeries in Australia, &RANCE üTHEü5+ ü)NDONESIAüANDü-ALAYSIAüANDü was listed on the ASX in 1997. Paul Ramsay also became one of the country’s great philanthropists and before his death in 2014 had inculcated the simple yet EFFECTIVEüVALUEüOFüh0EOPLEü#ARINGüFORü0EOPLEvü at the core of his business model. Kevin has worked for the company 22 years and in the early days worked personally with Paul Ramsay. h(EüWASüANüINSPIRATIONü(EüWASüAüHUMBLEü man, a very respectful man and he taught me and all who came into contact with him that

MEDICAL FORUM

The Politician Roger Cook is long-time Opposition spokesperson for Health and an aspirant for the role of WA Health Minister after the March election. He believes strong values and Roger Cook sense of purpose are central to any successful organisation or system. 4HEYĂĽAREĂĽTHEĂĽBEDROCKĂĽINĂĽCHALLENGINGĂĽTIMESĂĽIFĂĽ ignored, an organisation will fail to reach their objectives. Patients must be put ďŹ rst, is his mantra while waste is the enemy. h(OSPITALĂĽSTAFFĂĽAREĂĽBEINGĂĽHOUNDEDĂĽTOĂĽSAVEĂĽ money and create efďŹ ciencies but look at mountains of waste in the system every day‌ around procurement, management of equipment and supplies. They see their colleagues being sacked in the name of saving money. That is in direct conict with the reasons they come to work, which is to provide care,â€? he said.

is accompanied by a strong value statement and action around why it’s necessary to do so in the ďŹ rst place. When people monitoring the system outnumber those in service positions, that sends mixed messages to people on the front line about the extent to which they are valued and the extent to which the organisation is following its stated values.â€? Waste, silos and bureaucracy Roger sees the new devolved health services as a positive step in breaking down silos and red tape. h)ĂĽTHINKĂĽTHEYĂĽHAVEĂĽTHEĂĽCAPACITYĂĽTOĂĽDELIVERĂĽREALĂĽ efďŹ ciencies and devolve decision making to the frontline and that has to be encouraged. Part of the problem we have had in WA, as it and the need to control the quality and costs of services have grown, decision-making has become centralised and that can undermine people who are in the best position to make a decision on the distribution of resources,â€? he said. Devolution should also help reconnect the primary and secondary arms of the system which have for so long been working at odds with each other, he said. "UTĂĽISĂĽBUDGETĂĽBELTĂĽTIGHTENINGĂĽTHEĂĽHEALTHĂĽ budget is now 26% of the entire state budget) THEĂĽMOSTĂĽSERIOUSĂĽTHREATĂĽTOĂĽVALUES h)TĂĽISĂĽCERTAINLYĂĽONEĂĽOFĂĽTHEĂĽCHALLENGESĂĽBUTĂĽITĂĽ doesn’t have to be a limiting factor,â€? Roger SAIDĂĽh)FĂĽWEĂĽTHINKĂĽCLEVERLYĂĽABOUTĂĽAĂĽSYSTEMĂĽ that is more integrated and that embraces the opportunities presented through digital disruption we will make head way.â€? h4HEREĂĽAREĂĽHUGEĂĽOPPORTUNITIESĂĽTOĂĽCREATEĂĽAĂĽ LEAN ĂĽRESPONSIVEĂĽINTEGRATEDĂĽHEALTHĂĽSYSTEMĂĽ)TĂĽ is simply a matter to have the political will and good faith to undertake the process and that whole discussion has to be underpinned by strong values.â€?

By Jan Hallam

h7ORKERSĂĽWILLĂĽRESPONDĂĽTOĂĽTHATĂĽCALLĂĽTOĂĽARMSĂĽIFĂĽITĂĽ

DECEMBER 2016 | 19


Feature

There’s a Big World Out There Retirement can be a tricky concept for professionals who have spent most of their lives focused on the fortunes of others.

The Baby-Boomer generation has been sliding into retirement for a few years now, with a lot more waiting in the wings, and some of them are doctors. Medical Forum spoke with three medicos who are winding down both gently and gradually.

Passionate retiree Dr Adele Thomas

Dr Adele Thomas, who works a 15-hour week, could best be described as ‘retirement pending’. h)MĂĽVERYĂĽFORTUNATEĂĽBEINGĂĽAĂĽ'0ĂĽBECAUSEĂĽOFĂĽ THEĂĽmEXIBILITYĂĽOFĂĽTHEĂĽHOURSĂĽ)ĂĽPLANĂĽTOĂĽDOĂĽANOTHERĂĽ THREEĂĽYEARS ĂĽ)MĂĽĂĽYEARS OF AGEĂĽNOWĂĽANDĂĽ)LLĂĽ reassess it again in 2019.â€? h)FĂĽ)ĂĽWEREĂĽAĂĽSURGEONĂĽORĂĽWORKINGĂĽINĂĽHOSPITALĂĽ setting it would be much more difďŹ cult to WORKĂĽPART TIMEĂĽ)VEĂĽGOTĂĽTHEĂĽBESTĂĽOFĂĽBOTHĂĽ WORLDSĂĽ-YĂĽHUSBANDĂĽANDĂĽ)ĂĽAREĂĽVERYĂĽACTIVEĂĽ with our business Passionate Retirees, we give talks, we write books and we’ve even embraced podcasting.â€? h!NDĂĽWEĂĽLOVEĂĽCHASINGĂĽTORNADOSv h)TSĂĽSOĂĽIMPORTANTĂĽTOĂĽHAVEĂĽAĂĽPURPOSEĂĽINĂĽLIFEĂĽ We’ve all heard stories of medicos who suddenly stop working, close their rooms and ENDĂĽUPĂĽSTARINGĂĽATĂĽTHEĂĽWALLSĂĽ)ĂĽCANĂĽUNDERSTANDĂĽ how some doctors are reluctant to give up their prescribing pads and we all know that’s BEENĂĽANĂĽISSUEĂĽWITHĂĽTHEĂĽ-EDICALĂĽ"OARDv

h"EINGĂĽABLEĂĽTOĂĽPRESCRIBEĂĽFORĂĽFAMILYĂĽMEMBERSĂĽ is often the last vestige of professional identity and that can be a difďŹ cult thing for some people.â€? h4HEREĂĽAREĂĽSOMEĂĽINSPIRATIONALĂĽSTORIESĂĽOUTĂĽ THERE ĂĽTOOĂĽ)ĂĽKNOWĂĽONEĂĽCOLLEAGUEĂĽWHOSĂĽVERYĂĽ active in seniors’ organisations and also volunteers as a guide in Kings Park. And there’s another in his early ’90s who, despite early signs of Parkinson’s, has discovered a real talent as a sculptor.â€? h!NDĂĽ)ĂĽREADĂĽTHATĂĽTHEĂĽOLDESTĂĽPERSONĂĽTOĂĽ swim the English Channel is a 74-year-old cardiothoracic surgeon!â€? Adele points out that, as doctors, there are some constraints when sharing stories in a social situation.

h!ĂĽWOMANSĂĽWORLDĂĽTENDSĂĽTOĂĽBEĂĽHIGHLYĂĽGROUP focused and a lot of interesting things in our lives as doctors are patient-centred. There’s something of a barrier there because that’s privileged information and it can be quite difďŹ cult to fully participate in social chit-chat.â€? h)MĂĽEXPERIMENTINGĂĽWITHĂĽTHATĂĽASPECTĂĽINĂĽ MYĂĽQUILTINGĂĽGROUP ĂĽBUTĂĽ)MĂĽBEGINNINGĂĽTOĂĽ understand that there are some areas of my LIFEĂĽ)LLĂĽNEVERĂĽBEĂĽABLEĂĽTOĂĽTALKĂĽABOUTv h-EDICINEĂĽHASĂĽBEENĂĽANĂĽINCREDIBLEĂĽCAREERĂĽ )VEĂĽHADĂĽONEĂĽPATIENTĂĽFORĂĽNEARLYĂĽĂĽYEARSĂĽWHOĂĽ came here as a refugee with hardly a word OFĂĽ%NGLISHĂĽANDĂĽBABIESĂĽ)ĂĽDELIVEREDĂĽAREĂĽNOWĂĽ bringing their own children to see me.â€? h)TSĂĽALLĂĽBEENĂĽSUCHĂĽAĂĽPRIVILEGEv

and Northam with a farmhouse that’s more THANĂĽAĂĽCENTURYĂĽOLDĂĽ)VEĂĽHADĂĽAĂĽFULLĂĽYEARĂĽOFĂĽ SEASONSĂĽTHERE ĂĽ)ĂĽLOVEĂĽITĂĽANDĂĽ)LLĂĽNEVERĂĽMOVEĂĽ AGAINĂĽ4HISĂĽISĂĽWHEREĂĽ)ĂĽWILLĂĽDIEv h7HENĂĽ)ĂĽlRSTĂĽMOVEDĂĽHEREĂĽLOTSĂĽOFĂĽPEOPLEĂĽ SAID ĂĽ@NOĂĽONEĂĽWILLĂĽVISITĂĽYOUĂĽBUTĂĽ)ĂĽHAVEĂĽMOREĂĽ VISITORSĂĽHEREĂĽTHANĂĽ)ĂĽEVERĂĽDIDĂĽINĂĽ&REMANTLEĂĽ They’re not just day-trippers, either. Many of them stay a few nights in the farmhouse. My grandchildren ourish out here and my entire family throw themselves into every project.â€? Susan’s grandmother used to say to her, ‘time passes faster when you’re older’ and she is starting to agree.

Woman of the soil Another medico with three years left in her stethoscope is Dr Dr Susan Downes Susan Downes. She penned some thoughts about her retirement plans on an aircraft bound for a 10-day stint in Port Hedland. h)MĂĽĂĽYEARS OLDĂĽANDĂĽSTILLĂĽWORKINGĂĽASĂĽHARDĂĽASĂĽ ever, although the medical component has REDUCEDĂĽAĂĽLITTLEĂĽASĂĽ)ĂĽDEVOTEĂĽMOREĂĽTIMEĂĽTOĂĽMYĂĽ FAMILYĂĽANDĂĽNEWĂĽPROPERTYĂĽ!SĂĽAĂĽLOCUMĂĽREMOTE

20 | DECEMBER 2016

3O ĂĽWHEREĂĽWOULDĂĽ3USANĂĽ$OWNESĂĽRATHERĂĽBE

h)VEüJUSTüREACHEDülVEüYEARSüPOST BREASTü cancer, awaiting the results of my last checkup and have just made a review appointment with my surgeon. My hair, nails and energy AREüRETURNINGüANDü)üFEELüPRETTYüGOODü4HEREVEü been a few ordeals over the last few years. My husband died from a rare lymphoma, my widowed Mum also has breast cancer and ISüVERYüFRAILüWITHüFRACTURESü)üALSOüHADüAüVERYü traumatic home burglary and all my family’s antique jewellery was stolen.�

h)ĂĽSWAPPEDĂĽAĂĽHOUSEĂĽINĂĽ&REMANTLEĂĽFORĂĽĂĽ acres of glorious rolling hills between York

h)MĂĽAĂĽBITĂĽCONCERNEDĂĽTHATĂĽ)VEĂĽPROBABLYĂĽONLYĂĽ GOTĂĽĂĽGOODĂĽYEARSĂĽINĂĽMEĂĽANDĂĽTHENĂĽTHERELLĂĽ

RURALĂĽOBSTETRICĂĽ$-/ĂĽ)ĂĽTHOUGHTĂĽ)DĂĽJUSTĂĽACCEPTĂĽ fewer jobs, however, there’s a ďŹ ne balance between working less and retaining my credentials.â€? h-YĂĽSTRENGTHĂĽISĂĽREMOTEĂĽCLINICALĂĽWORKĂĽINĂĽ UNCONVENTIONALĂĽSETTINGSĂĽ)VEĂĽNEVERĂĽLIKEDĂĽ board meetings, committees, paperwork and )ĂĽABSOLUTELYĂĽHATEĂĽLINESĂĽOFĂĽTRAFlCĂĽANDĂĽSHOPSv

MEDICAL FORUM


need to be a change from helping everyone else to needing help myself.� h)üKEEPüTELLINGüMYüSELFüTHATü)üHAVEüTOüBEüHAPPYüANDüMAKEüTHEüMOSTüOFüEACHü DAYü&ORüME üTHATüMEANSüGARDENING üKEEPINGüBEESüANDüSHEEPüANDü)üALSOü BUILDüDRYSTONEüWALLSü)TSüAüSKILLü)üLEARNTüINü#UMBRIAüBEFOREüRETURNINGüTOü !USTRALIAüANDü)VEüGOTüMANYüMOREüTOüGOv

ORT HO C O M P WA

h)üINTENDüTOüBEüAüLOVINGüANDüWHACKYüGRANDMOTHERüTOüMYüTHREEü grandchildren (one more to come) and expose them to the beauty of nature and the land.� h(OPEFULLYüTHATüWILLüPROVIDEüAüBALANCEüTOüTHEüDIGITALüHYPEüANDü commercialism of their modern world.�

Pays to think ahead A career in obstetrics means late nights, working weekends and an incessantly RINGINGüTELEPHONEü"UTüDr Helen Clarke wouldn’t have had it any other way. h)üCANüABSOLUTELYüSAYüTHATüTHERESüNOüOTHERü MEDICALüSPECIALTYü)DüRATHERüHAVEüDONEü)Mü DELIGHTEDüTHATü)üCHOSEüOBSTETRICSv h)TSüBEENüAüJOYüANDüAüPRIVILEGEüTHATü people have trusted me to look after their Dr Helen Clarke babies. The hardest part now is seeing PATIENTSüANDüKNOWINGüTHATü)MüNOTüGOINGü TOüBEüAROUNDüFORüTHEIRüNEXTüDELIVERYü)VEü been well-blessed because medicine has given me a great career and a wonderful life.�

Orthopaedic Surgeons specialising in Workers Compensation & Motor Vehicle Accident injuries

Helen, who is 61, has her eyes ďŹ rmly focused on June 2017.

The Orthocomp WA Specialists are a dedicated team of highly experienced Surgeons trained in trauma and elective surgery. With Guardian Exercise Rehabilitation as our preferred provider, we cover ALL aspects required for the successful treatment of upper & lower limb injuries.

h)MĂĽSOĂĽLOOKINGĂĽFORWARDĂĽTOĂĽITĂĽ!CTUALLY ĂĽ )ĂĽHAVENTĂĽTOLDĂĽTOOĂĽMANYĂĽPEOPLEĂĽABOUTĂĽ this so it’ll be ‘breaking news’ courtesy of Medical ForumĂĽ4HEĂĽPEOPLEĂĽ)ĂĽHAVEĂĽ told all say, ‘good on you and well DONEĂĽWHICHĂĽISĂĽNICEĂĽ)MĂĽPRETTYĂĽ excited about it, actually.â€? h1UITEĂĽSOMEĂĽTIMEĂĽAGO ĂĽWHENĂĽ)ĂĽWASĂĽ wondering just where obstetrics was heading with all the insurance COMPLICATIONS ĂĽ)ĂĽDIDĂĽAĂĽDEGREEĂĽINĂĽ 5LTRASOUNDĂĽ)VEĂĽBEENĂĽWORKINGĂĽ in that area, on and off for a WHILEĂĽNOWĂĽ/NCEĂĽ)VEĂĽSTOPPEDĂĽ DELIVERINGĂĽBABIESĂĽ)LLĂĽDOĂĽAĂĽFEWĂĽSESSIONSĂĽOFĂĽ ULTRASOUNDĂĽAĂĽWEEK ĂĽWHICHĂĽISĂĽGREATĂĽBECAUSEĂĽ)ĂĽTHINKĂĽ)DĂĽ STRUGGLEĂĽIFĂĽ)ĂĽHADĂĽTOĂĽRETIREĂĽABRUPTLYv h)ĂĽDONTĂĽREALLYĂĽSEEĂĽMEDICINEĂĽWITHĂĽAĂĽTYPICALĂĽ@RETIREMENTĂĽLABELĂĽATTACHEDĂĽTOĂĽ it. That seems to ďŹ t an ofďŹ ce or corporate job, the ‘gold watch’ scenario. Most of us have worked long and hard and are probably not well suited to a complete and sudden halt in our professional lives.â€? h!NDĂĽITSĂĽNOTĂĽTOOĂĽDIFlCULTĂĽTOĂĽHAVEĂĽAĂĽSMOOTHĂĽTRANSITIONĂĽIFĂĽWEĂĽPUTĂĽSOMEĂĽ thought into it early enough.â€? Helen’s plans post-June next year involve family, languages and perhaps a little more work. h)ĂĽHAVEĂĽAĂĽDAUGHTERĂĽWHOLLĂĽBEĂĽSTUDYINGĂĽMEDICINEĂĽINĂĽ-ELBOURNEĂĽNEXTĂĽYEARĂĽ SOĂĽ)LLĂĽBEĂĽVISITINGĂĽHERĂĽ)MĂĽALSOĂĽLEARNINGĂĽ)TALIANĂĽANDĂĽ)DĂĽLOVEĂĽTOĂĽBECOMEĂĽREALLYĂĽ mUENTĂĽINĂĽTHAT ĂĽTOOĂĽ!NDĂĽTHERESĂĽAĂĽLOVELYĂĽ)TALIANĂĽHOSPITALĂĽINĂĽ4ANZANIAĂĽTHATSĂĽ DESPERATEĂĽFORĂĽPEOPLEĂĽ)ĂĽMIGHTĂĽVOLUNTEERĂĽMYĂĽOBSTETRICĂĽSKILLSĂĽANDĂĽIMPROVEĂĽ MYĂĽ)TALIANĂĽATĂĽTHEĂĽSAMEĂĽTIMEĂĽ

By Peter McClelland

OUR SPECIALISTS: Associate Professor Gareth Prosser - Hip, Knee, Trauma Professor Piers Yates - Hip, Knee, Trauma Mr Satyen Gohil - Shoulder, Knee, Trauma Mr Ben Witte - Knee, Hip, Trauma Mr Andrew Mattin - Shoulder, Knee, Hip, Trauma Mr Thomas Bucher - Hip, Knee, Trauma Mr Simon Wall - Hip, Knee, Trauma

O RT H O C O M P

WA

Suite 15, Level 1 Wexford Medical Centre Barry Marshall Parade, Murdoch WA 6150 Phone: 08 6424 8094 Fax: 08 9332 1187 Email: info@orthocompwa.com.au Website:www.orthocompwa.com.au

MEDICAL FORUM

DECEMBER 2016 | 21


Guest Column

Offering Skills, Receiving Insight Obstetrician Dr Chris Gunnell writes for Medical Forum about his volunteer experience in Ethiopia and discovers the power of dedication and team effort.

hĂĽ

Despite my aversion to dirt, discomfort ANDĂĽDISORDER ĂĽ)ĂĽANSWEREDĂĽAĂĽSMALLĂĽ advertisement in the RANZCOG MAGAZINEĂĽANDĂĽFOUNDĂĽMYSELFĂĽEMBARKINGĂĽ on a life-changing adventure as a volunteer OBSTETRICIANĂĽINĂĽAĂĽTOWNĂĽCALLEDĂĽ"ARHARDIRĂĽINĂĽ Ethiopia. $RĂĽ!NDREWĂĽ"ROWNINGĂĽISĂĽANĂĽ!USTRALIAN TRAINEDĂĽ gynaecologist who started his inspiring working life in Africa as a ďŹ stula surgeon with the famous Hamlins in Addis Ababa. He

Dr Chris Gunnell with some of the Barhardir staff; and, top, with Australian gynaecologist Dr Andrew Browning (black shirt).

went on to open his own ďŹ stula hospital in "ARHARDIRĂĽWHEREĂĽHEĂĽWORKEDĂĽFORĂĽSEVERALĂĽYEARSĂĽ Realising that prevention is better than a cure, he then started up several maternity hospitals INĂĽ%THIOPIAĂĽANDĂĽ4ANZANIAĂĽ(EĂĽCURRENTLYĂĽLIVESĂĽ ANDĂĽWORKSĂĽINĂĽ4ANZANIA "ARHIRDARĂĽISĂĽAĂĽTOWNĂĽINĂĽCENTRALĂĽ%THIOPIAĂĽBYĂĽ BEAUTIFULĂĽ,AKEĂĽ4ANAĂĽ)TĂĽISĂĽAĂĽTOURISTĂĽTOWNĂĽSOĂĽ areas are quite Westernised and there are several large hotels (which came in useful WHENĂĽ)ĂĽNEEDEDĂĽAĂĽlXĂĽOFĂĽ7I &IĂĽORĂĽWINE ĂĽ However, there is also extreme poverty both in and around the town. The hospital provides free maternity service to THEĂĽPOORĂĽ)TĂĽISĂĽSTAFFEDĂĽBYĂĽAĂĽGROUPĂĽOFĂĽĂĽHAND picked and highly skilled local midwives. Two volunteer doctors support these midwives, ASSISTINGĂĽWITHĂĽDIFlCULTĂĽMEDICALOBSTETRICĂĽ issues, complicated vaginal births and CAESAREANSĂĽ)ĂĽSTARTEDĂĽOFFĂĽTHEREĂĽWITHĂĽAĂĽ$UTCHĂĽ tropical medicine specialist, however, she needed to leave the country to renew her visa – leaving me (very anxiously) alone for two long weeks. Patients ready and waiting

Chris's ďŹ rst delivery

22 | DECEMBER 2016

requested or offered. Vacuums, forceps and manual removals are all done without any pain relief. The women are generally discharged six hours after delivery to make space for more. Caesareans are performed under spinal block (done by an anaesthetic technician). The theatre facilities are basic but all essentials are available (apart from consistent electricity). One night during a dramatic thunderstorm, JUSTüAFTERü)üMADEüTHEüINITIALüINCISION üTHEüPOWERü went out and plunged us into total darkness. While waiting for a staff member to brave the rain and manually turn on the generator, )üCONTINUEDüTHEüSURGERYüUNDERüTHEüLIGHTüOFüTHEü midwife’s smartphone torch. Even in Ethiopia there is debate about the appropriate Caesarean section rate! This procedure has dramatically decreased both maternal morbidity and mortality, but there is then the risk of uterine rupture in subsequent LABOURSüPARTICULARLYüINüTHOSEüWOMENüLIVINGü FARüFROMüAüHOSPITALü)TüISüEVENüMOREüIMPORTANT ü therefore, to perform only those caesareans that are absolutely necessary.

My ďŹ rst of many confronting experiences was walking into the hospital on the ďŹ rst day to ďŹ nd one big Nightingale ward completely full. Antenatal, postnatal and labouring women are all thrown in together with very little privacy.

10% CS rate hard to beat

When a woman starts to push, she is quickly shufed into a separate birthing room for the delivery, then afterwards immediately walked back to her ward bed. There is no analgesia

The hospital delivers between 150 and 210 babies a month. There have been no maternal deaths for three years and, given the background rate for Ethiopia, this is

!TüTHEüHOSPITALüINü"ARHIRDAR üTHEü#3üRATEüISü GENERALLYüSTEADYüATüAüVERYüRESPECTABLEüü)ü couldn’t quite bring myself to confess our rate in Western Australia!

MEDICAL FORUM


Guest Column

an incredible achievement. The perinatal mortality rate is low compared to many other hospitals and health care centres in the country. The midwives are very proud of these statistics and this gives them the incentive TOĂĽCONTINUEĂĽTHEIRĂĽHARDĂĽWORKĂĽ)ĂĽWASĂĽAMAZEDĂĽTOĂĽ learn that the midwives work 28 out of every ĂĽDAYSĂĽFORĂĽĂĽMONTHSĂĽOFĂĽTHEĂĽYEARĂĽ $URINGĂĽMYĂĽTIMEĂĽ)ĂĽFOUNDĂĽMYSELFĂĽFACEDĂĽWITHĂĽ some confronting but fascinating medical ANDĂĽOBSTETRICĂĽPROBLEMSĂĽ)ĂĽREGULARLYĂĽTREATEDĂĽ typhoid, amoebic dysentery and syphilis. During my month-long placement, we had SEVERALĂĽWOMENĂĽDIAGNOSEDĂĽWITHĂĽ()6ĂĽANDĂĽAĂĽFEWĂĽ DELIVERIESĂĽOFĂĽ()6ĂĽPOSITIVEĂĽWOMENĂĽALTHOUGHĂĽ the overall rate is quite low compared to other African countries). )ĂĽMANAGEDĂĽAĂĽWOMANĂĽWHOĂĽWALKEDĂĽHERSELFĂĽ INĂĽFROMĂĽTHEĂĽCOUNTRYĂĽWITHĂĽAĂĽ"0ĂĽOFĂĽĂĽ and miraculously prevented her from ďŹ tting. Eclampsia is a relatively common phenomenon. However, probably my most rewarding experience was doing caesareans for women with obstructed labour – knowing that not too long ago, these women would have been the ones facing days of labour, a foetal death and subsequent ďŹ stula. This is WHENĂĽ)ĂĽTRULYĂĽFELTĂĽ)ĂĽWASĂĽMAKINGĂĽAĂĽDIFFERENCE Past patients work for others The highlight of my trip was meeting and SPENDINGĂĽTIMEĂĽWITHĂĽ!NDREWĂĽ"ROWNINGĂĽ WHOĂĽPAIDĂĽAĂĽVISITĂĽTOĂĽ"ARHIRDARĂĽANDĂĽSHOWEDĂĽ MEĂĽAROUNDĂĽHISĂĽOLDĂĽlSTULAĂĽHOSPITALĂĽ)TĂĽWASĂĽ emotionally overwhelming to meet and

CS theatre Barhardir

interact with the staff at this hospital – most of whom were Andrew’s cured past ďŹ stula patients. 4HEIRĂĽADORATIONĂĽWASĂĽHEARTWARMINGĂĽ)TĂĽISĂĽ impossible to not be inspired by this humble man who has given so many women their lives back and who has also gone on to establish hospitals to prevent further death and disease. He has made an astounding contribution to global women’s health and )ĂĽHOPEĂĽONEĂĽDAYĂĽRECEIVESĂĽTHEĂĽRECOGNITIONĂĽHEĂĽ deserves. )ĂĽWASĂĽWARNEDĂĽABOUTĂĽ@REVERSEĂĽCULTUREĂĽSHOCKĂĽ on returning home and prepared myself for the ‘First World problems’ of my private PATIENTSĂĽ)VEĂĽBEENĂĽSURPRISEDĂĽBYĂĽTHEĂĽEXTENTĂĽOFĂĽ

Happy mother happy baby

my emotions dealing with every-day issues. The huge disparity between our lives, our cultures, our health care and our priorities is overwhelming at times. !LTHOUGHĂĽ)ĂĽAMĂĽSLOWLYĂĽSETTLINGĂĽBACKĂĽINTOĂĽ my comfortable Western life, my short visit to Ethiopia has certainly put this life INTOĂĽPERSPECTIVEĂĽ)ĂĽHADĂĽTHEĂĽMOSTĂĽAMAZINGĂĽ EXPERIENCEĂĽANDĂĽDIDNTĂĽWANTĂĽITĂĽTOĂĽENDĂĽ)ĂĽAMĂĽ already planning my next trip! ED: If you want to be further inspired or to understand more about ďŹ stula surgery, Andrew Browning spoke at the RCOG World Congress in 2013: https://vimeo.com/71503311 and https:// www.youtube.com/watch?v=w6DULSxZlpg4

Therapeutic Manuka Honey: No Longer So Alternative by Prof Dee Darter Abstract. Medicinal honey research is undergoing a substantial renaissance. From a folklore remedy largely dismissed BYĂĽMAINSTREAMĂĽMEDICINEĂĽASĂĽALTERNATIVE ĂĽWEĂĽNOWĂĽSEEĂĽINCREASEDĂĽINTERESTĂĽBYĂĽSCIENTISTS ĂĽCLINICALĂĽPRACTITIONERSĂĽANDĂĽTHEĂĽ GENERALĂĽPUBLICĂĽINĂĽTHEĂĽTHERAPEUTICĂĽUSESĂĽOFĂĽHONEYĂĽ4HEREĂĽAREĂĽAĂĽNUMBERĂĽOFĂĽDRIVERSĂĽOFĂĽTHISĂĽINTERESTĂĽlRST ĂĽTHEĂĽRISEĂĽINĂĽANTIBIOTICĂĽ RESISTANCEĂĽBYĂĽMANYĂĽBACTERIALĂĽPATHOGENSĂĽHASĂĽPROMPTEDĂĽINTERESTĂĽINĂĽDEVELOPINGĂĽANDĂĽUSINGĂĽNOVELĂĽANTIBACTERIALSĂĽSECOND ĂĽ an increasing number of reliable studies and case reports have demonstrated that certain honeys are very effective WOUNDĂĽTREATMENTSĂĽTHIRD ĂĽTHERAPEUTICĂĽHONEYĂĽCOMMANDSĂĽAĂĽPREMIUMĂĽPRICE ĂĽANDĂĽTHEĂĽHONEYĂĽINDUSTRYĂĽISĂĽACTIVELYĂĽPROMOTINGĂĽ STUDIESĂĽTHATĂĽWILLĂĽALLOWĂĽITĂĽTOĂĽCAPITALIZEĂĽONĂĽTHISĂĽANDĂĽlNALLY ĂĽTHEĂĽVERYĂĽCOMPLEXĂĽANDĂĽRATHERĂĽUNPREDICTABLEĂĽNATUREĂĽOFĂĽHONEYĂĽ PROVIDESĂĽANĂĽATTRACTIVEĂĽCHALLENGEĂĽFORĂĽLABORATORYĂĽSCIENTISTSĂĽ)NĂĽTHISĂĽPAPERĂĽWEĂĽREVIEWĂĽMANUKAĂĽHONEYĂĽRESEARCH ĂĽFROMĂĽ observational studies on its antimicrobial effects through to current experimental and mechanistic work that aims to take honey into mainstream medicine. We outline current gaps and remaining controversies in our knowledge of how HONEYĂĽACTS ĂĽANDĂĽSUGGESTĂĽNEWĂĽSTUDIESĂĽTHATĂĽCOULDĂĽMAKEĂĽHONEYĂĽAĂĽNOĂĽLONGERĂĽALTERNATIVEĂĽALTERNATIVEĂĽ &ULLĂĽARTICLEĂĽISĂĽATĂĽHTTPJOURNALFRONTIERSINORGARTICLEFMICBFULL

For more information contact Paul Callander on 0438 990 426

MEDICAL FORUM

DECEMBER 2016 | 23


Myocardial perfusion scans Bulk Billed at all Perth Radiological Clinic nuclear medicine sites STRESS

REST

Nuclear medicine cardiac stress testing is an important tool in the work up for patients with known or suspected coronary artery disease and to exclude coronary artery disease in patients with atypical chest pain

Myocardial perfusion scans available at these hospital sites:

MOUNT HOSPITAL

4

MIDLAND PUBLIC HOSPITAL

BENTLEY HOSPITAL

convenient locations for easy patient access

www.SHUWKUDGFOLQLFFRPDX 24 | DECEMBER 2016

JOONDALUP HEALTH CAMPUS

Leaders in Medical Imaging MEDICAL FORUM


Feature

Full Steam Ahead Dr Paul Collin has practised medicine in far ung places, but wherever that might have been, it’s a safe bet a train of some description was close by. It’s little wonder that Dr Paul Collin ďŹ nds trains and all-things-railway utterly fascinating. They were in his blood from a young age and his passion has morphed into a lot more than a hobby. h)ĂĽWASĂĽBORNĂĽINĂĽ%DINBURGHĂĽANDĂĽBEFOREĂĽ)ĂĽCOULDĂĽ WALKĂĽ)ĂĽCAUGHTĂĽMYĂĽlRSTĂĽSTEAMĂĽTRAINĂĽTOĂĽ,ONDONĂĽ)ĂĽ didn’t know it at the time but apparently it was doing 70-80mph. We moved to Perth when my father took up a position in the Physiology $EPARTMENTĂĽATĂĽ57!ĂĽANDĂĽSOMEĂĽYEARSĂĽLATERĂĽWEĂĽ all went back to Edinburgh while my dad took a sabbatical.â€? h7EĂĽLIVEDĂĽNEARĂĽAĂĽRAILWAYĂĽLINEĂĽANDĂĽ)ĂĽCANĂĽSTILLĂĽ remember watching the A4 PaciďŹ c’s travelling down to London. That same A4 locomotive still holds the world speed record for steam engines.â€? h4RAINĂĽSPOTTINGĂĽISĂĽSTILLĂĽINCREDIBLYĂĽPOPULARĂĽINĂĽ THEĂĽ5+ ĂĽCROWDSĂĽOFĂĽPEOPLEĂĽLININGĂĽTHEĂĽTRACKSĂĽ and recording registration numbers. When )ĂĽWASĂĽTHERE ĂĽ)ĂĽSAWĂĽTHEĂĽ&LYINGĂĽ3COTSMANĂĽ travelling down the east-coast main line. That locomotive actually came here in the early 1980s, travelled from Sydney to Perth and did a trip out to Kambalda.â€?

Dr Paul Collin at Whiteman Park

Flying with the Scotsman h!FTERĂĽTHATĂĽITĂĽWENTĂĽBACKĂĽTOĂĽTHEĂĽ5+ĂĽANDĂĽDIDĂĽTHEĂĽ run from London to York. On its ďŹ nal journey to the National Railway Museum people paid hundreds of pounds for a ticket.â€? Paul’s route to medicine was interesting, complete with a twist in the tracks during his training. h)ĂĽACTUALLYĂĽWANTEDĂĽTOĂĽBEĂĽANĂĽENGINEERĂĽATĂĽSCHOOLĂĽ but the career adviser told me my marks WERENTĂĽGOODĂĽENOUGHĂĽ(EĂĽSUGGESTEDĂĽ)ĂĽDOĂĽ MEDICINEĂĽINSTEADĂĽ)NĂĽTHEĂĽMIDDLEĂĽOFĂĽMYĂĽMEDICALĂĽ TRAININGĂĽ)ĂĽTOOKĂĽAĂĽTWO YEARĂĽBREAKĂĽANDĂĽJOINEDĂĽ the WA Government Railways as a trainee engineman before qualifying as an acting ďŹ reman, which basically involved helping the driver.â€? h)ĂĽDIDĂĽEVERYTHINGĂĽFROMĂĽTHEĂĽHUMBLEĂĽJOBĂĽOFĂĽ shunting locomotives in the yards to working ONĂĽTHEĂĽ)NDIANĂĽ0ACIlCv Rattling with politicians h)NĂĽTHEĂĽSĂĽ)ĂĽWASĂĽBASEDĂĽINĂĽ-ERREDINĂĽAND ĂĽ at the time, they named the locomotives AFTERĂĽPOLITICIANSĂĽ4HEĂĽlRSTĂĽONEĂĽ)ĂĽWASĂĽONĂĽWASĂĽ the Gough Whitlam and the next was the Malcolm Fraser, which was faintly amusing. ,ATERĂĽONĂĽ)ĂĽTOOKĂĽSOMEĂĽLEAVEĂĽANDĂĽTRAVELLEDĂĽ ACROSSĂĽTHEĂĽCOUNTRYĂĽONĂĽTHEĂĽ)NDIANĂĽ0ACIlCĂĽASĂĽ a passenger and then down to Canberra sitting in beautiful, vintage carriages complete with brass handles and varnished wooden panelling.â€? h)ĂĽWASĂĽACTUALLYĂĽSITTINGĂĽINĂĽTHEĂĽPUBLICĂĽGALLERYĂĽATĂĽ Parliament House when Gough Whitlam was sacked!â€?

MEDICAL FORUM

The siren-call of medicine remained and there was a good ďŹ nancial reason to dust off the stethoscope.

h)VEĂĽDONEĂĽTHREEĂĽTRIPSĂĽTOĂĽ+ALIMANTAN ĂĽAĂĽREMOTEĂĽ AREAĂĽINĂĽ)NDONESIA ĂĽANDĂĽ)ĂĽWASĂĽTHEĂĽONLYĂĽONEĂĽ there who spoke English.

h!PARTüFROMüOTHERüPEOPLEüTELLINGüMEü)üWASü WASTINGüMYüLIFEüDRIVINGüTRAINSü)üALSOüTHOUGHTü there was a good chance that the student payment might be stopped. So, after two YEARSüWITHüTHEüRAILWAYS ü)üWENTüBACKüTOü university.�

Beyond steam in China

h)ĂĽCERTAINLYĂĽHAVEĂĽNOĂĽREGRETSĂĽABOUTĂĽGOINGĂĽ back to medicine but my interest in trains has certainly made me less of a ‘one-track’ PERSON ĂĽIFĂĽYOULLĂĽPARDONĂĽTHEĂĽPUNĂĽ"EINGĂĽAĂĽ DOCTORĂĽISĂĽFASCINATINGĂĽBUTĂĽ)VEĂĽGOTĂĽAĂĽLOTĂĽOFĂĽOTHERĂĽ interests and one of them is the study of languages. And that’s dove-tailed quite nicely with my passion for tracking down working steam locomotives all around the world.â€? Steaming over the savannah h4HEĂĽTIMEĂĽ)ĂĽSPENTĂĽINĂĽ:IMBABWEĂĽWASĂĽ INTERESTING ĂĽTOOĂĽ)ĂĽWASĂĽWORKINGĂĽTHEREĂĽASĂĽ a doctor and it was during the time that sanctions were in place so they started refurbishing their old steam locomotives. )VEĂĽGOTĂĽFONDĂĽMEMORIESĂĽOFĂĽTAKINGĂĽTHEĂĽTRAINĂĽ FROMĂĽ"ULAWAYOĂĽTOĂĽ6ICTORIAĂĽ&ALLS ĂĽWHICHĂĽWASĂĽ complete luxury with freshly ironed sheets and a beautiful dining car.â€? h7EDĂĽGOĂĽAROUNDĂĽAĂĽCURVEĂĽANDĂĽWHENĂĽYOUĂĽ looked out you could see the Garrett steam locomotive up ahead with elephants and giraffes running away from the train.â€?

h)üALSOüTAKEüTOURüGROUPSüTHROUGHü#HINAü)ü SPEAKüWHATü)DüCALLü@TRAVELLERSü#HINESE üWHICHü is enough to buy tickets and work out where to get on and off the train. China actually made its last steam engine in 1999 and there’s still some operating in coal mines and INDUSTRIALüPLANTSü)TüNOWüHASüTHEüWORLDSüFASTESTü train that clips along at a pretty respectable KMHRvü And it’s not all overseas jaunts in the pursuit of trains for Paul. There are plenty of local opportunities, too. h)MüANüACTIVEüMEMBERüATüTHEü"ASSENDEANü Railway Museum and they have a very large collection of rolling stock and locomotives on permanent display. A few were purchased from private hands and there’s one that was hauling timber from Yarloop up until the early 1970s.� One last wish for this dedicated follower of STEAMüTRAINS h)DüLOVEüTOüGOüBACKüTOü:IMBABWEüANDüSTANDü on the footplate of a Garrett locomotive. They weigh around 200 tons, they’re hauling really heavy loads and sometimes the drivers let you get behind the wheel.�

By Peter McClelland

Paul’s multi-lingual talents come in handy when he’s globe-hopping in search of exotic steam trains.

DECEMBER 2016 | 25


Medicolegal

“We’re all doctors here‌â€? While colleagues often discuss cases with each other, a cautionary note is issued by Mr Chad Edwards-Smith who says WA is a very small place.

Mr Chad Edwards-Smith

Over the party din, Maureen clearly heard him SAY â€œâ€Ś and she comes to me to complain about shortness of breath and low exercise tolerance. The woman is 120kg plus and clearly isn’t in any shape to be tackling the Rottnest Channel Swim! So I tactfully suggest she might ďŹ rst lose a bit of weight and recommend some lifestyle changes. But then she starts lecturing me about my weight and starts asking about my diet. Apparently she’s a dietician, if you can believe it, and suddenly I’m copping a serve from my patient about my lifestyle!â€? There’s laughter all round.

After all, we’re all doctors, and we all share a duty of conďŹ dentiality don’t we?â€?

This part of the Privacy Act enables the healthcare system to work, without the need to constantly obtain the patient’s consent for each and every interaction between healthcare providers.

The Privacy Act (1988) allows for disclosure of SENSITIVEĂĽHEALTHĂĽINFORMATIONĂĽWHERE

So remember, when it comes to disclosing CONlDENTIALĂĽINFORMATIONĂĽAMONGĂĽCOLLEAGUES

Maureen wonders whether he might be talking about her friend Alice – a dietician and once an avid swimmer. Last time they met, Alice had certainly put on a few kilos but she didn’t know she was planning to compete in the Rottnest swim. She’d try to catch up with her on Facebook and ask.

sĂĽ THEĂĽDISCLOSUREĂĽSECONDARYĂĽPURPOSE ĂĽISĂĽ directly related to the reason that the patient provided the information in the ďŹ rst place (being the primary purpose – which is USUALLYĂĽTOĂĽENABLEĂĽTREATMENT ĂĽANDĂĽ

sĂĽ 4HEĂĽCOMMONĂĽDUTYĂĽAMONGSTĂĽDOCTORSĂĽTOĂĽ maintain patient conďŹ dentiality does not mean that doctors can indiscriminately share patient information.

While doctors (and healthcare providers generally) routinely disclose conďŹ dential health information between themselves for the purpose of facilitating the patient’s healthcare, this ‘sharing’ of information is permissible, not because the conversants are doctors or healthcare providers, but because of the purpose of disclosure.

A few weeks later a doctor contacts the our ADVISORYĂĽLINE “Someone’s complained that I’ve breached patient conďŹ dentiality. But it wasn’t like that, all of the people I spoke to were actually doctors, and I was only trying to get some feedback on a difďŹ cult case. I never mentioned any names! Surely I can do this?

Doctors may feel the need to vent about their day but any disclosures regarding patients should be limited to completely de-identiďŹ ed scenarios – remembering it is not enough to merely refrain from mentioning names.

sü THEüPATIENTüWOULDüREASONABLYüEXPECTüTHATü their information would be disclosed in such circumstances. A well-recognised situation of disclosure is where healthcare providers share information to facilitate the patient’s care. This would include a GP liaising with a specialist, or a registrar taking advice from a senior colleague as to the best treatment.

sü !NYüDISCLOSUREüBETWEENüCOLLEAGUESü needs to be for the purpose of facilitating the patient’s care. De-identifying a case involves more than just omitting the names (particularly in Perth).( Refer to the /!)#ü'UIDELINESüONüDE IDENTIlCATIONüOFü data and information. ED: Chad is head of Avant’s Medical Defence Services (WA)

Radiation therapy for breast cancer is now even safer

A breath of fresh air for patients with left-sided breast cancer INTRODUCING DEEP INSPIRATION BREATH HOLD (DIBH)

Perth Radiation Oncology, Wembley

Now also available at Shenton House, Joondalup

Dr Margaret Latham

Dr Yvonne Zissiadis

Asst. Prof Raphael Chee

Dr Evan Ng

Clinical Prof Nigel Spry

MBBS, FRANZCR Radiation Oncologist

MBBS, FRANZCR Radiation Oncologist

MBBS, FRANZCR Radiation Oncologist

MBBS, FRANZCR Radiation Oncologist

MBBS, PhD, FRCP, FRCR, FRANZCR, FRACHPM Radiation Oncologist

In some patients with left-sided breast cancer, the risk of incidental radiation exposure to the heart can be a concern. While other protective methods exist, a new and more efficient non-invasive technique asks patients to hold their breath. By holding a breath, the amount of air in the lungs is increased, moving the heart away from the chest wall to further minimise the risk of radiation exposure to the heart. To request a referral pad or find out more, phone 1300 977 062 or visit genesiscancercarewa.com.au

26 | DECEMBER 2016

MEDICAL FORUM


2 01 6

s a m t s i r Ch re u t a e F s g Greetin

B Best wishes from WA's Health Professionals

Medical Forum wishes all our readers and supporters a Merry Christmas and a Happy New Year

MEDICAL FORUM

DECEMBER 2016 | 27


Best of health festive season FOR THE

;OL,_LJ\[P]L4HUHNLTLU[HUK:[HɈH[9HTZH`/LHS[O*HYL>( ^V\SKSPRL[V[OHURV\Y:WLJPHSPZ[ZYLMLYYPUN+VJ[VYZHUKHSSVM[OL TLKPJHSJVTT\UP[`MVY[OLPYPU]HS\HISLZ\WWVY[[OYV\NOV\[[OL`LHY >L^PZO`V\HSSHZHMLHUKOHWW`MLZ[P]LZLHZVUHUKHWYVZWLYV\Z Attadale Rehabilitation Hospital

28 | DECEMBER 2016

Glengarry Private Hospital

Hollywood Private Hospital

Joondalup Health Campus

Peel Health Campus

MEDICAL FORUM


“On a busy day twenty-two ty-two thousand peo people come to visit Santa, and I was told that it is aan elf's lot to remain merry in the face of torment orment and adversity. I promised to keep that in mind.”” David Sedaris

T There ain’t nno Sanity Clause.

The Cardiologists and Staff of Western Cardiology wish all a very Merry Christmas and Happy New Year. Thanks to all referring doctors for their support during the year. We look forward to continuing excellence in patient care. Dr Mark Hands Dr Stephen Gordon Dr Philip Cooke Dr Brendan McQuillan Dr Johan Janssen Dr Paul Stobie Dr Chris Finn Dr Eric Yamen

Dr Joe Hung Dr Michelle Ammerer Dr Luigi D’Orsogna Dr Andre Kozlowski Dr Tim Gattorna Dr Devind Bhullar Dr Kalil Anvardeen

Chico Marx

From all of us at the SleepMed team, we thank you for all your support throughout the year. Wish you an abundance of happiness and fun this holiday season and beyond. We look forward to assisting g and serving g yyour patients in 2017.

PIVET MEDICAL CENTRE 7ISHINGåOURåCOLLEAGUESååFRIENDSåALLåTHEåJOYSå 7ISHING OUR COLLE EAGUESS  FRIEND DS ALL THE E JO OYS off the e fes festive stivve season. season. We sincerely sinc cere ely a appreciate pprrec ciate e yourr co continued onttinu ued d support through throughout houtt 20 2016 016 6a and nd loo look ok fforward orw warrd to working working together toge ether a again gain in 2017. 20 017. $R *O OHN 9OVIICH  THE TE EAM AT 0)6 6%4 4 $Rå*OHNå9OVICHååTHEåTEAMåATå0)6%4

MEDICAL FORUM

DECEMBER 2016 | 29


Perth Breast and Thyroid Multidisciplinary Care

Dr Corinne Jones Specialist Breast and Endocrine Surgeon Thank you to friends and colleagues for your support throughout the year. Wishing you all a Christmas of good food and good cheer, and a busy and prosperous 2017.

Dr Phil Daborn A special thank you to all my referring colleagues for your continued support throughout 2016. 7ISHINGåYOUååYOURå families a joyful festive season, and all the very best for 2017.

The office Christmas party is a great opportunity to catch up with people you haven't seen for 20 minutes. Julius Sharpe

We sincerely appreciate your continued support and goodwill throughout 2016. We wish you, your staff & your families all the joys of this holiday season on behalf of the Doctors and staff at SKG Radiology.

Dr Sue Ulreich, CEO & Radiologist

www.skg.com.au

30 | DECEMBER 2016

MEDICAL FORUM


Prof Luc Delriviere and his team at The Liver Centre would like to wish you a very joyful Christmas and safe, happy and prosperous New Year. Thank you to all our referring GP and specialist colleagues for your continued support during 2016. We look forward to working with you further. Luc Delriviere

Wishing you, your loved ones and your staff a joyous, healthy and safe holiday season and all the best for the New Year. Thank you kindly for your CONTINUEDåSUPPORTåANDå)åLOOKå forward to working with you in 2017. Marek Garbowski & Staff at Perth Vascular Clinic www.perthvascularclinic.com.au Perth Vascular Clinic Suite 218 SJOG 25 McCourt St, Subiaco All enquiries and appointment bookings phone: 9382 9100

Dr Phillip McGeorge and his team wish you a Merry Christmas and a Happy New Year. Thank you for your support over the last year. We look forward to providing general ophthalmology and refractive surgery to your patients in 2017. 218 7666 For a prompt and early appointment call 9218

Dr Phillip McGeorge MBBS FRACS FRANZCO

MEDICAL FORUM

Suite 55, St John of God Murdoch Suite 318, St John of God Subiaco www.murdocheye.com.au www.perthlaservision.com.au

DECEMBER 2016 | 31


Sharing the seeds of happiness and goodwill St John of God Health Care wishes our doctors and everyone working in Western Australia’s health care community a blessed and happy Christmas and a fruitful new year.

32 | DECEMBER 2016

MEDICAL FORUM


The team at Western Eye would like to thank you for your continuing support during this past year. Merry M Mer erry Christmas an and nd a prosperous prosspe pros erous New Year fro from om tthe he e tteam eam at Panetta McGrat ath. McGrath. We hope that the Christmas holiday ay is is lLLEDåWITHåREST åPEACEååJOY lLLED WITH REST PEACE  JOY

Listed as a Leading Defender of WA Medical Me .EGLIGENCEåå-ALPRACTICEå#LAIMS .EGLIGENCE  -ALPRACTICE #LAIMS MS

We wish you and your families a safe and happy Festive Season and look forward to working with you in 2017. www.westerneye.com.au

Mosman Park | Karrinyup | Subiaco | Kalamunda

A warm thank you to all of our referrers and colleagues for your support in 2016. We wish you all the best over the holidays and we look forward to working with you in 2017 and beyond.

MEDICAL FORUM

DECEMBER 2016 | 33


Dr Anjana Thottungal Caring commitment to women’s health Wishing all my colleagues and their staff a merry Christmas and a very happy New year. Thank you for your continued support over 2016. 7EåALLåATå0/'5åLOOKå forward to working with you in the new year.

å&ORRESTå3T å#OTTESLOE 4ååå&REECALLååå %åINFOR WBINETAUå7åWWWWBINETAU #LINICåWILLåBEåCLOSEDåFROMååTOå

-ERRYå#HRISTMASåå "ESTå7ISHESåFORåAå (APPY å(EALTHYåå Prosperous 2017.

Merry Christmas hristmas as and hopi h hoping ng g this th s year yea concludes oncludes on a cheerful note note and an makes m s way fo forr a fresh f and brigh bright ght New Year! Year! Thank ha k you yo ou for a grea g great reat 2016! Cheers Jen & Jaz Chee az

We thank you for your support this year and look forward to continue delivering high quality service tto yourselves and yyour yo ur patie patients in 2017.

34 | DECEMBER 2016

MEDICAL FORUM


C Christmas to a child is the ďŹ rst terrible proof th that to travel hopefully th is better than to arrive. Stephen Fry

Dr Mini Zachariah To all my referring doctors and colleagues. A Merry Christmas and a Safe & Happy New Year. Thank you for your continued support and I look forward to working with you in 2017.

Thankyou for your continued support throughout 2016. We wish you all a very joyful festive season.

Warmest wishes Mini

Warmest wishes Dr Peter Hugo, Dr Aparna Baruah & staff

heartcarewa.com.au

The Cardiologists and Staff from HeartCare Western Australia wish our referrers and their support staff a...

Merry Christmas & Best Wishes for a Healthy & Prosperous 2017 We thank you for your support this year and look forward to continuing high quality service to yourselves and your patients in 2017.

COM COMPREHENSIVE SERVICES: CONSULTATIONS | FULL NON-INVASIVE CO CA CARDIAC TESTING DIAGNOSTIC AND IN INTERVENTIONAL CARDIOLOGY

MEDICAL FORUM

Dr Randall Hendriks Dr Mark Ireland Dr Ben King Dr Donald Latchem

Dr Allison Morton Dr Mark Nidorf Dr Vince Paul Dr Peter Purnell

Dr Pradyot Saklani Dr Nigel Sinclair Dr Isabel Tan Dr Angus Thompson

Dr Peter Thompson Dr Alan Whelan Dr Xiao-Fang Xu

DECEMBER 2016 | 35


I once wantedd to become an atheist, but I gave up – they have no holidays. days. Wishing you a joyful season. With the support we received this year, we have been able to provide vital family planning services to millions of people in need worldwide. Thank you from the team at Dr Marie Midland.

ng Henry Youngman

We W landed a ship on a comet and a the batteries don’t last. Is th any different from your that ďŹ Christmas? ďŹ rst Albert Brooks

Dr John Teasdale and the Team at WA Vascular Centre would like to wish you a very Merry Christmas and a Happy New Year. Thank you for your valued support during 2016 and we look forward to working with you in 2017. 0ERTHĂĽ"ASSENDEAN ĂĽ&REMANTLE ĂĽ*OONDALUP ĂĽ -ANDURAHĂĽĂĽ.ORTHAM !PPOINTMENTSĂĽ4ELĂĽĂĽĂĽnĂĽ www.wavascularcentre.com.au

36 | DECEMBER 2016

MEDICAL FORUM


get your patient’s spine working Workspine’s team of hand picked specialists provide comprehensive occupational spine injury management under one roof. From pain management to surgery, cognitive therapy and rehabilitation exercise programmes, Workspine covers all aspects required for the successful treatment of work related spinal injury. Studies have shown that a comprehensive approach to spinal injury treatment results in better patient outcomes. Put an end to the spiral of endless referrals and self management and send your work related spinal injury patients to Workspine. We get spines working.

Dr. Andrew Miles FRACS NEUROSURGEON

Dr. David Holthouse FRACS INTERVENTIONAL PAIN SPECIALIST

Dr. Michael Kern FRACS NEUROSURGEON

Dr. Graham Jeffs FRACS NEUROSURGEON

Guardian EXERCISE REHABILITATION

EXERCISE REHABILITATION

wisdom health PSYCHOLOGY SERVICES

1800 WRK SPN 1800 975 776

MURDOCH Suite 77, Level 4 St John of God Wexford Medical Centre 3 Barry Marshall Parade Murdoch WA 6150 MEDICAL FORUM

WEMBLEY Suite 10, First Floor 178 Cambridge Street Wembley WA 6104 www.workspine.com.au DECEMBER 2016 | 37


season’s

greetings

W w We would like to extend our sincere thanks to all our since refer referrers for your support this year. We wish you and your family a wonderful and safe holiday season and the very best for 2017.

178-190 Cambridge Street | Wembley 6382 3888 | envisionmi.com.au 38 | DECEMBER 2016

MEDICAL FORUM


Guest Column

Road Less Travelled (While Sober) The statistics of Australians’ love affair with alcohol is sobering enough, but anaethetist Dr Ralph Longhorn wanted to go one step further. Alcohol plays a signiďŹ cant role in many cultures. Indeed, it goes all the way back to 10,000BC with the Greeks and Bacchus, the god of wine. )TSĂĽVERYĂĽMUCHĂĽPARTĂĽOFĂĽMODERNĂĽ!USTRALIANĂĽ culture, too. So much so that in 2012 we spent just over $14b on the stuff! We celebrate birth, adulthood and marriage with alcohol and use it to commiserate with friends and family at funerals. Like many doctors, my own relationship with ALCOHOLĂĽSTARTEDĂĽINĂĽMEDICALĂĽSCHOOLĂĽ)TĂĽBEGANĂĽWITHĂĽ an occasional beer with a couple of mates and led to the drunken excess of student parties plus an all-day hangover. Youth is wasted on the young, they say, but it seemed like a lot of fun at the time. A career as an anaesthetist and the arrival of children necessitated a moderation in my drinking habits but it remained a part of my life MOREĂĽTHANĂĽ)ĂĽCAREDĂĽTOĂĽADMITĂĽ )NĂĽ*ANUARYĂĽĂĽ)ĂĽREADĂĽABOUTĂĽFebFast on a 3TĂĽ*OHNĂĽOFĂĽ'ODĂĽWEBSITEĂĽANDĂĽTHOUGHTĂĽ)DĂĽGIVEĂĽ it a try. The idea of giving up alcohol on the shortest month of the year and after Christmas excess seemed like a good idea, so much so

Why do we consider it absolutely normal to drink alcohol as an integral part of socialising? THATü)üDIDüITüTHREEüTIMESü!TüTHEüENDüOFüTHEülRSTü TWOü)üREWARDEDüMYüACHIEVEMENTüWITHüAüBEERü or three! )üDECIDEDüTHATü)üWANTEDüKNOWüAüBITüMOREü about the effects of alcohol and in a moment OFüSOBERüCRAZINESSü)üABSTAINEDüFORüAüYEARü)ü couldn’t have imagined the effect it would have on people around me.

)ĂĽWOULDĂĽARRIVEĂĽATĂĽPARTIESĂĽEARLYĂĽANDĂĽTRYĂĽTOĂĽSPEAKĂĽ to as many people before they got drunk. "EINGĂĽSOBERĂĽDOESNTĂĽNECESSARILYĂĽMEANĂĽYOUREĂĽ boring but trying to talk to people who are drunk often is. )ĂĽBEGANĂĽTOĂĽSEEĂĽWITHĂĽFRESHĂĽEYESĂĽTHEĂĽSIGNIlCANTĂĽ ROLEĂĽALCOHOLĂĽPLAYSĂĽINĂĽOURĂĽSOCIETYĂĽ)TĂĽPERVADESĂĽ just about everything from relentless television advertising to watching junior sport with a drink in your hand. When we catch up with friends it’s usually to invite them for a ‘drink’. Spending time with others seems to be of less importance compared with the consumption of alcohol. Why do we consider it absolutely normal to DRINKĂĽALCOHOLĂĽASĂĽANĂĽINTEGRALĂĽPARTĂĽOFĂĽSOCIALISING

My drinking buddies were disgusted and tried to tempt me away from my abstinence. People at parties were shocked by someone who wasn’t drinking and kept their distance. Perhaps they thought a sober person WOULDNTüBEüANYüFUNü!NOTHERüNON DRINKERü advised me to carry a glass of wine around WITHOUTüPUTTINGüITüANYWHEREüNEARüMYüLIPSüBUTü)ü wanted to confront the situation.

.ONEĂĽOFĂĽUSĂĽCANĂĽSEEĂĽINTOĂĽTHEĂĽFUTUREĂĽBUTĂĽ)ĂĽPLANĂĽ TOĂĽREMAINĂĽAĂĽTEETOTALERĂĽ)ĂĽPREFERĂĽTOĂĽBEĂĽSOBER ĂĽTOĂĽ really listen to other people and show them the real me and not a personality altered by alcohol.

)ĂĽREMAINEDĂĽANĂĽOUT AND PROUDĂĽTEETOTALER

And that’s made all the difference.

)LLĂĽLEAVEĂĽYOUĂĽWITHĂĽTHISxĂĽ Two roads diverged and I took the one less travelled.

Put all your patients’ sleep disorders comfortably to bed.

Comfortable, non-hospital environment.

Get in touch today At SleepMed, we understand the value of a good night’s sleep. As Perth’s ďŹ rst accredited and licensed sleep investigation centre outside of a hospital, we focus on individual and holistic care to diagnose sleep disorders including snoring, sleep apnoea, and insomnia. Our highly trained sleep experts and therapists then develop personalised treatment solutions, prioritising the comfort of our patients at all times. Both insured and non-insured patients can access our professional Level-1 sleep studies, now in the comfort of a non-hospital environment.

Murdoch Specialist Centre 78 Farrington Rd Leeming 6149 Dr Sina M Keihani T (08) 6161 7647 F (08) 6162 0547 E info@sleepmed.com.au Online referral welcome: www.sleepmed.com.au

Accredited by:

Licensed Day Hospital SleepMed Healthcare

MEDICAL FORUM

DECEMBER 2016 | 39


Left Intentionally Blank to comply with Medicines Australia Code


Guest Column

Talking About Gambling When it comes to problem gambling it’s all about having community conversations, says Linkwest Projects Manager, Mihaela Nicolescu. Like many people who attend Our ACE Community Beyond Gambling program, AďŹ a, a refugee who arrived in Australia in 2008 with her son and husband, found that gambling began as a small problem and quickly became a large one. The family thrived in their new country, AďŹ a’s husband had found a good job and their son was doing well in school. After about two years her husband met some new friends who introduced him to the ‘Australian’ ritual OFĂĽGOINGĂĽFORĂĽAĂĽDRINKĂĽATĂĽTHEĂĽCASINOĂĽAFTERĂĽWORKĂĽ)TĂĽ seemed like a pretty harmless and enjoyable way of socialising. Sadly, this soon escalated into gambling and alcohol addiction. The family began borrowing money and fell behind in paying their bills. AďŹ a decided to take part in our program and encouraged her husband to sign-up for workshops at their local neighbourhood CENTRE ĂĽBUTĂĽHEĂĽREFUSEDĂĽ)NĂĽTHEĂĽENDĂĽ!lAĂĽ stepped away from her marriage and the "EYONDĂĽ'AMBLINGĂĽPROGRAMĂĽWASĂĽABLEĂĽTOĂĽHELPĂĽ her through a difďŹ cult period in her life. The program began in 2015 when Linkwest – the peak-body for neighbourhood centres in

Social gambling is a highly normalised pastime in Australia. WA – wanted to address problem gambling at a community level. A number of centres deliver the program in partnership with ďŹ ve expert agencies, including Centrecare where the workshops discuss alternatives to social gambling and provide information on ďŹ nancial counselling. )NĂĽADDITION ĂĽFRONTLINEĂĽSTAFFĂĽPARTICIPATEĂĽINĂĽ accredited training sessions on various aspects of addictive behaviour. There needs to be a greater focus on the challenges of tackling problem gambling, particularly in this country with its passion for betting on just about anything. Social gambling is a highly normalised pastime in Australia and, while many are able to enjoy it as a pleasurable activity, about 500,000 people are at risk of becoming, or are, problem gamblers. And only approximately 15% of problem gamblers

by Medical Director PROF JOHN YOVICH

actually seek help, with shame being the major obstacle. Many people struggle to appreciate the complexities of this issue, regarding it as a lack of character or willpower rather than than an actual addiction. )NĂĽADDITIONĂĽTOĂĽlNANCIALĂĽPROBLEMS ĂĽPROBLEMĂĽ gambling is linked with depression, relationship breakdown, loss of employment, CRIMEĂĽANDĂĽSUICIDEĂĽ)TSĂĽNOĂĽSURPRISEĂĽTHATĂĽPEOPLEĂĽ struggling with gambling are four times more likely to have problems with alcohol than non-gamblers. The actions of one problem gambler have a negative, ow-on effect that can impact on up to 10 other people and add to the burgeoning social cost currently standing at $4.7b a year. Neighbourhood community centres are a logical place to start conversations around this issue. They provide a safe, welcoming space, offer information, support, and referrals and – most importantly – encourage social interaction. For people such as AďŹ a it was those very conversations that helped her work through her problems.

SPECIALISTS IN REPRODUCTIVE MEDICINE & GYNAECOLOGICAL SERVICES

PIVET MEDICAL CENTRE

Eliminating risks in Assisted Reproduction ‌ Australia leads the way The annual ANZARD report was released September 2016, detailing all the ART (assisted reproductive technology) treatments in Australia and New Zealand conducted during 2014 with all resultant pregnancies tracked through 2015.  üBABIESüüLIVEBORN üRESULTEDüFROMü ü!24üCYCLESü INITIATEDüüBEINGüCONDUCTEDüINü!USTRALIAü4HESEü!24üBABIESüWEREü üOFüTHEüTOTALüLIVEBIRTHSüFORü!USTRALIAüINüü!24üDATAüINCLUDESü)6& ü )#3)üANDü3URGICALüSPERMüRETRIEVALSüBUTüDOESüNOTüINCLUDEüBABIESüARISINGü FROMü)5) üOVULATIONüINDUCTIONü and other fertility treatments. Hence an estimate might be 7.5% of children in Australia arise from various fertility treatments undertaken AMONGüTHEüüACCREDITEDü Fertility Clinics (plus 8 in NZ). Circa 1985: Not 36 weeks pregnant; severe OHSS

The two outstanding complications from ART

NOW AT 2 LOCATIONS PERTH & BUNBURY

MEDICAL FORUM

treatments since births in Australia commencing with #ANDICEĂĽ2EAD ĂĽNOWĂĽAGEDĂĽĂĽ YEARS ĂĽHAVEĂĽBEEN 1. multiple pregnancies, associated with a high prevalence of preterm deliveries 2. Ovarian hyperstimulation syndrome (OHSS), requiring Same person: OHSS; recovering and high-level medical management pregnant such as paracentesis for ascites, drainage of pleural effusions and treating a hypercoagulation state. !USTRALIAĂĽHASĂĽLEDĂĽTHEĂĽWAYĂĽINĂĽREDUCINGĂĽMULTIPLESĂĽTOĂĽĂĽBYĂĽAĂĽSTRONGĂĽ3%4ĂĽĂĽ single embryo transfer) policy. For 2014, the multiple pregnancy rates were ĂĽINĂĽ%UROPEĂĽANDĂĽĂĽINĂĽTHEĂĽ5+ĂĽ4HEĂĽ53!ĂĽSTILLĂĽREPORTSĂĽSOMEĂĽHIGH ORDERĂĽPREGNANCIESĂĽANDĂĽ ĂĽOVERALL ĂĽBUTĂĽTHEĂĽ3!24ĂĽGROUPĂĽHASĂĽRECENTLYĂĽ documented improvement for their clinics at 20.1%. 7ITHĂĽRESPECTĂĽTOĂĽ/(33 ĂĽ!.:!2$ĂĽREPORTSĂĽĂĽOFĂĽCYCLESĂĽHADĂĽĂĽORĂĽMOREĂĽ oocytes recovered and OHSS rate 4.1% in that group. The application of 0)6%4ĂĽ!LGORITHMSĂĽHASĂĽBEENĂĽSHOWNĂĽTOĂĽREDUCEĂĽTHISĂĽRISKĂĽTOĂĽ ĂĽRECENTLYĂĽ PUBLISHEDĂĽBYĂĽ$OVEĂĽ0RESSĂĽWITHĂĽTHEĂĽPOTENTIALĂĽTOĂĽCOMPLETELYĂĽELIMINATEĂĽTHISĂĽRISK

For ALL appts/queries: T 9422 5400 F 9382 4576

DECEMBER 2016 | 41


Guest Column

MSK Ultrasound and Injections

Radiologists, Dr Peter Morgan and Dr Stephen Cartoon, are pleased to advise the opening of a private practice, at 3 Hampden Road Nedlands, specialising in musculoskeletal ultrasound and guided injections.

‘Dud’ Doctor or a Mismatch? A recent Doctor’s Drum breakfast meeting explored the issue of underperforming doctors. The shorthand moniker of ‘Duds’ raised more than a few eye-brows so Dr Roger Paterson decided to throw his hat into the ring. While I was munching my bacon and eggs at Medical Forum’s Doctor’s Drum, my brain searched for a more helpful label and I eventually plucked one from my everyday practice as a psychiatrist. Many of my patients struggle with interpersonal relationships and one word I use in this context is ‘Mismatch’. )ĂĽSAYĂĽSOMETHINGĂĽALONGĂĽTHEĂĽLINESĂĽOF ĂĽyou and your partner/colleague/boss are ‘mismatched’ at the moment and, quite possibly, in the longer term.

Dr Stephen Cartoon will continue to perform ultrasound of the thyroid and neck as well as ultrasound guided biopsies of the thyroid.

They may well have been a good ‘match’ at some stage but for now something is not working very well. The key aspect is that it’s not the fault OFĂĽJUSTĂĽONEĂĽPERSONĂĽ)TSĂĽMOREĂĽTHATĂĽSOMETHINGĂĽINĂĽTHEĂĽINTERACTIONĂĽISĂĽNOTĂĽQUITEĂĽ CLICKINGĂĽANDĂĽTHEĂĽFAULTĂĽLIESĂĽ"%47%%.ĂĽTHEĂĽTWOĂĽPARTIESĂĽ

Our goal is a small specialist practice committed to providing the highest level of patient service and care.

The great advantage that doctors have is they have a choice in seeking out an area of medicine which they think will match their personality type. )TĂĽMAKESĂĽTHINGSĂĽEASIERĂĽFORĂĽALLĂĽOFĂĽUSĂĽIFĂĽWEĂĽCANĂĽlNDĂĽANĂĽAREAĂĽTHATĂĽDOVETAILSĂĽ with both our strengths and our weaknesses.

Scanning and procedures will be performed only by either Dr Morgan or Dr Cartoon both of whom have performed thousands of ultrasound guided procedures. We are hopeful that both referring doctors and patients will appreciate the beneďŹ t of having procedures performed in a timely manner by dedicated experienced radiologists, focussed only on performing these procedures, freed from other reporting responsibility. The practice is conveniently located at 3 Hampden Road Nedlands, a single level dwelling with onsite parking at the rear of the building. If you feel we may be of assistance to you and your patients please contact us (see below) to arrange delivery of referral pads. Referral form templates in PDF and RTF format can alternatively be downloaded from the website.

Phone: 63891577 Email: info@morgancartoon.com.au Website: www.morgancartoon.com.au

42 | DECEMBER 2016

"UTĂĽSOMETIMES ĂĽAFTERĂĽTRYINGĂĽAĂĽNUMBERĂĽOFĂĽDIFFERENTĂĽMEDICALĂĽlELDS ĂĽAĂĽDOCTORĂĽ may have to concede that medicine may not be a good â€˜ďŹ t’ and it’s time TOĂĽPURSUEĂĽANĂĽALTERNATIVEĂĽCAREERĂĽ)TĂĽWOULDĂĽBEĂĽMOREĂĽPREFERABLEĂĽTOĂĽlNDĂĽTHISĂĽ OUTĂĽINĂĽMEDICALĂĽSCHOOL ĂĽANDĂĽTHISĂĽDOESĂĽHAPPENĂĽ"UTĂĽINĂĽAĂĽBROADERĂĽSENSEĂĽ all medical students should be encouraged to frankly appraise their attributes and deďŹ ciencies.

For some it may be best to simply move on to a different environment or even a different career path where their strengths will be ensure a more positive ‘match’ Of course they should not be made to feel like ‘failures’, but rather as a square peg in a round hole and encouraged to look for a square hole rather than endure an interminable process of carborundum. )NĂĽTERMSĂĽOFĂĽENCOURAGINGĂĽAĂĽ@MISMATCHEDĂĽDOCTORĂĽTOĂĽSEEKĂĽMOREĂĽSUITABLEĂĽ pastures it would be useful to reect on just how the situation came ABOUTĂĽINĂĽTHEĂĽlRSTĂĽPLACEĂĽ)SĂĽITĂĽALLĂĽDOWNĂĽTOĂĽAĂĽPERSONALITYĂĽTYPEĂĽILL SUITEDĂĽTOĂĽAĂĽ MEDICALĂĽCAREERĂĽ$IDĂĽITĂĽDEVELOPĂĽDUEĂĽTOĂĽANĂĽUNSUPPORTIVEĂĽSYSTEMĂĽORĂĽDIFlCULTĂĽ COLLEAGUESĂĽ!REĂĽTHEREĂĽPERSONALĂĽISSUES ĂĽSUCHĂĽASĂĽILL HEALTHĂĽORĂĽBURNOUT Whatever the reason there will be some doctors who may need to have their ‘mismatch’ clearly pointed out. This can be a difďŹ cult process and needs to be approached with sensitivity. These individuals may need to be ‘pushed’ to take some action to address their deďŹ ciencies. For example, further training, peer support or some constructive advice relating to interpersonal communication. For some it may be best to simply move on to a different environment or even a different career path where their strengths will be ensure a more positive ‘match’. Even with the best of intentions, some doctors will defy any form of @REFRAMINGĂĽANDĂĽCONTINUEĂĽTOĂĽUNDERPERFORMĂĽ)FĂĽTHATSĂĽTHEĂĽCASE ĂĽATĂĽLEASTĂĽTHEĂĽ system can say it did its best before pressing the ‘Reject’ button. MEDICAL FORUM


Clinical Opinion

Diabetes and the new ‘Fitness to Drive’ standards

By Dr Ken Thong Endocrinologist Murdoch

Since October 2016, new medical standards for assessing driving licensing for commercial and private vehicle drivers have been introduced, replacing standards published in 2012.

licensing standard prevents such events. My personal observation is that the more conscientious patients who self-report their diabetes to the driving licence authorities are those who are burdened, WHILEĂĽWEĂĽFAILĂĽTOĂĽhCAPTUREvĂĽTHOSEĂĽWHOĂĽAREĂĽ ultimately involved in collisions.

What has changed for persons with diabetes A major welcome change is the removal of requirements for hSATISFACTORYĂĽCONTROLĂĽOFĂĽDIABETESv ĂĽ deďŹ ned previously as HbA1c of less than 9.0%. This was a contentious requirement since hypoglycaemia, rather than hyperglycaemia, is the predominant risk to driving in diabetes. A new questionnaire to help assess lack of hypoglycaemia awareness has also been included in the guidelines. What hasn’t changed There remains a similar focus on issues such as hypoglycaemia, hypoglycaemia unawareness, end-organ diabetes complications affecting driving and evaluation of common comorbidities such as sleep apnoea. Categories of patients requiring GP versus diabetes specialist assessment remain unchanged. These are based on the licence category pursued (private versus commercial), type of diabetes treatment used, and whether patients face diabetes issues as above.

Author opinion These standards for drivers with diabetes, ABOUTĂĽWHICHĂĽ)ĂĽHAVEĂĽSEVERALĂĽCONCERNS ĂĽWEREĂĽ written in conjunction with the Australian Diabetes Society. Diabetes is a very prevalent chronic disease so a large number of drivers need to be assessed and reassessed, adding to the personal burden those affected by diabetes face. Licensing diabetes consultations divert substantial healthcare resources, largely unaccounted for. While the evidence linking medical conditions TOĂĽROADĂĽCOLLISIONSĂĽISĂĽACCUMULATING ĂĽ)ĂĽBELIEVEĂĽ that there is still lack of evidence that any

Many general practitioners are still unfamiliar with situations whereby a diabetes specialist assessment is needed for a driving licence assessment. While owcharts are provided and are easy to refer to, the categorisations are unnecessarily complex. Currently, drivers are categorised as treated with metformin only, other non-insulin agents, or insulin. Since most other diabetes medications beside sulphonylureas and insulin CARRYĂĽAĂĽLOWĂĽHYPOGLYCAEMIAĂĽRISK ĂĽ)ĂĽBELIEVEĂĽTHEĂĽ categories should be simpliďŹ ed to patients on insulin or sulphonylurea treatment, or those who are not. ED. If you have comments about the “Fitness to Driveâ€? standards please email Medical Forum at editor@mforum.com.au

Author competing interests: none. Questions? Contact the author at murdoch.endocrinology@ gmail.com

ED presentations The AIHW’s annual report on the country’s ED statistics shows rising numbers of presentations – a national ďŹ gure of 7.5m, or more than 20,000 presentations each day – representing a 2.7% increase each year on average over the past ďŹ ve years. )NĂĽ7!ĂĽINĂĽ  ĂĽTHEREĂĽWEREĂĽ ĂĽ PRESENTATIONS ĂĽAĂĽĂĽINCREASEĂĽFROMĂĽTHEĂĽ PREVIOUSĂĽYEARĂĽANDĂĽ ĂĽOFĂĽTHOSEĂĽWEREĂĽ at principal referral and women’s and CHILDRENSĂĽHOSPITALSĂĽ ĂĽWEREĂĽATĂĽACUTEĂĽ GROUPĂĽ!ĂĽHOSPITALSĂĽANDĂĽ ĂĽTOĂĽ0UBLICĂĽ ACUTEĂĽ"ĂĽHOSPITALS Of the reported causes of presentation,  ĂĽWEREĂĽASĂĽAĂĽCONSEQUENCEĂĽOFĂĽINJURYĂĽ ORĂĽPOISONINGĂĽĂĽANDĂĽOTHERĂĽEXTERNALĂĽCAUSESĂĽ  ĂĽCASESĂĽOFĂĽRESPIRATORYĂĽDISEASEĂĽ ĂĽ ')ĂĽCASESĂĽ ĂĽINFECTIOUSĂĽANDĂĽPARASITICĂĽ DISEASESĂĽ ĂĽMENTALĂĽANDĂĽBEHAVIOURALĂĽ disorders and 29,918 genitourinary cases. Diseases of the circulatory system saw 26,248 presentations and musculoskeletal.  

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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 speciďŹ cally 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: www.southbankdaysurgery.com.au

DECEMBER 2016 | 43


Clinical Update

Kits for travellers

By Dr Peter Burke Travel Physician Nedlands

Most medical problems in travellers cannot be prevented through vaccination. So having standby treatment can make good sense, especially for travellers to remote locations, or where medical facilities are unreliable, unsafe, or nonexistent. Why take a kit? Consider the traveller following the Silk Road across Central Asia. She is half way between Tashkent and Samarkand and the boil on her BOTTOMĂĽISĂĽSTEADILYĂĽENLARGINGĂĽ)FĂĽTHEĂĽBOILĂĽGETSĂĽ uctuant, it may need incision and drainage at the local clinic, where infection control measures are likely to be less than perfect. This would expose her to the risk of infection. )TĂĽWOULDĂĽBEĂĽAĂĽGREATĂĽRELIEFĂĽFORĂĽHERĂĽTOĂĽDISCOVERĂĽ some cephalexin in her ďŹ rst aid kit. Or consider the surfer in the Mentawai )SLANDSĂĽSOUTHĂĽOFĂĽ3UMATRA ĂĽ)NDONESIA ĂĽWHOĂĽ develops dysentery from a Campylobacter infection. He would be very pleased to treat WITHĂĽAZITHROMYCIN ĂĽRATHERĂĽTHANĂĽENDINGĂĽUPĂĽONĂĽ a drip at the local clinic, with the real risk of ACQUIRINGĂĽ(EPATITISĂĽ"ĂĽASĂĽAĂĽBONUSĂĽ As doctors, our main responsibility to those heading off to remote parts of the developing world is to keep them out of the local medical FACILITIESĂĽ3ICKĂĽPEOPLEĂĽGOĂĽTOĂĽLOCALĂĽCLINICSĂĽ)FĂĽ your travellers go there they will be exposed to whatever is endemic, especially if a drip, suturing or surgical drainage is required. $)9ĂĽTREATMENTĂĽMAYĂĽBEĂĽPREFERABLEĂĽ!ĂĽWELL designed medical kit will permit the lay traveller to get out of most common medical emergencies, such as minor injuries, traveller’s diarrhoea, respiratory infections, and altitude sickness. Why not buy drugs on the cheap as you travel? Australian pharmaceutical standards are very high - the medication on the box will be in the TABLETĂĽ)NĂĽMANYĂĽPARTSĂĽOFĂĽTHEĂĽWORLD ĂĽCOUNTERFEITĂĽ medications are common, storage is substandard, and drugs are frequently sold or repackaged beyond their expiry dates. When you are visiting the latrine for the sixth time THATĂĽNIGHT ĂĽYOUĂĽREALLYĂĽNEEDĂĽTHOSEĂĽAZITHROMYCINĂĽ tablets to work! Travellers aren’t doctors. Isn’t there a risk in self-medicating? Yes, there certainly is some risk for both the traveller and the prescribing doctor. Clear instructions are absolutely essential to minimise any risk. A bag of miscellaneous unlabelled drugs is not a medical kit. Ditto if the drug labels just say ‘take as instructed by your doctor.’ A good quality traveller’s medical kit must be prescribed for one individual traveller, taking into account known medications and allergies. A kit containing prescription medications must never be shared.

44 | DECEMBER 2016

)TĂĽMUSTĂĽHAVEĂĽTHEĂĽEXTERNALĂĽAPPEARANCEĂĽ E of a quality medical kit, for appearance is everything at customs. s. There must be a kit booklet that contains a list of medications, a signed authorisation, and the contact details of the prescribing doctor. For each treatable condition, the kit booklet must give clear instructions about what to do ‘Where there is no doctor.’ The instructions should also indicate when self-treatment cal should cease and professional medical assistance be sought. The medication on labels must be very clear so the lay person can UNDERSTANDĂĽITĂĽINĂĽAĂĽCRISISĂĽWHATĂĽEACHĂĽDRUGĂĽISĂĽ used for, the correct dosage, and any special precautions. The kit guide and the medication LABELĂĽMUSTĂĽUSEĂĽEXACTLYĂĽTHEĂĽSAMEĂĽTERMSĂĽ the traveller will be bafed if your booklet refers to ‘Stemetil’ while the box is labelled @PROCHLORPERAZINEĂĽ What Goes in? This depends on the itinerary, duration, and the traveller’s predisposition to certain PROBLEMS ĂĽBUTĂĽMAYĂĽINCLUDE

&INALLY üTHEü"OYü3COUTüPRINCIPLEüSHOULDüAPPLYü TOüPRE EXISTINGüMEDICALüPROBLEMSü)FüYOURü traveller has asthma at home, they may have it when away. Don’t let them wander about the Annapurnas without their rescue inhalers ANDüPREDNISOLONEüTABLETSü"Eü0REPAREDü ED: Dr Burke offers kit bags and instruction booklets to GPs. Questions. Email the author on pburke@ulyssesmedical.com

sü $RESSINGS ü"ETADINEü4HERMOMETER sü 4RAVELLERSüDIARRHOEAüEGüSEEüMYü algorithm, or ’Stop The Flow Chart’) sü 2ESPIRATORYü)NFECTIONSü0ARACETAMOL ü6ICKS ü perhaps a broad spectrum antibiotic, and PERHAPSüOSELTAMIVIRüIFüTHEREüISüANüINmUENZAü outbreak or the traveller is susceptible.) sü !LTITUDEü3ICKNESSüEGüACETAZOLAMIDEüOFü not allergic to sulfa drugs.) sü -ALARIAüSTANDBYüTREATMENTüEGü2IAMETüIFü in high risk and remote location for more than two weeks.)

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Dr Vince Chapple

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Fertility, Gynaecology and Endometriosis Treatment Clinic MEDICAL FORUM

DECEMBER 2016 | 45


ADVERTISING FEATURE

Improving Outcomes for Chronic Pain Patients

By Dr John Salmon Pain Specialist Cottesloe

Recent research findings that are potential game changers Chronic pain remains a massively expensive challenge. For many patients medication and surgical interventions, particularly back surgery, have proved ineffective or unsafe and it’s become evident that chronic pain has much more to do with changes in the nervous system than peripheral pathology. Liberalisation of opiate prescription was a dream that became a nightmare, multiple studies now document that strong opiates are relatively ineffective for most patients long-term and some opioids make the nervous system more sensitive to pain at high doses. Diversion and abuse of medical opioids in America is now considered the leading cause of preventable death and is associated with 200,000 deaths over the last 10 years 1.

Fortunately, Australia has not gone so far down that track and current efforts to curtail and rationalise opiate prescription appear to be succeeding. Another misguided medical epidemic is back surgery for the primary complaint of back pain – rather than surgery for pain associated with CLINICALLYĂĽSEVEREĂĽINSTABILITYĂĽANDORĂĽ NEURALĂĽIMPINGEMENTĂĽ"ACKĂĽSURGERYĂĽ has quadrupled in countries like America and Germany and has doubled in Australia in recent years but with minimal evidence of efďŹ cacy and incontrovertible evidence of harm to many (MJA April 2016). Over 60% of lumbar fusion surgery patients remained disabled two years post-surgery (Juratle Spine 2006) and currently in the workers compensation system in NSW ONLYĂĽĂĽOFĂĽLUMBARĂĽFUSIONĂĽSURGERYĂĽ patients return to their preinjury work and 70% remain on strong opioids (Harris ANZ JSsurg 2012).

)NĂĽTHEĂĽWORKĂĽINJUREDĂĽTHEREĂĽISĂĽAĂĽFOURFOLDĂĽ increase in risk of poor outcomes from surgery of all kinds (Harris JAMA 2005). So where is the positive news about pain management? 4HEĂĽRECENTLYĂĽRELEASEDĂĽ7ORKĂĽ)NJURYĂĽ 3CREENĂĽ%ARLYĂĽ7)3% ĂĽSTUDYĂĽDATAĂĽ0ROFĂĽ Michael Nicholas RNSH personal communication) has already won two awards and is most deďŹ nitely a game changer. This 580 patient rigorous RCT screened injured health workers off work for more than one week in 19 hospitals in NSW for risk of remaining disabled and developing chronic pain (10 item OMPQ). Twenty-four percent had increased risk and this group was divided into intervention and control groups, the latter having treatment as usual whilst the intervention group had treatment ASĂĽUSUALĂĽPLUSĂĽAĂĽRELATIVELYĂĽBRIEFĂĽ#"4ĂĽ pain management and rehabilitation intervention speciďŹ cally addressing the patient’s perceived obstacles to returning to work. The result was that virtually all the intervention group returned to work in about half the time and with 22% less cost than the control group, whilst a proportion of the control group became chronic pain disabled. The remarkable ďŹ nding was that at one year post intervention blinded INTERVIEWSĂĽREVEALEDĂĽTHATĂĽĂĽOFĂĽ the control group were reporting chronic pain compared to 11% of the intervention group. This powerful study demonstrates that psychosocial risk factors addressed early, whilst maintaining a positive connection to work activity can prevent the evolution of chronic pain.

46 | DECEMBER 2016

MEDICAL FORUM


4HEĂĽ&$!ĂĽSUPERVISEDĂĽ3ENZAĂĽ2#4ĂĽ study demonstrates remarkable long-term outcomes in a challenging patient cohort (86% had failed BACKĂĽSURGERY ĂĽANĂĽAVERAGEĂĽOFĂĽĂĽ of patients maintained an average 67% of back pain reduction (av.VAS 2.4) at two year follow-up . Similar ratios were observed for leg pain REDUCTIONĂĽ)NĂĽADDITIONĂĽPATIENTSĂĽINĂĽTHEĂĽ HF 10 group demonstrated markedly reduced disability and opiate medication intake compared to an active control group, which received traditional low frequency spinal cord stimulation treatment from another MANUFACTURERĂĽ)NĂĽTHISĂĽARMĂĽONLYĂĽĂĽ of back pain patients obtained an average 41% pain relief (av.VAS 4.5). Furthermore much less functional improvement was observed in the traditional SCS arm than in the HF10 therapy arm.

This data indicates that long-term disability after work injury is not due primarily to failure to apply adequate MUSCULOSKELETALĂĽINTERVENTIONSĂĽ)TĂĽ results from failure to apply proven screening and treatment techniques that address the highly individualised response of the nervous system and psyche to injury and perceived threat of harm. This has implications for the early medical management of patients post trauma including motor vehicle accident victims. Workers compensation insurers in the eastern states are now implementing this strategy, realising that it saves money and produces better outcomes. Whether the biomedical entrenched system in W.A. will follow suit is yet to be seen! What to do with severely disabling chronic back and leg pain including failed back surgery syndrome?

KEY POINTS sĂĽ #HRONICĂĽPAINĂĽISĂĽMOREĂĽABOUTĂĽTHEĂĽBRAINĂĽĂĽ ĂĽ (and cord) than peripheral pathology. sĂĽ %ARLYĂĽPSYCHOSOCIALĂĽRISKĂĽDETECTIONĂĽANDĂĽĂĽĂĽ collaborative management can prevent the evolution of chronic pain following work injury.

Results were recently published in the journal Neurosurgery (November 2016) from a large multicentre two-year outcome study, proďŹ ling AĂĽUNIQUEĂĽĂĽK(ZĂĽSPINALĂĽCORDĂĽ stimulation therapy (HF 10 TM therapy Nevro corp).

sĂĽ )MPLANTEDĂĽNEUROMODULATIONĂĽFORĂĽ otherwise intractable back and leg pain is now strongly evidence-based as well as low risk and should be considered before more invasive and irreversible interventions.

SUPERIOR BACK PAIN RELIEF WITH HF10 THERAPY 10

BACK PAIN VAS SCORE

9 8 7

4.5

6

AT 24 MONTHS 41.1% REDUCTION

5 4

This study should make consideration of a trial of treatment with HF 10 SCS a priority for the more severe category of back and leg pain patients who have not responded to conservative treatment and have continuous rather than just activity related pain. The fact that treatment can be trialled before implant (which lowers the procedural risk) and is fully reversible, makes HF 10 treatment an option that should be considered before taking the irreversible step to spinal surgery for back pain. Neuromodulation is only effective for neuropathic pain, this indicates what a large component of severe back and leg pain is neuropathic RATHERĂĽTHANĂĽBIOMECHANICAL nociceptive in nature. This ďŹ ts with the well documented lack of correlation between severe pain and the severity of physical pathology. Neuromodulation integrated with early and adequate CBT management could result in much less chronic pain disabled and medication dependent patients in the future. Reference: 1. Rose A Rudd et al., ‘Increases in drug and opioid overdose deaths-United States, 2000-2014,’ MMWR. Morbidity and Mortality weekly report 64, 50-51 (2016)

3 2

This study is a rare demonstration of a surgical intervention rigorously evaluated by RCT with large patient numbers (171) and minimal dropouts, demonstrating comparative efďŹ cacy between two manufacturers competing to get the best outcomes for their product. Adverse outcomes were minor and temporary in both groups.

2.4

AT 24 MONTHS 66.9% REDUCTION

1 0

3

6

9

12

15

18

21

24

ASSESSMENT (MONTHS) Traditional SCS

HF10 Therapy

n = 171 at baseline, 3, 6, and 12 months (n = 90 test, n = 81 control) n = 156 at 18 and 24 months (n = 85 test, n = 71 control) p-value < 0.001

Back Pain Relief VAS

MEDICAL FORUM

This Feature is Sponsored by Nevro -EDICALĂĽ!USTRALIAĂĽ4HEĂĽ.EVROÂ&#x161;ĂĽ3ENZAÂ&#x161;ĂĽ SCS System received CE mark in 2010, TGA approval in 2011, FDA approval in 2015, and is commercially available INĂĽ%UROPE ĂĽ!USTRALIA ĂĽANDĂĽTHEĂĽ5NITEDĂĽ States.

DECEMBER 2016 | 47


Clinical Update

Non-medical management of open angle glaucoma With roughly one in eight Australians over 80 years developing glaucoma, usually Primary Open Angle Glaucoma (POAG), innovations in laser and surgical management offer new treatment pathways. Laser trabeculoplasty is postulated to work in open angle glaucoma by helping ďŹ&#x201A;uid egress out of the trabecular meshwork, lowering INTRAOCULARĂĽPRESSURESĂĽ)/0S ĂĽ4RADITIONALLYĂĽ!RGONĂĽLASERĂĽTRABECULOPLASTYĂĽ (ALT) has been used, but over the last decade, selective laser trabeculoplasty (SLT) has become more widely used, lasering the same AREAĂĽTHEĂĽTRABECULARĂĽMESHWORK ĂĽBUTĂĽUSINGĂĽAĂĽLARGERĂĽSIZEDĂĽLASERĂĽBEAMĂĽ THATĂĽUSESĂĽLESSĂĽENERGYĂĽ"ECAUSEĂĽOFĂĽTHEĂĽREDUCEDĂĽENERGY ĂĽINmAMMATIONĂĽISĂĽ less post laser and it is relatively repeatable compared with only one or two possible treatments with ALT. Laser efďŹ cacy is around 70%, often REDUCINGĂĽ)/0SĂĽFORĂĽUPĂĽTOĂĽTHREEĂĽYEARS ĂĽWHICHĂĽISĂĽPARTICULARLYĂĽBENElCIALĂĽFORĂĽ patients unable to administer drops (arthritic rheumatoid hands) or those forgetful or non-compliant. Incisional glaucoma surgery is implemented when more conservative measures have failed or are likely to fail. Divided into three TYPES ĂĽITĂĽISĂĽTHEĂĽMOSTĂĽEFFECTIVEĂĽWAYĂĽOFĂĽLOWERINGĂĽ)/0 Penetrating Glaucoma Surgery (Trabeculectomy) is probably the most common incisional glaucoma surgery having a long track record of safety and reliability. Here, one creates a pathway for ďŹ&#x201A;uid to drain from inside the anterior chamber to outside the eye through a scleral ďŹ&#x201A;ap, diffusing around the eye under the conjunctiva. Non-penetrating Glaucoma Surgery (Deep Sclerectomy and 6ISCOCANALOSTOMY ĂĽISĂĽNEWERĂĽ4HISĂĽAIMSĂĽTOĂĽLOWERĂĽ)/0SĂĽBYĂĽOPENINGĂĽUPĂĽ Schelmmâ&#x20AC;&#x2122;s Canal and peeling away the outer layer of the trabecular meshwork (where the greatest resistance to aqueous outďŹ&#x201A;ow is thought

Colin Street Day Surgery Plastic and Reconstructive Surgery, Cosmetic Surgery, Otolaryngology, Oral and Dental Surgery

By Jason Lim Ophthalmologist Murdoch

While most glaucoma patients manage with drops, other modalities offer other possibilities, often for those severely affected or those adversely affected by eye drops. to be), without penetrating through the trabecular meshwork. This creates a barrier to excessive egress of ďŹ&#x201A;uid out of the eye, minimising the risk of vision threatening hypotony (excessively low intraocular pressure).

ED

An indication of the comparative size of an iStentTM (a type of MIGS) inject implant.

Glaucoma Tube insertions involve placing silicone tubes into the eye and feeding them externally under the conjunctiva, secured to the sclera. Whilst very effective ATĂĽLOWERINGĂĽTHEĂĽ)/0 ĂĽ the risks of certain conditions including hypotony, corneal decompensation and ocular motility An internal view of the angle of the eye showing two iStentTM injects seen in the disorders are higher. trabecular meshwork These tubes are often reserved with those who have failed other forms of incisional glaucoma surgery. Minimally invasive glaucoma surgeryĂĽ-)'3 ĂĽISĂĽWHEREĂĽTINYĂĽSTENTSĂĽ are placed inside the eye (see images), traversing through the trabecular meshwork (where the greatest site of resistance to aqueous ďŹ&#x201A;uid out of the eye is), allowing ďŹ&#x201A;uid to drain from the anterior chamber to outside THEĂĽEYEĂĽ7HEREĂĽTHEYĂĽlNALLYĂĽEXITĂĽTHEĂĽEYEĂĽISĂĽWHEREĂĽEACHĂĽ-)'3ĂĽDIFFERS ĂĽWITHĂĽ some exiting in the subconjunctival space, suprachoroidal space or into 3CHLEMMSĂĽ#ANALĂĽ"EHINDĂĽTHISĂĽSURGERY ĂĽPERFORMEDĂĽMOREĂĽTHESEĂĽDAYS ĂĽ is the desire to have a relatively fast and reasonably effective procedure THATĂĽLOWERSĂĽ)/0 ĂĽWITHOUTĂĽTHEĂĽNEEDĂĽFORĂĽADDITIONALĂĽTOPICALĂĽGLAUCOMAĂĽ medication, and with a relatively safer side effect proďŹ le (c.w. incisional glaucoma surgery). Over time patientâ&#x20AC;&#x2122;s ocular surfaces can become sensitive or uncomfortable to long term use of glaucoma drops and -)'3ĂĽMAYĂĽHELPĂĽREDUCEĂĽTHISĂĽ6ARIOUSĂĽSTENTSĂĽAREĂĽAVAILABLE ĂĽSOMEĂĽ0"3ĂĽ approved for patients who also have cataract surgery, with others in the pipeline.

Three decades of efďŹ cient and quality service to surgeons and their adult and paediatric patients. For all enquiries regarding available operating time contact CEO Ms Marie Sheehan on 0411 738 809

KEY POINTS sĂĽ 4HEĂĽMAJORITYĂĽOFĂĽPATIENTSĂĽWILLĂĽSTILLĂĽUSEĂĽGLAUCOMAĂĽDROPS ĂĽWITHĂĽLASERĂĽ as second line treatment. sĂĽ )NCISIONALĂĽSURGERYĂĽISĂĽVERYĂĽEFFECTIVEĂĽBUTĂĽOFTENĂĽNOTĂĽlRSTĂĽLINE sĂĽ -)'3ĂĽWILLĂĽLIKELYĂĽBEĂĽINCREASINGLYĂĽUSED

COLIN STREET DAY SURGERY 51 Colin Street, West Perth csds.com.au

48 | DECEMBER 2016

Author competing interests: nil relevant. Questions? Contact the author on doctorjasonlim@gmail.com

MEDICAL FORUM


Antibiotic Resistance Myths? 4HEĂĽ0ROFĂĽOFĂĽ#LINICALĂĽ-EDICINEĂĽATĂĽTHEĂĽ5NIVERSITYĂĽ OFĂĽ3OUTHERNĂĽ#ALIFORNIA ĂĽ"RADĂĽ3PELLBERGĂĽ-$ ĂĽ has raised some interesting points about antibiotic resistance on a website posting. He SAYS ĂĽ "ACTERIALĂĽANTIBIOTICĂĽRESISTANCEĂĽISĂĽANĂĽ inevitable part of Nature. 2. Yes, avoid prescribing antibiotics unnecessarily. When they are appropriate, prescribe the narrowest-spectrum agent and the shortest duration possible. ĂĽ $OĂĽNOTĂĽTELLĂĽPATIENTSĂĽTOĂĽTAKEĂĽEVERYĂĽDOSEĂĽ PRESCRIBEDĂĽ"EĂĽAVAILABLEĂĽTOĂĽCOACHĂĽPATIENTS ĂĽ encouraging them to stop antibiotics early when symptoms resolve. 4. Prescribed antibiotics select for resistance in the patient's microbiome. 5. When choosing antibiotics, cidal vs static is largely irrelevant. His expanded comments say genetic analysis indicates that bacteria invented antibiotics about 2 billion years ago â&#x20AC;&#x201C; killing each other with these weapons, and using resistance mechanisms to protect themselves. Resistance to modern antibiotics, including multi-drug resistance, was found in bacteria in a New Mexico cave that had no previous exposure to mankind. Antibiotic use causes selective pressure by killing off bacteria, whether prescribing is appropriate or inappropriate. The difference is that inappropriate use offers no beneďŹ t. Eliminating inappropriate antibiotic use may slow the emergence of resistance (but does not cause resistance per se). There are no data to support the idea that continuing antibiotics past resolution of signs and symptoms of infection reduces the emergence of resistance. Every randomised clinical trial that has ever compared shortcourse therapy with longer-course therapy, across multiple types of acute bacterial infections, has found shorter-course therapies AREĂĽJUSTĂĽASĂĽEFFECTIVEĂĽ)NĂĽACUTEĂĽINFECTIONS ĂĽ if patients feel substantially better, with resolution of symptoms of infection, they can stop antibiotics early. )NĂĽMOSTĂĽCASES ĂĽRESISTANCEĂĽEMERGESĂĽNOTĂĽATĂĽ the site of infection during therapy, but rather among bacteria in the gut or on the skin as a result of genetic sharing of pre-existing resistance mechanisms (e.g. plasmids, transposons, phages, naked DNA). Resistant strains can cause future infections, or spread to others in communities or hospitals.

Prof Roger Hart

Fertility Preservation WA At Fertility Specialists of Western Australia We are pleased to formally announce our fertility preservation service for women and men with a cancer diagnosis. Fertility specialists aim to see individuals WITHINĂĽĂĽWORKINGĂĽDAYSĂĽOFĂĽREFERRALĂĽTOĂĽOURĂĽ CLINICĂĽATĂĽ"ETHESDAĂĽ(OSPITALĂĽ&ERTILITYĂĽ Specialists of WA). Specialists are trained in the challenging ďŹ eld of fertility preservation. Generally, chemotherapy and some aspects of radiotherapy treatment have a signiďŹ cant gonadotoxic effect. Providing suitable cancer patients the opportunity TOĂĽFREEZEĂĽGAMETES ĂĽORĂĽIFĂĽAPPROPRIATEĂĽ embryos, prior to commencing cancer treatment should be considered a moral imperative. A particular challenge may exist for any woman with an oestrogen sensitive tumour, such as breast cancer. )6&ĂĽCYCLEĂĽMANAGEMENTĂĽFORĂĽAĂĽWOMANĂĽ SEEKINGĂĽTOĂĽFREEZEĂĽOOCYTESĂĽBEFOREĂĽSTARTINGĂĽ cancer treatment can be challenging for the treating fertility specialist, as often there is no opportunity to await the onset of the next menstrual cycle â&#x20AC;&#x201C; they have TOĂĽPERFORMĂĽAĂĽ@RANDOMĂĽSTARTĂĽ)6&ĂĽCYCLE ĂĽ ORĂĽUNDERGOĂĽAĂĽPROCEDUREĂĽOFĂĽ)6-ĂĽ(in-vitro maturation of oocytes). )NĂĽANĂĽ)6-ĂĽCYCLEĂĽOOCYTESĂĽAREĂĽCOLLECTEDĂĽ after only a few days of drug stimulation, and their maturation continues in the laboratory, rather than the patient continuing to self-administer the drugs ASĂĽINĂĽTRADITIONALĂĽ)6&ĂĽ&ERTILITYĂĽ3PECIALISTSĂĽ

performs this procedure which is only performed in a few units in the world. Furthermore, treating a woman with cancer is underpinned by a realisation there is â&#x20AC;&#x2DC;only one chance to get it rightâ&#x20AC;&#x2122; as the cycle cannot be postponed if it is not going according to plan, as is the way when treating a sub-fertile couple. The best opportunity to review, provide adequate supportive counselling and arrange appropriate investigations happens when patients are referred as early as is feasible after the cancer DIAGNOSISĂĽSOĂĽTREATMENTĂĽCANĂĽBEĂĽPLANNED ĂĽ often in the interval between surgery and commencement of chemotherapy. On review, men may be offered the opportunity to bank sperm, or undergo testicular sperm retrieval. Women may discuss the use of GnRH analogues to suppress ovarian activity during chemotherapy, the place of oocyte or EMBRYOĂĽFREEZING ĂĽORĂĽPERHAPSĂĽOVARIANĂĽ TISSUEĂĽFREEZINGĂĽ !LLĂĽPATIENTSĂĽAREĂĽOFFEREDĂĽCOUNSELLINGĂĽ)FĂĽAĂĽ woman decides not to undergo a fertility preservation procedure, she is offered a review at the completion of her cancer treatment, to evaluate her ongoing fertility and discuss any potential risks of an early menopause. 5NLIKEĂĽSO CALLEDĂĽ@SOCIALĂĽEGGĂĽFREEZINGĂĽ fertility preservation procedures attract a Medicare beneďŹ t.

Treatments offered Women

Men

Oocyte and embryo freezing

Sperm banking

Ovarian stimulation for women with oestrogen sensitive tumours

Testicular aspiration/biopsy

In-vitro maturation of oocytes (IVM) Contrary to common belief, bacteriostatic STATIC ĂĽANTIBIOTICSĂĽDOĂĽKILLĂĽBACTERIAĂĽTHEYĂĽJUSTĂĽ require a higher concentration to do it. We DElNEĂĽAĂĽBACTERICIDALĂĽCIDAL ĂĽANTIBIOTICĂĽBASEDĂĽ on laboratory conventions, not on speciďŹ c scientiďŹ c principles. There is no clinical trial evidence of beneďŹ t of cidal agents over static agents (more to the contrary in fact!).

By Dr Rob McEvoy

MEDICAL FORUM

Ovarian tissue cryopreservation protocols to minimise follicular damage GnRH analogue suppression for ovarian protection To discuss urgent cases with Professor Roger Hart, please call KEMH switchboard 6458 2222, or Fertility Specialists WA on 9284 2333.

DECEMBER 2016 | 49


Clinical Update

Tests that help with unexplained anaemia Thankfully, anaemia is easy to resolve in most cases. Obvious bleeding, iron deďŹ ciency, renal failure, B12 and folate deďŹ ciency account for a majority of cases. That leaves a mixture of causes, maybe not readily apparent, for which these questions help deďŹ ne things. Has iron deďŹ ciency been masked? )RONĂĽDElCIENCYĂĽANAEMIAĂĽ)$! ĂĽASĂĽDIAGNOSEDĂĽ by a low ferritin, remains the main cause of anaemia. Ferritin may however be falsely hNORMALvĂĽINĂĽ)$!ĂĽ%XAMPLESĂĽINCLUDEĂĽONGOINGĂĽ bleeding during iron replacement, and inďŹ&#x201A;ammation. Look for a low transferrin saturation, and if the CRP is elevated, remember the ferritin may be inďŹ&#x201A;ated up to threefold. In a young patient (<35), could it be congenital? Congenital causes are far more likely when anaemia is longstanding and stable. These particularly include thalassemia (microcytic), sickle cell disease (normocytic) and other HAEMOGLOBINOPATHIESĂĽLIKEĂĽ(BĂĽ#ĂĽ(B%ĂĽ Again the blood ďŹ lm should provide useful hints (e.g. teardrops, target cells), and haemoglobinopathy studies will conďŹ rm. Some inherited anaemias cause haemolysis, described below. What is the reticulocyte count? This under-ordered test can be run on ANYĂĽ&"#ĂĽWITHINĂĽĂĽHOURSĂĽOFĂĽCOLLECTIONĂĽ 2ETICULOCYTES ĂĽORĂĽhFRESHLYĂĽMADEvĂĽREDĂĽBLOODĂĽ cells, should account for 1% of our red cells.

Table: Reticulocytes in Anaemia LOW &EĂĽ"ĂĽFOLATEĂĽ deďŹ cient

HIGH Haemolysis

Renal failure

Acute blood loss

Dr Matthew Wright Haematologist Fiona Stanley Hospital

Flow Chart - Haemolysis Is the Patient Haemolysing? LDH Haptoglobulin Retics

Marrow pathology 2ESPONSEĂĽTOĂĽIRONĂĽ"ĂĽ replacement Chronic disease Coombs Test

)NĂĽPATIENTSĂĽWHOĂĽAREĂĽBLEEDINGĂĽORĂĽHAEMOLYSING ĂĽ a healthy marrow will churn out more than that in response (elevated reticulocytes). The retic percentage will be low if the patient lacks the basic elements needed to make blood (iron, b12, folate deďŹ ciency, renal failure causing low EPO) or has a failing marrow (see table). Has haemolysis been considered? )NĂĽTHEĂĽNONBLEEDINGĂĽPATIENT ĂĽITĂĽISĂĽIMPORTANTĂĽ to exclude haemolysis (see ďŹ&#x201A;owchart). To conďŹ rm haemolysis perform an LDH (raised), haptoglobin (low) and reticulocyte count (increased). A positive Coombs test will conďŹ rm the cause to be autoimmune. This may be idiopathic, or rarely associated with INFECTION ĂĽLUPUSĂĽORĂĽLYMPHOMAĂĽ#,, )FĂĽTHEĂĽ#OOMBSĂĽTESTĂĽISĂĽNEGATIVEĂĽCONSIDERĂĽ congenital processes including G6PD deďŹ ciency and spherocytosis. The blood ďŹ lm

West Coast Endoscopy Centre ,OCATEDĂĽINĂĽ*OONDALUPĂĽ#"$ĂĽNORTH ĂĽ7ESTĂĽ#OASTĂĽ%NDOSCOPYĂĽ Centre is an independent private endoscopy unit with a strong focus on the individual and commitment to quality improvement and excellence in Gastroenterology, since opening in 2008. sĂĽ sĂĽ sĂĽ sĂĽ sĂĽ

4IMELY ĂĽQUALITYĂĽ')ĂĽ%NDOSCOPYĂĽANDĂĽ#OLONOSCOPY 0RIVATEĂĽ$AYĂĽ%NDOSCOPYĂĽ5NITĂĽLICENSEDĂĽWITHĂĽ(EALTHĂĽ$EPTĂĽOFĂĽ7! )3/ĂĽCERTIlEDĂĽANDĂĽ!CCREDITEDĂĽWITHĂĽ.ATIONALĂĽ3TANDARDSĂĽOFĂĽ1UALITYĂĽANDĂĽ3AFETYĂĽINĂĽ(EALTHCARE Waiting time usually 1 week for private procedures. Committed to GP education and regular national Gastroenterology conference presentations. sĂĽ Services include endoscopy, colonoscopy, capsule endoscopy, biologic and iron infusions and gastroenterology consultation. sĂĽ Patient satisfaction in excess of 95 % on all criteria assessed since inception. sĂĽ Ongoing procedure audit to ensure continual quality improvement.

Non-immune Causes include hereditary, medication

Immune

Warm

Cold

SHOULDĂĽOFFERĂĽSUGGESTIVEĂĽCOMMENTSĂĽ)FĂĽTHEĂĽ patient is not haemolysing and reticulocytes are reduced, consider marrow pathology. Could it be bone marrow pathology? Marrow pathology becomes more likely AFTERĂĽTHEĂĽAGEĂĽOFĂĽĂĽ4HEĂĽCHANGEĂĽINĂĽ&"#ĂĽOVERĂĽ time is helpful, as a continuous downtrend. Other cytopenias are suspicious but benign pathology may cause ďŹ&#x201A;uctuating anaemia (bad things always get worse). Consider these three marrow diseases when obvious CAUSESĂĽFORĂĽANAEMIAĂĽHAVEĂĽBEENĂĽRULEDĂĽOUT  ĂĽ -YELOMAĂĽCLUESĂĽMAYĂĽBEĂĽ2OULEAUXĂĽANDĂĽANĂĽ elevated ESR, high total protein compared to albumin, hypercalcemia or renal IMPAIRMENTĂĽ/RDERĂĽANĂĽ%0')&%ĂĽANDĂĽ3ERUMĂĽ Free Lite Chains  ĂĽ -YELODYSPLASIAĂĽPATIENTSĂĽMAYĂĽHAVEĂĽOTHERĂĽ cytopenias and are often macrocytic. 4HEĂĽ&"#ĂĽUSUALLYĂĽDECLINESĂĽSLOWLYĂĽOVERĂĽ months. Film comments include hANISOPOIKILOCYTOSISv ĂĽhHYPOGRANULARITYv ĂĽ h0SEUDO PELGERĂĽ(UETĂĽCELLSvĂĽ  ĂĽ -YELOlBROSISĂĽWHILEĂĽRARE ĂĽTHEĂĽPRESENTATIONĂĽ is classic, featuring splenomegaly, and abnormal blood ďŹ lm descriptions INCLUDINGĂĽ.2"# ĂĽBASOPHILSĂĽANDĂĽAĂĽ hLEUKOERYTHROBLASTICĂĽlLMvĂĽĂĽ

Author competing interests: no relevant disclosures. Questions? Contact the author on 9224 1165

To refer please call 93014437, fax 93014438, email bookings@wcendo.com.au and for further information visit our website www.westcoastendoscopy.com.au.

50 | DECEMBER 2016

MEDICAL FORUM


Clinical Updates

Helicobacter pylori in children Helicobacter pylori (H. pylori) infection is acquired in early childhood, more so in developing countries than developed countries like Australia. Complications are fewer in children with less than 10% of those infected develop peptic ulcer disease (PUD) conďŹ rmed by endoscopy. A recent meta-analysis concluded that (ĂĽPYLORIĂĽINFECTIONĂĽINĂĽTHEĂĽABSENCEĂĽOFĂĽ05$ĂĽ is not associated with abdominal pain in children. The â&#x20AC;&#x2DC;test and treat policyâ&#x20AC;&#x2122; is not recommended for children with abdominal symptoms (European Society for Paediatric Gastroenterology Hepatology and Nutrition and the North American Society for Paediatric Gastroenterology Hepatology and Nutrition). There is no clear evidence to prove causality of other extra-gastric symptoms including otitis media, upper respiratory infections, dental diseases, food allergies, sudden infant death syndrome and short stature. H. pylori has been considered to be a signiďŹ cant risk factor for certain types of gastric malignancies especially in younger people (under age 45). However, apart from a few cases of mucosa associated lymphoid tissue (MALT) lymphoma, no other H. pylori associated malignancies are reported in children.

By Dr Kunal Thacker Paediatric Gastroenterologist Murdoch

Who to screen Screening could be considered for children with a ďŹ rst degree relative with gastric cancer at a young age. As they would have similar genetic makeup and environmental exposure to their relatives, eradication of detected H. pylori may prove to be beneďŹ cial. KEY MESSAGES sĂĽ 4ESTĂĽANDĂĽTREATĂĽSTRATEGYĂĽFORĂĽ(ĂĽPYLORIĂĽ is not recommended for children with abdominal symptoms. sĂĽ )NDICATIONSĂĽFORĂĽ(ĂĽPYLORIĂĽSCREENINGĂĽAREĂĽ refractory iron deďŹ ciency anaemia and ďŹ rst degree family relative with gastric cancer. sĂĽ 3TOMACHĂĽBIOPSIESĂĽONĂĽENDOSCOPYĂĽAREĂĽ required to conďŹ rm diagnosis. sĂĽ .OĂĽROLEĂĽFORĂĽSERUMĂĽANTIBODIESĂĽORĂĽSTOOLĂĽ antigen for diagnosis.

)RONĂĽDElCIENCYĂĽANAEMIAĂĽISĂĽCOMMONLYĂĽSEENĂĽINĂĽ children with poor socioeconomic conditions and dietary inadequacy, for which oral iron THERAPYĂĽISĂĽEFFECTIVEĂĽINĂĽMOSTĂĽOFĂĽTHEĂĽCASESĂĽ"UTĂĽ iron deďŹ ciency anaemia refractory to oral iron therapy needs to be investigated for an underlying gastrointestinal cause.

More Windows 10 Tips

Automatic tips Now click â&#x20AC;&#x2DC;Systemâ&#x20AC;&#x2122;, then on the left, @.OTIlCATIONSĂĽĂĽACTIONSĂĽ4URNĂĽOFFĂĽ@'ETĂĽTIPS ĂĽ tricks and suggestions as you use Windowsâ&#x20AC;&#x2122;. Default printer One of the most confounding settings is the ability to print automatically to the printer you used last. This leads to the occasional print job going to an unwanted printer. To turn this off, go to â&#x20AC;&#x2DC;All settingsâ&#x20AC;&#x2122; again and this time click

MEDICAL FORUM

ED

H. pylori infection needs to be screened for in addition to coeliac disease and other gastrointestinal disorders. How to screen Diagnose H. pylori infection with gastric biopsies for histopathology in addition to CULTUREĂĽANDORĂĽRAPIDĂĽUREASEĂĽTESTĂĽ There is no role for antibodies in serum, urine or saliva for diagnosis or for conďŹ rmation of eradication â&#x20AC;&#x201C; speciďŹ c antibodies can remain positive for months after infection is resolved. 5REAĂĽBREATHĂĽTESTĂĽREMAINSĂĽAĂĽHIGHLYĂĽSENSITIVE ĂĽ speciďŹ c and accurate post treatment test for (ĂĽPYLORIĂĽINFECTIONĂĽ)TĂĽCANĂĽBEĂĽHARDĂĽTOĂĽPERFORMĂĽINĂĽ children and stool antigen of H. pylori is more PRACTICALĂĽ5REAĂĽBREATHĂĽTESTĂĽANDĂĽSTOOLĂĽANTIGENĂĽ could be effectively used for conďŹ rmation of eradication after therapy.

Author competing interests: no relevant disclosures. Questions? Contact the author on 0474 205 761

By Mr Jerome Chiew

)FĂĽNOT ĂĽSIMPLYĂĽSELECTĂĽ@%NGLISHĂĽ!USTRALIA ĂĽANDĂĽCLICKĂĽ â&#x20AC;&#x2DC;Set as defaultâ&#x20AC;&#x2122; in the pop-down, then click the other languages listed and click â&#x20AC;&#x2DC;Removeâ&#x20AC;&#x2122;.

Microsoft released the Windows 10 Anniversary Update on 03/08/16, rolling it out in waves over the coming months. If you are currently on Windows 10, your PC may have already applied this major update. The look and feel has been reďŹ ned further, based on customer feedback, along with some hidden surprises. There has been a shufďŹ&#x201A;ing around of several options in Settings, so things will look different. Here are some tips to customise Windows to turn off unwanted features. Click the speech bubble on the bottom right of THEĂĽSCREEN ĂĽNEXTĂĽTOĂĽTHEĂĽDATEĂĽĂĽTIME ĂĽTHENĂĽCLICKĂĽ â&#x20AC;&#x2DC;All settingsâ&#x20AC;&#x2122; or if it keeps closing, right click and select â&#x20AC;&#x2DC;Open action centreâ&#x20AC;&#x2122;.

Diagnosing and treating H. pylori is well established in adults. But how do we approach this in children?

@$EVICES ĂĽTHENĂĽ@0RINTERSĂĽĂĽSCANNERSĂĽANDĂĽSCROLLĂĽ down the bottom of that screen and turn off the setting under â&#x20AC;&#x2DC;Let Windows manage my default printerâ&#x20AC;&#x2122;. Set suggestions and default language Go to â&#x20AC;&#x2DC;All settingsâ&#x20AC;&#x2122; again, then click â&#x20AC;&#x2DC;Personalisationâ&#x20AC;&#x2122;, then â&#x20AC;&#x2DC;Startâ&#x20AC;&#x2122; and turn off â&#x20AC;&#x2DC;Occasionally show suggestions in Startâ&#x20AC;&#x2122;. "ACKĂĽTOĂĽ@!LLĂĽSETTINGS ĂĽTHENĂĽSELECTĂĽ@4IMEĂĽĂĽ LANGUAGEĂĽTHENĂĽ@2EGIONĂĽĂĽLANGUAGEĂĽANDĂĽ ensure Australia is the â&#x20AC;&#x2DC;Country or regionâ&#x20AC;&#x2122; and â&#x20AC;&#x2DC;English (Australia)â&#x20AC;&#x2122; should be the only entry.

ED: Questions? Contact Jerome www.critical-it.com.au

DECEMBER 2016 | 51


Social Pulse

The Mount Hospital marked this special occasion with a couple of events so that as many people as POSSIBLEåCOULDåCELEBRATEåTHEå YEARå milestone of the hospital in its current LOCATION åNESTLEDåINTOå-Tå%LIZAåINåTHEå #"$å!åDOCTORSåCOCKTAILåPARTYåWASå HELDåATåTHEå/LDå3WANå"REWERYåHOSTEDå by general manager Carl Yuile, chair of the Medical Advisory Committee Dr Paul Taylor and Medical Director Dr Greg McGrath. 1

Oncologist Dr Albert Gan and head of Mount Pharmacy Andrew Twaddle

2

Perth Radiology Clinic (PRC) Caryn Fong, Kaye Miller from the Perth "REASTå#LINIC åONCOLOGISTå$Rå!LBERTå Gan and Geraldine Ormonde from PRC

Ã¥

#LINIPATHSÃ¥$RÃ¥'ORDONÃ¥(ARLOEÃ¥WITHÃ¥ Jean and Carl Yuile

4

Cardiothoracic surgeon Dr Deepak Mehrotra and Gabrielle Warren Chainey from the Mount

Mount Hospital Celebrates 30 Years

1

3

Bethesda Expands

2

4

4HEÃ¥0REMIERÃ¥#OLINÃ¥"ARNETTÃ¥OFlCIALLYÃ¥OPENEDÃ¥THEÃ¥ NEWÃ¥OPERATINGÃ¥THEATRESÃ¥ATÃ¥"ETHESDAÃ¥(EALTHÃ¥ Care as part of the hospitalâ&#x20AC;&#x2122;s $10m expansion program, which also includes a new dining ROOMÃ¥ANDÃ¥STAFFÃ¥AMENITIESÃ¥"ETHESDAÃ¥#%/Ã¥-SÃ¥ 9ASMINÃ¥.AGLAZASÃ¥SAIDÃ¥THEÃ¥BUILDÃ¥WASÃ¥ONÃ¥TIMEÃ¥ ANDÃ¥ONÃ¥BUDGETÃ¥4HEÃ¥CHAIRÃ¥OFÃ¥"ETHESDASÃ¥BOARD Ã¥ Dr Neale Fong, welcomed the Premier on behalf of the board and management. Ã¥

$Rå.EALEå&ONG å2HONDAå7YLLIE å9ASMINå.AGLAZASå ANDå0REMIERå#OLINå"ARNETT

2

One of the new operating theatres

1

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!Ã¥VIEWÃ¥TOÃ¥MAKEÃ¥YOUÃ¥FEELÃ¥BETTER

2

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52 | DECEMBER 2016

MEDICAL FORUM


Travel Dr SimonZilko cycling with his son in Amsterdam

d n u o r A g n i l l e v a Tr

p U g n i Bon By Dr Simon Zilko, Orthopaedic Surgeon

Most orthopaedic surgeons see going away on fellowship as a rite of passage – a great chance to bone-up on advanced sub-specialty knowledge and enjoy time away before life as a consultant kicks in. With my love of foot and ankle orthopaedics I undertook the University of Toronto Foot and Ankle Clinical Fellowship program. But I also wanted to tap into the expertise of surgeons I had met at conferences or read research by. So I did something far less common – I organised my own travelling fellowship.

the OR to save space, minimise clutter, and decrease the dangers of cords from all directions. This was the stuff that isn't in any of the textbooks.

Over six months, I visited orthopods in Charlotte and Chicago, USA; Vancouver, Canada; Amsterdam, Netherlands; and London, UK. Apart from being great teachers, the surgeons were internationally recognised experts in some types of foot and ankle surgery, subsubspecialists, if you will.

Another boon of travelling around was the chance to see cutting edge procedures. In Chicago, I saw a new revision ankle joint replacement – the first in the world for that new system. In Charlotte, the surgeon who treats many NBA and NFL sports stars demonstrated a new operation for recalcitrant stress fractures (in this instance, on a foot worth millions of dollars). In London, the surgeon showed me his ankle reconstruction for Premier League soccer players to enable early mobilisation and return to play.

Working with these master surgeons was a privilege. Inside the operating theatre, they surrounded themselves with the best teams possible. It was efficiency personified. In Charlotte, for example, the theatre nursing staff did foot and ankle orthopaedics, and nothing else. It was like watching a symphony orchestra, such was the level of teamwork and coordination. Each surgeon had unique tricks to make operations easier: I saw an ingenious cheap leg bolster; at another centre, an effective way of providing traction for ankle arthroscopy; and another surgeon had organised the stack of equipment in

MEDICAL FORUM

One thing I learned about a so-called expert surgeon is that surgical skill is not the only thing that counts. Without exception they were superb communicators, adept at explaining complex procedures in straightforward terms to patients. Even I understood concepts better having listened to them.

An inspiring common theme was the surgeons’ pursuit of excellence and improvement. They invested time and money into collecting data on their outcomes – not just for research but to figure out where they can do better. The Chicago orthopod took standardised clinical photos of every single patient – literally down on all fours on the floor, snapping away. He has more than a million photos in his database now, a collection

A co mplex ankle revision by Dr Steve Haddad (Chicago).

probably unrivalled anywhere in the world. They all made me promise to collect my own outcomes data (plus photos!). Perhaps the best part of the whole adventure was the camaraderie and friendships I made. Wherever I went, the orthopods welcomed me into their practices and, in many cases, their homes. We sat down for beers at the end of long days and simply chatted about foot and ankle orthopaedics. And now I can email many of these specialists for advice on difficult cases or new techniques. When I reflect on my travels, seeing different approaches to the exact same problems was fantastic. It’s definitely made me a better surgeon – and at the end of the day, that’s what fellowship is all about.

DECEMBER 2016 | 53


Musical Theatre

Grant Almirall as Don Lockwood in the iconic scene of Singin’ in the Rain. Pic: Hagen Hopkins Hebe

h s a l Sp MAKING A

If you can sing and you can dance – why not do both in the rain. Jack Chambers does it eight times a week and loves it. This timeless classic is a celebration of song and dance with 12,000 litres of rain onstage every night. Singin’ in the Rain is coming to Crown Theatre on New Year’s Eve and Jack Chambers, aka Cosmo Brown, says that waterproof jackets for people sitting at the front are an absolute must!

the first five rows. If I’m feeling particularly energetic I can manage to splash the water beyond Row 5!”

away in a nappy. I’ve always had a knack for picking up a tune and putting the choreography up there on stage.”

“This show is pure entertainment and escapism. We want to see people leaving the theatre with a smile on their faces and humming some tunes!”

“I hope people have a big smile on their face when the curtain comes down. They may also be a little damp but you do get a complimentary poncho if you’re sitting in

“It tells a story and most people know the songs, particularly if you’ve seen the movie. The show stays very close to the essence of the film and audiences love the wow factor of seeing it live on stage.”

“When I won So You Think You Can Dance I was only 19 years-old and it put me in some stressful situations that tested my capabilities a performer. I was young, ready for a challenge and it put my face on the map. It’s really opened doors both here and overseas.”

The show is physically tough and, with a distinctly distinc slippery stage, not for the faint-hearted. f nt-he fai It has claimed the original lead l d Adam lea Ad Garcia who had to withdraw from the th show after slipping and injuring himself. himsel On Perth, the role of Don Lockw Lockwood is being shared by Rohan Brown and Grant Almirall. Browne “We’r doing eight shows a week “We’re (prev (previews begin December 29) and, for th the three lead characters, there are rrapid costume changes so you defin definitely need to be pretty fit and agile A lot of stretching is required!” agile. “Mu “Musical theatre is a real passion of min the first musical I did when I mine, wa 10 years-old was Singin’ in the was Ra and I played the young Cosmo Rain Brown. Br It’s nice that it’s all come fu circle and I’m now Cosmo as full an a adult.”

ett a s, Gretel Sca rl Jack Cha mberho mas Pic: Da rren T

54 | DECEMBER 2016

nd Roha n Bro

wne.

T Tripping the light fantastic goes a long l way back for Jack Chambers and, at the age of 28, he’s really going places. “I can’t actually remember a moment when I thought ‘this is it’! But there is Super 8 film footage of me happily dancing

“I’ve had a fairly diverse career so far, from shows on Japanese television to the Joffre Ballet School in New York. I love creating content for performers and I have my own dance company in Brisbane where we run fulltime courses and tour our own productions. I love working behind the scenes to create content for other performers. It’s a good skill to have because there are this industry can get a bit lean at times.” “Actually, I’m a little unsure what comes next when this show closes.” With a previous stint as a young Cosmo Brown under his belt, is there a new Jack Chambers spin on this current role? “I hope so! I try to bring something of myself to every role and there’s certainly a fair bit of ‘Jackness’ in this character without making himself unrecognisable, of course.” “It’ll be great having opening night in Perth on New Year’s Eve. I’m guessing it’ll be pretty hot so the onstage rain might be nice. And having a few doctors in the audience might come in handy if one of us slips over!”

By Peter McClelland

MEDICAL FORUM


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DECEMBER 2016 | 55


Competitions

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COMP Movie: Ballerina An animated feature telling the story of Felicia (voiced BYĂĽ%LLEĂĽ&ANNING ĂĽAĂĽYOUNGĂĽORPHANĂĽFROMĂĽ"RITTANY ĂĽWHOĂĽ dreams of dancing at the Paris Opera, and her best friend, Victor, who wants to become a great inventor. Together they escape from their orphanage for Paris. "ALLERINAÂĽĂĽnĂĽ-ITICOĂĽnĂĽ0#&ĂĽ"ALLERINAĂĽ,EĂĽ&ILMĂĽ)NCĂĽnĂĽ'AUMONTĂĽnĂĽ-ĂĽ&ILMS

Musical Theatre: Cabaret is Ace Melbourne-based Aceâ&#x20AC;&#x2122;s Cabaret is curating a season of acts at Downstairs at The Maj during Fringe World from January 21 to February 18. David Read has produced various Fringe acts, including former Olympic diver Matthew Mitchum and Spanky, for the past four years to much acclaim. Now, he says, itâ&#x20AC;&#x2122;s time to put on an entire season at the cityâ&#x20AC;&#x2122;s established cabaret venue in the basement of His Majestyâ&#x20AC;&#x2122;s Theatre.

In Cinemas, January 12

Movie: Resident Evil â&#x20AC;&#x201C; The Final Chapter The ďŹ nal instalment of this popular video game-ďŹ lm franchise, sees Alice (Milla Jovovich) the only survivor of humanityâ&#x20AC;&#x2122;s battle against the undead. Now, she must return to where the nightmare began â&#x20AC;&#x201C; The Hive in Raccoon City for the last ditch stand.

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Medical Forum winners get tickets to the launch on January 21 at 6pm

In Cinemas, December 26

Movie: A United Kingdom

Movie: Lion

Doctors Dozen Winner Thereâ&#x20AC;&#x2122;s never a bad time to win a Doctorâ&#x20AC;&#x2122;s Dozen carton of Rockcliffe wine and coming up to Christmas is very good timing indeed. Dr Genevieve Robbins is partial to a sparkling drop or two and has fond memories of a family trip to France and the Champagne region in 2010.

Here is a sweeping journey through the chaos of the Kolkata streets to suburban Hobart where a YOUNGĂĽ)NDIANĂĽBOYĂĽlNDSĂĽHIMSELFĂĽINĂĽTHEĂĽCAREĂĽOFĂĽADOPTEDĂĽ PARENTSĂĽ"UTĂĽTHEREĂĽAREĂĽQUESTIONSĂĽTOĂĽANSWERĂĽ3TARRINGĂĽ Dev Patel, Nicole Kidman, Rooney Mara and David Wenham. In cinemas, January 19

Musical Theatre: Singinâ&#x20AC;&#x2122; in the Rain The show made famous on the screen by Gene Kelly and Debbie Reynolds hits the Crown from New Yearâ&#x20AC;&#x2122;s %VEĂĽ'RANTĂĽ!LMIRALLĂĽANDĂĽ2OHANĂĽ"ROWNEĂĽALTERNATEĂĽASĂĽ leading man Don Lockwood, with Gretel Scarlett and Jack Chambers as the dancing chums. Crown Theatre, from December 31; MF performance January, 3, 7pm

8JOOFST from the October issue Kids Theatre â&#x20AC;&#x201C; Snugglepot and Cuddlepie: Dr Ben McGettigan Music â&#x20AC;&#x201C; The Tallis Scholars: Dr Merryn Seymour

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