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CONTENTS FEATURES

GUEST COLUMNS

8 Spotlight: Police

10 Drugs – A Case for

Commissioner Karl O’Callaghan

Decriminalisation Dr Geoff Gallop

23 GP Supervisor

12 Flying Doctor

Shortage Looms

with Altitude 16 Lessons from

Blaxell Report 24 Reform Not

Running Out of Puff

NEWS & VIEWS

8

2 Letters to the Editor:

Dr Sean Stevens

26 FGM – An Emerging

Child Protection Issue Dr Aesan Thambiran

27 Surgical

Mortality Audit Dr James Aitken

CLINICAL FOCUS

Dr Frank Jones, Dr John Hayes, Dr Bertel Bulten, Mr Chris Rose, Dr Chris Rynn, Mr Paul Coates, Mr Phillip Shepherd

5 Fine Needle

Aspiration Dr Mark Neville

6 Year in Review

7 Non-Valvular Atrial

10 GP After Hours

Fibrillation Oral Anticoagulants

14 Are you Listening

to the Kids? By Dr Rob McEvoy

18 2012 Guest

Column Award 20 Have You Heard?

12

Research Dr Stephen Stick

43 PlaquenilTM Dr Jo Richards

of GP Training

44 Severe Traumatic

Brain Injury

22 GP Supervisors

Dr Stephen Honeybul

and Trainees

47 Oncoplastic

28 Rural Medicine 2012

Breast Surgery

30 RACGP Membership 31 Beneath the Drapes

41 Cystic Fibrosis

Effects on Vision

21 The Future

30 Vaccination Grants

Dr Mark Hands

Dr Farah Abdulaziz

16

48 Psychotropic Drug

Information Service

LIFESTYLE 50 Friendly Town

with Benefits Mr Peter McClelland

Pages

51 Spirit of the Season

32-39

52 Travel: Budapest

to Amsterdam 54 Kitchen Confidential:

Red Cabbage

Christmas ure eat Greetings F

medicalforum

24

45 Wine Review:

Capel Vale Dr Craig Drummond MV

56 The Funny Side 57 Competitions

1


PUBLISHERS Ms Jenny Heyden - Director Dr Rob McEvoy - Director

Letters to the Editor

RACGP on specialising GPs Dear Editor,

MEDICAL FORUM MAGAZINE 8 Hawker Ave, Warwick WA 6024 Telephone (08) 9203 5222 Facsimile (08) 9203 5333 Email editor@mforum.com.au www.mforum.com.au

ISSN: 1837–2783 ADVERTISING Mr Glenn Bradbury advertising@mforum.com.au (0403 282 510) EDITORIAL TEAM Managing Editor Ms Jan Hallam editor@mforum.com.au (0430 322 066) Medical Editor Dr Rob McEvoy (0411 380 937) rob@mforum.com.au Clinical Services Directory Editor Ms Jenny Heyden (0403 350 810) jen@mforum.com.au

The results outlined in a recent survey in Medical Forum are not surprising (GPs Who Choose to Sub-specialise, October edition). By the very nature of a generalist, “a person whose knowledge, aptitudes, and skills are applied to a field as a whole or to a variety of different fields”, GPs will always retain an overview, but will have different skill bases that will vary in the trajectory of a lifetime career in general practice. Some GPs will develop a specific area of expertise; others will have a specific focus. The term sub-specialisation clouds the real debate. We all remember the heady days of being a student/ resident then registrar, mostly everything we did was new, challenging and exciting. Each specialty held specific demanding intellectual rigour and the need to acquire new skills.

Journalist Mr Peter McClelland journalist@mforum.com.au

At a personal level, the problem I had was that I enjoyed each job and was inclined to stay with this specialty… until I tried the next one! And so for me it became increasingly obvious I was destined to be a generalist, a decision I have never regretted.

EDITORIAL ADVISORY PANEL Dr John Alvarez Dr Scott Blackwell Ms Michele Kosky Dr Joe Kosterich Dr Alistair Vickery Dr Olga Ward

The bottom line is: “General practice provides person-centred, continuing, comprehensive and coordinated whole-person healthcare to individuals and families in their communities” (www.racgp.org. au). The completion of Fellowship of the RACGP recognises the ability to practise unsupervised general practice anywhere in Australia.

SYNDICATION AND REPRODUCTION Contributors should be aware the publishers assert the right to syndicate material appearing in Medical Forum on the MedicalHub.com.au website. Contributors who wish to reproduce any material as it appears in Medical Forum must contact the publishers for copyright permission. DISCLAIMER Medical Forum is published by HealthBooks as an independent publication for the medical profession in Western Australia. The support of all advertisers, sponsors and contributors is welcome. Neither the publisher nor any of its servants will have any liability for the information or advice contained in Medical Forum . The statements or opinions expressed in the magazine reflect the views of the authors. Readers should independently verify information or advice. Publication of an advertisement or clinical column does not imply endorsement by the publisher or its contributors for the promoted product, service or treatment. Advertisers are responsible for ensuring that advertisements comply with Commonwealth, State and Territory laws. It is the responsibility of the advertiser to ensure that advertisements comply with the Trades Practices Act 1974 as amended. All advertisements are accepted for publication on condition that the advertiser indemnifies the publisher and its servants against all actions, suits, claims, loss and or damages resulting from anything published on behalf of the advertiser. EDITORIAL POLICY This publication protects and maintains its editorial independence from all sponsors or advertisers. GRAPHIC DESIGN 2 Thinking Hats

The article suggests that only ageing GPs should sub-specialise. One of the many attractions of general practice is the ability to develop specific interests, that is, a GP with Specific Interests (GPSI). The RACGP has recognised this as a feature within 21st century general practice and has endorsed the creation of a specific faculty within the College structure to support group discourse and reflection. The National Faculty of Specific Interest (NFSI), made up of 17 groups so far, is charged with ‘recognising the additional interest and expertise held by general practitioners in selected areas of general practice’ and facilitating GP members practising in these areas to ‘promote the area of specific interest and to share and develop related knowledge and materials’.

our GP respondents said let them get on with it as a GP “and ensure patient safety standards are kept”. Does the college QI&PD program do that for the sub-specialising GP? This is a real dilemma for the college as it promotes a generalist philosophy but may face a different reality for many of its fellows and others (70% of our GP respondents knew of a subspecialising GP).

Heat on Euthanasia Debate Dear Editor, RE: Guest Column: Dying in a Vaguely Horrific Society (October edition). Dr Philip Nitschke has effectively killed off any political interest in euthanasia. Politicians do not trust him. Readers will recall the nationwide Nancy Crick euthanasia campaign. We were repeatedly told that Mrs Crick was 'terminally ill' even though her doctors told Nitschke that she was free of cancer. You cannot tell lies and expect the public to trust you. There was never any apology, and incredibly the Australian media said nothing because many newspapers (including The West Australian) openly support euthanasia. The truth is that the euthanasia lobby believes that everyone should have the right to end their life at their own time and choosing. They supported the euthanasia of Nancy Crick, who was simply "tired of living". Dr Nitschke publicly stated that anyone 75 years or older with a chronic disease and "tired of living" should have access to euthanasia. He also wants euthanasia for chronic depressives and long-term prisoners who want to die. A Nitschke-operated euthanasia clinic in suburbia would be like a magnet for anyone wanting to end their life. The Netherlands now has six mobile euthanasia teams that can be called in if your GP refuses to carry out euthanasia. The Royal Dutch Medical Association strongly opposed the mobile teams and some members are now having secondthoughts about euthanasia. The Dutch also practise involuntary euthanasia where large numbers of frail-aged dementia patients are euthanised even though by definition they are not "of sound mind".

On occasion the lines between ‘true’ generalists and ‘focused’ GPs can be blurred. The one common theme is the RACGP QI&PD Program which reflects the broad knowledge base required by all vocationally registered GPs in Australia. The RACGP Council has strongly endorsed the view that a GPSI will always be subsidiary to comprehensive general practice (generalist). The College will not initiate, nor will it support any GPSI chapter claim for differential remuneration. Dr Frank Jones, Chair RACGP WA Faculty ED. How do we deal with the GP who chooses, as a result of semi-retirement or whatever, to confine their work to a sub-specialised area (maybe not within the college’s GPSI grouping)? Around two thirds of medicalforum medicalfor


Graduating doctors pledge ‘to maintain the utmost respect for Human Life', a key tenet in The Declaration of Geneva, the modern version of the Hippocratic Oath. It is of interest that The Netherlands is not a signatory to the Declaration. After three failed Euthanasia Bills in WA, euthanasia is a "dead issue". Dr John Hayes, Consultant Physician, Wembley.

Response: Dr Bertel Bulten In my guest column I try to advocate an open debate based on facts around euthanasia. I strongly believe the discussion can't be declared dead despite the failure of several euthanasia bills and the arguments of slippery slopes and horrific societies. We cannot ignore voices in favour of an ongoing debate within Australian society. In view of (rare) individual cases where terminally ill patients are in serious need and have explicit ideas about how their end should be, it is almost impossible as a doctor to not be engaged in this complicated medical, ethical and political issue. For some, the Netherlands is an example of a horrific society, for others an enlightened beacon for the rest of the world. Therefore it might be helpful to be led by facts only, after the Dutch experience of 10 years’ of legalised voluntary euthanasia: 1. In the Netherlands euthanasia is prosecutable, unless performed by physicians who act in accordance with all the statutory criteria. The most important criteria are:

t WPMVOUBSZBOEXFMMDPOTJEFSFESFRVFTUCZ the patient t VOCFBSBCMFTVGGFSJOHXJUIPVUQSPTQFDUPG improvement t BUMFBTUPOFPUIFSJOEFQFOEFOUQIZTJDJBO has to be consulted, who has to confirm that the due care citeria are satisfied t UIFDBTFIBTUPCFSFWJFXFECZBO independent review board afterwards 2. There have never been reported cases PGGSBJMBHFEEFNFOUJBQBUJFOUTCFJOH involuntarily euthanised. If physicians would do so, it would be murder. 4PDBMMFENPCJMFhFVUIBOBTJBUFBNTh  which also have to meet the above criteria, are an undesirable development according to the Royal Dutch Medical Association (KNMG) because they may lead to tunnel WJTJPOSFHBSEJOHFOEPGMJGFNBOBHFNFOU 4. The Dutch Hippocratic Oath is based on its modern version as stated in the Declaration of Geneva. Respect for human life can be explained as the untouchable sanctity of human life, also explained as deep respect for humans and their wishes and dignities. Euthanasia therefore, according to the KNMG, is not in contradiction to the modern oath. References: Bregje D Onwuteaka-Philipsen, Arianne Brinkman-Stoppelenburg, et al. Trends in end-oflife practices before and after the enactment of the euthanasia law in the Netherlands from 1990 to 2010: a repeated cross-sectioned survey. Lancet 2012; 380:908-15 Bernard Lo, Euthanasia in the Netherlands: what lessons for elsewhere. Lancet 2012; 380: 869-70 http://knmg.artsennet.nl/Publicaties/KNMGpublicatie/ Position-paper-The-role-of-the-physician-in-thevoluntary-termination-of-life-2011.htm www.euthanasiecommissie.nl/ overdetoetsingscommissies/jaarverslag/ – Annual Report 2010 of Euthanasia Review Board; for English version: click on " jaarverslag 2010 Engels" http://knmg.artsennet.nl/Publicaties/KNMGpublicatie/ Guideline-for-palliative-sedation-2009.htm

Dengue fever warning Dear Editor, Last March my wife and I went to Bali for a bit of R&R. Little did we know what was awaiting us. The weather was a little rainy but not too bad so we made the most of our time – eating out at night, swimming by the pool and shopping. After about four days we both felt ill – no appetite at all and complete lack of energy. A visit to one of the local clinics confirmed dengue fever. I knew little about it as there were no warnings in Australia about the dangers of catching this infection in Bali. Symptoms rapidly worsened so we returned to Australia and almost immediately experienced severe symptoms – extreme headaches, fever, complete loss of appetite, diarrhoea and vomiting. This was followed by muscle weakness and severe joint pain. I started bleeding from my gums and my tongue peeled, leaving me with virtually no sense of taste. My wife's symptoms were similar but slightly less severe. At one stage we simply could not look after ourselves. In my case, symptoms continued for three weeks until one morning I could not get out of bed. I called an ambulance and was admitted where 5.5 litres of saline were administered – the drip saved me but I actually knew more than the doctors about dengue fever infection. It was another three weeks before I recovered enough to return to work. A blood test confirmed haemorrhagic dengue fever – 20% fatality rate in some tropical areas. It has taken seven months to regain full muscle strength and I have had two

Returning the Public’s Faith This year marked a special anniversary for the UWA Medical School. Exactly 50 years ago, 34 young doctors became the school’s first graduating cohort. Those students have been gathering each year since, but this year’s milestone needed a special celebration. Dr Lewis Blake said that the 50th anniversary was the opportunity to thank the public for its support of the medical school because without public fundraising, the school would not have gotten off the ground when it did. “We as a group are very grateful to the public for our careers. Communities, especially in rural areas, held fundraising events to get the medical school started so they would have doctors,� he said. medicalforum

The school, which opened in 1957, was funded jointly by the State Government and public fundraising and signalled a new era for the medical profession. Up until QGraduates of the UWA Medical School’s Class of ’62 at the 50th anniversary dinner. 1957, aspiring young in Scotland. The link was organised by the medicos had to respective medical school deans – Prof Ian travel to the Eastern States or train overseas. Puddey, from UWA, and Prof David Reid, .BOZTUBZFEXIFSFUIFZIBERVBMJGJFE  from Aberdeen University. leaving WA with a doctor shortage. Dr Blake said he and his fellows hoped The Class of ’62 gathered at the university that the contact would be the start of last month and celebrated with the sole a collegiate exchange between the two surviving Foundation Professor, Prof medical schools. O David Sinclair, via Skype from Aberdeen 3


Letters to the Editor relapses of a day each – muscle pains, headaches etc. My sense of taste took four months to return and I still can’t eat much meat. I do feel that more warning should be given to travellers about the dangers. My doctor said I could easily have died had I not called that ambulance. Needless to say I will not be returning to Bali – ever. Mr Chris Rose, traveller

Expert Comment: We asked Dr Chris Rynn who specialises in travel medicine to comment. Dengue fever affects over 100 countries and Indonesia is one of them, reporting 150,000 cases in 2007. Australian travellers to Bali are becoming more aware – local Bali press reports 200-300 cases per year, peaking towards the end of the wet season (October to March) – and a similar number of Australians return with the illness. The disease is due to the Dengue flavivirus (4 serotypes – DENV-1, DENV-2, DENV-3, DENV-4) transmitted by the Aedes mosquito, which is found worldwide and has adapted well to urban environments. In the Asia-Pacific region, the main culprits are Ae. aegypti and Ae. albopictus. They will lay eggs in water-capturing containers (e.g. plastic containers, old car tyres, pot-plant bases), which are resistant to dessication and can remain viable for months. When moisture is available, they will hatch in about seven days. The adult female mosquito bites preferentially during the day or early evening. Incubation is typically 4-7 days, and dengue fever should be suspected in unwell travellers from the tropics presenting within two weeks of possible exposure. Presenting symptoms are fever, headache, retroorbital pain, sore and reddened pharynx, conjunctival erythema, myalgia, arthralgia, nausea and vomiting – with up to 50% developing a generalised blanching maculopapular rash. There may be minor bleeding from the nose and gums or cervical lymphadenopathy. Prolonged fatigue and depression are possible post-infection sequelae but recurrences of symptoms without re-infection is unusual. Diagnosis is often made clinically in resourcepoor countries (a positive ‘tourniquet test’ increases suspicion) but otherwise by dengue serological tests – antibody testing more than six days after onset of symptoms may be positive but if not, paired convalescent serology is necessary; in the first five days of illness, dengue virus antigens may be detectable with rapid tests. Other abnormalities may include leucopaenia, lymphocytosis, mild thrombocytopaenia, and elevated liver transaminases. 4

Dengue fever may progress to dengue haemorrhagic fever (DHF) or dengue shock syndrome – vascular plasma leakage, resulting in hypovolaemia and abnormal blood clotting. DHF risk increases with previous exposure to dengue virus, in a phenomenon referred to as antibody dependent enhancement – a 3% risk of DHF with subsequent exposure to a different dengue virus serotype. Untreated DHF mortality may reach 50%, reduced to 1% with good supportive care. Dengue vaccines are undergoing testing but are not commercially available. Therefore, avoiding mosquito bites is the mainstay of prevention: light-coloured clothing cover; treatment of the clothing with insecticides; personal skin repellents containing di-ethyl-tolumide (DEET) or picaridin; accommodation kept closed to prevent mosquito entry and cooled to 16C to discourage mosquito entry. It is important for travellers to be aware of the biting behaviour of Aedes mosquitoes – they are day-time active mosquitoes (i.e. mosquito bed-nets do not offer protection!) – and these precautions need to be taken during day-time and early evening in tropical environments when there has been recent rain activity.

Support for Grandparents Dear Editor, The article Parents Second Time Around (November edition) struck a chord with the work that we do at Carers WA. Given that the cases in the article are far from isolated it may be helpful to remind your readers of the services we provide to support people in these sorts of circumstances, who qualify for assistance. Carers WA advocates and provides services for people who provide unpaid care and support for a family member who has a disability, is frail aged or has a mental or chronic illness. In fact in WA, the first legislation in Australia – the Carers Recognition Act 2004 – recognises and supports carers. While our work does not apply to grandparents who are parenting a child that is in sound health, we can still provide assistance in many cases. As the article indicates, often the reason that the grandparent takes over the role of full-time parent of the grandchild is because there are physical and or mental health issues relating to the child’s parent. In this case the grandparent is not only 'parenting' the grandchild but they are also caring for and supporting the parent. Obviously if the grandchildren themselves have a disability or poor health issues (physical or mental) the grandparent is not only a parent but a carer and therefore qualifies for services and supports. GPs will frequently come into contact

with carers because they are statistically more likely to suffer ill health, including depression. So if they are caring for another family member with a disability, mental illness, chronic illness or is frail aged they are likely to need support and I would encourage your readers to point patients to Carers WA on 1300 277 377 or via www.carerswa.asn.au. Mr Paul Coates, CEO, Carers WA

Aged Care Records Dear Editor, Dr Simon Torvaldsen’s excellent critique of the shortcomings in the electronic clinical record keeping in Residential Aged Care Facilities (Aged Care … Just for the Record, November 2012) makes a set of powerful points – about the difficulties of keeping RACF patient records current, accessing them and synchronising them with the doctor’s practice records. There is a time/cost impact on every GP who services RACFs and similar institutional care environments. He asks “what can be done?” to improve the quality of the electronic patient records and resigns himself to “writing my old fashioned notes”. There is a simpler electronic solution available. GPs can use an e-health tool set that will update their practice patient records, allow e-prescriptions to be written and tests to be ordered, results to be consulted and examination notes updated, all from the patient’s bedside using the same clinical system the GP uses in their practice. This technology is reliable and proven as demonstrated during a MediSecure trial in Cairns in October 2010 where GPs were able to write e-prescriptions from an iPad in the conference hall using a Best Practice clinical system that was operating hundreds of metres away. With the use of wireless broadband and mobile computing, the job of GPs is made a lot easier, especially when they are not in their practice. With the mymedisecure™ platform, the GP’s clinical system stays current and the RACF has access to a summary of the patient’s medicines, results and key clinical data. Mr Phillip Shepherd, CEO, MediSecure Pty Ltd ED. Mr Shepherd told Medical Forum that a RACF only required a wireless internet connection to run this ehealth system or the doctor could use his own mobile network.

medicalforum


Fine needle aspiration (FNA) – fast and effective F

NA is performed using a 25 or 23-gauge (0.51-0.64mm) needle to withdraw a sample of cells from a mass lesion. This may be done with suction using a syringe, or without suction (the so-called acupuncture technique). The cells are then smeared onto glass slides, stained and interpreted by a cytopathologist. A combination of airdried Diff-Quik stained and fixed Pap stained slides is most efficacious.

into transport medium, from which a cell block can be made. FNA may also be limited by heterogenous lesions where this blind sampling method fails to pick up diagnostic material. In these situations, clinical correlation is very important. Generally, any inconsistency between FNA results and clinical findings requires further investigation, such as histology. Ancillary testing of FNA material may be helpful in some cases.

What lesions are suitable for aspiration?

These examples highlight the limitation of FNA and the importance of clinical correlation and ancillary tests:

FNA is a very useful primary investigation of both superficial and deep lesions for primary diagnosis, assessment of tumour recurrence and in particular, to identify patients who can be safely followed from those that need further investigation. In the latter situation, FNA results can help determine the most appropriate further investigation e.g. lymph node biopsy for histological subtyping and applicable grading where FNA is suspicious of, or consistent with, lymphoma. Superficial local lesions that are easily palpable are suitable for FNA by a pathologist. Non-palpable deep lesions and lesions within internal organs can be aspirated by a radiologist using imaging guidance. Suspicious breast microcalcifications may require stereotactic guidance. FNA is contraindicated for suspected carotid body tumours and phaeochromocytomas (due to post-aspiration release of hormones), vascular lesions such as haemangioma or angiosarcoma (due to the risk of haemorrhage), and hydatid cysts (due to the risk of seeding).

Interpretation of results As with any test, correct interpretation requires knowledge of the limitations of the test, and the clinical correlation. The value of FNA may be limited when diagnosis relies on assessing tissue architecture (as in histology). This can sometimes be partly overcome by placing some of the aspirate

Thyroid. A hyperplastic nodule in multinodular goitre, a follicular adenoma and a minimally invasive follicular carcinoma have a similar appearance cytologically. These are reported as an indeterminate: repeat FNA in 6-8 weeks; or atypical, suspicious of a follicular neoplasm: refer patient to an endocrine surgeon. Lymph nodes. Cytologically, low-grade lymphomas can mimic benign reactive lymph nodes. Hence any lymphadenopathy should be followed clinically and investigated further if it does not resolve. Flow cytometry for lymphocyte surface marker analysis may be helpful to separate reactive lymphadenopathy from a nonHodgkin’s lymphoma. Metastatic tumours may only partially involve a lymph node which can result in a false negative diagnosis. Clinical correlation is important and histology may be required. Breast. It is not possible cytologically to distinguish benign atypia in a papilloma from a papillary carcinoma, and excision is necessary for these lesions. Similarly, it is not always possible to separate cellular fibroadenomas from phylloides tumours and even tubular carcinomas. Cystic tumours. FNA may sample only the macrophages and fluid of the cystic component without the diagnostic cells from the cyst lining. Re-aspiration should be performed if a cyst re-collects or if any residual mass is present.

By Dr Mark Neville, Histo/Cytopathologist

Non-diagnostic (unsatisfactory) specimens These happen if there is insufficient cellular material on the slides for assessment. This may be due to the nature of the lesion, for example, an extensively necrotic tumour may yield debris only and a very sclerotic lesion may yield a virtually acellular aspirate. Non-diagnostic specimens may also result from the obscuring of cellular material by blood or inflammatory cells. Problems in smear preparation, such as crush artefact or air-drying prior to fixation can also render specimens unsatisfactory. These two photos highlight the necessity for good smear preparation. QWell preserved cells in which assessment of nuclear detail enables a diagnosis of malignancy. (Papsmearx40)

QPoorly preserved cells as a result of airdrying due to a delay in fixation. Nuclear details unable to be assessed and a diagnosis cannot be made. (Papsmearx40)

TO OBTAIN AN FNA KIT Fine needle aspiration kits containing the necessary equipment to perform FNA are available on 08 9476 5238. Non palpable lesions and lesions within internal organs should be aspirated under image guidance and require referral to a radiologist skilled in the procedure. To book a patient for FNA performed by a Pathologist at Clinipath Pathology, please contact 08 9476 5209.


Year in Review

A Year to be Proud Of... In the age of ‘information overload’, reader encouragements and participation are reassuring indicators that our doctorto-doctor communications are still hitting the mark. Yes, we are a small production team but we have heaps of experience – wading through the fluff and puff to dissect out what is both relevant and helpful to the medical profession in WA. Like what? GP training, getting a return on research, recognising specialisation among GPs, proper handling of complaints against doctors, protecting professional ethics and accountability, tackling rural problems, doctors across cultural divides, placing nurse practitioners, work-life (im)balance, what doctors want from organisations that represent them, women juggling medicine, and more – all with a unique WA flavour. Add to this the marvellous Guest Columns – reigniting the euthanasia discussion, mental health patients forsaken, child abuse, avarice in the profession, hospital IT shortfalls, kids before the courts, helping on foreign shores – it’s a mix with something for everyone. With only a few exceptions, doctors are a progressive lot and regard reproaches as a catalyst for change; maybe not immediately but certainly after consideration. Australia is lucky that most doctors put the greater good ahead of feathering their own nests. When that isn’t the case, the wider profession has a right to know and to express an opinion. In much the same way, we know our independence comes with an obligation for balanced reporting within ‘the medical club’. A special thanks to all the thoughtful participants in our E-Polls. We now have a better understanding of how WA doctors perceive things like translational research, complaints against them, pharmaceutical sponsorship, their representatives, e-health readiness, trust in the profession, sexualisation of girls, and health waste. We 6

work hard for WA doctors to have their point of view heard and published. The wonderful support of our Major Sponsors for 2012 has allowed us to achieve much. t t t t t

8FTUFSO$BSEJPMPHZ $MJOJQBUI1BUIPMPHZ "WBOU 4JMWFS$IBJO )FFOBO-BN4LJO1BUIPMPHZ

Wide participation within the Clinical Services Directory makes it a much-used resource for referring doctors. Thanks to all the clinicians who contributed Clinical Updates during 2012 – diverse and informative articles in easily digestible packages, often with a local flavour to help WA doctors. Responding to reader requests, the social reach of Medical Forum is stronger, with stories around what doctors do in their spare time, spotlights on well-known Australians, medical pioneers, philanthropy, work-life balance, photography and plain fun. Our jokes pages remain a favourite! We gratefully acknowledge our wine reviewers Drs Martin Buck, Louis Papaelias and Craig Drummond, contributing satirist Wendy Wardell, cartoonist Dave Freeman and our editorial panel who have stuck with us despite external pressures –

Q(From top left) Drs Martin Buck, Louis Papaelias and Craig Drummond (wine reviewers), Wendy Wardell (contributing satirist), Michele Kosky with Drs Joe Kosterich, Scott Blackwell, Olga Ward John Alvarez and Alistair Vickery (editorial panel), Jan Hallam, Glenn Bradbury, Peter McClelland and Terri Sedgman (MF Staff)

Michele Kosky with Drs Joe Kosterich, Scott Blackwell, Olga Ward, John Alvarez and Alistair Vickery.

We are delighted Medical Forum has a place in the hearts and minds of WA doctors – our ‘labour of love’ for the profession for many years. It is our friendships with many doctors, the hard work of our small dedicated team and the participation of many contributors, sponsors and advertisers that keep us going, no matter what comes our way. As the leading publication for doctors in WA, constant improvement and a reputation for ethical, balanced journalism and entertainment value, keep us there. As someone once said: “We’re free but we’re not cheap” – happy reading! Ms Jenny Heyden RN and Dr Rob McEvoy, Publishers

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Non-valvular Atrial Fibrillation and Oral Anticoagulants N

on-valvular atrial fibrillation accounts for up to 15% of strokes in patients of all ages, and up to 30% of strokes in patients over age 80. For many years, Warfarin has been the mainstay anticoagulant to reduce the rate of ischaemic strokes in patients with atrial fibrillation, however, with well-known limitations â&#x20AC;&#x201C; the need for frequent monitoring, constant dose adjustment at times, and a potential for significant drug interactions. Two new oral anticoagulants have become available following large randomised controlled trials: t "EJSFDUUISPNCJOJOIJCJUPS Dabigatran (PradaxaTM) t "EJSFDUGBDUPS9BJOIJCJUPS  3JWBSPYBCBO 9BSFMUPTM) Dabigatran is a potent direct, competitive inhibitor of thrombin, renally excreted (80%), with a 12-17 hour half-life, and administered twice daily. Randomised Evaluation of Long Term Anticoagulation Therapy (RELY) study compared the efficacy of Dabigatran versus Warfarin in non-valvular atrial fibrillation in 18,113 patients worldwide. Participants required at least one of the following risk factors: previous stroke/ TIA; a left ventricular ejection fraction of < 40%; NYHA Class II or higher heart failure; age >75 years; or age 65-74 years with either diabetes mellitus, hypertension or coronary artery disease. The mean CHADS2 score was 2.1 +/- 1.1. Patients were randomised to either 110mg oral bd or 150mg oral bd of Dabigatran versus adjusted dose Warfarin (INR target 2.0 - 3.0). Dabigatran at 110mg was non inferior to Warfarin with regards to the composite of stroke and systemic embolisation (1.53% versus 1.69% per year, P<0.01). The 150mg Dabigatran group (1.1% per year) was superior to Warfarin with regards to reduction of stroke and systemic embolisation (P<0.01). The rate of major bleeding was less in the 110mg Dabigatran group compared to Warfarin (2.71% per year versus 3.36% per year). Notably, rates of lifethreatening bleeding and intracranial

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bleeding were higher in the Warfarin group than in either Dabigatran group (P<0.05). Dyspepsia was higher in the Dabigatran groups. RivaroxabanJTBEJSFDU9BJOIJCJUPS  renally excreted (60-70%), with a 9-13 hour half-life. The ROCKET AF trial (the Rivaroxaban Once Daily Oral Direct 'BDUPS9B*OIJCJUJPO$PNQBSFEXJUIB Vitamin K Antagonist for Prevention of Stroke and Embolism trial in Atrial Fibrillation) randomised 14,264 patients worldwide with non-valvular atrial fibrillation to fixed oral dose of Rivaroxaban (20mg daily or 15mg daily in patients with a creatinine clearance of 30-49ml/min) or adjusted dose Warfarin (INR target 2.0 - 3.0). The patients were at moderate to high risk for stroke, with either a history of stroke or TIA, and at least two of the following: heart failure with a left ventricular ejection fraction of <35%; hypertension; age >75; or diabetes mellitus. The mean CHADS2 score was 3.48 +/- 0.94. Rivaroxaban was demonstrated to be non-inferior to Warfarin with a composite of stroke (ischaemic or haemorrhagic) and systemic embolism being 2.1% per year versus 2.4% per year in the Warfarin group. Notably, rates of major and clinically relevant non-major bleeding was similar in both Rivaroxaban and Warfarin groups. Like Dabigatran, the rate of intracranial bleeding was significantly lower in Rivaroxaban group (0.5% versus 0.7% per year, P value 0.02).

Discussion The exact reason why the newer anticoagulants, Dabigatran and Rivaroxaban, reduce the risk of

Dr Mark Hands Clinical Associate Professor (UWA), Interventional Cardiologist

About the author Dr Mark Hands graduated from UWA and trained in cardiology at Sir Charles Gairdner Hospital and Brigham Womenâ&#x20AC;&#x2122;s Hospital, Harvard Medical School. He is an interventional cardiologist in private practice at Western Cardiology (chairman) and emeritus consultant cardiologist at SCGH. In addition to general cardiology and echocardiography his special interests include investigation and treatment of acute and chronic ischemic heart disease. Dr Handsâ&#x20AC;&#x2122; interventional procedural skills include coronary angiography, angioplasty and stenting in stable angina and in acute unstable angina and acute myocardial infarction, cardiac pacing, percutaneous closure of atrial septal defects and patent foramen ovale.

intracranial bleeding compared with Warfarin is not clear. It is possibly due to the fact that the new novel anticoagulants inhibit only one factor in the coagulation pathway compared with Warfarin, which inhibits vitamin K dependent multiple DPBHVMBUJPOGBDUPST ** 7** *9BOE9  The data does have some limitations. Firstly, the quality of adjusted dose Warfarin was sub-optimal and variable between the trials; the mean percentage time of INR within the 2.0 - 3.0 target was 64% in the Dabigatran trial and only 55% in the Rivoraxaban trial. One could argue that the results of Warfarin could have been better if the target was achieved more often. On the other hand, it highlights Warfarin dosing is indeed difficult and at times unreliable. Secondly, patients in the trial are at different risks of stroke (CHADS score of 2.1 with Dabigatran and 3.48 with Rivaroxaban). There are the practical issues of cost, lack of reversible agents for the newer anticoagulants and non-PBS listing. However, they are presently being supplied to patients by the respective companies in patient familiarisation programs, limited to non-valvular atrial fibrillation patients with the recommendation of reduced dosage (as outlined in the trials) for patients with renal impairment. The drugs provide a real alternative to Warfarin for nonvalvular atrial fibrillation, particularly in those patients who have had difficulties with Warfarin or are resistant to constant INR monitoring.

7


Spotlight

‘Commish’ Ready to Rock On Police Commissioner Karl O’Callaghan won’t be sad to see the end of 2012 but a renewed contract has him eyeing some tough issues in the next three years. There aren’t many senior police officers in Australia who can call themselves ‘Doctor’ though WA Police Commissioner Karl O’Callaghan is one of them. With a PhD thesis on Police Reform, the commissioner celebrates the intrinsic value of ‘ordinariness’, eschews the negative aspects of overt hierarchy and underlines some of the similarities between the practice of medicine and policing. “My parents are ordinary people from humble backgrounds. My mother left Germany during the war and met my father, who was a tyre salesman, in the UK. We arrived here when I was 14 and I ended up doing three years of the WA curriculum in one year – Year 10 at school and Years 8 and 9 at home. That’s probably where my academic focus developed so strongly,” the Commissioner said. “The main value of the PhD was to broaden my perspective: it’s important to be able to stand outside an organisation and look back in. The thesis on police reform was timely because there have been some significant changes in policing over the last 10 years. It’s a lot more open and transparent now and when you open things up people realise they’re being scrutinised and, hopefully, there’s a new level of honesty and clarity.” Leadership style is a highly subjective concept and Karl O’Callaghan has firm views on his approach to managing a multi-layered organisation embracing tactical strategy and human resources while juggling more than a few different coloured political balls at the same time. “I’ve spent a fair bit of time softening the old paramilitary culture. With Year 12 Leavers for example, we’ve developed a policy of getting the rules down early and educating the kids by going out to schools and talking to them. It’s the same with the name change – Police ‘Force’ to ‘Service’ – it’s all a bit academic really. I prefer to call us the WA Police – you don’t need to articulate whether it’s a ‘force’ or a ‘service’.” “As Commissioner you have to deal with governments and the changing fortunes of political parties create challenges for police policy because sometimes you have to change direction. Tactically, we have independence but from a policy perspective it’s driven by government and you have to be cognisant of that fact.” 8

QPolice Commissioner Karl O'Callaghan

There are real risks in frontline policing and significant differences between metropolitan and regional operations. And the parallels between policing and practising medicine are considerable. “The case of Constable Ryan Marron, who contracted Murray Valley Encephalitis in Balgo is a tragic one. And that underscores the fact that the risk doesn’t always lie in dealing with offenders. Policing in the metropolitan area is frenetic due to the high call-load and the uncertainty of what lies ahead. It’s a bit like a doctor in an emergency department – they just don’t know what’s coming through the door next. In regional areas it’s not quite so hectic, but they have to be much more ‘generalist’ in their approach.” The Commissioner regards the culture of what he terms, ‘determined drunkenness’ – binge drinking – as a high tactical priority. He also makes a perceptive distinction between the overlap of policing and health as a social issue. “We’re going to be looking at this culture of ‘determined drunkenness’ very closely. But I have to stress that this is a broad issue with factors such as advertising and the cost price per unit of alcohol. This is a problem that requires community participation and not just a tactical response.” “And the same goes for drugs, too. Legalising some drugs isn’t going to send bikie gangs out of business because organised crime syndicates will always find another way to generate money. There’s more profit in global match fixing than running drugs around the country. In any case, the decriminalisation of drugs is a health debate rather than a policing issue. If we moved to decriminalise cannabis or

Legalising some drugs isn’t going to send bikie gangs out of business because organised crime syndicates will always find another way to generate money. methamphetamines we’d need to assess the impact that would have on both the health system and wider society.” For Karl O’Callaghan, 2012 has been something of an annus horribilus. There’s been a CCC investigation and his son, Russell’s public battle with drugs. Effective coping strategies for any person – police commissioner or medical practitioner – are absolutely vital in order to perform at a high level. “I have a policy of ‘3 Fs’ – Fitness, Family and Focus. I’m very keen on maintaining my fitness, and that’s both physical and mental. My family is very important to me and I also have an alternative focus, something completely separate from policing and that’s playing in a rock band.” Having recently had his contract renewed for a further three years, the Police Commissioner has his immediate future mapped out, but after that he says he’s ready for a change. “All bets are off for me when I leave this job. I’m not fascinated by policing and I don’t go home and watch crime shows on television. It’ll be something right out of the box when I leave this job, I do have a strong academic background so maybe I’ll be lured into a university.” O

By Mr Peter McClelland medicalforum


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9


Guest Column

Drugs – A Case for Decriminalisation Former WA Premier now Sydney academic Prof Geoff Gallop says the key to the drug problem is to put the welfare of individuals first.

E

arlier this year I was asked to participate in a round table on drug policy organised by the nonprofit research organisation, Australia 21. It helped clarify my beliefs on a subject much influenced by rigid and fundamentalist rather than humane and pragmatic thinking. I was already well down this track and was proud of the reforms my government made in Western Australia following the Drug Summit (2001). It’s clear, however, that the road to reform will be a difficult one and, indeed, some of the changes we made were overturned by the next government, even though there was evidence for their effectiveness. Reform, of course, can mean different things. Some advocate decriminalisation of illicit drug use while others say we ought to go further and legalise and regulate drug supply, as is the case with the licit products such as tobacco and alcohol. My judgement is that evidence and experience certainly supports

decriminalisation but is not as clear cut in relation to the proposal to legalise drug supply. When considering the case for decriminalisation there are several questions we have to ask. Is it right to use the criminal law in relation to drug taking? Does the use of the criminal law actually discourage drug use? Does it actually help those for whom drugs cause harm? Might it not, in fact, make it harder for us to tackle problematic drug use while imposing an unnecessary impediment to those for whom drug use is not harmful? In keeping with a reforming answer to both these questions, Portugal decriminalised purchase, possession and consumption of illicit drugs in quantities consistent with personal use in 2000. At the same time resources were invested in a range of harm reduction measures. The government also created panels called Dissuasion Commissions to assist and advise – and sometimes even apply penalties – to those found in possession of up to 10 days’ worth of an average daily dose of drugs for personal use.

As is always the case “evidence” relating to these issues has been contested. But it is agreed by most that the sky hasn’t fallen in. Reported drug use in vulnerable groups has even fallen. Indeed “the innovative nature of the Portuguese approach proves it is not generals, police officers, or criminal court judges, but rather doctors, social workers, and researchers who need to address drug-related issues” (Artur Domoslawski, Drug policy in Portugal, Open Society Foundations, 2011, p.10). Indeed it’s the same story pretty well everywhere that decriminalisation is given a chance – life is normalised for those previously under the dark shadow of the criminal law and it’s easier for the health professions to offer and give assistance where needed. All too often we look for simplicity in a world of complexity and imperfection. Much better, I say, to put the rights and welfare of the individual first, and provide help when it is needed – it’s more humane and it produces better results for individuals, their families and the wider community. O References on request.

GP After-Hours Makes Headway

T

a survey of 452 people in its area and concluded that there was need for more promotion of the after-hours services.

he GP After Hours campaign which began in late April is starting to see some dividend with the latest figures showing a modest increase in the number of attendances at the 62 after-hours clinics listed on the WA Health department’s website.

“About two thirds of people surveyed thought the access could be improved and one in five said the services needed promotional activity. As a result we have taken out advertisements to bring people back to the website and to the phone app.”

In the September quarter, 17,869 people attended a GP after hours service – 1676 more people (or an increase of 10.4%) than the same quarter last year. The media campaign targeted groups with the most semi-urgent and non-urgent presentations at emergency departments, including 18-30 year olds, parents of young children (0-15). The campaign included digital, press and outdoor advertising directing people to the website as well as to a specially launched iPhone application. As a result there were 142,971 unique visitors to the clinic webpage and 9002 downloads of the iPhone app during May and June. A spokesperson for the department said that while the public was finding the resources useful, there was anecdotal evidence from some Medicare 10

“In terms of our doctors, we’d like more, of course, but the majority of our sessions are filled and generally there has been good uptake.” “We have gone back to basics to ensure we make it as easy as possible for doctors as they go between sessions.” Locals and individual GPs that the campaign also provided useful promotion of their services. The Fremantle Medicare Local operates the GP after-hours clinic at Fremantle Hospital and has received After Hours Health Networks funding to operate services for the Cockburn region, drawing on existing general practices which are using their own staff to extend services. The CEO of the Fremantle ML Ms Christa Riegler said her organisation had conducted

The WA Government has committed $8.4m over four years to encourage GPs to extend their opening hours to include weeknights and weekends. Of the 62 after-hours clinics listed on the WA Health website and iPhone app – 47 are located in the Perth metropolitan area including two locum services, and 15 in regional WA and the campaign to recruit more GP services continues. O

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Feature

Flying Doctor with Altitude It’s not every doctor who gets to listen to the roar of the radial engines on his very own Beech 18, but Stuart Adamson is not your average medico. Geraldton GP and skin cancer clinician Dr Stuart Adamson lives life at maximum revs! As his wife Di Walton, nurse practitioner and fellow-aviator, says “Stuart reckons if you’re not living on the edge you’re taking up too much space.” When Medical Forum rang Stuart he’d just taken possession of a World War II Willy Jeep – and it started first time. “It arrived last night from Rockhampton – a genuine 1941 US Army Jeep and an awesome bit of kit. It’ll go nicely with our 1948 Twin Beech 18 for our annual airshow, the Valley View Vintage and Military Weekend. We had about 4000 people last year and raised more than $6000 for local community groups. The flying has another side, too. We have a Cessna 185 as well and we do medical clinics and quarterly checks to mine sites,” Stuart said. “We’ve been doing this since 2004 when we started at the Sir Norman Brearley Terminal at Geraldton airport. Now our surgery is near the front gate of the aerodrome and

QDr Stuart Adamson

we look straight down the runway from the consulting rooms.” Stuart is passionate about the symbiosis of medicine and aviation and he’s keen to get young doctors out of their comfort zone.

disorder like me it’s a wonderful opportunity. Free flying lessons, rural mentoring and attending the clinics with us. You’ll end up with a Private Pilot’s Licence and then you can stay if you want to or go off and do something else, it’s up to you.”

“We’ve been offering a Midwest Aero Medical Rural GP Flying Scholarship for quite a while now. For a Gen Y doctor with half a personality and a degree of attention

“A few people have called but they all want to do some sort of FIFO – come up here, do a flying lesson and the odd clinic and then go back to their comfort zone in

Growing to meet Western Australia’s health care needs We are gearing up for the future with major redevelopments at our Bunbury and Murdoch Hospitals, completing in 2012 and 2015, and new public and private hospitals in Midland, opening in late 2015.

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There will be more career prospects for doctors as we grow to six Western Australian hospitals, with new and expanded specialties. St John of God Midland Public Hospital will have significant specialist and junior medical workforce requirements.

s 59,400 more patients a year s 551 new beds s 1,230 extra staff s Extensive new facilities s Education and training prospects s For more information, visit www.sjog.org.au HEAD OFFICE Ground Floor 12 Kings Park Road West Perth WA 6005 T (08) 9213 3636 F (08) 9213 3668 E info@sjog.org.au

12

BUNBURY Cnr Robertson Drive & Bussell Hwy Bunbury WA 6230 T (08) 9722 1600 F (08) 9722 1650 E info.bunbury@sjog.org.au

GERALDTON 12 Hermitage Street Geraldton WA 6530 T (08) 9965 8888 F (08) 9964 2015 E info.geraldton@sjog.org.au

MIDLAND PO Box 1254 Midland WA 6936 T 1800 735 719 F 08 9213 3668 E info.midland@sjog.org.au

MURDOCH 100 Murdoch Drive Murdoch WA 6150 T (08) 9366 1111 F (08) 9366 1133 E info.murdoch@sjog.org.au

SUBIACO 12 Salvado Road Subiaco WA 6008 T (08) 9382 6111 F (08) 9381 7180 E info.subiaco@sjog.org.au

PATHOLOGY 23 Walters Drive Osborne Park WA 6017 T 1300 367 674 F (08) 9204 2974 info.pathology@sjog.org.au

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Perth. Variety is the spice of life as a GP, it maintains your sanity. It’s too easy to become staid, bitter and twisted. If you’re a procedural registrar who wants to do some anaesthetics and a bit of flying on the side it’s a great opportunity.” According to Stuart, there are some real problems within rural medicine in WA – IMGs and bureaucratic bungling being two of them. “The IMGs sometimes find themselves in quite difficult situations. They go to very remote places lacking Australian medical experience and, at times, their supervision and mentoring suffers accordingly. Issues such as cultural differences and language proficiency make it very difficult for some of them to pick up subtle cues in a consult.” “And as for bureaucracy – there’s a town to the east of us that just might be Mount Magnet, they’ve got a multi-million dollar AMS that’s designated for chronic disease management and everyone walks in with coughs, colds and sore holes. And just up the road is the WA Country Health Service

It’s too easy to become staid, bitter and twisted. If you’re a procedural registrar who wants to do some anaesthetics and a bit of flying on the side it’s a great opportunity. that’s designed for acute care. So that’s two health services in a small country town both running at one-third steam and competing against each other for funding. Where’s the sense in that?” Stuart, understandably, is a passionate advocate for nurse practitioners. That’s not surprising because his fellow-aviator in the Beech 18 cockpit is one and also his wife. So who gets the captain’s left-hand seat? “That’s our only source of marital discord. I’ve got my night flying rating and Di’s qualified to fly in formation so it usually comes down to scissors/paper/rock. Our profession can be so ego-driven and some

doctors actually believe that they’re the only ones who can prescribe panadol or dispense bandaids. We’ve got a finite health dollar, unlimited demands on the health system and an ageing population rife with obesity and diabetes. Some of these nurse practitioners are spot-on!” Stuart’s looking forward to next year’s Valley View extravaganza in early April. There’ll be military aircraft, gliders and a Saturday night concert with a special guest. And yes, there’ll be a genuine Willy’s Jeep too. “It’s a great weekend and this year, after going through a four foot thick dossier of documents with CASA, we’re hoping to be a fully-fledged air-show. And the future? My next purchase will be a Ferret Scout Car and I’d love to own a P40 Kittyhawk. There’s one going for $3.7m but I’m probably a few Powerballs short of that!” O

By Mr Peter McClelland Valley View Vintage Weekend: www.coralcoastair.com.au

EXPAND YOUR SKILLS THROUGH HANDS-ON SIMULATION TRAINING ECU Health Simulation Centre is a specialist training centre situated at ECU’s Joondalup Campus in Perth. The Centre offers a selection of high and medium fidelity simulation training courses, offered in conjunction with the Department of Health, Western Australia. Featuring a range of state-of-the-art facilities and equipment including Laerdal’s SimMan® 3G patient simulator and METI’s Human Patient Simulator®, the only patient simulator with the ability to provide respiratory gas exchange, anaesthesia delivery, and patient monitoring with real physiological clinical monitors, the courses are designed to expand upon a practitioner’s existing skills and knowledge. Course selection: ȸ ARC Advanced Life Support Level 1: Immediate Life Support ȸ Intensive Care Crisis Resource Management ȸ Emergency Medicine Crisis Resource Management ȸ Advanced Post-Anaesthesia Care Unit ȸ Anaesthesia Crisis Resource Management ȸ Effective Management of Anaesthetic Crisis (EMAC) – Accredited with the Australian and New Zealand College of Anaesthetists ȸ Advanced and Complex Medical Emergencies (ACME) – Accredited with the Australasian College of Emergency Medicine The next round of courses commence in November, 2012. To register your interest, contact ECU Health Simulation Centre on 6304 3557, email simulation@ecu.edu.au or visit us online at www.ecu.edu.au/simulation 303 LOWE ECU7581 CRICOS IPC 00279B

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13


News & Views

Are You Listening to the Kids? Processing complaints from children requires particular savvy, which government departments and the rest of us can take on board. t "DDFTTBOESFTQPOTFJTGBJS USBOTQBSFOU and timely.

How can a complaints system in a government department be more accessible and responsive to children? The Commissioner for Children and Young People (CCYP) held a seminar to explain how. About the same time, the State Government said it would use CCYP to implement one recommendation of the Blaxell Report stemming from events in Katanning â&#x20AC;&#x201C; to set up an independent complaints advocate to assist children, parents or guardians deal with relevant government agencies. This strengthens CCYPâ&#x20AC;&#x2122;s role under current legislation, which only allows it to monitor how government agencies perform in handling child complaints (but not to deal directly with complaints). As it happens, the legislation governing CCYP is due for review at the end of the year. Issues to consider include: the mandatory reporting of child abuse (with the Country High School Hostels Authority now on the mandatory reporting list); the ombudsmanâ&#x20AC;&#x2122;s role; and the fact that children at risk may not have regular access to a guardian or parent (e.g. in a boarding school or children in the custody of the State). The recent CCYP seminar emphasised that making government agencies more childfriendly in handling complaints remained a priority. Allan MacDonald from Equal Opportunities Commission said the commission was required to take complaints in writing from a legal guardian or parent. Although most complaints ended up being conciliated, some people wanted compensation or to make an employer (e.g. of a teenager) accountable, so these complaints could end up being handled by the State Administrative Tribunal (SAT) and overseen by the Justice system. As senior legal officer with the EOC, Allan assists people to present cases to SAT, or he conciliates between employer, young person and parent. Gail McCahon, Assistant Manager of the Complaints Division of the Health and Disabilities Services Complaints Office (HaDSCO), said less than 3% of complaints to them were from people under the age of 18. In fact, 30% of complaints were from prisoners. A parent or guardian is necessary to access relevant medical records but, otherwise, a complainant can be represented by another interested person. More serious matters are handed to AHPRA. 14

Amy said when Michelle Scott was appointed as the Stateâ&#x20AC;&#x2122;s first Commissioner in late 2007 she investigated a â&#x20AC;&#x2DC;best practiceâ&#x20AC;&#x2122; complaints system for children. A national search yielded little to go on so she used consultation with a focus group of 30 young people and other resources to produce guidelines for a child-friendly complaints system, Are You Listening (see www.ccyp. wa.gov.au). Other government departments indicated that complaints from children were rare. QCCYP Principal Policy Officer Amy Tait

We put the perspective that children probably have as much to complain about as the rest of us and if they are not complaining it is because there is a barrier. The seminar was told the mental health advocate role was already important in advancing complaints through the system, as well as overcoming any distrust of government agencies. A lack of advocacy for at-risk children was one of the concerns expressed by Amy Tait, Principal Policy Officer at CCYP, when highlighting solutions for children having problems getting their complaint heard. Although Katanning was never mentioned, everyone is acutely aware of what happens when a childâ&#x20AC;&#x2122;s complaint goes unheeded, not least of which is the child not having the courage to complain again. Amyâ&#x20AC;&#x2122;s guiding principles for agencies included: t ,FFQUIFDIJMETCFTUJOUFSFTUTQBSBNPVOU t 5IFZOFFEUPCFIFBSEBOEUBLFO seriously â&#x20AC;&#x201C; children find the power imbalance with adults intimidating and they have intense fears around being believed, respected, exposed and victimised (as a troublemaker). t 1SPWJEFTVQQPSUBOEBEWPDBDZoUIJT includes a safe place, non-reliance on writing skills, face-to-face with one advocate, and being kept up-to-date with complaint progress. t 3FTQFDUDVMUVSBMBOEPUIFSEJGGFSFODFT (e.g. differing needs and capabilities).

â&#x20AC;&#x153;We put the perspective that children probably have as much to complain about as the rest of us and if they are not complaining it is because there is a barrier. So itâ&#x20AC;&#x2122;s incumbent on the agencies to open up to enable them to participate,â&#x20AC;? Amy said. â&#x20AC;&#x153;A lot of government agencies have a significant role in young peopleâ&#x20AC;&#x2122;s lives â&#x20AC;&#x201C; health, education, transport â&#x20AC;&#x201C; they impact a lot. Children face unique barriers. They have a deeply held fear of not being taken seriously. Itâ&#x20AC;&#x2122;s amazing how consistent this is. Being dismissed by adults or laughed at is a fear to be overcome.â&#x20AC;? â&#x20AC;&#x153;They also donâ&#x20AC;&#x2122;t understand government processes and what happens when they make a complaint, which can lead to concerns about being exposed or victimised, or worse, that the person they complain about will find out, which is incredibly scary. They are taking on Goliath.â&#x20AC;? â&#x20AC;&#x153;At the front end, itâ&#x20AC;&#x2122;s about inviting them, making sure there are different ways of lodging complaints â&#x20AC;&#x201C; Child Protection will now accept complaints by SMS.â&#x20AC;? Amy said simple explanations and straightforward systems should be available and accessible to the most vulnerable children to help establish relationships. The Commissionerâ&#x20AC;&#x2122;s consultation highlighted how children often preferred to have an advocate complain on their behalf. Friends, teachers, and parents were mentioned. â&#x20AC;&#x153;Children at risk might not have an advocate or parent to support them, so the system needs to support the child to make a complaint.â&#x20AC;? The first step is the CCYP complaints advocate. O

By Dr Rob McEvoy

t )FMQDIJMESFOOBWJHBUFUIF workings of bureaucracy â&#x20AC;&#x201C; simplify and minimise barriers. medicalforum


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Feature

Blaxell Inquiry: Lessons Around Child Abuse In country towns and elsewhere, family doctors hear a lot of what goes on, often relayed in confidence, so these events should interest Medical Forum readers. Even a casual browse through the 465page Blaxell report, St Andrew’s Hostel Katanning: How the System and Society Failed Our Children, leaves those with compassion and a sense of fair play astounded that events like this could happen for so long. Little wonder that the Katanning community is fractured, and many people are angry and coming to terms with what has been allowed to happen. The inquiry’s revelations, and now a national Royal Commission on child abuse pending, will all make health workers and others more alert to possibilities. Whether it will embolden Western Australians to speak out, no matter the consequences, is another matter. Changing mandatory reporting and defamation laws, or how government departments handle child complaints is one thing, but the real change needed is in community attitudes and behaviour. For small communities, the knock-on effect will be felt for many years. The report estimates that about half of those directly affected are unlikely to have come forward during the 40 days of hearings, 85 witness accounts, and 64 statements before Hon Peter Blaxell. Of the 160 people who contacted the WA Inquiry, 38 gave information regarding St Christopher’s Hostel in Northam and 11 spoke of other hostels under the Country High School Hostel Authority. This restricted public sector inquiry said 48 people have alleged sexual abuse while residing at St Andrew’s Hostel (38 against Dennis McKenna, seven against Neil McKenna and two against a third staff member). Abuse commenced mostly at ages 13 and 14, often continuing for years. Another 10 alleged victims have disclosed sexual abuse but chosen not to proceed with a prosecution (five against Dennis, four against Neil, and one against both).

Background St Andrew’s Hostel at Katanning offered residential care to students from outlying areas who were attending Katanning Senior High School. The Hostel opened in 1964 and between 1975 and 1990 the warden was Dennis John McKenna, and between 1985 and 1990 the senior male supervisor was his brother Neil Vincent McKenna. Dennis allegedly abused between three and seven boys each year between 1976 and 1988 (i.e. those who have come forward). He was first convicted of 19 offences in the Albany District Court in 1991 and sentenced to 16

seven years imprisonment. He was released in April 1993 after serving the non-parole period. By 2010 a further six victims had come forward and he pleaded guilty to 10 additional offences in the Perth District Court in August 2011. That guilty plea and his reimprisonment triggered the Inquiry and demands for answers as to why his offending was allowed to continue for so long. A further 15 new complainants have come forward and he has only recently pleaded guilty to another string of offences. In 2012, Neil was convicted and imprisoned for three offences committed on a female student in 1991.

Lesson 1: Dubious appointments During 1975, Dennis successfully applied for an advertised position as “housemaster” at St Andrew’s Hostel, which was having trouble attracting staff. Aged 29 and single, he had no prior experience applicable to the position. He provided the names of a priest and a nun as referees and after an interview by three Board members was given a favourable reference by the Catholic youth group he had been working with. In February 1976, after the then warden resigned, he was promoted to warden by the then board, ahead of a married couple who had applied. During Dennis’s time as warden, two of his brothers (Wayne and Neil), and four of his brothers’ wives were appointed to fill vacant staff positions at the hostel. All but one took supervisory positions and none had previous similar experience working with children, only one position was advertised, and no one was interviewed by Hostel board members before appointment. In later evidence, Dennis McKenna confirmed he had employed his family without any formalities and agreed that

one reason was that a child abused by him would find it difficult to confide in one of McKenna’s relatives.

Lesson 2: Grooming and pattern of offending The Inquiry heard that vulnerability to McKenna’s offending was increased by the lack of scrutiny of his behaviour and the belief (by parents) that he would do the right thing (by their children). To enable his offending, McKenna groomed chosen students so that they would succumb to his wishes, using a process of rewards and threats. The rewards included privileges with late nights and TV watching in his flat, through to supplying alcohol, special trips or appointing students to positions of authority over other students. The threats, real or implied, included imposing unpopular hostel duties or organised public humiliation of students, through to suspensions and expulsions or threatened defamation. Each of the junior and senior boys’ dormitories had a set of showers with no doors or curtains, which Dennis visited regularly under various pretences, even taking and developing photos of students with his camera. Drinking alcohol was sometimes a prelude to the sexual abuse, as was watching pornographic or explicit videos (after VHS technology became available in the early 1980s). McKenna regularly intimidated students and ensured compliance by telling them of his influence with the Authority and the Hostel board. This included threats of expulsion and making it difficult for students to enrol at other hostels, which for families facing an expensive boarding school at Perth, raised the prospect of their children not being able to complete

INQUIRY RECOMMENDATIONS 1. The Country High School Hostel Authority (CHSHA) put in place a proper complaints system for children, one that facilitates complaints made externally.

4. The Education Department review how schools deliver protective behaviours programs, including whether they be mandatory.

2. The State Government establish a proper' complaints system for child abuse that is across all government agencies and acts as a ‘one stop shop’ for any complaint; and recommends steps to remove fear of legal retaliation in making a complaint. [Partially implemented].

5. The CHSHA review the roles and responsibilities of College Boards of Management and their relevant Constitutions and consider training Board members in complaint handling, duty of care and protective behaviours.

3. Staff of CHSHA become mandatory reporters under the Children and Community Services Act 2004. [Implemented]

ED. These recommendations fit the Inquiry’s limited terms of reference (only some public sector agencies could be examined).

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secondary education. As early as 1977, a complaint of sexual abuse from one of McKenna’s victims to the Head Prefect resulted in the complainant’s immediate expulsion, on fabricated grounds.

Lesson 3: Exerting control “The evidence shows that Dennis McKenna ruled St Andrew’s Hostel with an iron fist, and that he played favourites with some selected students while at the same time targeting others for vilification. He was able to orchestrate campaigns to humiliate particular students with impunity.” The report outlines how favouritism was used to groom groups of boys and victims within them. He also controlled student behaviour to reduce the chance of any complaint: boasts and threats of his ability to expel students; restricting their ability to communicate with parents and friends; opening students’ mail; and not tolerating friendships with potential allies. “This mixed environment of intimidation and favouritism within the Hostel was one of the significant contributing factors which enabled McKenna to evade justice for his crimes for a period of 15 years,” Blaxell said.

Lesson 4: Grooming significant others McKenna endeared himself to members of the local community in a variety of ways. He ensured Hostel students were involved in many voluntary community activities, from doorknocking for the Red Shield Appeal and operating stalls at the Katanning Show, to helping Meals on Wheels and fundraising for Freedom from Hunger. Police cadets stationed at Katanning were boarded at the Hostel, acting as parttime supervisors during evenings and on weekends. The Hostel installed additional facilities that made it a shining example in the WA school hostel community. medicalforum

WA DOCTORS ON SEXUAL ABUSE In our April 2012 E-poll, of the 92 GPs who responded, 76% thought early education of children in schools to say no and/or speak up could help a recurrence of such instances of sexual abuse as occurred in Katanning. ED. The response fits closely with Recommendation 4 of the Blaxell report

Lesson 5: People failing to act Witnesses testified that McKenna often threatened defamation proceedings against them, which stopped them from exposing his behaviour. This went as far as one member of the Hostel Board not reporting matters when his own son was involved, something Peter Blaxell described as gross breaches of responsibility to others. Police failed to investigate an allegation that McKenna was a paedophile while dealing with a related matter in 1980. The Hostel Authority failed to investigate an allegation of sexual abuse against McKenna in 1980, as did the Hostel Board in 1982. Both agencies failed again despite written allegations in 1986, and instead joined with McKenna in threatening the authors of the allegation (and others) with defamation proceedings. The report outlined how Maggie Dawkins, as group leader for the Westrek project at Katanning, was told by a former St Andrew’s Hostel student of sexual abuse by McKenna. Despite confronting Katanning Police, her superiors and her supervisor within DET and McKenna himself with this allegation, McKenna was able to bring pressure to bear on her from within her own department – she thereafter remained silent and was transferred to Bunbury. A school official failed to respond appropriately to written allegations made by a student in 1986, instead siding with McKenna and intimidating the student. In another instance the headmaster rejected

allegations of sexual abuse from a Hostel student and his mother, and did not investigate further.

Lesson 6: Defamation law as a weapon The report says a very significant factor that inhibited allegations of sexual abuse was that many people who otherwise would have done so were fearful of being sued for defamation. There were 11 specific instances where people were threatened with defamation proceedings. It says McKenna used these threats very effectively to prevent exposure of his sexual abuse. He even successfully manipulated the Authority into paying the legal costs for his solicitor’s letters threatening defamation proceedings against four parents who had circulated correspondence referring to his “suspicious suggestions”. All further mention of the “suspicious suggestions” ceased. But for fears of defamation proceedings, the report says McKenna’s offending would have been exposed in 1976. Ms Haddow’s evidence to the Inquiry highlighted how laws on criminal defamation were used by McKenna as a weapon against her, rather than as a defence, backed by a school official and leaving Ms Haddow feeling she had no choice but to comply with McKenna’s demand that she apologise. The report notes that these days, as far as children are concerned, there are statutory provisions that allow voluntary reporting of abuse, neglect or concerns about a child's wellbeing, with protection from liability for the informant (Children and Community Services Act 2004). O

By Dr Rob McEvoy

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Guest Column Award

Standing Up and Speaking Out One of things we celebrate most here at Medical Forum is our guest columns. Each month we ask columnists from all walks of life but mostly from within the medical profession to speak out about the things that concern them, amuse them or just plain annoy them. We are constantly blown away by the quality of opinion and the elegance of expression, so we thought it right and fitting to acknowledge the best opinion writing of the year in our last issue for 2012. This year we have inaugurated a perpetual award for the best guest column up and including our October issue.

We asked our advisory panel of Dr John Alvarez, Dr Scott Blackwell, Ms Michele Kosky, Dr Joe Kosterich, Dr Alistair Vickery and Dr Olga Ward as well as the national president of the Australian Medical Writers Association, Dr Justin Coleman, to adjudicate from a shortlist of nine columns. We asked them to score each columnâ&#x20AC;&#x2122;s merits when it came to: t t t t

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This yearâ&#x20AC;&#x2122;s shortlisted columns were Mr

Tim Costelloâ&#x20AC;&#x2122;s The Poverty of Silence and Dr David Borshoffâ&#x20AC;&#x2122;s When the Piper Calls the Tune from February; Dr Sarah MacEwanâ&#x20AC;&#x2122;s The Real Tyranny of Distance from May; Dr Peter Wintertonâ&#x20AC;&#x2122;s Creating a New Paradigm and Judge Denis Reynoldsâ&#x20AC;&#x2122; Early Invention is the Key from August; Mr Geoff Diverâ&#x20AC;&#x2122;s Is it Time to Reform Confidentiality and Hospital IT has a Long Way to Go by Dr Richard Riley in September; Dr Bertel Bultenâ&#x20AC;&#x2122;s Dying in a â&#x20AC;&#x2DC;Vaguely Horrificâ&#x20AC;&#x2122; Society and Dr James Quirkeâ&#x20AC;&#x2122;s Bureaucracy Affects All in October. The winner of this yearâ&#x20AC;&#x2122;s Medical Forum Guest Column award is Bertelâ&#x20AC;&#x2122;s forthright column on

QThe Judges: Dr John Alvarez, Dr Olga Ward, Dr Alistair Vickery, Dr Joe Kosterich, Ms Michele Kosky, Dr Justin Coleman and Dr Scott Blackwell.

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If you have a vacancy â&#x20AC;Ś â&#x20AC;Ś WEâ&#x20AC;&#x2122;LL FIND THE PERFECT FIT E recruit@ruralhealthwest.com.au T 08 6389 4500 W www.ruralhealthselect.com.au

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The Winner... euthanasia, a debate which continues to rage this month in our letters page. Justin Coleman said of Bertelâ&#x20AC;&#x2122;s column: â&#x20AC;&#x153;Bultenâ&#x20AC;&#x2122;s argument journeys smoothly from his personal experience to the broader legal controversy, and we are shown a lucid view of his final position without feeling we have been dragged there.â&#x20AC;? Justin also congratulated Geoff Diverâ&#x20AC;&#x2122;s column. Geoff, who has been a powerful advocate for mental health patients, spoke bravely and eloquently about the issue of patient confidentiality only a few short months after he lost his daughter to suicide not long after being discharged from hospital. Our judges gave his column second. In third was Dr Sarah McEwanâ&#x20AC;&#x2122;s eloquent nt piece on her frustrations dealing with mental health patients in remote areas.

Geraldton GP Dr Bertel Bulten said he was honoured to win the first Medical Forum guest column award. His column has sent a few ripples through his community in the Mid-West and also through the medical community. He believes the debate on euthanasia is important. â&#x20AC;&#x153;People want to have this discussion. Itâ&#x20AC;&#x2122;s (euthanasia) not for everyone, definitely not, but a lot of people want to be able to discuss it.â&#x20AC;?

n Guest Colum

Bertel says he thinks itâ&#x20AC;&#x2122;s very important for doctors to speak out on all manner of issues. â&#x20AC;&#x153;In my opinion, doctors tend to be obedient â&#x20AC;Ś thatâ&#x20AC;&#x2122;s good on one hand but on the other itâ&#x20AC;&#x2122;ss also good to speak up sometimes. hand it I have opinionss so I thought OK, itâ&#x20AC;&#x2122;s it s good to share them to t ensure the discussions remain open.â&#x20AC;?

We would like to salute all our columnists mnissts who took time out from their crazy, hectic schedules to share their thoughts with readers and colleagues and we look forward to more in 2013. O

Society guely HorriďŹ c Dying in a Va draws on his experiences in genoneraeutl prahancticasiea and open.

ate lten a keeps the deb Dr Bertel Bu Almost all died Geraldton GP ds to suggest the profession ly ill patients. was from terminal suffering that tralia h without the in the Netherlan ia here in Aus -of-the-art natural deat n of euthanas thanks to state

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h is what my horrific deat wn feared the patient Mr Bro 90 years old most. Nearly inoma, this tic bowel carc with metasta end was nigh w cer kne his ex-marine offi ensure he me if I cou ld and he asked dignity. The in home and wou ld die at , not with den not bed-rid latter meant hav ing to g catheter, not an indwellin above all, e opioids and take high-dos ent and end g tota lly dep not becomin

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19


Have You Heard?

Clinipath acquisition Following the ACCC green light, Clinipath Pathology is finalising acquisition of Healthscope Pathology in WA. Apart from rebranding cars, collecting centres, stationery etc, the laboratories in Kalgoorlie, Busselton and the Mount Hospital need to be converted to Clinipath’s computer system and new chemistry analysers installed. Doctor reporting preferences and billing for Medicare rebatable tests remain unchanged. Clinipath Pathology CEO Dr Gordon Harloe cut his teeth on the Accord acquisition some years back so none of this is particularly new. He said people were his main focus, from training staff in new systems to taking on new lab staff. The cytopathology and histopathology labs have already been amalgamated as has the Kalgoorlie laboratory.

Mental health smoking At the recent HDWA Chronic Lung Diseases forum high smoking rates were noted in mental health. Apparently, 32% of mental health patients smoke (60% of those with schizophrenia), compared with 17% in the general population. A national tobaccofree program was combating this nationally – psych hostels, inpatient wards, drop-in centres – 10 weeks at two-hours-perweek involving motivational interviewing and follow-up phone calls. Relapses and boredom were two big barriers to people quitting. Getting patients to believe in themselves is very powerful but smoking staff were a strong demotivating force – cigarette rewards handed to patients or staff arriving early at work for a smoko. In WA, 28 people have been trained to deliver the 10-week programs (with some Mental Health Commission funding).

said there was a clear need for the private sector to complement traditional public teaching in hospitals, given future demands. Their hospital group has 64 junior medical officers starting training in 2013, 40 of whom are under the Commonwealth’s Specialist Training Program, with Subiaco Hospital offering a new medical and surgical program for training doctors. Each year, their hospitals and laboratory in WA and Victoria also provides rotations to 600 medical students.

Healthdirect value questioned UWA’s Prof Daniel Fatovich and RPH anaethetist Dr Joseph Ng had their study into Healthdirect’s telephone triaging published in the MJA. The big finding from 2008-09 data was that 52% people who attended the RPH emergency did so after Healthdirect had advised them to stay away. Daniel said factors around low compliance with Healthdirect advice were limited availability to after-hours primary care, and consumer attitudes to the helpline – more research was needed to justify the cost of the service on the grounds of reduced demand on EDs. Medical Forum’s GP August E-poll on Healthdirect showed over half of polled doctors thought the service was either a waste of money, had little impact on patient care or was a political tool, not a medical one. Only 8.3% thought it might lessen their load and 7.5% said it was a useful adjunct. So value to primary care is in question as well.

Private sector doctor training WA will get funding for 40 new hospital internships from 2013. St John of God Health Care noted that 32 of these positions would be in private hospitals (federally funded) and CEO Dr Michael Stanford 20

Serco getting started Serco Australia, with the contract for nonclinical services at Fiona Stanley Hospital, has received some adverse press in the UK. The BMJ reports that an independent

clinical review found that between JanuaryJune 2012 the company gave false data 252 times about how it was performing when handling GP after-hours services for two local NHS trusts. Serco apologised for the breaches, found to be ‘inaccuracies’ rather than a deliberate attempt to enhance performance reporting. The NHS said it still considered the company ‘safe and effective overall’. Serco had an exhibitors stand at the recent WA Health Conference.

Pharma code The ACCC has approved the 17th edition of the Medicines Australia Code of Conduct, allowing it to be implemented next January for another three years. In WA, 250 doctors polled by us on pharmaceutical sponsorship wanted greater transparency than the Code offered, putting them at odds with one of the federal AMA’s points in its submission to the ACCC. Around 43% disagreed or strongly disagreed (cw. 31% agreed) with the idea that declaring sponsorship or payments to individual doctors by pharma companies may wrongly damage the doctors’ independence. Specialists especially disagreed. And about 1 in 3 GPs and specialists said doctors would not declare to their patients any conflicts of interest arising through pharmaceutical sponsorship. There is disquiet amongst our ranks.

Professional transparency Peel Health Campus management has been answering questions from The Legislative Council Estimates and Financial Operations Committee, which according to the government website is investigating the recovery by HDWA from Peel Health Campus or Health Solutions (WA) Pty Ltd of overpayment of about $1.8m and whether payments for services to doctors working at the Campus included a payment for patients admitted to ED there. Those interested to read transcripts can go to www.parliament.wa.gov.au and click on Committees>Current Inquiries – public hearings were scheduled as we went to press. Or if you are interested in recent SAT deliberations or rulings go to www.austlii.edu.au/ and search by keyword ‘Medical Board’. O medicalforum


GP Training

The Future of GP Training In 2010, WA General Practice Education and Training (WAGPET) surveyed all its GP supervisors and practices, their teaching workforce in effect(1). The idea was to do a rain check on the WA situation, in light of apparent increased demand for training placements in general practice – 144 GP supervisors in 74 practices responded during JanuaryMarch 2010 (over 70% response rate). With an apparent surplus of more experienced trainees to come, maintaining traineeship standards and numbers for junior posts, those that are more work with less return for the practice, is becoming an issue. Back in 2010, survey questions covered attitudes to teaching, current teaching levels, capacity to expand and activities associated with teaching. Some of the key findings still apply and were: t1FSTPOBMFOKPZNFOU BTTJTUJOHUIF profession, and exposing students and doctors to general practice were the main motivations of teachers and practices involved. tPGQSBDUJDFT BOEPG(1 supervisors) taught medical students and registrars, 21% (15%) medical students only, 10% (13%) registrars-only training. tPGQSBDUJDFTTBJEQBUJFOUDBSF improved due to GP registrar training.

the most direct teaching time. Most junior medical students sat in with the GP supervisor. t"NPOHTUUIFTVQFSWJTPST UIFSFTPVSDFT most called for were increased teaching staff, increased subsidies, more space and more supervisors. Some indicated that extra space was needed before they could take on extra teaching. t5FBDIJOHNFEJDBMTUVEFOUTBOEKVOJPS doctors cost practices (e.g. $3321 per week for PGPPP trainees). Only GPT1 and GP2 registrars returned a net financial benefit (e.g. $579 per week for GPT2). Of all the teaching models developed, the largest net financial benefit to a practice came from teaching more than one learner within the same training level. Financial support for teaching of medical students was rated most inadequate of all training levels. tTVQFSWJTPSTTUBUFEUIFZDPVMEJODSFBTF their teaching load in the short term and when the break-up of teaching preferences was considered, this equated to 85 more medical students, 17 more junior doctors and 74 more GP registrars. 1 Report – Sustainable Teaching in General Practice in WA prepared by Adelaide to Outback GP Training Program; method based on an earlier study undertaken in South Australia.

t(1TVQFSWJTPSTBUUFOEFEUFBDIFS up-skilling workshops relevant to junior doctors for 20 hours per year, and GP training 14.5 hours, and medical students 9.5 hours.

Current situation WAGPET now has 305 GP supervisors in 115 GP practices (excluding branch practices) and gets 1-2 inquiries per week from practices interested in taking registrars and prevocational QWAGPET CEO doctors. We Dr Janice Bell monitor capacity very carefully – especially to enhance vertical integration and deliver interesting composite posts. For 2013 WAGPET will place nearly 400 registrars and 100 prevocational doctors, with a majority in private general practices,” WAGPET CEO Dr Janice Bell said. By “vertical integration” she means one trainee teaching another. The rise in numbers equates to 25% more registrars and 150% more prevocational doctors than in 2010, more than was predicted capacity back then. “We focused on rural capacity first, and now we have the ability to address the outer metropolitan need without risking our rural contribution. We are very mindful of the need to manage capacity, especially if we want to maintain the safe and high quality experience, supervision and practical education that our GPs consistently provide to WA doctors in training.” She said that streamlined accreditation makes it easier for practices to participate. New practices and support from existing practices will be needed to manage the extra 40 registrars for WA that were recently announced for the coming two years. O

t5IFKVOJPS(15SFHJTUSBSTSFDFJWFE

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GP Training

Viewpoint: GP Supervisors Dr Keren Witcombe, Fremantle “Our practice takes students from UWA and Notre Dame, as well as nursing students and even some work experience high school students. We usually have 1-2 GP registrars at any time, and have been fortunate enough to retain some fantastic registrars at the end of their training. The quality of the registrars is extraordinarily high and they are a delight to have in the practice. There can be some organisational difficulties having registrars, with complicated paperwork to complete and indecipherable contracts to work out. However, this is easily beaten by the pleasure of having bright young things around the place, with their fresh outlook, dedication and IT savvy.”

Dr Peter Maguire, Narrogin "I am sure we all hope to see the discipline of General Practice prosper, and much of our motivation to supervise comes from a belief that our efforts will contribute to that. The task of the GP is undoubtedly getting more challenging and it is up to the current generation of experienced GPs to provide the training to meet those challenges.”

Dr Phil Reid, Kalgoorlie “It is a privilege to be asked by a trainee doctor for your opinion on a patient. At the conclusion of the consultation I take the learning point to the trainee for clarification or, better still, save it up for the 22

weekly meeting where everything that has flummoxed us is discussed in rapid fire e.g. this week, the diagnosis of chicken pox. A teaching practice is great fun; everyone’s point of view is valuable, and there is always a patient with a diagnosis of uncertainty that very occasionally the ‘old silverback’ who has known the patient for 32 years can solve. The problem is have we trained enough supervisors? The good teachers in medicine are often also in active clinical practice or have recently semi-retired to concentrate on teaching. There is no doubt you need to put a lot of work into educating yourself to teach. Good teachers are there to be discovered and to be encouraged and valued by the medical profession. Who will do that? It is important to allow teachers enough time to teach and, more importantly, enough time to prepare to teach a topic – as well, as pay them for it!”

Dr David Tadj, Albany

Dr Mike Civil, Kalamunda “Supervising GP registrars is very rewarding. Sharing some of our experiences with those who are keen to learn can lift what might be an otherwise routine morning surgery. We often underplay (and undervalue) our health care role; our patients appreciate our care but we don’t necessarily get a lot of recognition from our profession. A GP Registrar can change that. Not only is there immediate interaction and discussion but being involved in wellorganised training schemes gives great peer feedback.”

Dr Michael Comparti, Bunbury

“We have had GP registrars for over 10 years, and it is now difficult to imagine practising without them. One of our practice's objectives is to train and indeed inspire GP trainees about a career in rural medicine. I am lucky to work with a great team of doctors who share and support this passion for teaching. Our trainees get exposure to practice consulting as well as hospital medicine, as they take part in caring for our inpatients at Albany Regional Hospital. A number of our registrars also practise obstetrics or anaesthetics there.

“On reflection, the most amazing thing about the chance to sit and talk (‘teaching sessions’) with my registrars is my wonderment about both the complexity of cases they are seeing, and the enthusiasm they express. There is a lingering bemusement that I may have been that enthusiastic once, and that I am doing the same work but it never occurs to me that it is so complex. I do enjoy questions that force me to research why I do something rather than the obvious answer that it just works!

Preparing their tutorial has been a great way to update my clinical knowledge and reflect on my own practice, indeed our practice-wide systems. Trainees tend to have good IT skills and some useful insights into the latest developments at tertiary hospitals. Having GP registrars has been a rewarding and fun-filled experience for us, making them feel welcome in beautiful Albany and involved in our community.”

I am somewhat overwhelmed by the support offered! Whilst still feeling young, I realise that in my late 50s I must be a dinosaur. Our generation felt quite comfortable learning what we needed before getting on with it. I do feel the amount of 'training' I am told I need as a supervisor is probably a bit excessive. The number one reason we might stop taking registrars is the amount of red tape." O

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Guest Column

Looming Shortage of GP Supervisors Dr Sean Stevens was GP Supervisor of The Year, 2006, and as a younger GP he questions how we will impart his craft to upcoming GPs.

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he coming ‘tsunami’ of medical graduates will strain all levels of medical education. Already we are seeing inadequate numbers of intern places, next it will be RMO spots, then training places in all of the clinical specialties, including general practice. The challenge for our Regional Training Providers (RTPs) like WAGPET is to keep the quality of GP training high whilst expanding training places dramatically. My concern is that RTPs will either have to drop standards and allow poor quality practices to teach, or they will have to find alternative methods to train GP registrars. I am a firm believer in the current master/ apprentice model of teaching and I feel we should strongly resist any attempt by the universities or other institutions to take over GP training with theory-based programs. The only way to learn general practice is to start doing it under adequate supervision! That then leaves us with the question of how

to recruit, retain and expand good quality teaching practices. In a Senate Estimates Committee earlier this year, the Government revealed it wanted to expand the number of GP supervisors from the current 3438 to 4762 by 2017, a 40% increase. To do this, it will rely on an RTP budget expanded by only 20%. The Government also said it expected to gain extra registrar places by “a combination of recruitment of new supervisors and existing supervisors taking on additional registrars”. The supervisors I have spoken to plan to take less, not more, registrars. The reason is simple. At present, due to the GP shortage, teaching practices have the option of either a registrar or an empty room. Once the ‘tsunami’ starts to wash through, the option will become a permanent GP or a registrar. Registrars add an enormous amount to a practice but it is hard to justify taking extra registrars with all of the supervision and education requirements, paperwork, disruption and workforce issues that this entails while turning away committed,

quality GPs who require no supervision and will be a permanent fixture. A recent survey of 270 supervisors revealed 68% felt that teaching and supervision payments were inadequate, while only 10% believed they covered all practice costs. The GP Registrars Association is also on the record encouraging additional supervisor supports and a review of the business model behind supervision. GPRA estimates that practices supervising first year registrars are losing between $420 and $800 per week in patient income due to face-to-face training. This assertion is backed up by the fact that the corporates have refused to take registrars as the financial benefits don’t stack up. My advice to policy planners is to improve the practice subsidies for taking registrars, provide infrastructure funding to have dedicated teaching rooms, reduce the paperwork burden, and do it before the ‘tsunami’ is upon us. Unfortunately, recent experience of policy planning does not auger well. O

Viewpoint: GP Trainees Dr Carla DrakeBrockman, Nedlands “The last 18 months of GP training has been a remarkable journey of increasing responsibility from resident to registrar and soonto-be Fellow. I have had amazing support from my supervisors, training adviser and WAGPET through this process; right from the beginning with workshops, monthly regional education sessions, weekly in-practice teaching and daily chats in the corridors. This not only improved my knowledge and procedural skills but also my confidence and workplace satisfaction. To gain the most from my supervisor, we established a learning plan early on. I felt comfortable speaking about concerns and they encouraged me to seek regular feedback to push my own boundaries and expectations – clinical scenarios, work-life medicalforum

balance and self-care – so I have a long and happy career in general practice.”

Dr Louise Pearn, Esperance “To get the most out of your supervisor, pick one who will meet your specific educational needs – hard facts (basic term) versus practice management and consultation skills analysis (subsequent term). A 'learning plan' sounds dull but it does mean there is a sit-down discussion about what you and your supervisor thinks you need to know. Keep a list of topics for 'questions without notice' conversations. Teaching over coffee or breakfast first thing in the morning is a great way to make sure teaching happens and that everyone gets their coffee fix. Go with the flow initially at a new practice but review progress early if you would like to

change content or timing. Being enthusiastic is infectious – offering to give a tute is a great way to learn. To pick a training practice, go rural and remote, out of your comfort zone; this is an experience every trainee should have – you might even like it!”

Dr Dayani Subawickrama, Leeming I like to have a scheduled time with my GP Supervisor to go through complicated patient cases/dilemmas each week. Ask your supervisor to sit in with you while you consult to pass on practice tips/advice and ‘corridor’ teaching is great – if they are free, go get them! And finally, don't be shy to ask lots of questions, even if they feel like they’re obvious. In selecting a training practice, I talk to the registrar currently employed there to get a feel for the place – i.e. teaching, pay, hours etc. O 23


Health Networks

Reform Not Running Out of Puff Dr Rob McEvoy reflects on the recent Respiratory Network forum on chronic lung conditions, aimed at bettering service delivery. The recent forum ‘Chronic Lung Conditions – Improving Care in Health Reform’ left strong impressions with this observer who had limited background knowledge. NGO representatives and health professionals dealing with such issues as smoking, cystic fibrosis, COPD and lung cancer gave presentations, asked questions and took part in workshops and panel discussions. The purpose was to network as part of implementing the Respiratory Network’s model of care for chronic lung problems. With many participants in the public health system, particular perspectives and needs predominated. The workshop noticeboard notes reflected the complex considerations – “accredited CPD, online training, identify people with skills, remuneration of training and upskilling, more open communication between health professional groups, e-health and project specialists, complement services across GPs and pharmacists, patient education and referral, apps for phones and tablets”, and so on. All exciting possibilities for people open to change and not bunkered down in their treatment silos. One major impression is that everyone is grappling with information overload and speed-of-change, and this needs to be managed. The Models of Care and Health Networks that have emerged from the Health Department under Dr Simon Towler, an evidence-base convert, are an attempt to put overwhelming amounts of information into a digestible form. But they must function as more than a script for obtaining more research funds.

QProf Stephen Stick

Next, if community-based coordinated care (or a ‘multidisciplinary approach’) is necessary to reduce costs and compensate for dwindling health professional numbers, we must seriously learn what others are doing and be willing to actively share or hand over responsibilities. What are the best ways to use others in respiratory health? WA medical schools now teach medical and allied health students this approach to problem solving. In the same vein, supporters of Medicare Locals see them as facilitators for coordinated care while others say they just add to the confusion. The current scenario seems to cry out for managers who have both the responsibility and a licence for purposeful coordination, at selected levels along a referral pathway. With more disease management devolved into communities, existing community health professionals will need extra training in specialised care while hospitals remain tertiary problem solvers. It probably follows that access to tertiary experts will need to be more efficient – will nurse practitioners or telemedicine provide a worthwhile linkage?

Next, we should cherry-pick the health conditions that will benefit from a coordinated approach, ones that have recognised comorbidities, and hone our multidisciplinary skills on these alone – COPD, asthma, cystic fibrosis, diabetes, renal failure, cancer, etc. Last, change driven by health bureaucrats wanting to stretch budgets and aided by Medicare rebates and other funding considerations, is quite different to adoption of bright ideas at a ground level to create efficiencies through innovation. While funding models are important, they can stifle innovation, such as more mobile or adaptable service delivery. O

Lead or Follow – We Choose Respiratory Clinical Lead Prof Stick said the Respiratory Health Network that formed in 2007 now had 450 members – patients, clinicians, NGOs – with the stated aim of treating people closer to where they live and providing better access. “It is clear from the Commonwealth that funding for health is going into the community and care for complex chronic diseases in tertiary hospitals is going to be more difficult because funding is not going in that direction. If we don’t buy

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Fourthly, improved services means changes in human behaviours, especially uptake of consumer self-management. This requires skilful marketing at ground level. No more unused out-of-date consumer health directories but simpler consumer access points instead. And service providers will need to filter demand more skilfully, to minimise bottlenecks.

into this strategy then those of us looking after chronic respiratory disease are going to miss opportunities for our patients. It is important we network and get to know others providing services.” Models of care have been created for cystic fibrosis, COPD and asthma; then came chronic lung disease as an umbrella model, although COPD is the biggest consumer of resources in respiratory disease. “It provides us with a strategic direction for respiratory health and the restructuring medicalforum


QA chance to digest someone else’s point of view (syn. networking).

Rethinking Silos of Care Dr Scott Blackwell presented his primary care perspective, having worked with Palliative Care, the Federal General Practitioner QDr Scott Blackwell Council, and the Collaborative Primary Care Network.

demand was rising, and hospitalisation for people with chronic diseases may in fact worsen some patients.

He said different health professionals forming partnerships to care for chronic disease patients must cater for need and maximise both community and individual self-reliance, participation and control. This means health professionals need to relinquish some control and adopt a multidisciplinary approach, as happens routinely in palliative care.

“Why is this important? Not all chronic diseases are the same. It’s their journey and we need to devise a model that fits their disease and their lives. At one end we see chronic diseases where there are immediate consequences for which there are technological answers. Myopia or cataracts are good examples.”

“We have got to stop fighting people and massaging them into programs and ideas that we as clinicians have. The really important point is to be person-centred. People don’t live a life of chronic disease – that’s how we think – they actually live life and we need to impact positively on that.”

He suggested that current hospital and primary care models of chronic disease management were many years out of date,

“On the other hand, macular degeneration has deferred consequences for which it is important to diagnose early and manage properly to reduce the risk of blindness

within the Health Department means we sit alongside policy and can have more traction with respect to implementation. We have a focus for discussion with NGOs and others and improve access to services within the community.”

and education for consumers. The models include action plans for adults and children with asthma, directions for oxygen therapy use, and a framework for treatment of nicotine addiction (which includes online, workplace and other resources).

Models of care approach service delivery broadly – minimising risk factors, early intervention focus, accurate diagnosis, appropriate referral pathways, access to integrated and coordinated services, care for patients in an appropriate location,

He pointed to the success of the Living Well Without Smoking program to get young smokers to quit in the Rockingham Kwinana area and said pilot programs that work can then change service models. For example, the South Coast Medicare Local

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later. It needs a different plan. Obesity, addiction, type 2 diabetes etc. – diseases where symptoms are deferred or people ignore them – these are areas where society needs to spend a lot of money.” He said generalists like GPs would probably see value in coordinators whose job it was to pin it all together, while trust and respect between the primary and tertiary sectors need to be worked on. “In the future, hospitals will be solution shops, where someone with a chronic disease goes when there is a high intellect or technology capacity to solve a problem. Then the care needs to come back to where they live. People with chronic disease and their carers are making most of the decisions in the home. They need a lot of information to help them, and there are a lot of organisations and people who can do that and help them.” O

will set up a program for the 40 local adults and children with cystic fibrosis (CF), to deliver services close to home by integrating secondary and primary care. “The transition to a more district model will be a good test of the process because we will have to build capacity in the community through education – a way forward for partnerships between the health department, NGOs, and primary care.” O

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Guest Column

Emerging Child Protection Issue Female Genital Mutilation (FGM) is a complex issue which poses unique challenges for doctors, as Dr Aesan Thambiran explains.

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ecent local and national media reports have highlighted the issue of Female Genital Mutilation (FGM). While uncommon in Australia, it is an area that all health professionals who care for women and children from culturally and linguistically diverse backgrounds should be familiar. With the changing demographics in WA, FGM is an emerging child protection issue. The World Health Organisation defines FGM as “all procedures involving partial or total removal of the female external genitalia or other injury to the female genital organs whether for cultural or other non-therapeutic reasons”. FGM is an ancient cultural practice which predates organised religion. Today it is practised in some countries in West and East Africa and the Middle East and in some communities in Asia. It is not mandated by any religion and is not isolated to any religious community. In some parts of Africa, Christian and Islamic practise FGM and some Muslim communities do not practise it at all. It is often difficult for health professionals to understand the cultural belief systems which promote the practice. Typically, FGM is performed on young girls between the ages of five and eight years by a female elder, in unhygienic conditions without

anaesthesia. However, even young infants can be subjected to FGM. The reasons given for FGM include tradition, sense of belonging, preserving family honour and virginity, aesthetics and hygiene. It is important to remember that within these cultures, families believe they are acting in the best interest of their daughters. They do not consider FGM to be harmful. Many communities use the terminology “female circumcision” and/or “female genital cutting” and find the term FGM offensive. Depending on the presenting problem, it may be appropriate to ask female patients from high prevalence communities about FGM. It is preferable to start the discussion in a non-judgemental way e.g. “I am aware that in your country some women are circumcised, do you know anyone who has had this procedure?” Importantly, many women and/or children who have been circumcised may (1) not know the extent of their circumcision and/ or (2) be asymptomatic until menstruation or childbirth. Section 306 of the Criminal Code of Western Australia states that it is a crime to perform FGM on another person or to take a child from the state with the intention of having the child subjected to FGM. Under the Children and Community Service Act 2004, FGM is considered to be a form of physical abuse and is not currently governed

MERCEDES BENZ SPECIALIST

Over the past 10 years, Australia has resettled many families from countries where FGM is prevalent including Somalia, Sudan, Eritrea and parts of West Africa. Young girls from these cultural groups, who may have been born in Australia, are now at an age when FGM would traditionally be performed in their homelands. Health and education professionals need to be aware of FGM in this setting. Identifying a child at risk of FGM is difficult and needs to be handled sensitively. When taking a history from a mother with poor proficiency in English, it is advisable to use a professional female interpreter. The principle risk factor for a child at risk of FGM is having a mother or older sister who has already undergone FGM. Other risk factors include: t 4PDJBMMZJTPMBUFEXPNFOBOEDIJMESFO t 8PNFOBOEDIJMESFOXIPIBWFMJNJUFE contact with health care providers t "SSJWBMPGBGFNBMFFMEFSGSPNUIF community for a special event t "GFNBMFDIJMEDPOGJEJOHUIBUUIFZBSF going to undergo a “special procedure” and/ or travelling overseas for a “special event” Health professionals concerned that a child is at risk of having FGM should contact the Child Protection Unit at Princess Margaret Hospital or WA Police CAIT 94281666 or DCP on 92231125. Health staff should inform parents that FGM is illegal in Australia and anyone who performs FGM on a child, or takes a child out of WA for the purpose of FGM is committing a crime. This should also be documented in the child’s record. Any child who has been subjected to FGM in the past should also be referred to a paediatric gynaecologist for review. Doctors needing clinical advice can contact Dr Tamara Walters at KEMH or the Clinical Lead Paediatrician at the PMH Refugee Health Clinic.

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by mandatory reporting requirements.

• All repairs and servicing • All work guaranteed • Courtesy Vehicle available

For more detailed information about FGM the Royal Australian and New Zealand College of Obstetrics and Gynaecology has an excellent resource on its website http://www.ranzcog.edu.au. Click onto the publications tab. (Acknowledgments; Martha Teshome, Paula Chatfield and Sarah Cherian.) O ED: Dr Thambiran is Medical Director of the Humanitarian Entrant Health Service

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Guest Column

Surgical Audit: a personal view Dr James Aitken introduced the surgical mortality audit to WA, which has since been taken up nationally. He feels there is more to do.

D

uring the first 10 years of the WA Audit of Surgical Mortality (2002- 2011), the number of notified deaths under a surgeon fell from over 700 to under 600, or from 34.9 to 24.6 deaths per 100,000 population per annum (a 29.7% fall).

On the strength of WAASM, the ANZ Audit of Surgical Mortality was established in 2005 and data from two other earlyadopting states appears to be showing the same falling mortality. Historically, the public and government have afforded medicine considerable independence, notably in the area of selfregulation, a luxury not afforded other professions or safety-critical industries. Each time there is a major medical misadventure the appropriateness of selfregulation is re-evaluated. The UK inquiry into paediatric cardiac surgery in Bristol was a watershed event. Public anger forced a response from the government. The Minister of Health made a commitment to the collection and open publication of ‘detailed, robust and risk

adjusted’ data for individual surgeons. Independent organisations, such as Dr Foster, started to publish data over which the profession had no control. The subsequent open publication of individual cardiac surgeon’s outcomes has been accompanied by a 50% fall in risk-adjusted mortality. These outcomes are now 25% better than the rest of Europe. Numerous studies show that open publication improves outcome. In Australia there have many inquiries into medical failures, but none has had the potent combination of children and hearts. With no critical watershed event to trigger change, compounded by a lack of political leadership, the implementation of a more widespread and open audit has been delayed. The profession needs to use this temporary hiatus to put itself at the centre of inevitable changes. In July 2012 the British Medical Journal challenged the medical profession to ‘measure your team’s performance, and publish the results’. The ANZASM has started this process and its annual report shows data by each state. However, the

data is anonymous, in large part because some state health departments objected to the publication of indentified data, even at a state level. Note that the WA Health Department was not one of the objectors and has always encouraged WAASM to widely disseminate its data and reports. Such anonymity is not sustainable. Those who pay for health care (government) and use it (patients) want to know what they are purchasing. Surgical audit in Australia has not moved as far as the UK, but it has moved further than Australian surgeons appear willing to acknowledge. Full participation, that WAASM has now achieved, is an obligation, not optional. The next steps will be increasingly detailed open publication of individual performance. Surgeons who have always been at the forefront of audit need to lead the process. Or it will be done for them. O ED. These comments are the author’s personal view and may not reflect the view of the WAASM Management Committee, the A&NZ Audit of Surgical Mortality, the RACS or the WA Health Department.

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Conference Report

Rural Medicine Conference 2012 Western Australia recently hosted the national Rural Medicine Conference featuring Rural Doctors Association of Australia (RDAA) and the Australian College of Rural and Remote Medicine (ACRRM). A pleasing 449 delegates from around Australia visited Fremantle, mostly doctors, with 88 from WA. Rural and remote GPs, along with some interns, medical students and nurse practitioners participated in preconference workshops around Advanced Life Support, Obstetrics, Ultrasound Emergency Use, and Burns Management as well as the conference proper. The influence of information technology was evident with Telehealth showcased, presentations on media and lobbying, point of care testing, tele-ophthalmology and e-learning modules. Things have changed for bush doctors. As one GP said, he can do his rounds with his iPad and when a diagnosis is made, check management online and email the patient an information sheet, there and then. Keynote speakers were Dr Lachlan McIver (WHO, Fiji), Dr Tim Wolfe (emergency physician Utah), Prof David Atkinson (Kimberley Aboriginal Medical Services Council) and A/Prof Richard Matthews (chair of GPET).

QGeraldton’s Dr Kim Pedlow tries out exhibited ultrasound equipment on Sonosite rep Michael O’Hara. He recalled how his practice PGPP had recently been able to use his practice ultrasound with vaginal probe to diagnose a viable six week ectopic pregnancy. The patient had just returned from Bunbury with vaginal bleeding and pain that had settled. Local gynae Dr Sara Armitage operated and she was sent home the next day.

QTrent Little (UWA final year student), Dr Raj Pillay (rural locum), and Sophie Plowman (UWA student) enjoy a break in the exhibitors’ area.

WAGPET was the major sponsor, and the busy trade display included six or so training providers and a similar number of recruitment agencies, which gives you a fair indication of where the current emphasis lies. O

A Morawa Story “I went to Queensland Uni on a rural scholarship then did work in Mt Isa, Weipa, Thursday Island and every little mining town you can think of. Morawa compares well – about 1000 people and a good little hospital. There are about four mines around and 600 people in Perenjori,” she said before adding that her enlistment in the ADF Pilbara regiment sees her up there twice a year. “The mental health sessions have been great. We’ve got depression, alcohol and drug abuse, and adolescent problems. A mental health nurse does two or three days a week during the day, and a social worker come counsellor – so I get called after hours.” “The fishbowl effect isn’t a worry. All my patients are on Facebook so they know what I’m doing but if I’m going away I put something up. They know I have a life, my parents live with me, I have a four-year-old and my partner is an orthopod in Townsville.”

QDr Nalini Rao (with cup in hand) has been in Morawa for 2.5 years. She is from Fiji originally and says she will be in the town for at least another three or four years. 28

“The nurses at the hospital are great if patients rock up after hours – they triage them and ring me and a lot of things can be sorted out on the phone.” O

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Mental health workshop Medical Forum popped in on the ACRRM Mental Health Core Skills Training session. This was a conference version of the mental health training offered online. Completion of either gives doctors enough grounding to access Medicare Item 2715 to develop a Mental Health Treatment Plan in consultation with a patient. This training package was developed by Prof Geoff Riley, Dr Louise Stone and Dr Mike Eaton especially for rural GPs. Ben Tan said he found the course helpful, if only to confirm what he was doing with item numbers. Dr Russell Young from Albany learnt the importance of a good assessment of patients and the framework around Medicare item numbers. “Finding item numbers and what is going

QCourse developers Drs Mike Eaton (Busselton WA), Geoff Riley (Albany WA) and Louise Stone (Sydney).

to give you the best result for the patient can be very confusing. I spend a lot of time doing that. I work in ED so I do see patients with psychotic episodes in the middle of the night and in Albany we are well serviced with psychiatrists.” He said the ‘goldfish bowl’ effect of living in Albany was not bad compared to smaller towns but his wife, also a GP, has had some uncomfortable moments with mental health patients contacting her using social media. O

QDrs Margaret Trudgen (Perth-Pilbara), Mike Eaton (Busselton WA) and John Parry (Qld) get involved in group discussion. Margaret learnt that most GPs are in the same boat – things are complicated in mental health and the hardest part is finding time. She said she had been navigating the item numbers since they first came out and she tends to use the treatment plan item number and forget about the rest.

QDrs Richard Hayter (Qld), Russell Young (Albany WA), John Cooper (Thursday Island, ex Albany WA) and Ben Lee Tan (Lancelin, WA).

QDrs Bill Gunn (Qld) and Sarah Moore (Busselton WA).

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Course background

QDr Louise Stone said getting the best treatment costeffectively for patients is at the absolute core of what doctors do. GPs learn which item numbers to bulk bill to assist patients who cannot afford to pay.

“Good rural and remote doctors are also very strategic in the way they set things up – the practice nurse doing something, getting the psychologist to do a group session, talking to the schools so they can introduce things –investing time in group things,” she said. Being well known in a small town has its difficulties.

“Relationships are important. Your next door neighbour is hitting his wife and she comes to you for help – it’s tangled so you have to pick what you can do in the therapeutic relationship, say when your kids go to school together. It’s tough, especially when you have to schedule patients.” “Every time I run a mental health session, whether online or face-to-face, there is some rural or remote doctor in the audience who has had a horrible trauma they haven’t been able to fix, or faced a suicide of someone close they think they should have picked. It’s a good thing to get doctors together so those stories get told.” “Geoff Riley tells us sometimes things are not preventable, even with the best will in the world – we don’t pick up heart disease, diabetes or depression sometimes and we have to live with that. You do your best and it’s about the realness of it – a complex business with no perfect solution. Honesty is very important.” “Geoff gets it because he has been rural and a psychiatrist. Mike Eaton and I are both on the mental health services collaboration. Mike is very real and very practical. He has a gentleness and speaks of his patients with great respect, which is really important.” O

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Members on the rise The RACGP annual report says college membership is rising. In WA, this equates to 1742 full members as of September 28. DOHA figures put the total number of GPs in WA at 2664. In the 2011/12 financial year there were 1760 Australian registered GP members in WA, including IMG Associates who are registered GPs, but not included Affiliates, who are not registered. â&#x20AC;&#x153;Other membersâ&#x20AC;? include affiliates, GPs residing overseas, students and non-GPs. As membership is no longer compulsory to maintain registration/VR status, the full members presumably all believe the college offers value for money and is worth supporting. A full-time member pays $1050 a year, part-time $525 and registrars (not yet fellows) pay $330. Uptake of free associate membership by medical students is historically low. Those WA fellows of the RACGP who choose just to be QI & CPD participants number 692. WA does not keep a tally of GPs who are not VRâ&#x20AC;&#x2122;d or non-fellows. O

Vaccination Grants Sanofi Pasteur has awarded two of its five $20,000 Vaxigrants to WA â&#x20AC;&#x153;immunisation organisationsâ&#x20AC;?. UWA Medical Centre, which provides travel medicine advice to UWA students, aims to increase vaccinations by 30% for travelling students, by 20% for booster and missed childhood vaccinations, while increasing pre-travel advice consultations by 50%. Immunisation Alliance WA, a group of pro-immunisation Western Australians of unknown identity (www.immunisationalliance.org.au), has received two yearsâ&#x20AC;&#x2122; funding from the Department of Health to set up an office and part-time project officer (as a charitable NFP organisation). Its grant is aimed at increasing childhood immunisations within lowuptake consumers through a campaign called â&#x20AC;&#x153;... And I immuniseâ&#x20AC;?. O

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BENEATHthe Drapes X Former RPH Director of Nursing Maha Rajagopal has been appointed Commissioner Lead, a role created to prepare for the transition of some services to FSH in 2014. RPH will be recommissioned as a 450 bed Tertiary Training Hospital from its current status as 650+ bed Tertiary Hospital. X Dr Doug Bridge recently retired as RPH’s Head of Department of Palliative Care. Dr Kevin Yuen is the new replacement. X The new State Director for DonateLife WA is Dr Bruce Powell, previously at ICU Rockingham General Hospital.

ALL THE BEST FROM SUBARU

X Brightwater Care Group CEO Dr Penny Flett has won the 2012 WA Seniors Award in the category Westscheme/ COTA WA Champion for Seniors Award. X Dr Lin Chan has been named 2012 WAGET GP Registrar of the Year, Dr Graeme Fitzclarence has won the 2012 Prevocational Community Medicine Award and the South Regional Medical Group has been name Training Practice of the Year. X Mr Brad Potter, has been named National Business Broker of the Year for 2012. Brad, who won the national rookie’s award in 2011, has been brokering businesses in the health care sector. X Mr Jeffrey Williams has been appointed Director of Nursing at St John of God Midland Public and Private Hospitals. X Dr Catherine Engelke, from Kununurra, has won the RACGP General Practice Registrar of the Year Award for 2012. X Mr Frank Prokop has been appointed executive director of the Health Consumers’ Council of WA. Frank was previously head of Recfishwest. Mr Mitch Messer replaces Ms Anne McKenzie as chairperson, Ms Lorraine Powell continues as Deputy Chair, Mr Glenn Pearson is Secretary and Mr Alan King is Treasurer. X A/Prof Kevin Pfleger, head of Molecular Endocrinology at WAIMR, Dr Alex Hewitt, a glaucoma genetics researcher from the Lions Eye Institute, and Prof Lea-Ann Kirkham, a researcher with the Vaccine Trials Group from UWA, each won the UWA Young Tall Poppy Science Award. X The Australian-first WA Vaccine Safety Surveillance System (WAVSS) won the Director General’s Award for 2012 at the WA Health Awards. The WAVSS project team consisted of Dr Paul Effler, Dr Dale Carcione, Ms Megan Scully, Dr Debbie Turner, Dr Donna Mak, Ms Kamala McDonell, from the Prevention and Control Program, Communicable Disease Control Directorate; Mr Ben Gordon, Ms Jo Daly, Dr Peter Richmond, Dr Chris Blyth from the Child and Adolescent Health Services, and Mr Kevin Marsh, Mr Jeff Ewen and Mr John Paul from the Health Informations Network. medicalforum

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31


2012 Best Wishes from WA's Health Professionals Christmas Greetings Feature

Sarah Moore Rural GP

My most memorable Christmas was in 2009 when my husband and I were volunteering in Bolivia and staying with a local family. Christmas was celebrated in the traditional Bolivian way, waiting until midnight Christmas Eve to begin the festivities. There were firecrackers followed by a roast dinner feast then present opening until the wee hours of the morning. We felt so welcomed by this lovely family, despite the fact that we couldn't speak much Spanish and their English was minimal! The highlight this year was celebrating my daughter Alice's first birthday and the hope for the new year is that Baby No. 2 arrives on time and is healthy!

Dr Phil McGeorge Dr Phil McGeorge and his team would like to thank you for your support in 2012. All the very best for a Merry Christmas and a Happy New Year.

The Cardiologists and Staff from Heart Care Western Australia and Coastal Cardiology wish our referrers and their support staff a

Merry Christmas and Best Wishes for a Healthy and Prosperous 2013 We thank you for your support this year. We look forward to continuing high quality service to yourselves and your patients in 2013.

L to R: (rear) Dr Peter Thompson, Dr Randall Hendriks, Dr Mark Nidorf, Dr Alan Whelan (front): Dr Nigel Sinclair, Dr Donald Latchem, Dr Peter Purnell, Dr Isabel Tan, Dr Vincent Paul, Dr Xiao-Fang Xu, Dr Mark Ireland, Dr Bernard Hocking

www.heartcarewa.com.au

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Dr Mini Zachariah Dr Louisa Case

To all my referring doctors and colleagues.

GP Trainee, Busselton

This Christmas is going to be our most amazing ever! It will be the first in our new home in Quindalup and we’ll only have had two days to move from Perth, unpack and set up the tree. Then we’ll have to get the local possums out of the chimney so Santa can fit down it! We're looking forward to meeting our neighbours at the Christmas Carols service and then it’ll be Boxing Day alongside the beautiful waters of Quindalup Bay. It’s going to be fabulous!

A Merry Christmas and a Safe & Happy New Year Thank you for continued support and I look forward to working with you in 2013. Warmest wishes Mini

Dr Susan Downes GP remote Kimberley

Dr Judith Nash and her team at The Women’s Clinic. Thank you for your support during 2012 and wish you and your families a happy and safe Festive Season.

My most memorable Christmas was when I, my husband and two boys then aged five and 12 spent two weeks in the warmth of Tunisia. f England l d in i freezing f i weather and returned to the longWe lleft term car-park to only just find our car totally covered in snow. Footnote: Christmas 2012 will be spent with granddaughter Willow who was born this year after generations of males.

SEASONS GREETINGS Dr Victor Chan and staff Wish to thank all GPs who have supported them during the year.

Nanyara Fertility Control Clinic 2 Cleaver Terrace, Rivervale 6103 Tel: 9277 6070

MERRY CHRISTMAS and a HAPPY NEW YEAR to all doctors medicalforum

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The caregivers of St John of God Health Care

wish their doctors and the medical community

a blessed and joyful festive season.

May peace be your gift at Christmas and your blessing all year through.

SJG26266

www.sjog.org.au

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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 quality care for your patients in the future. Dr Mark Hands Dr Eric Whitford Dr Stephen Gordon Dr Philip Cooke Dr Brendan McQuillan Dr Johan Janssen Dr Paul Stobie Dr Chris Finn

Thank you for your continued support and I look forward to working with you in 2013. My warmest greetings for the season and for a prosperous New Year. With best wishes, Kannan Venugopal

Dr Eric Yamen Dr Joe Hung Dr Michelle Ammerer Dr Luigi D’Orsogna Dr Darshan Kothari Dr Andre Kozlowski Dr Tim Gattorna

MXSolutions

Drs Phil McGeorge, Kai Goh and Tze Lai wish all our referring doctors and colleagues an enjoyable Christmas and a Happy New Year. We look forward to working with you in 2013.

Comprehensive Practice Management Software for Health Professionals On behalf of the management at MxSolutions we would like to thank all of our customers for your continued support and wish you a

Merry Christmas & a Happy New Year. We look forward to working with you in 2013. Call Robyn on 0419 449 110

Dr Stuart Adamson Geraldton GP, aviator

My most amazing ‘Aviation Christmas’’ was coming into Perth on my first nightt flight as 'pilot in command'. We were flying down from Geraldton to do somee shopping and there were more fairy lights than a Christmas tree on steroids. No wonder Buzz Aldrin called Perth the city of lights. Brilliant!

Matthew Akpo GP, Clarkson

My most memorable Christmas was in 2010 in Carnarvon. We had a progressive dinner among doctor colleagues and their families. It was an opportunity to taste the h various i iinternational i l di dishes. My wife and I, together with our two daughters, hosted the entree. After dessert, we exchanged gifts in a great atmosphere of fun. I'm looking forward to a reunion of my medical school graduating class. It will be great to meet mates who are scattered and practising around the globe.

medicalforum

Dr Cliff Neppe Wishes all his referring doctors and colleagues an enjoyable Christmas and a Happy New Year.

I look forward to working with you in 2013

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Perth Obstetrics & Gynaecology Ultrasound would like to wish all our specialists and referring Doctors a safe and Merry Christmas. Thank you for all your support in 2012. We look forward to working with you in the New Year.

WA Vascular Centre Wishes you all a Great Xmas and a Happy New Year

WAVC continues in its tradition of frequent Newsletters advising on the latest developments in noninvasive Diagnosis and minimally invasive Treatment of Vascular Disease. www.wavascularcentre.com.au Phone: 9279 4333Â 36

medicalforum


Wishing all Venosan referrers, clients, and colleagues a very safe, happy and prosperous Christmas and New Year. Thank you for all your wonderful support throughout the year.

Jenny Heyden RN Consultant Venosan WA

Dr Angela Cooney GP, Onslow Road Family

Practice

The best Australian Christmas I had was in Alice Springs about 22 years ago. wa Lots of people had gone back to their h home states to see family and those of us who stayed had a Christmas Eve party where local musicians got everyone singing carols by candlelight all accompanied by wonderful food and a few drinks. Christmas Day was spent around the hospital pool and then it was time for my shift in A&E. The ‘celebrations’ continued – treating star picket head injuries, glass lacerations and other festive conditions. OK, maybe that part wasn't quite so good.

Dr Corinne Jones Specialist Breast, Thyroid and Parathyroid Surgeon

Christmas is trees, trimming and sparkle, Christmas is shared gifts, food and laughter, Christmas is a story of 3 men, a birth and a star, Christmas is a time to thank all colleagues, and wish them all the very best for 2013.

medicalforum

Merry Christmas and a Happy New Year from Perth Radiological Clinic. Santa has come early to us with the delivery of ˆ7lice Low Dose CT for Joondalup ˆ816-JSV.SSRHEPYT,IEPXL'EQTYW ˆ7PMGI0S[(SWI'8JSV7YFMEGS ˆ%RSXLIV816-JSV7YFMEGS The list goes on! We look forward to letting you know more about our new equipment in the new year and offering an even better service to your patients.

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Dr Helen Wilcox GP and RACGP WA Sta

te Censor

My Christmas wishes, in a professional ssense, are for a superb health system and, as GPs, weâ&#x20AC;&#x2122;ll be proud of our place at the heart of it. The demands and challenges of he patient care rightly absorb most of our time and attention, but I hope that as clinicians, as educators and as a College we can continue to support each other. We need to advocate for better education and training for our IMGs and the medical students under our tuition.

Susan Ryan

Merry Christmas from Dr Yovich and the team that gives the greatest gift of all.

Age Discrimination Commissioner

Christmas is always spent with my extended family - with various grandchildren, and now great grandchildren and my sisterâ&#x20AC;&#x2122;s children making an appearance. The extended family gets more extensive every year. In 2013 I especially hope to see that more people over 55 have been successful in maintaining their jobs, or if unemployed, find a new job. Economic security is essential to living in dignity and with security.

For all appointments & enquiries:T: (08) 9422 5400 | E: info@pivet.com.au Visit www.pivet.com.au for more information

Mr Marek Garbowski Vascular & Endovascular Surgeon To all my referring doctors and colleagues. Thank you for your outstanding and continued support throughout 2012. Our mutual patients' care and wellbeing is of paramount importance to me and my staff. At Perth Vascular Clinic you are provided with the professional assurance that your patients are cared for by a College recognised Vascular & Endovascular Surgeon who is also a member of the Australian & New Zealand Society for Vascular Surgery. I look forward to co-working with you in 2013 in mutually caring for the wellbeing of our vascular patients. Wishing you, your loved ones and your staff a joyous, healthy and safe holiday season and all the very best for 2013. Warmest wishes Marek Garbowski & Staff at Perth Vascular Clinic www.perthvascularclinic.com.au SUBIACO - JOONDALUP - GLENGARRY - BUNBURY - GERALDTON

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medicalforum


Dr Robert Davies Surgeon

The most bizarre Christmas I ever had, well, it was consecutive Christmases really. I performed a radical orchidectomy on Christmas Eve and then went back to the hospital the next morning to discharge the patient so he could open presents with his kids at home. The following Christmas it was exactly the same story for another patient! My family was convinced there was a testicular cancer conspiracy going on.

SleepMed Sleep and Respiratory Team Dr Sina Keihani and the team at SleepMed Australia, hope you have had a wonderful, joyous year and wish you a safe and Merry Christmas and a Happy New Year.

Michelle Scott

Commissioner for Childr en and Young People

Thank you for all your support in 2012.

My best Christmas was when my mum took away my old bike and had it repaired and repainted and it came back all shiny and new! It taught me that I don’t always know the full story. My wish for 2013 is for all children and young people in WA to be loved, nurtured and safe. I believe everybody has a role to play in achieving this. I hope everyone in the WA community will take the time next year to ask themselves what more they can do to help our youngest citizens.

We look forward to continuing quality service to yourselves and your patients in 2013.

Dr Kees Bakker Car nar von GP – Rural Medical School

Christmas is fantastic up here! I usually C hop on my catamaran and sail up to Monkey Mia or head to Gnaraloo Station. Fishing, skin-diving, kite surfing fi – take k your pick. All the water sports are here!

C T w  M R I w X - R AY w  U LT R A S O U N D w  N U C M E D w  D E N TA L

We would like to extend best wishes to our colleagues and their staff for an enjoyable festive season. We look forward to working with you all in 2013.

Merry Christmas

medicalforum

Happy New Year

Dani Meinema together with the Executive team at Glengarry Private hospital would like to wish all our Specialists and referring Doctors a Safe and Merry Christmas and a Happy New Year Thank you for all your support in 2012, we look forward to working with you in 2013.

39


TRANSLATIONAL RESEARCH FEATURE

Brought exclusively to you by

Back to basics – cystic fibrosis research C

ystic fibrosis presents a number of dilemmas for researchers like Prof Steve Stick, currently clinical lead for the Respiratory Health Network, head of the respiratory department at PMH and Senior Principal Investigator at Telethon Institute for Child Health Research. Past research has been largely targeted at improving symptoms in affected individuals but the onset and progression of destructive bronchiectasis remains largely unaltered. Now attention is turning to new disease-modifying treatments.

modifying drug because this antibiotic has anti-inflammatory effects and inflammation was found to be the main driver of early bronchiectasis. Azithromycin is also off patent and has known safety profiles. The COMBAT CF trial has started its twoyear recruitment phase and will finish in 2016. This “repurposing” of an established drug may also apply to statins, which are being considered because of their antiinflammatory activity.

“Inflammation and risk of infection are pathways you can target independently of any genetic abnormality. Inflammation is probably most important because it can occur in the absence of infection. Airway dehydration and activated inflammatory cells play a part and CF may increase vulnerability to viral infections. It appears also that CF has an altered innate immune response to viruses which can kick into a vicious cycle of inflammation.”

Establishing endpoints in infants “How do you determine ‘disease modification’; what outcomes do you measure? How do you do it in kids under the age of two, early enough to be convinced someone needs to be on lifelong medication? Our focus has been to develop clinical endpoints you can use in the first two years of life that the regulatory bodies will accept for clinical trials.”

“Neutrophil elastase, a protease found in increased amounts in brochioalveolar lavage fluid, is one of the biggest risk factors for the development of bronchiectasis. It chews up the collagen matrix on which the airways are built. Released from neutrophils, it overwhelms the protease defences in the lung, so if you can treat with an antiprotease like alpha 1 antitrypsin, it’s possible you can antagonise the effects of neutrophils. A range of drugs are being investigated that are antiproteases.”

For cystic fibrosis (CF), he said the FDA’s endpoints of spirometry changes and patient-reported symptoms are irrelevant when doing trials in young kids.

He said their research efforts back in 2005 allowed lung CT to emerge as a gold standard endpoint.

QProf Stephen Stick, respiratory paediatrician

“Using our data we have advocated very hard so that CT can be used as a clinical endpoint. It has now just been accepted by the European regulatory body, the MEA, and I hope the FDA will follow.”

He said that the challenge to develop new drugs for use in infants will also throw up drugs like IvacaftorTM, a specific gene modifying drug, the first of its type in CF with FDA-approved use in older children (which means it will probably never be trialled in young children where he believes it has the greatest potential).

Refocus on early disease modification

What offers most promise, in his eyes?

“So the whole paradigm of early intervention, and disease modification, with bronchiectasis as the endpoint measured by lung CT, is the sort of template that companies will use for new drug trials.”

“IvacaftorTM is a small molecule that was identified by high throughput screening and it changes the activity of the abnormal protein from one specific mutation that affects about 3% of the CF population,” he explained, adding that there are around 3000 gene mutations identified in CF.

Prof Stick said this was the endpoint being used in the first ever clinical trial to prevent lung disease – the COMBAT CF trial – being run in 10 centres in Australasia. The trial will serve as a template for future studies in infants and pre-school children. It assesses azithromycin as a disease medicalforum

“We know you only have to restore about 20% of function, perhaps by targeting one of the mutations, to alleviate a lot of the problems.” Other gene therapies are being researched as is airway inflammation.

This means trials are needed in young children with cystic fibrosis, most of whom show signs of inflammation and infection, both predictors of bronchiectasis, by three months of age. Prof Stick explained.

“If you really believe a drug will modify disease it should prevent bronchiectasis not just improve FEV1. Lung disease is progressive from birth and is evident at three months of age in the majority of kids, with bronchiectasis present in 80% by five years.”

advance. Now the hunt is on for more of these small molecules. It’s a bit like finding the first antibiotic and it will be the catalyst for the discovery of a whole range of molecules that modify genes, which are relevant to a whole range of single mutation genetic disorders, not just CF.”

“The recognition that you have to get in early has changed how people think about the disease. You can’t move past the fact that you can now modify gene function with small molecules. It’s the biggest

Perth researchers based at the Telethon Institute for Child Health Research have the largest tissue biobank for early CF lung disease, which Prof Stick says is useful for a lot of things. It can define early disease markers, potential targets for therapy, and be used by industry and academics. It includes blood, bronchio-alveolar lavage fluid, epithelial cells and other tissues, along with images and clinical data. O

Medical Forum thanks the Telethon Institute for Child Health Research for assistance in preparing this feature, made possible by an independent educational grant from Avant.

Avant is a leading provider of medical indemnity insurance for doctors and healthcare practitioners. T: 1800 128 268 E: memberservices@avant.org.au W: www.avant.org.au 41


CLINICAL UPDATE

Hydroxychloroquine (Plaquenil ) effects on vision TM

P

(OCT) and mfERG. Screening takes place on initiation of therapy, after year 2, year 4 and then yearly. Fluorescein angiography and fundus autofluorescence are used if suspicious signs of early toxicity develop. OCT, which images the retina at near histological resolution, now represents the standard of care for monitoring numerous retinal conditions. Its cost is as yet not covered by Medicare. As a result it is not affordable to all patients or ophthalmic practices. Sir Charles Gairdner department of electrophysiology performs mfERG for the whole private and public sector of Western Australia so that in each monitoring cycle, most patients need two different clinic visits with pupils dilated on both occasions.

laquenil is an antimalarial commonly used as a disease modifying antirheumatic drug in the management of autoimmune diseases such as rheumatoid arthritis and lupus. It is cheap but requires expensive time-consuming monitoring that should be taken into consideration when prescribing. Systemic side effects are uncommon.

Ophthalmic side effects In the eye, it frequently causes inconsequential vortex like corneal deposits (cornea verticillata). Unmonitored, it can result in devastating bull’s eye maculopathy, which is usually bilateral. Toxicity initially causes paracentral reduced vision that may worsen, even after stopping the drug; mild difficulty with reading may progress to loss of a driver’s licence and rarely, complete central visual loss. QNormal OCT of macula.

Beware short overweight patients

multifocal electroretinography (mfERG). Hydroxychloroquine should be avoided in patients with impaired renal function, liver disease, advanced age or pre-existing macular disease, each of which increases the risk of toxicity.

Monitoring QExample of electroretinogram (mfERG).

Risk The risk of macular damage is small (between 1-5 per 1000 patients taking plaquenil for under 5 years at a dose of <6.5mg/kg ideal body weight). Risk increases to 1% after 5-7 years, with a further rise over time and after a cumulative dose of 1000g plaquenil. Some patients develop changes in under five years. These may be detected using

By Dr Jo Richards, Ophthalmologist

The level of screening offered varies widely across the developed world. Royal Perth Hospital and many private ophthalmologists now offer a modified protocol based on the 2011 American Academy of Ophthalmology recommendations (see ref). This requires up to two hours of technician and clinician time for each cycle, sometimes amounting to 4-5 hours of clinic time for public patients. It includes visual acuity testing, retinal examination and photography, automated central visual field testing, optical coherence tomography

They require special consideration as they are over represented in case series of plaquenil toxicity. Why? ONLY in lean patients may dose may be calculated by weight (i.e. <6.5mg/kg ideal body weight). To prevent overdose use this rule of thumb: If short and wide, beware! Patients under 170cm in height should be taking less than 400mg plaquenil per day. (Use 200mg daily if you do not have time to do a calculation based on lean body weight.) References: Revised Recommendations on Screening for Chloroquine and Hydroxychloroquine Retinopathy. Michael F. Marmor, et al. Ophthalmology, Vol118, Issue 2 , 415-422, Feb 2011 O

Declaration: Perth Eye Centre P/L, the management company for the Eye Surgery Foundation, has supported this clinical update through an independent educational grant to Medical Forum. Author – no competing interests.

Dr Ross Agnello Tel: 9448 9955 Dr Malcolm Burvill Tel: 9275 2522 Dr Ian Chan Tel: 9388 1828 Dr Steve Colley Tel: 9385 6665 Dr Dru Daniels Tel: 9381 3409 Dr Blasco D’Souza Tel: 9258 5999 Dr Graham Furness Tel: 9440 4033 Dr Annette Gebauer Tel: 9386 9922

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CLINICAL UPDATE

Severe traumatic brain injury T

he medical management of severe traumatic brain injury (TBI) has evolved as knowledge increases around the complex molecular response to neurotrauma and the basic pathophysiology. Diffuse brain swelling and raised intracranial pressure continue to be recognised as being highly predictive of morbidity and mortality and it is widely acknowledged that cerebral perfusion must be optimised in order to avoid cerebral ischemia. However, over recent years it has become increasingly apparent that many interventions routinely used for many years to lower the intracranial pressure may not necessarily provide clinical benefit.

We also have been able to appreciate that there is considerable overlap between the pathological processes at initial impact and the secondary injury that follows. Substantial neuronal cell death is from deleterious neuroexcitatory cascades initiated at the time of injury and causing apoptotic cell death many hours later. One such cascade is the glutamate neuroexcitatory cascade, amplified by the well-known secondary insults of hypoxia and hypotension (Figure 1); in the context of severe closed head injury (with no mass lesion to evacuate), the end result is cerebral swelling and raised intracranial pressure (ICP).

Osmotherapy, and more recently super salt therapy, are used to reduce cerebral water content (oedema).

Initial medical management

ICP and the Monroe Kellie Doctrine

Neurointensive care aims to optimise cerebral perfusion and oxygenation in order to minimise secondary insults. This usually involves a period of intracranial pressure monitoring followed by protocol driven, step-wise administration of sedation, ventilation and neuromuscular paralysis to control and optimise cerebral perfusion.

However, ICP has limitations in guiding therapy because it is, in effect, a marker of end organ injury. Moreover, many medical therapies aimed at reducing the ICP may be of limited benefit. For many years patients were routinely hyperventilated, placed in a â&#x20AC;&#x153;barbiturate comaâ&#x20AC;? and (more recently) rendered hypothermic. These measures often successfully lower ICP but this does

Monitoring intracranial pressure via either an external ventricular drain or a parenchymal transducer is a cornerstone of management. It can: detect early an evolving mass lesion (e.g. enlarging contusion) and thereby facilitate timely surgical intervention; guide cardiorespiratory management used to optimise cerebral perfusion; and be of prognostic value because of the strong correlation between outcome and the hours that ICP remains above 20mmHg.

not necessarily translate into better clinical outcomes. The constraints observed by Alexander Monroe in 1783 and confirmed by George Kellie in 1824 still apply. That is, the cranium is a "rigid box" filled with a "nearly incompressible brain". An injured brain that starts to swell does so at the expense of blood and CSF volume. As the brain swells further or a mass lesion increases in size, compensatory mechanisms become exhausted, and for incrementally smaller increases in volume there are greater increases in pressure.

Medical therapies re-examined Fresh knowledge explains why therapies are used far less frequently than in previous years. Hyperventilation reduces the arterial carbon dioxide which in turn alkalinises the CSF and induces a reflex vasoconstriction. Whilst this reduces the cerebral blood volume and ICP, it does so at the expense of cerebral blood flow, for which the risk of cerebral ischaemia is well established. Barbiturates and hypothermia depress neuronal activity and reduce cerebral metabolism, which leads to a reduction in cerebral blood flow and blood volume due to autoregulatory flow metabolism coupling. There is no doubt that both these therapies can be neuroprotective due to their influence on many aspects of the cellular response to injury such as calcium mediated toxicity, glutamate excitotoxicity, free radical peroxidation and cellular apoptosis. However, the fundamental mechanism by which the ICP is lowered is the same as for hyperventilation and the last thing the injured brain needs is less blood. Some of these therapies are now far more judiciously, often as a stop gap method to buy time prior to surgical intervention or for life-threatening acute rises in intracranial pressure.

QFig 1: Glutamate Neuroexcitatory Cascade. The initial cerebral injury triggers a massive uncontrolled release of the neurotransmitter glutamate which triggers the cascade leading to cytotoxic and apoptotic cell death. The cascade is reinforced by secondary insults and by impaired cerebral perfusion due to raised intracranial pressure. 44

medicalforum


By Dr Stephen Honeybul, Consultant Neurosurgeon SCGH and RPH

PIVET MEDICAL CENTRE Specialists in Reproductive Medicine & Gynaecological Services

FERTILITY NEWS

Medical Director Dr John Yovich

FSA: Sharing the Knowledge The Fertility Society of Australia was initiated 30 years ago and, from the outset, joined clinicians, scientists, nurses, psychologists, social workers (counsellors), administrators, epidemiologists and even consumer groups in its efforts to embrace all the relevant aspects. I am personally very proud to have been part of the Steering Group as well as a stint as President of FSA in 1986 when the accreditation body RTAC was inaugurated. This unique society ensures the highest standards in its Code of Practice along with accurate reporting of data. This year the annual FSA meeting was held in Auckland, NZ and also drew international speakers presenting the latest ideas in ART, including advances in embryo culture systems; examination of chromosomes, DNA and mRNA of sperm, oocytes and embryos; safer and more effective ovarian stimulation schedules; as well as the ethical and logistical issues of sperm & egg donation as well as surrogacy. PIVET presented in 3 areas:

However, the need for more dynamic monitoring of the complex cellular response has led to multimodal monitoring techniques.

Future developments Multimodal monitoring aims to record a number of physiological and biochemical parameters in order to accurately assess the development and severity of secondary injuries, so appropriate treatment can be instigated early to prevent pathophysiological progression. A variety of modalities are currently available, the most common of which are brain tissue oxygenation, microdialysis, intracranial temperature, cerebral blood flow, transcranial doppler and electroencephalography.

 7KHHIIHFWLYHXVHRI9LWULÀFDWLRQIRU(JJEDQNLQJE\ Lab Director, Jason Conceicao  $UHDVVXULQJ\HDUIROORZXSRI3,9(7·VÀUVW,9)EDELHV by Senior Nurse, Leigh Clifton 3.

A comparison of DHEA and Growth Hormone used for poor prognosis patients by Medical Director, John Yovich

Of course sharing the knowledge was accompanied by sharing the company of colleagues and together enjoying the wonderful environs of Auckland which provided great weather and warm evenings for social interaction.

Some debate whether the data merely reflects the severity of the injury rather than acts as a useful guide to therapy and suggest that invasive monitoring increases medical and surgical interventions and may actually worsen outcome. However, adopting this position fails to recognise that it is the clinician’s interpretation of the information and the appropriateness of their clinical response that can harm the patient. Overall, there is a lack of new therapies that significantly improve severe traumatic brain injury. Pharmacological neuroprotective agents that can interrupt the numerous molecule cascades include glutamate antagonists, steroids, free radical scavengers, calcium antagonists – all have failed to show clinical efficacy which has led some to change focus from single to combination therapies, much like chemotherapy agents for cancer. Therapies currently being investigated include early therapeutic hypothermia, dexanabinol, citicoline, erythropoeitin, progesterone and cyclosporine. Finally, investigators are exploring a possible genetic component to explain different individual responses to similar injuries. O

Competing interests: None Declared

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PIVET team enjoying the conference dinner in Auckland after their presentations. From left, Michelle Jago, Leigh Clifton, Doug Yek, Jason Conceicao, Jeanne Yovich, Sara Mayes & John Yovich.

NOW AT 3 LOCATIONS LEEDERVILLE, JOONDALUP & BUNBURY

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

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Heenan Lam Skin Pathology Part of Perth Medical Laboratories P/L (APA): Independent, Pathologist Owned and Operated.

Heenan Lam Skin Pathology is a new independent non-corporate specialty dermatopathology service, available to dermatologists, plastic surgeons and general practitioners. Our focus is to provide prompt, accurate and clear diagnoses to facilitate the best patient care. All cases are reported by Dr Peter Heenan and Dr Minh Lam. Dr Peter Heenan Peter Heenan graduated MBBS (UWA), and completed his pathology training at the Radcliffe Infirmary, Oxford, where he developed a special interest in skin pathology. After returning to Perth he joined the Department of Pathology, UWA, as Senior Lecturer, later as Associate Professor. Peter established Cutaneous Pathology, the ďŹ rst private skin pathology service in WA, in 1987, combining teaching and research with a comprehensive diagnostic service. He has contributed to the WHO Histological Typing of Skin Tumours, the UICC TNM clinical staging of melanoma, the ACN Guidelines for the Management of Melanoma and was the ďŹ rst director of the WA Melanoma Advisory Service. Peter is a past President of the Australian Dermatopathology Society, past Vice President of the International Society of Dermatopathology and is currently a Clinical Professor of Pathology, UWA.

Dr Minh Lam Minh Lam graduated from the University of Western Australia (MBBS) in 1994 and completed his training in Anatomical Pathology (FRCPA) in 2001. He worked as a consultant pathologist for Specialist Histopathology and Cytopathology Services, Fremantle and Cutaneous Pathology, Nedlands before moving to San Francisco in 2006 to complete a twelve month postdoctoral fellowship in dermatopathology at the University of California. During that time, Minh also passed the examinations for International Board CertiďŹ cation in Dermatopathology under the auspices of the International Committee for Dermatopathology. He has most recently worked as a consultant dermatopathologist for Cutaneous Pathology and Clinipath Pathology before teaming up with Dr Peter Heenan to form Heenan Lam Skin Pathology. Minh is also a pathology assessor for the Western Australian Melanoma Advisory Service and is actively involved in the teaching of dermatopathology to registrars.

Services

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Histologic diagnosis â&#x20AC;&#x201C; We pride ourselves on providing prompt, accurate and clear diagnoses. Routine cases are reported within 24hours. Results are available in hard copy, via electronic downloads or via web access.

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Immunofluorescence â&#x20AC;&#x201C; Direct immunofluorescence can be performed on fresh, unfixed, skin or mucosal biopsies and is useful for confirmation of immunobullous dermatoses, connective tissue disease and vasculitis. Please contact us for the IF transport medium.

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Consultation/Second opinion â&#x20AC;&#x201C; Dr Peter Heenan and Dr Minh Lam are available to provide second opinions on cases reported in other laboratories. There is no charge for this service. Please contact them directly to use this service.

Billing information Bulk billing is available for outpatients. No gap is available for private inpatients.

Contact For referral stationery, specimen pots, courier pickups or general information Phone: 93863500q'BY93863511q26 Leura St Nedlands WA 6005 46

www.heenanlamskinpathology.com.au

medicalforum


CLINICAL UPDATE

Oncoplastic breast surgery T

he diagnosis of breast cancer is a life-changing event. Patients must face a potentially fatal illness, along with the potential for disfiguring surgery and other significant morbidity from their treatment. Surgical options include mastectomy or wide local excision (WLE) followed by radiotherapy, which offer the same survival. Oncoplastic breast surgery in select women seeks to aesthetically preserve breast shape while allowing wide local excision of breast cancer. The main aims are to avoid mastectomy, achieve safe margins of tumour excision, preserve the natural shape of the breast and avoid breast deformities following radiotherapy. The well-established surgical techniques are not unlike plastic surgery for breast reduction.

By Dr Farah Abdulaziz, Breast Surgeon, Hollywood Private Hospital

result in breast deformity that many now consider unacceptable.

Benefits from associated breast reduction Surgery results in a smaller breast and the other breast is operated on to create symmetry. This can be done at the time of tumour excision or later, depending on several factors such as the potential for positive margins, patient choice and the cosmetic outcome.

Patient considerations Women who are best suited to this approach are younger, have medium to large breasts and seek a more cosmetic result from surgery that includes avoidance of mastectomy.

Oncoplastic surgery, by reducing the risk of later deformity, helps avoid later surgery to correct a deformity that is in turn hindered by radiotherapy fibrosis. QFig 3. The residual defect. The medial and lateral pillars of the gland are apposed. The breast is then reshaped and the nipple–areolar complex relocated to the de-epithelialised area.

WLE is not feasible for all patients because removing more than 20% of the breast volume will result in deformity of the breast. Therefore WLE is really only suitable if the tumour size is small relative to the breast size.

Therapeutic oncoplastic mammoplasty allows for larger tumour excisions (relative to breast size) than standard surgery. Oncological indications are the same for standard breast conserving surgery, including tumours up to 4cm diameter. Patients with very large breasts have greater morbidity from adjuvant radiotherapy, which is standard treatment in women who opt for breast conserving surgery. Mammoplasty reduction techniques can reduce the morbidity and deformity caused by the radiotherapy. References:

QFig 1. The types of incision in oncoplastic mammoplasty depend on tumour location and the size and shape of the breasts. Preoperative skin markings are done in the upright position. In this example, tumour location is marked and the dotted line marks the skin incisions.

Clough KB, et al. Improving breast cancer surgery: a classification and quadrant per quadrant atlas for oncoplastic surgery. Ann Surg Oncol 2010 May;17(5):1375-91 Bonomi S, et al. The Use of Immediate, Delayed-Immediate and Delayed Oncoplastic Reduction Mammaplasty Techniques following Breast Conserving Surgery. Anaplastology S1:002. doi:10.4172/2161-1173.S1-002 McCulley SJ, Macmillan RD. Planning and use of therapeutic mammoplasty-Nottingham approach. BJ of Plastic Surgery (2005) 58, 889-901 O

QThe end result are smaller breasts with preservation of the natural breast shape.

QFig 2. The area surrounding the nipple–areolar complex is de-epithelialised (crosshatched) and the skin incision begins at the inframammary fold. Excised tissue consists of the tumour with a wide margin of normal tissue, plus tissue excised for mammoplasty.

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Standard WLE can give an excellent cosmetic result initially but some longer term changes may be problematic. The ‘standard’ WLE cavity fills with fluid (seroma) postoperatively to provide acceptable initial shape and size of the breast. However, the appearance often deteriorates with post-operative radiotherapy that causes fibrosis in the breast tissue, and perhaps in the seroma cavity. Contracture and retraction can

Declaration: The clinical update is supported by an educational grant to Medical Forum by Hollywood Private Hospital. 47


Pharmacy

Tapping into the Psychotropic Drug Information Service Graylands Hospital pharmacist Barrat Luft is one of a kind – he’s chasing more work! In particular, he wants to ensure primary care doctors, practice nurses and other health professionals are taking full advantage of the state-wide Psychotropic Drug Information Service he heads. Many times the number of QPharmacist Barrat Luft current calls from primary care doctors would be OK and based on his experience in Glasgow, he has high hopes. “We didn’t get overwhelmed there despite mention of the service by others and you tend to build up a core of regular users,” he said.

You can now prescribe exercise! As part of our commitment to health of Western Australia the team at Obesity Surgery WA, is now offering exercise programmes at no cost. To enrol, we need a referral to our practice for exercise. Everyone gets a health review to check their suitability and will get a personal plan or get to join one of our group sessions. The service is open to anyone who needs a little help to get fitter, even if they are not considering surgery. < Mr Harsha Chandraratna Surgeon Jo Climo > Clinical Nurse & Exercise Co-ordinator

Obesity Surgery WA (08) 9332 0066 SUBIACO 48

MURDOCH

Employed as the chief drug information pharmacist, he manages the service from the Pharmacy Department in Graylands Hospital, where he can tap into the knowledge of seven experienced clinical pharmacists who work on wards and advise on clinical use of medications. This work with other clinicians has him itching to go out and present on common treatments with psychiatric drugs. “For example, we know withdrawal effects from antidepressants can be significant and can go on for some time, so slow withdrawal is best. We are happy to receive any enquiry. You may want to know which drug treatment to use when standard options have failed, how to manage side effects, the correct dose of a drug or whether a medicine is safe to take in pregnancy,” he said. Knowing that doctors are time poor and need good practical advice, Medical Forum tested the service anonymously on 9347 6400, using a query very much on the edges of psychotropic medicine. The pharmacist (which we later learnt was Barrat Luft) promptly answered the phone and responded immediately to our question about whether Lyrica could be making Parkinson’s worse in an elderly patient. We were told ataxia was a known side effect of the drug and this could be lost in her Parkinsonism symptomatology and that if we wanted to trial drug withdrawal to do this gradually over a twoweek period. We were told, as it happens, Lyrica was used off label in the UK hospital system to treat anxiety in some mental health patients. Our score was 9 out of 10 for this service encounter. Later on, Barrat said most enquiries are dealt with during the first phone call. However, if it is a bit harder they can do literature searches and provide evaluated information. “Use of medicines is one of the most common interventions in psychiatry. It is also one of the most complex and finding the right drug for a patient is often difficult. There are usually several options, and new medicines are becoming available all the time. Health professionals are swamped with prescribing guidance from numerous sources – keeping abreast can be overwhelming and time consuming,” he said, adding that the service responds with accurate unbiased information. Any health professional within WA can use it on 9347 6400, 8.30am to 4.30pm Monday to Friday or on druginformation.graylands@health.wa.gov.au O medicalforum


FROM

PRIVATE HOUSE

TO HOSPITAL Mercy Hospital celebrates 75 years of serving and caring for the community. 2012 marks a very special milestone for Mercy Hospital Mount Lawley, a service of MercyCare. It’s celebrating a remarkable 75 year history, built on the courage and determination of Catherine McAuley, founder of the Sisters of Mercy. In 1935, with the support of the then Archbishop Dr R Prendiville, the Sisters of Mercy bought Killowen House, a regal private residence in Mount Lawley, originally owned and built by Mr RT Robinson. With commanding views of the Swan River and Darling Ranges, this was to be the site for St Anne’s Nursing Home, as the hospital was then known. The Sisters of Mercy, led by Mother Brigid McDonald were assigned the challenge of turning this home into a hospital. The original vision for the hospital was to provide general nursing services, but upon opening, it was announced that midwifery services would also be offered. Thus, St Anne’s became the first maternity hospital run by a religious order in Western Australia. With thousands of babies born at St Anne’s - now known as Mercy Hospital - over the past 75 years, countless Western Australian families have experienced the quality maternity services for which the hospital has become renowned. In this 75th year of service to the community, the staff at Mercy Hospital are looking forward to the challenges of the hospital’s next phase of development. Building on the achievements of the past and the present, staff are preparing to meet the demands of a growing and diverse Perth population. Mercy Hospital marked the occasion with a gala cocktail event on 13 November 2012, at the Golden Ballroom of Perth’s Pan Pacific Hotel. The pioneering Sisters of Mercy Hospital were humbly remembered for beginning a tradition of care that has been continued throughout the decades and which provides the foundation for Mercy Hospital to step proudly into a future of delivering wellbeing and justice for all.

Photo: Killowen House

FROM THEN

TO

NOW...

BABIES BORN

OPERATIONS

X-RAYS

1937/1938:

1937/1938:

1937/1938:

60

146

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2011/2012:

2011/2012:

2011/2012:

1,384

9,432

20,386

CURRENT STATISTICS In the past year, Mercy Hospital has: — admitted 17,755 patients — performed 9,432 surgical procedures — performed 7,550 endoscopy procedures — cared for patients over 51,265 patient days — delivered 1,384 babies

With special thanks to our Corporate Partners and Sponsors.

To find out more about Mercy Hospital’s Specialists, go to www.mercycare.com.au/fms

Mercy Hospital Mount Lawley, Thirlmere Road, Mount Lawley WA 6050. p: 08 9370 9222 e: hospital@mercycare.com.au w: www.mercycare.com.au Mercy Hospital is a MercyCare service. medicalforum

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Lifestyle

FRIENDLY TOWN

with Benefits

Dr Kees Bakker came to Carnarvon for the windsurfing. He’s got a great balance between work and play and is passionate about passing on his medical skills to young doctors and IMGs.

It’s a long way to Carnarvon from Holland and the UK where Kees Bakker did his medical training. He came for the watersports, he’s still there 12 years later and he’s not leaving anytime soon. “I arrived here with overseas medical qualifications but I wasn’t an economic refugee and nor was it a family reunion. I came for the windsurfing! My first job was as a locum in Perth covering weekend night calls. This temporal ‘area of need’ was linked to both my visa and my medical qualifications and I found myself in a very unusual position. On the weekend I was a doctor until the sun came up! If I touched a patient after sunrise I was in breach of my visa and my licence to practise medicine,” Kees said. “I know there’ve been

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recent moves to integrate IMGs more fully but it’s a slow process.” Carnarvon is very much a regional location but, from a medical point of view, that doesn’t necessarily equate with being ‘out of the loop’. “I own a practice up here and I’m also involved in the Rural Clinical School. It’s important to have consistency within medical training and we’ve had an unbroken chain of mentoring young doctors in the Prevocational GP Placement Program (PGPPP) for the past two years. That’s great for us as a practice – it’s good to see fresh faces! The interaction with the next generation of doctors and the education that goes with it is interesting in its own right. It keeps me informed of new developments and it’s nice to keep that involvement going with the UWA clinical school.” “I’ve always said that medicine, and being a GP in particular, is a great job as long as you don’t have to do too much of it. It can be very draining both physically and emotionally. I try and diversify as much as I can with three and a half days in the practice, a day of university work, the occasional flight to a remote clinic and long weekends. It adds up to a nice balance.” u The practice of medicine in a small T regional town where (almost) re ‘everyone knows everyone’ has ‘e the potential to exacerbate the th emotional drain on doctors. em “Every doctor accumulates a “E

store of heart-wrenching stories in their professional lives and you can form a strong bond with some patients. Within medicine there’s obviously a lot of sadness and loss when you’re dealing with illness and disease. That’s the nature of the job. Nonetheless, it’s important to keep reminding yourself that it is actually a job and make sure that you keep some sort of barrier between the personal and the professional.” The population of Carnarvon stands at around 6000 people with 13 doctors attending to their medical needs. And, as Kees points out, the medicos who leave do so for family reasons and not because of the town itself. “It was definitely more of a frontier 12 years ago, but there’s been a very positive change since then. It’s a privilege to live in Carnarvon and there’s a varied population mix, everyone from Aboriginal to Yugoslavian and Portuguese people so from a medical

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Charity Dr Gracie Vivian will be waving off her partner, palliative care nurse Bruno Cordier next month as he sets off to ride from Sydney to Perth to raise funds for Hamlin Fistula Ethiopia.

point of view it’s interesting. The schooling of children is one issue regarding long-term residency, as is employment opportunities for partners and spouses. Doctors often have partners who are also highly qualified and it can be difficult for them to find a fulfilling position. Interestingly, many doctors who do leave often come back. Andy Foote (Medical Forum, October) is one of them!” As far as work-life balance is concerned, Carnarvon has a lot to offer.

Kees describes a typically wonderful day off. “I’ll take my boat and sail over to Shark Bay. If you look at a map of Australia, there aren’t too many beautiful islands in warm temperate zones. Between Carnarvon and Karratha there’s so much coral reef and lots of fish. The watersports are absolutely amazing!”O B

By Mr Peter McClelland

“In the five weeks Bruno takes to pedal across Australia more than 46,000 women in Africa will die from pregnancy and childbirth complications,” Gracie said. “Obstetric fistula is such a horrific condition and it’s so easy to fix! Australian obstetrician Dr Catherine Hamlin runs six hospitals in Ethiopia for women who’ve suffered birthing injuries so we’re raising money and awareness for her wonderful work.” Gracie has done much of the planning for Bruno’s ride, but when he hops on his bike off she’ll be in Broome commencing her GP ttraining. “Bruno won’t have any support vehicles so he’s completely on his own. His plan is to get up really early and start pedalling at around 4am to beat the heat. He’ll have ttwo panniers on his bike with food, water, puncture repairs and a small medical kit. And across the Nullarbor he’ll be weighed down with 10 litres of water.” w “At medical school we’re encouraged to have a sense of social responsibility and to consider doing medical electives in developing countries. It’s important to look outside our own privileged little box and think more deeply about social justice issues. We’re looking for sponsors for Cycling for Fistulas, there’s a movie night on the December 17 at the Windsor Cinema and donations are welcome. We're hoping to raise a total of around $20,000.” http://hamlin.org.au/bruno

Singing for Others Fremantle Urologist Dr David Sofield is a keen singer-songwriter and surfer and he’s giving a concert to raise funds for SurfAid. “I’m a passionate surfer and I’ve seen the living conditions of the local people of the Mentawai Islands in Indonesia. There’s a huge disconnect between the Western surfers on their $300 a day boat charters and the Indonesian people living on the coast who don’t have very much at all,” David said. David has organised a concert at the Nexus Theatre, Murdoch University on December 8 at 7pm. Tickets through www.trybooking.com/BWPE and all proceeds go to SurfAid.


Travel

Soaking up the Sights in Rhine Time A 15-day cruise down the Rhine and Danube is a mixture of bustling sight-seeing and leisurely hours watching the quaint world go by. Perth to Dubai, to Frankfurt, to Budapest rolls off the tongue quickly but the plane trip is not so quick. However, holidaying Aussies take such long hauls in their stride, dragging bags through jetlag fog in the dark to find their accommodation. If Budapest is your destination then you will be rewarded the next morning by waking up to one of the most spectacular cities in Europe. A quick Google can give you an insight into Buda and Pest, split by the Danube and numerous wars. A two-day pass on the open-top red double-decker bus is even better. Buses leave every 30 minutes from a some of the city’s most famous and picturesque landmarks - monuments, castles, churches, museums, palace, markets and cafes (for goulash), parliament, state opera house, galleries – just take your pick. And there’s easy walking to the various stops. Folk are friendly, you feel safe and the dollar stacks up nicely against the Hungarian Forint, which is not pegged to the Euro. Although locals will try and talk you out of it, especially the younger ones who have listened too often to their ‘oldies’, a visit to Memento Park gives some tangible insights into Communist rule and the days of concrete monoliths and over-the-top public sculptures. It also gives you a more realistic 52

glimpse into how run down the outer suburban tramways are.

bliss of not having to lug your stuff between B&Bs or hotels.

The ‘Must sees’ are Parliament from the hill across the river; and Hero’s Square, Zoo & Botanical Garden, Széchenyi thermal bath, Vajdahunyad Castle and City Park Ice Rink; the Hungarian State Opera House; the Fisherman’s Bastian; and the Hungarian

First stop, Vienna, is a haven for the arts with sculptures punctuating roof tops and squares and elegant walks throughout the city and the famous Vienna State Opera is a must. More sobering is a visit to the square and balcony where Hitler announced his annexation of Austria.

Most travelling is by night and tours with local guides, bike rides, walks, or a sleep-in are choices offered at each stopover. National Museum – all within comfortable walking distance from each other. Our time in Budapest was marked by the start of our 15-day Rhine cruise to Amsterdam, via 64 locks and numerous scenic stopovers. News sheets keep you in touch with each day’s events and food and wine is matched to the locations you travel through – Hungary, Germany, Austria, Slovakia and Netherlands. Most travelling is by night and tours with local guides, bike rides, walks, or a sleep-in are choices offered at each stopover. And there’s the

A day trip to Bratislava (capital of Slovakia, which split from Czechoslovakia in the early 1990s), by contrast, demonstrates just how run-down and boring life under Communism was, with flashes of entrepreneurial flair now visible around the city. Next morning, the quaint village of Durnstein inspired us for a 38km bike ride to Melk (optional) alongside the river – pretty and invigorating and it set us up for the following day’s bus tour to the World Heritage-listed city of Cesky Krumlov in the Czech Republic, situated on the banks of the Vltava River. The guide of the walking tour explained how no one could afford to buy houses there because they were unable to insure against the regular flooding of the lower town. While it may not be one of the world’s most liveable areas, it certainly made a beautiful spot for lunch. We rejoined the boat at Passau where

medicalforum


Travel

everyone was sitting out in beer gardens watching the home team in the World Cup. The ladies of the party were thrilled to learn that the town boasted a shoe store that occupied three storeys, the men in the party were relieved to learn that it was closed. Next stop was Nuremberg, toy capital of the world, home to famous Nazi rallies and war trials, a fortified castle and gingerbread. The guide says the city was flattened in about 90 minutes in World War II by Allied bombing and rebuilt lovingly using traditional methods and materials. It’s astounding to see what looks to be a 13th Century medieval city and know that it is only 60 years ago. Our boat has reached the Main Danube Canal, which links the North Sea to the Black Sea and Bamberg is a town located at the entrance to the canal. Known as the “Franconian Rome” Bamberg is a UNESCO world heritage site with a population of 70,000. Levi Strauss and Willy Messerschmitt came from around here. A long hop brings us to Kitzingen, one of the oldest towns on the Main River. With its famous wine, fairytale medieval town and Count Dracula’s grave as drawcards, Kitzingen boasts more tourists than locals. A midday bus to the picturesque walled city of Rothenburg is well worth the trip. It’s home to Germany’s famous Kathe Wohlfahrt Christmas Store and the Puppen & Spielzeug doll museum, or if your tastes run to the darker side, the Torture Museum shows what was done in the name of religion back when. As the boat wends its way down the river, time is well-spent on the lower deck sipping the cocktail of the day and watching the picture postcard villages pass by. Many of the locks, however, are negotiated at night, so each morning there is a fresh adventure ashore. Waking up to Rudesheim was a treat. Here Siegfried’s musical museum, a stunning collection of mechanical music instruments and organs housed in an old town mansion, enthrals, as does the cable car ride to the top of the hill. As cruising resumes, quaint villages make way for castles – about 30 of

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them until we reach the Rhine River Gorge and pass the famous ‘Loreley Rock’ where the Rhine has its narrowest and deepest stretch. The next morning it’s Cologne, famous for its awe-inspiring cathedral – the only building left standing after Allied bombing flattened the city, including the bridge, which is now rebuilt and takes 1000 trains a day. During the walking tour you hear about Eau de Cologne, the Ford Works, the media industry, and pharmaceutical companies such as Bayer, and see where the latest archeological dig is happening, a stone’s throw from the cathedral. As we enter the Netherlands there’s a bus trip planned to Maastricht, home to waltz king Andre Rieu. At Strokstraat the credit cards start getting impatient as our party passes by some very expensive designer label shops. Retreating to the boat, the cruise continues, sailing to Amsterdam overnight, marked with a celebratory Captain’s Farewell Gala ala Dinner.

The canal cruise of Amsterdam orientates you to the famous sights such as Anne Frank’s house, the Maritime Museum, and the Tulip Museum, ready for a return trip on foot. At night, no one escapes the Red Light Area where blue lights for boys herald the days of equal rights. The city has 300 million tourists visiting a year and there is plenty to see. While the wear and tear on the city was obvious from my last visit 20 years ago, Amsterdam still offers exquisite dining and sightseeing if you stay away from the main drag. Catch a tram to the markets, buy cheese and provisions, and sit beside a canal with a bottle of beer or wine. After being on the move for 15 days, it was bliss to just sit and watch the world go by. O

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Kitchen Confidential

Where did you grow up? Manchester, England.

What were your earliest food memories? Braised hotpots, stew and dumplings with pickled red cabbage. Have you always wanted to be a chef? Not always! As a young boy I wanted to work in my Dad’s car business. At 16 I wanted to be a cook and travel. When I qualified I travelled to Australia on a working holiday and worked at the Sydney Opera House. I have worked on the Channel Islands as well as in France. I came to live in Australia in 2000. I opened up Red Cabbage in South Perth with my wife Hazel in 2007. How would you describe your menu? Modern Australian using our classical French training. We are using modern molecular techniques which also help us expand on our creativity. What do you love about WA produce? We have products other Eastern states crave for, like our Rottnest scallops, our black truffles and our amazing marron. What is your favourite produce to cook with? I have had Blue Ridge marron from Manjimup on the menu at Red Cabbage for five years and before that in other establishments. We get them fresh every week and they are always a consistent product. They pair so well with confit pork or lamb belly but are perfect on their own. Chefs have become the new rock stars, how has the media hype and celebrity impacted on your work? Everybody is interested in cooking, for sure, but it has only highlighted the glamour side of it. I don’t watch any of the shows on TV, I’d rather do something else. To work 15 hours a day all year round is like an Olympic sport, we have to sacrifice so much! Has TV exposure made it easier or tougher to be in the restaurant game? Everybody’s now a critic, they think they have seen it all on MasterChef. I keep one simple rule for customers. Do your homework before booking into a high-end restaurant. Check their website to get a feel for the place and check their menu! What are your opinions on food bloggers? I know some lovely food bloggers who do really well and I know some terrible ones! I tend to ignore most of them and stick to the newspaper food critics as they really make or break you. You can’t be everything to everyone! It’s a chef’s job to concern themselves with flavour and texture, in this day and age do you also have to keep an eye on healthy food? Of course it is. Lifestyles are changing and the demand for healthier food is on the rise. Do restaurants need to consider the specific needs of patrons, such as gluten free; vegan diets etc? Yes they do. I would suggest vegans give 24 hours’ notice so we can plan a menu for them but for gluten-free dietaries, most of our dishes are gluten free or can be altered with little notice. What do you do to relax? Do you cook at home?

10 minutes with... Scott O’Sullivan

I have two days and two nights off a week, the restaurant is closed Sundays and Mondays. I’m usually exhausted so any spare time I have will be spent with my one year old daughter at home, or we take her out to the park or swimming. I never cook at home, my wife Hazel does all the cooking.

Red Cabbage restaurant in South Perth has cemented its place at the top end of the Perth food scene with chef-owner Scott O’Sullivan being named Chef of the Year in the latest West Australian Good Food Guide.

What would be your last meal? I can’t name just one so I will name a few. I would have a chippy from England – chips, mushy peas, steak and kidney suet pudding, gravy and loads of vinegar! My sister’s roast dinner. She makes the best one! And maybe the biggest bowl of sticky toffee pudding with toffee sauce and vanilla ice cream – my recipe but I would get Hazel to make it! O

By Ms Jan Hallam 54

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Capel Vale

Wine Review

SUPER POWER

OF

Regional Series 2011 Pemberton Semillon Sauvignon Blanc A great example of a South-West SSB. It exudes those wonderful vibrant, freshcut grass characters and pithy green fruits. Zesty with crisp SB acid, but balanced with semillon fruit weight. Pemberton is making some great wines from these varieties. Regional Series 2011 Margaret River Chardonnay A wine that invites aromas of fresh, warm cashews and hazelnuts. Nicely interwoven oak leading onto a palate showing good fruit weight and texture. Flavours of stone fruit, cashew and nashi pear. Shows good length, a fresh finish and enough acid to drink over 2-4 years.

By Dr Craig Drummond MW

Regional Series 2011 Mount Barker Shiraz This is a good wine. The nose exhibits lifted 'Rhone-like' aromas with white pepper, allspice and a touch of wood smoke from the oak. In the mouth it is mellow and friendly. Blueberry flavours come through. Shows fruit concentration with oak taking a background role. Drink over 3-5 years.

Radiologist Peter Pratten obviously had big ambitions when he planted his original vineyard on the banks of the Capel River back in 1974. His Capel winery is still the headquarters for what has become a vinous empire in WA. I became aware of Peter's business prowess, scrutinising application and pursuit of quality when our viticultural paths briefly crossed in the mid-1980s, and it is no surprise to me that Capel Vale Wines has become one of the 'superpowers' of our local industry. The vineyards now encompass WA's key cool climate regions – Capel (36ha), Mount Barker (25ha), Margaret River (28ha) and Pemberton (77ha) producing recognised varieties and styles from the respective regions. The wines are marketed under a three-tier labelling format to appeal to a wide consumer market. The Debut Range (not reviewed, but recommended) is fresh, fruity, consistent and immediately approachable, and at about $18, good value. The Regional Series offers recognised varietals from specific geographical regions, reflecting what these areas have become noted for. Then at the pinnacle are the 'Single Vineyard' wines, which are made from the very best parcels of fruit from specific vineyard sites and given detailed attention in the winery.

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Single Vineyard Series 2009 'The Scholar' Margaret River Cabernet Sauvignon A real MR Cab Sav. Overt fruit with mulberry, cassis and some moist vegetation. As the wine is so youthful there is still a raw oak edge on the nose, which will dissipate. The palate is mellow, the tannins fine grained, and there is a gentleness with a nice persistent length. Will drink well over the next 10 years. Single Vineyard Series 2009 'Whispering Hill' Mount Barker Shiraz WOW - for me the 'top drop' of this selection. As an early part owner of this vineyard site I know every inch of the ground and am not surprised by the quality of this wine as the 'terroir' from which it came is excellent. A wine of personality. Deep, rich and layered. Bouquet of camphor, dried herbs and exotic spices. The flavours are of ripe/sweet black fruits – dark plum, black cherries and aniseed. A wine that will evolve and reward for the next 12-15 years.

WIN a Doctor’s Dozen! Which Capel Vale wine has the aroma of fresh warm cashews and hazelnuts? Answer:

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

ENTER HERE!... or you can enter online at www.MedicalHub.com.au! Competition Rules: One entry per person. Prize chosen at random. Competition open to all doctors or their practice staff on the mailing list for Medical Forum. Competition closes 5pm, December 30, 2012. To enter the draw to win this month’s Doctors Dozen, return this completed coupon to ‘Medical Forum’s Doctors Dozen’, 8 Hawker Ave, Warwick WA 6024 or fax to 9203 5333.

Name:

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

E-mail: ......................................................................................................... Contact Tel:

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

Please send more information on Capel Vale Winery offers for Medical Forum readers.

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funnyside e

QQChristmas Cheer "In honor of the season" Saint Peter said, "You must each possess something that symbolises Christmas to get into heaven on this holy day." The first man fumbled through his pockets and pulled out a lighter. He flicked it on. “It represents a holy candle,” he said. "You may pass through the pearly gates," Saint Peter said. The second man reached into his pocket and pulled out a set of keys. He shook them and said, "They're bells" Saint Peter said that he too might enter into the kingdom of heaven. The third man started searching desperately through his pockets and finally pulled out a pair of woman's underwear. "What do these symbolise?" Saint Peter asked sternly. The man replied, "They're Carol’s." **Just before Christmas, there was an honest politician, a kind lawyer and Santa Claus travelling in a lift of a very posh hotel. Just before the doors opened they all noticed a $5 note lying on the floor. Which one picked it up?? Santa of course, the other two don't exist! **What do you call a cat on the beach at Christmas time? Sandy Claus! **How do sheep in Mexico say Merry Christmas? Fleece Navidad! **What do you call people who are afraid of Santa Claus? Claustrophobic.  **Why was Santa's little helper depressed? Because he had low elf esteem.  **How come you never hear anything about the 10th reindeer 'Olive'? Olive? You know, "Olive the other reindeer used to laugh and call him names..."  **What do you get if Santa goes down the chimney when a fire is lit?  A Crisp Cringle

56

QQHospital Snip-its

QQOi Oi Oi

Two little boys, Sammy and Tim, were sharing a room in hospital. As they were getting to know each other, Sammy eventually asked Tim, "Hey, what're you in for?" "I'm getting my tonsils out. I'm a little worried," said Tim. "Oh, don't worry about it," Sammy said. "I had my tonsils out and it was a blast! I got to eat all the ice cream and jelly I wanted for two weeks!" "Oh yeah?'' replied Tim. "That's not half-bad. So, Sammy, how about you? What're you here for?" "I'm getting a circumcision, whatever that is," Sammy answered. "Oh my god, circumcision? I got one of those when I was a baby and I couldn't walk for two years!"

The following are results from an OZ-words Competition where entrants were asked to take an Australian word, alter it by one letter only, and supply a witty definition.

QQYou saw what? While walking to the shop this morning I heard the sound of an approaching horse moving at quite some speed. As I turned to look, a knight in full armour shot past, galloped up a big ramp and jumped clean over four buses waiting in the bus lane before landing in a shower of sparks. He then disappeared up the street without missing a beat. I thought who on earth could possibly do something like that? Then I realised it must have been…. med-Evel Knievel.

**Billabonk: to make passionate love beside a waterhole **Bludgie: a partner who doesn't work, but is kept as a pet **Dodgeridoo: a fake indigenous artefact **Fair drinkum: good-quality Aussie wine **Flatypus: a cat that has been run over by a vehicle **Mateshit: all your flat mate's belongings, lying strewn around the floor **Shagman: an unemployed male, roaming the Australian bush in search of sexual activity **Yabble: the unintelligible language of Australian freshwater crustaceans **Bushwanker: a pretentious drongo, who reckons he's above average when it comes to handling himself in the scrub **Crackie-daks: 'hipster' tracksuit pants. And for the Kiwis amongst us: **Shornbag: a particularly attractive naked sheep.

A bloke down the road has just been shot with a starting pistol! Police think it's race related. I've just heard our local cinema has been robbed to the tune of $5000. Apparently the thieves made off with a packet of Maltesers and a choc top.

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Competitions

Entering Medical Forum’s COMPETITIONS has never been easier! Simply visit www.medicalhub.com.au and click on the ‘Competitions’ link (below the magazine cover on the left).

Festival: Pol Art Perth will host the triennial PolArt Festival of Polish Visual and Performing Arts at the end of December. For 10 days Perth will experience Polish dance, theatre, music, film, visual arts and literature – the PolArt Festyn in the Perth Cultural Precinct and Museum Plaza, dance ensembles at the Perth Concert Hall, theatre in the Studio Underground and visual arts at Hackett Hall. Medical Forum readers have the chance to win tickets to see the vibrant dance spectacular, The Jewels of Polish Folklore. Perth Concert Hall, Wednesday, January 2

Movie: Hitchcock Hitchcock is a love story about one of the most influential filmmakers of the last century, Alfred Hitchcock and his wife and partner Alma Reville. The film takes place during the making of Hitchcock’s seminal movie Psycho. Stars Anthony Hopkins, Helen Mirren, Scarlett Johansson, and Toni Collette. In Cinemas January 10

Movie: Life Of Pi (3D) Yann Martel’s award-winning book is brought to stunning 3D life by Academy Award-winning director Ang Lee. This is the fantastical story of a young teenager who survives a disaster at sea by clinging to life in a lifeboat with only a Bengal tiger for company. Life of Pi takes you through his incredible adventure – at turns thrilling and spiritual; harrowing and triumphant; humorous and inspirational. Life Of Pi is in cinemas New Year’s Day

Lotterywest Film Festival Medical Forum readers have the chance to win tickets to one of two films at this year’s Lotterywest Film Festival at the Somerville Auditorium. Satellite Boy (an Australian premiere of a WA film) is set in Wyndham where a young boy and his grandfather (David Gulpilil) live in an abandoned drive-in cinema. (Tickets for Monday. December 10). On December 31 win tickets to see the hilarious French Quebec film, Starbuck. Satellite Boy, December 10; Starbuck, December 31; Somerville Auditorium, UWA

Movie: Save Your Legs Inspired by true events, Save Your Legs is the story of one man who refuses to lose his cricket team to the realities of growing up. It’s an uplifting adventure filled with comedy, cricket and Bollywood music, that takes viewers from the suburbs to the Sub-continent in pursuit of a boyhood dream. In cinemas from January 24

Special Glen Eldon for Occasions e luck y

th wipatayi was en. Prof Patrice M Doctor’s Doz er ob ct O e ves lo n winner of th surgeo orn vascular e The French -b ch na re G cularly the red wine, parti len Eldon’s n bottles of G ze do A . variety easurable pl e provide som finest should t to become ineries Patrice’s ques has visited w assistance in na io do. Patrice ic … and af ce e in an w Fr d in a fully-fledge and Bordeaux a ric Af toph g ut bi ch, So se. There’s a in Stellenbos River, of cour t trice re Pa ga d ar an M 13 in 20 down south in Christmas up g at. in th m r fo co ation Eldon wines secret celebr e of the Glen m so ng vi sa says he’ll be

MEDICAL F ORUM

WINNERS FROM THE OCTOBER ISSUE A Chorus Line – theatre: Dr Tricia Charmer To Rome with Love – movie: Dr Rachel Price, Dr Tony Connell, Dr Michael Leung, Dr Linda Wong, Dr Donna Mak, Dr Ernest Tan, Dr Robyn Lawrence & Dr Ann Ngui Bangarra Dance Theatre: Dr Donald Reida

Career Transplant La

Arbitrage – movie: Dr Byrne Redgrave, Dr Mukti Biyani & Dr Bastiaan de Boer

wyer to Ru ral GP

t250 Drs E-p oll: Compla ints; Sponsors; Specialisation tGuest Co lumn: Euthan asia tLoyalties for Region s tSpending Money to Make Mo ney?

Remembrance Concert – music: Dr Victor Wang & Dr Boey-Leng Loy Anthony Marwood & Aleksandr Madzars – music: Dr Senq J Lee, Dr Stephanie Green & Dr Colin Stewart

OCTOBER 2 012

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The Danny Kaye Show – theatre: Dr Stephen Cohen & Dr Anne Beaton

Major Sponsors

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October 2012

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Do you want to kill the pig? Generous relocation packages available at a progressive rural practice 2 hours from Perth. Collie in WA. is not in the dusty hot North of WA but the only serious mining town in the South West close to Perth. Aside from procedural opportunities, great location and a progressive practice with all the usual modern practice requirements, there is some serious money for relocation and retention available. SIHI is offering very generous payments for GPs willing to commit to the town. There are limited numbers of relocation packages, so first in best dressed! Ideal opportunity for a GP registrar with procedural skills, either finishing or about to finish training. We are an accredited training practice and so there is excellent teaching opportunities and support. We have recently expanded the practice for the anticipated growth in the region so there is loads of opportunity for progressive new Drs. For more information, contact Angela 08 9734 4111.

JANUARY/FEBRUARY 2013 - next deadline 12md Tuesday 15th January - Tel 9203 5222 or jen@mforum.com.au

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