Medical Forum 06/12

WA’s Independent Monthly for Health Professionals

Doctors’ Dilemma

Taking the Fight to Diabetes

• Kimberley Renal Service; Diabetes & Cancer; Diabetic Maculopathy;

• Kim Snowball’s Balancing Act • Lexus GS 350 Hits the Road

June 2012

www.mforum.com.au

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Contents

Major Sponsors

FEATURES

CLINICAL FOCUS

4 Director-General of

31 Tips For Reducing

Health Kim Snowball

Opioids

8 Kimberley Renal

Support Service

12 Roger Cook, Shadow

Health Minister

24 Nepal Challenges

Young Doctors

NEWS & VIEWS 2 Letters:

4

Ms Julia Sutton, Dr Russell Clarke. Dr Neil Ozanne

20 Diabetes Management

Overload

Dr Rob McEvoy

22 Making CoNeCTions 23 Beneath the Drapes

8

24 Student Ethics Award

Forward in Palliative Care

29 Care for Those Under

the Rainbow

Mr Peter McClelland

12

Complaints are Conquered

Ms Morag Smith

22 Tackling Chronic

Disease

Dr Will Thornton

35 Diabetes, a Patient

39 The Lack of

Dizziness: Bilateral Vestibulopathy Dr Vincent Seet

41 Pancreatic Cancer –

Reason for More Hope Dr Andrew Dean

43 Surgical Management

of Colorectal Liver Metastases

Freedom

Mr Peter McClelland

46 Funny Side 47 Wine Review:

Hartz Barn

Dr Craig Drummond MW

48 Car Reivew: Lexus

350GS F Sport

50 Photo Competition:

Wild Times and Fun Times

GUEST COLUMNS Guidelines: What is Their Legal Status?

Over Gestational Diabetes

Dr Daryl Sosa and Dr Peter Bradley

30 Divided, the

14 Clinical Practice

34 Influence of Exercise

44 Free-Wheeling

Mr Peter McClelland

28 Collaboration a Move

Dr Joey Kaye

LIFESTYLE

26 Fighting for Rebecca

Primary Health Care

the Good, Bad and Uncertain

Dr Krishna Epari

Winner

26 The Business Side of

33 Diabetes and Cancer:

Dr Brad Johnson

Dr Rob McEvoy

Mr Peter McClelland

Group

37 Diabetic Maculopathy

and Accountability

18 Financial Planning

32 Diabetes WA Support

Assist/Prof Kym Guelfi PhD

3 Editorial: Transparency

16 Have You Heard

Drs Stephanie Davies, Eric Visser, Roger Tan and Nick Cooke

24

Dr Susan Downes, Dr Gary Dowse, Dr Julia CharkeyPapp and more

52 10 Minutes With

George Calombaris

52 The Mundaring Truffle

Festival

Ms Jan Hallam

54 Competitions

Perspective

Ms Barbara Daniels

medicalforum

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PUBLISHERS Ms Jenny Heyden - Director Dr Rob McEvoy - Director

Letters to the Editor

Consider Kids in Pain 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 Journalist Mr Peter McClelland journalist@mforum.com.au Editorial Advisory Panel Dr John Alvarez Dr Scott Blackwell Ms Michele Kosky Dr Joe Kosterich Dr Alistair Vickery Dr Olga Ward 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

I was interested to read your articles on pain management (May, 2012) and like to alert your readers to a campaign that has been launched by parents of children with chronic pain to improve pain services for young people in WA. PMH has no dedicated pain unit. Pain support services are currently shared between rheumatologist Dr Kevin Murray, physician Dr Payne and two rostered anaesthetists. These are fine doctors but they can’t offer the level of service that a dedicated pain unit could provide.

Even patients with a documented history of serious pain events still need to endure lengthy emergency department protocols before they can access anyone with specialist pain expertise. There can be serious consequences to these delays.

Some years ago I cared for my daughter after full spinal fusion surgery. I was given large quantities of medications such as Oxycodone and Oxynorm with very little training in how to administer them. There was no advice in the storage and disposal of these medications. This is in stark contrast to the locked cupboard double-checking procedures on the wards.

There was no follow-up contact with our family to monitor post-operative nursing or pain management.

A pain unit could provide education and support for families like us in caring for a young person in pain at home.

It is not just kids with chronic conditions or those recovering from major surgery who can’t access services. There is surprising evidence that even children dying from cancer will struggle to have access to appropriate pain management. A 2010 study at the Royal Children’s Hospital in Melbourne found that nearly half the children with terminal cancer were inadequately medicated for pain. This is something that needs to change.

I believe that doctors in WA need to be able to refer children and teenagers in pain crisis to PMH with confidence. This is an urgent problem and that can be solved with collective action on the part of parents and their family doctors.

Ms Julia Sutton, Jointpainrelief.com.au (Parent Advocacy Website)

Rethinking pholcodine prescribing Dear Editor, Pholcodine is the active ingredient in many cough suppressants freely available in WA. Exposure to this drug is now thought to be greatly increasing the incidence of anaphylactic reactions to muscle relaxants given intra-operatively.

Anaphylaxis is a life threatening complication of anaesthesia, with an estimated mortality rate of 3.5-10%1. The most common cause of anaphylactic reactions during anaesthesia in WA are muscle relaxants, and the incidence varies from 1/5,200

exposures in some countries where pholcodine is freely available to as low as 1/200,000 where it is not2.

Pholcodine was identified as the sensitising agent after some fascinating scientific detective work in Scandinavia. Norway had a high rate of muscle relaxant allergy, whereas Sweden had an extremely low rate. Investigators identified compounds with a similar chemical structure to muscle relaxants and compared their use between the two countries, finding pholcodine was the “decisive exception”.

Population-based antibody testing and a randomised controlled trial looking at the degree of sensitisation in allergic individuals later confirmed pholcodine as the causative agent1.

The drug was subsequently withdrawn from the Norwegian drug market in 2007. As a direct result, muscle-relaxant-specific antibody levels have decreased within the Norwegian population and muscle-relaxant allergy rates are falling3.

The Therapeutic Goods Administration has acknowledged this potential risk of pholcodine4, however, its use remains widespread in Australia.

Muscle-relaxant anaphylaxis is one of the most feared complications of anaesthesia. It seems we have the ability to reduce this risk. Although not a prescription medication, advice by general practitioners to avoid pholcodine containing antitussives may significantly reduce the community incidence of intra-operative anaphylaxis in the future.

Dr Russell Clarke, Consultant Anaesthetist, Anaesthetic Allergy Referral Centre of Western Australia SCGH. ED. Consultant Anaesthetists Peter Platt and Paul Sadleir are in the same SCGH group.

References 1. Florvaag E, Johansson SGO. The Pholcodine Story. Immunol Allergy Clin N Am 2009; 29: 419-427.

2. Johansson SGO, Florvaag E, Öman H et al. National pholcodine consumption and prevalence of IgE-sensitization: a multicentre study. Allergy 2010; 65: 498-502.

3. Florvaag E, Johansson SGO, Irgens Å et al. IgE-sensitization to the cough suppressant pholcodine and the effects of its withdrawal from the Norwegian market. Allergy 2011; 66: 955-960.

4. Therapeutic Goods Administration 2009, Review of cough and cold medicines in children, Australian Government, accessed 16/5/2012, http://www.tga.gov.au/pdf/consult/consult-labellingcough-cold-091022-review.pdf

Jumping for Joy Dear Editor, I’d been in Brisbane for a conference and came back to Perth to find my copy of Medical Forum and the article, ‘It’s All About the Horse”, which has been very well received, thank you.

My daughter, Rachel, has been contacted by a girl she went to school with who has a horse and works in a medical practice. She read the article and said Rachel was an inspiration to her. So much so, she’s intending to study nursing and then perhaps go on to study medicine.

Dr Neil Ozanne Chidlow

medicalforum

Editorial

Transparency and Accountability Dr Rob McEvoy looks at changing attitudes to governance standards and one instance that impacts the profession – the Medical Board.

The Global Financial Crisis. People at the top behaved badly, while the man in the street took the hardest fall, and as the huge debt burden shifted from the private to the government sector, thanks to various bail-outs and stimulus packages, communities began to realise the extent to which people with money or power have influence. Shareholders decried huge executive salaries and bonuses. Shonky practices that gave false hope to investors were exposed, as were greed and abuse of power.

trust? For example, the federal government will establish a new national regulator, the Australian Charities and Not-forProfits Commission, and is proposing to apply new reporting standards to the not-for-profit sector in legislation this year. Registered charities will be asked to comply first to “improve public trust and confidence in the sector, through promoting accountability and transparency” and other NFPs will follow, with financial reporting requirements commensurate with their level of revenue.

In WA, somewhat sheltered from the financial storm, ‘people behaving badly’ has been highlighted by the inquiry into abuses at the St Andrew’s Hostel in Katanning. Wikileaks, the Murdoch press in the UK and our own Health Services Union inquiries have shown two things – some people in power may breach trust and we need something better than an extraordinary exposé after the event.

The basic idea behind these changes is people have a right to know where their donated dollar is going, whether via a direct donation, tax concession or government grant. In Western Australia, some NFPs have jumped in first with their open financial reporting, notably St John of God Healthcare and Princess Margaret Hospital Foundation.

Will ‘transparency and accountability’, the new catchcry in governance, restore

As a profession, do we have anything to lose from being more accountable and transparent? Moving serious

misdemeanours to the State Administrative Tribunal (SAT) has opened things up, and the findings from this more judicial approach are posted on the web. While appointments to the Medical Board are posted on the AHPRA website (www.ahpra.gov.au), the names of the 30 or so doctor panellists appointed by the Board to hear complaints are not.

Yes, anyone called, in confidence, before a panel of three (two doctors, one consumer) has the opportunity to raise any concerns over panellist selection, and bring a lawyer. In contrast, however, no one in the profession is given the opportunity to inform the Medical Board about a panellist prior to their appointment. Can we assume Medical Board incumbents are fully informed? What is the process for appointment and how are the consumer’s or profession’s interests best served by this apparent lack of transparency?

These questions deserve answers. l

FREE ONLINE HEPATITIS LEARNING RESOURCE FOR GPs Edith Cowan University (ECU) and the Department of Health, WA have developed free online hepatitis B and C learning programs for general practitioners to increase the delivery of safe treatment to patients.

The hepatitis B learning program consists of two modules, incorporating cartoons to aid in understanding hepatitis B serology. The hepatitis C learning program consists of three modules, with the third module targeted at GPs interested in becoming S100 hepatitis C anti-viral prescribers.

Both programs have been approved by the RACGP QI & CPD program for 40 Category 1 points.

Explore the learning programs at hepatitis.ecu.edu.au or for further information contact hepatitis@ecu.edu.au

303 ECU7168 CRICOS IPC 00279B

ECU7168_188x125_MedicalMagazine_2.indd medicalforum

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10/05/12 4:51 PM 3

Feature

Budget v Outcomes – the Great Balancing Act The Director-General of Health Kim Snowball has got many things on his mind and he shares a few of them with Medical Forum readers.

He is the head of a workforce of 40,000 people, is managing a $6.5 billion capital works program and is responsible for delivering health services that cost billions to a fast-growing population that’s eating, smoking and drinking too much and exercising too little. And all this within budget. Despite all the weekend paperwork this CPA and former CEO of the WA Country Health Services says the job is a privilege.

works and what doesn’t, how people behave in a big system, about leadership – these things have given me focus in this role.

Working in the country…you get to see the emotional side of health – you can never lose sight of the human impact of what you do.”

“I also learnt that there a many really great people working out there in health. They are passionate about their roles and views and feel a need to advocate.”

Currently, the department is without a Chief Medical Officer after Dr Simon Towler finished up. Mr Snowball says he would like the role to be more full-time: “Not only to assist me in decisions around clinical issues but also around governance and the clinical workforce.”

“Not too many people get the opportunity to change the direction of people’s lives. But it’s not about me, it’s how this office can support people in the system to do their job better.”

Many remember Kim Snowball’s appointment as Acting D-G after his predecessor Dr Peter Flett had a fiery encounter with the then Treasurer, Troy Buswell, and resigned.

“The first role I took on was to get Health on a more stable footing in terms of its relationship with Government and Treasury, and to present plausible and credible solutions to what had been an impasse in terms of finances. I probably had a bit of an advantage on the financial side in that I’m a CPA and I also knew the health system very well. We fundamentally reformed our relationship with Government and Treasury.”

At the core of those reforms is setting targets based on complex modelling, which means more accurate forward estimates which in turn means avoiding what Government Treasuries loathe most – nasty surprises.

“We now have a very clear relationship with government in terms of what return there is for the taxpayers’ money. Treasury can keep an eye on the model and validate it themselves and that makes them feel more secure.”

Another catchcry of Government is value for money and it is not something Kim Snowball takes lightly either.

“There is an issue of affordability. We might like to have quicker, bigger buildings but we’ve got to make sure that we are not asking too much of government to deliver what we know we can deliver at a more

4

However, he insists there is no shortage of clinical advice and he is there to support them.

n Mr Kim Snowball

moderate cost. It’s our job to make sure we get absolute value for the taxpayers’ money with better health outcomes and the quality and safety of the services.”

“If you have areas that are inefficient it’s an opportunity lost – it means there’s less money for areas of high demand in our health system, it’s not about penny pinching but about value for money.”

Mr Snowball says his time working in country health, as head of both WACHS and St John of God Geraldton, plus five

It’s not just about knowing my way around a balance sheet, it’s about knowing what works and what doesn’t, how people behave in a big system, about leadership – these things have given me focus in this role. years consulting here and in other states, has honed his skills in senior management and policy development across the system.

“It’s not just about knowing my way around a balance sheet, it’s about knowing what

“If you set things up so people can do the best job they can, 99% of them are motivated for the right reasons, because it’s a vocation. If you connect with them the right way they will give 120% and work for nothing. I’ve seen them. Give them a clear path forward and they will absolutely do their best and enjoy the work as a consequence.”

The only slight hint of exasperation in a smooth veneer comes with a mention of privatisation.

“We often get accused of privatising the public health system but there has always been a close integration with the private system. We have private doctors working in public hospitals, is that privatisation?

St John Ambulance, RFDS – they are such long-term partners in hospital and health that people forget they are actually private.”

“In terms of privatisation, that’s life. There’s a perception that I’ve got an ideology, or the minister has an ideology, for privatising everything. That’s not the case. I am required to get value for money, if the private sector can run a service that’s cost effective and of better quality, then we’ll look at that. If not we will continue to run the service in the public sector.”

In the case of SJOG, contracted to run the Midland Health Campus but not provide Continued on Page 6 medicalforum

ADHD Drugs in the Young and Cardiac Risk, Not Such a Heartache A

ttention deficit hyperactivity disorder (ADHD) affects more than 5% of children and adolescents and many are treated with stimulant medication. In recent years, concerns were raised over the risk of sudden cardiac death, generated by isolated and rare reports of children and teenagers dying suddenly whilst on medication for ADHD, predominantly in North America. These events led to several regulatory and policy decisions regarding ADHD drug use in Canada and the United States.

In 2008, the American Heart Association released a policy that was interpreted as recommending routine ECGs during the evaluation of children with ADHD, prior to commencing stimulant medication.

Comment and controversy followed, particularly from the American Academy of Paediatrics and the American Academy of Child and Adolescent Psychiatry, stating there was a lack of evidence for such a recommendation and an ECG before medication may be "reasonable" but it was not mandatory.

As there was a lack of evidence of serious cardiac events relating to the use of ADHD drugs and there were no data on the benefits (including cost-effectiveness) of routine ECG screening, the American Academy of Paediatrics subsequently said that until these questions were answered, an ECG before children received ADHD medication is not warranted.

examination to identify risk factors and provided a corresponding check list. This was designed to screen for cardiac risk factors for sudden death among children starting stimulant medication. ECG assessment was not supported, due to lack of evidence.

In 2009, the sensible Canadians published a joint position statement from the Canadian Paediatric Society, Cardiovascular Society, and Academy of Child and Adolescent Psychiatry titled "Cardiac Risk Assessment Before The Use Of Stimulant Medications In Children And Youth". They emphasize that sudden cardiac death in children with ADHD on stimulant medication is rare and, using the best available data, it was likely the risk of sudden death was indeed similar to children in the general population.

They recommended that all children with ADHD, like all paediatric patients, undergo a careful history and physical

A very recent landmark article in the New England Journal of Medicine by Cooper et al titled "ADHD Drugs And Serious Cardiovascular Events In Children And Young Adults", further adds evidence to the lack of serious cardiac effects of these drugs and should be reassuring to prescribing physicians, patients and their families. The study cohort involved over 1.2 million children and young adults with 2.5 million person-years of follow up. The conclusion was that ADHD drugs were not associated with increased risk of serious cardiovascular events (including sudden

What of the Australian position?

Unfortunately, the Australian guidelines on ADHD reported in June 2009 by the Royal Australasian College of Physicians, still remain in "draft", yet to be approved by the NHMRC Council (see references).

These guidelines recommend that before initiating drug treatment for ADHD, cardiac risk factors are clinically assessed by history and physical examination.

No mention is made of routine ECG, presumably regarded as unnecessary.

Specialist cardiologist advice is recommended for people with cardiac risk factors.

Dr Luigi D'Orsogna

About the author Dr Luigi D'Orsogna is a UWA graduate who trained in Paediatrics at the Children's Hospital in Vancouver, Canada, and Princess Margaret Hospital. He completed a fellowship in Paediatric Cardiology at the Children's Hospital in Boston and the Harvard Medical School where he developed a special interest in Fetal Cardiology and interventional cardiac catheterisation procedures for congenital heart disease.

Currently, he is a visiting cardiologist at Princess Margaret Hospital and is the director of Fetal Cardiology in the Maternal Fetal Medicine Unit at King Edward Memorial Hospital for Women. His private practice includes all aspects of general Paediatric Cardiology.

cardiac death, acute myocardial infarction and strokes), in children and young adults up to the age of 24 years. In multi-variant analysis, an older age, current use of antipsychotic drug, a major psychiatric illness, a serious cardiovascular condition, and chronic illness were associated with an increased risk of serious cardiovascular events, whether on ADHD drugs or not.

Summary Based on current data, it appears that ADHD drugs in children and adolescents are relatively safe with respect to serious cardiac events. Prior to commencing ADHD medication, the best advice is to screen for risk factors using history and physical examination. Routine ECGs are only necessary when cardiovascular risk factors are identified and then a specialist cardiologist opinion should be sought.

References 1. SA Belanger, et al. Cardiac risk assessment before the use of stimulant medications in children and youth. A joint position statement by the Canadian Paediatric Society, the Canadian Cardiovascular Society, and the Canadian Academy of Child and Adolescent Psychiatry. Paediatr Child Health 2009; 14(9):579-585.

2. Australian guidelines on attention deficit hyperactivity disorder (ADHD), June 2009 - from The Royal Australasian College of Physicians. www.nhmrc.gov.au/publications/synopses/adhd_draft.htm.

3. WO Cooper, et al. ADHD Drugs and Serious Cardiovascular Events in Children and Young Adults. N Engl J Med November 17,2011. 365:1896-1904.

Feature

n Fiona Stanley Hospital – an aerial view taken in April 2012

Continued from Page 4 services like contraception and termination, he said the organisation made it clear from the start it would not provide those services.

every Sunday.”

He wishes others would take it up too.

“We didn’t think that made them ineligible because there were other providers who could deliver those services in the Midland area. Should those services actually be provided in a hospital? The answer is probably no. However, what services SJOG can’t provide will still be available at the Midland Health Campus, so there will be no reduction or lack of access to services.”

“This generation if the first whose longevity is going to go down and that’s going to n The proposed new children's hospital shock people. If we don’t shock He is proud of health reforms such as the them now to change their behaviours, we Four-Hour Rule but before he left the chair, will be building more beds and bigger he would like to achieve real change in the hospitals. The system struggles now to health outcomes of Aboriginal people. provide services for the obese – 25% of “Not many Aboriginal kids by the age of people waiting the longest for surgery are 10 have both parents alive. We just don’t waiting for bariatric surgery.” understand the impact that has on people.

I think most government agencies are committed to changing their relationship This generation if the first whose with Aboriginal people but we have to learn how to engage with them to achieve that. longevity is going to go down and that’s If there’s one thing I’ve learnt about being going to shock people. If we don’t shock born and living in the country is that you them now to change their behaviours, have to treat people with understanding we will be building more beds and and understanding brings respect.”

He said that private hospitals had a huge role to play, particularly in elective surgery.

“They do more than half of the elective surgeries in the state, which is healthy.

We’re lucky we’re a smaller state, we all know each other. It’s not nameless and faceless people. I have tried to make sure that the private sector knows and understands our modelling and predictions about demand so they can make sound decisions about new services."

Fiona Stanley Hospital, the new PMH, Midland Health Campus, etc – is bigger and better hospitals the future focus of health? Far from it, he says, pointing to an intense focus on primary care and promoting active, healthy communities.

“Exercise for me is really important – you have to be fit and healthy to do this job and my daughter is a personal trainer and flogs me to death at Challenge Stadium

6

bigger hospitals.

“GPs are going to assume bigger prominence in the model. We have far too few GPs, the worst GP to population ratio in the country, so new medical graduates are going to be encouraged to look seriously at general practice.”

“I have had Aboriginal people work with me who are in their 50s and they have said to me, ‘It won’t matter, we won’t be here for much longer’ that’s a sad attitude. If I don’t do anything about that with my background, I’d be sorry I didn’t achieve that.” l

By Ms Jan Hallam

medicalforum

Margins of Excision for Primary Melanoma: a New Approach W ide excision of melanoma (removal of normal tissue beyond complete excision of the tumour itself) has been the standard treatment for primary melanoma for more than a century. For much of that time, recommendations ranged from margins of 5cm to removal of as much surrounding normal tissue as possible, with the aim of improving survival and decreasing the risk of local recurrence (LR) by removing clinically undetectable residual primary melanoma cells and lymphatic metastases.

Those recommendations were based on the belief that metastasis from primary melanoma proceeds in a stepwise progression via lymphatics to regional lymph nodes with the establishment of nodal metastases as the precursor to systemic metastasis. When it became obvious that wide excision per se had no effect on survival the concept of varying the extent of excision according to tumour thickness was introduced on the assumption that patients with thicker tumours associated with a poorer prognosis should benefit from wider excisions by reduction of the risk of LR, not further defined.

Randomised controlled trials (RCT) have shown no effect of wide margins of varied extent according to tumour thickness on survival from melanoma and no significant effect on the risk of local recurrence (LR), but the recommended margins remain based on the notion that wider margins for thicker tumours may decrease the risk of LR. The continuing controversy concerning the rationale for margins of excision for primary melanoma rests on the interpretation of the term “local recurrence”. The traditional doctrine is that all LR are lymphatic metastases, whereas the histological features indicate that they comprise two entirely different entities, arising by different processes and with markedly different prognostic implications.

Understanding this concept rests on two basic principles.

1. The term LR correctly applies only to those cases of recurrence developing after complete excision of the primary melanoma, confirmed by histopathological examination, at the primary site i.e. involving the excision scar or graft. Any tumour arising beyond those sites must be, by definition, a metastasis due to either lymphatic or haematogenous spread, or by both routes. These recurrences include all those lesions known as in-transit metastases or satellites. Rarely, LR may arise by perineural spread classically from desmoplastic melanoma.

LR, therefore, is the key factor in resolving the controversy about margins of excision.

2. LR consists of two distinct entities with different morphologies and prognostic implications; A. Persistent growth of incompletely excised primary melanoma (persistent melanoma), usually with a good prognosis because most are residual in-situ components of lentigo maligna melanoma or acral lentiginous melanoma.

B. Local metastasis, the more common form of LR, is identical morphologically and biologically with satellites, in-transit metastases and distant cutaneous metastases and is a manifestation of systemic (haematogenous) metastasis, with a poor prognosis.

Salient Points Are: • Persistent melanoma and local metastases are not reported as distinct entities in any RCT, which have defined LR arbitrarily as any melanoma, occurring within 2–5cm from the primary excision scar or graft.

• Most LR are local metastases and relate to tumour thickness because they are metastases which are not preventable by surgical means.

By Dr Peter Heenan

• Persistent melanoma, the less common form of LR relates to melanoma growth patterns.

• Growth pattern, not tumour thickness, is the most important determinant of margin of excision.

• Genetic profiling is likely to become clinically useful in identifying the limits of in situ melanoma.

• Recommendations for arbitrary margins of excision based on tumour thickness should be discarded.

• The aim of excision of primary melanoma is the removal of the entire invasive and in-situ components, confirmed by comprehensive histopathological examination, including special techniques when necessary.

Suggested Alternative Recommendation for Clinical Margins for Excision of Primary Melanoma In situ melanoma.

5–10 mm

Invasive melanoma of common types (e.g. superficial spreading and nodular), regardless of tumour thickness.

5–10 mm

Lentigo maligna melanoma and acral lentiginous melanoma1

5–10 mm

Desmoplastic melanoma 2

10mm

(1) In this special category, serial sections, examination of the peripheral margin (e.g. modified Moh’s technique), and immunostaining are often necessary to define the extent of the in situ component. In future, genotyping may come into routine use. (2) Wider excision is often required due to the diffuse growth pattern and perineural invasion.

Feature

n The Kimberley renal support team in Broome

Wheel Turns for Kimberley Renal Patients A decade of commitment and perseverence by a legion of people has offered new hope for a generation people in the Kimberley.

If you ever needed an example of what can be achieved by vision, determination and gutsy, selfless persistence, you can’t look past the Kimberley Renal Service (KRS). It didn’t happen overnight, it didn’t happen because there were votes in it either. It happened because there was a desperate overwhelming need and there were community elders, doctors, nurses and health workers prepared to lobby and worry decision makers until they saw the sense of a medical service that would treat people with kidney disease close to their home.

The Kimberley Aboriginal Medical Service Council’s website carries a poignant story of Aboriginal elder Puggy Hunter, who it says was the driving force behind the push for kidney dialysis services in the Kimberley region. He certainly laid down the philosophy of the service, which people like KRS manager Maree Wearne says underpins her role – that is to help build a renal service that is effective and culturally appropriate.

In 1995 Puggy Hunter began meetings with Royal Perth Hospital’s renal physician 8

Dr Mark Thomas pressing for a satellite dialysis service to be established in the Kimberley to stem the heartache of families farewelling their loved ones with end-stage kidney disease to Perth, often never seeing them again.

This vision to establish a communitybased dialysis unit in the Kimberley has been shared as passionately by a core of dedicated medical staff who have been with the project from the beginning – the tireless Dr Cherelle Fitzclarence, nephrologist Dr Kevin Warr and renal nurse Maree Wearne.

Cherelle went to the Kimberley in 2001 to work at the Broome Regional Aboriginal Medical Service (BRAMS).

“I’d been there a couple of weeks when I was told that a dialysis unit was going to be built. I hadn’t done a renal term so I was like ‘dial-a-what?!’. I was reassured it wasn’t going to be a big deal and it would be run by nurses.”

The war on kidney disease in the Kimberley was also being waged in Government cabinet rooms in Canberra and Perth.

Persistent lobbying and the critical need to treat an ever-growing list of renal patients finally broke through the red tape and

a Commonwealth-State agreement was reached where federal money would build the centre and state funds would enable the Aboriginal health sector to run the service.

“BRAMS was the first Aboriginal community controlled health service in Australia to own and run a dialysis unit,” Cherelle said. “We had an interim unit which we opened in March, 2002, at the Broome hospital for eight patients then in October, 2002, we opened up the Kimberley satellite dialysis centre with those eight patients and the expectation that we would reach our capacity of 40 patients in three years. We were full within 18 months.”

“What became apparent was that these renal patients required a lot of input.

Managing them was not as straight forward as was first thought."

“Our consultant Dr Kevin Warr has been coming to the Kimberley for the past 15 years and with high doctor turnover, or papers getting lost, he would see a patient and when he’d come back in six months’ time, nothing had happened. So I began to sit in on consultations to keep continuity.

Maree, who was then employed by BRAMS to set up the dialysis unit, and I would also Continued on Page 10

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Feature Continued from Page 8 coordinate the local care for the peritoneal dialysis patients (RPH backup), so the KRS grew from this team work.”

As the team worked on, the wish list grew – a peritoneal dialysis nurse, a PD coordinator, a home haemodialysis nurse, an educator or two, some residents, all were urgently needed and by 2003 they were determined to make it happen and they put a business case to the state government.

“When I look back on the initial proposal we put forward, I cringe,” Cherelle said.

“We had no idea how to write up a proposal. However, the government saw merit in the idea, organised a review of renal service needs and a much more polished proprosal was put forward with input from many people. I was happy to swallow my embarrassment and I learnt a lot from there.”

The Kimberley Renal Service grew out of this. It is owned and operated by the Kimberley Aboriginal Medical Services Council (KAMSC) with Maree the manager.

It has grown to include the Kimberley Renal Support Service (KRSS) which works on prevention, and the dialysis units providing satellite haemodialysis throughout the Kimberley; Broome, Derby, Fitzroy Crossing and Kununurra.

The KRS now provides culturally appropriate haemodialysis treatment for 44 patients in Broome. Derby’s dialysis centre will grow from 8 patients to 40 in the next couple of years, while a new 24 patientcentre in Kununurra and an 8-patient centre in Fitzroy Crossing are planned to open later this year. In total the KRS will consist of four dialysis units and a prevention unit.

“From our proposal for more dialysis units we felt it essential to contribute to slowing the progression of people with kidney disease onto dialysis, and since the Aboriginal health sector run Primary Health Care services, we had the perfect environment to establish the Kimberley Renal Support Service. The KRSS is about supporting the people on the ground,” Maree said.

The KRSS has an East Kimberley and West Kimberley team that consists of predialysis coordinators that support PHC services

n KRSS team time

to educate and support those with endstage kidney disease about their treatment.

Educators also support PHC services with kidney disease awareness and prevention programs, screening and monitoring those at risk. A transplant coordinator supports those who have had a kidney transplant and Aboriginal social support workers and social workers are also involved.

Cherelle said that time had brought more doctors to the region. “A decade ago there were three doctors at the Broome Hospital so we just got in and did it. Now there are 16+ and that’s the same story in other parts of the Kimberley. The KRSS’s role now is to build capacity and assist the primary care services to look after these kidney patients. Kidney patients can be a bit scary if people aren’t used to managing them. The KRSS arm of the Kimberley Renal Service provides education for patients and staff and offers a safety net.”

Technology is also now playing its part.

While Cherelle talks to Medical Forum from her office at Corrective Services in Perth, where she is deputy director of health services, she takes a call from a doctor at Broome hospital. A renal patient, who has had a kidney transplant, has presented with a complication.

As Cherelle advises the doctor by phone, they are both viewing the patient’s notes via patient information management software called MMEX. It has led a quiet revolution in the care of patients in isolated and remote communities as clinicians and health workers can now speak to the same file.

Many of the service’s patients are itinerant but MMEX allows doctors to have a complete record of treatments. “It’s just awesome,” Cherelle said. “It enables me to be able to do a lot of this stuff from wherever I am. That’s the safety net.”

n Kimberley Satellite Dialysis Unit 10

While the KRS is a standout success, the problem continues to be enormous with the Kimberley having one of the highest incidence of kidney disease in the world.

“Renal failure is in epidemic proportions in society in general and closely parallels the epidemic in diabetes and obesity,” Cherelle said. “In the Aboriginal population in the Top End and the Kimberley, the rates of end-stage kidney disease are vastly worse than anywhere else – up to 30 times the rate of Sydney or Perth. So it’s a very significant issue.”

“The KRS allows us to recognise the problem sooner, diagnose it, manage it, educate the patient, prepare them for the fact that they might need dialysis, long before they need transfer. Now more of our patients are choosing to have therapy.

We still have about 30 Kimberley people dialysing in Perth, waiting for a machine to be available in the Kimberley, closer to home, that will get better when the units open later this year.”

Cherelle describes the KRSS the KRS as a wheel with many spokes – “no one more important than the other with everyone having an important role to play”.

So the dream of Puggy Hunter, Cherelle Fitzclarence, Maree Wearne, Kevin Warr and many others is now a growing reality.

A sad irony is that Puggy had to go to Perth for dialysis himself and didn’t live to see the huge difference this service has made to his community. l

By Ms Jan Hallam

Fact Box • For indigenous people in 2008, 2208 people per million population were dialysis dependent • The national rate at the same time was 471 pmp • When all the dialysis centres come on stream, there will be capacity to treat 116 renal patients in the Kimberley

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medicalforum

11

Feature

Going the Distance Following on from our spotlight on Health Minister Dr Kim Hames in the March edition, we look at the man in the Opposition who wants his job – MLA for Kwinana, Roger Cook.

The Shadow Minister for Health was just days away from competing in the Busselton Half Iron Man event when we spoke with him. And who said politicians aren’t in it for the long haul?

“I’m doing the full distance again this year – it will be the second Half Iron Man for me. I have to do it again just to prove it wasn’t a fluke the last time. I’d like to think I’m a highly principled man and one of the principles I live by is that you’ll never see me in a pair of budgie smugglers!”

Nonetheless, the Member for Kwinana takes triathlons seriously and he says there are positive spin-offs.

“Physical exercise frees me up physically and mentally and helps me manage the competing pressures of a busy, political life. Both individually and as a community we have to look after our own health, not just to take the burden away from the hospital system but also to lead happier and healthier lives.”

Roger Cook has medicine in his blood. Both his father and grandfather were GPs, in fact the latter served as AMA (WA) President in 1956.

And, in my case, that’s particularly so in an area such as Kwinana, which is challenged by so many social and economic issues.”

There are many individuals who, through no fault of their own, find it difficult to negotiate the complexities of the health system. Roger Cook tells one such story.

“I was at my GP the other day and overheard a conversation between the receptionist and one of the patients. It revolved around a referral to a specialist and this person was having problems coming to grips with what it was all about.

He really couldn’t understand the contents of the letter and what to do next."

“There are a lot of things we take for granted that are real challenges for some people. It’s too easy to look at hospital statistics and health profiles and pat ourselves on the back. We need to remember that there are those who struggle to get basic health care.”

Roger Cook gives a big tick to the way Kim Hames and the Liberal government has followed through on the 2004 Reid Review, a comprehensive report that led to the development of the WA Clinical Services Framework (2005-2015).

“The Reid Review was the most comprehensive analysis of the Health sector in WA’s history and this government has acknowledged those findings and I commend them for addressing those issues. One area of concern is the shortage of doctors, particularly specialists, and nurses in WA. There needs to be a longterm workforce development strategy.

When Fiona Stanley opens we need to make sure that it’s not at the expense of other hospitals.”

And the Shadow Minister would do things a little differently in a few other areas as well.

n Roger Cook MLA

“I didn’t follow in their career footsteps, but my father certainly instilled in me a great sense of civic duty and the importance of working for the public good. I know that motivated him as a GP." “I’ve always been interested in the political process. It can be a tough game but it is an immensely rewarding one though, as politicians we’re in such a privileged position to be able to serve the community.

12

There needs to be a long-term workforce development strategy.

When Fiona Stanley opens we need to make sure that it’s not at the expense of other hospitals.

“When we win government, I’d like to see much greater involvement by the consumer in the design and delivery of health care.

I’d like to see the devolution of services away from larger tertiary hospitals towards secondary institutions and regional health campuses. And I think there should be a far greater level of responsibility accorded to nurses and nurse practitioners in the delivery of medical services. We have to put control of these things back into the hands of the doctors and nurses and less in the hands of statisticians who have, in many ways, distorted the delivery of these services.”

One of the key themes underpinning Roger Cook’s maiden speech to the WA Parliament in November 2008 was social justice.

“My professional background was in Native Title so I’ve seen how these issues impact on the Aboriginal community and that speaks loudly regarding the health of indigenous people.”

“Mental health, particularly for young people, is another area where equity is an issue. When this government came into power there was an expectation that we’d see the redevelopment of Graylands and the Osborne Park Mental Health facility. That hasn’t happened, and that’s going to put real pressure on the system.”

A free weekend is a rarity for Roger Cook, but he’s got a pretty good idea how he’d spend it.

“I’d definitely go for a long ride on my road bike and spend some time with my family.

My wife, Carly Lane, has got a blossoming and very interesting career as an indigenous art curator so I’d like to spend some more time supporting her.” l

By Mr Peter McClelland

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n Photo: Courtesy Community Newspapers

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Medico-legal

Clinical practice guidelines: what is their legal status?

Avant’s senior solicitor Morag Smith looks at the evidentiary use of clinical guidelines and recommendations by coroners, in response to our E-poll.

T

he E-poll results published in Medical Forum (Coroner’s Remarks Stir Opinion, May edition) highlight the concern doctors have about the impact of coronial recommendations on individuals and on the health system generally.

In addition to determining cause of death, coroners in this state can, and frequently do, make recommendations on any matter connected with a death investigated by a coroner, with a view to preventing future deaths occurring in similar circumstances.

The E-poll focuses on a coroner’s recommendation that anyone who takes a call from a patient complaining of chest pain should advise the patient to call an ambulance or go to hospital. This recommendation is broad in nature and as a clinician you are still required to exercise your clinical judgement before deciding whether or not to refer a patient with chest pain to hospital.

Clinical judgment, developed through experience, knowledge and practice, is a core element of the practice of medicine.

However, evidence-based medicine and clinical practice guidelines are increasingly being used by the Coroner and Judges as evidence of what is acceptable professional practice.

Every health-care practitioner will be aware of the range of codes, policies and guidelines published by professional colleges, hospitals and the National Health & Medical Research Council (NHMRC).

One recent example is the homebirth policy published by the Department of

Health (WA) in February 2012, which sets out in detail care pathways and inclusion criteria for a home birth in the public health system. (1) While the main purpose of clinical guidelines is to improve patient care and reduce the probability of an adverse outcome, courts also take them into account when deciding whether a doctor’s conduct is in accordance with the expected standard of care.

How much weight is placed on clinical guidelines/codes in the legal arena?

Courts, including the coroner’s court, are not obliged to follow clinical guidelines and judicial officers are free to rely on a range of matters including expert evidence, medical literature and their own judgment to determine whether a doctor has breached his or her duty of care to a patient. In the coroner’s court guidelines and expert evidence assist the coroner in formulating recommendations.

Commenting on the legal status of clinical guidelines the NHMRC’s publication “Guidelines on the Development, Implementation and Evaluation of Clinical Practice Guidelines” states “It is certainly possible that guidelines could be produced as evidence of what constitutes reasonable conduct by a medical practitioner for the purposes of assessing whether the practitioner’s duty of care had been breached in a medical negligence action.

It is the view of the Health Advisory Committee, which oversaw the preparation of this document … that the existence of clinical practice guidelines will provide a measure of protection for practitioners who use the guidelines” (2)

Clinical guidelines are therefore a relevant consideration but they do not determine the standard of care a court will impose on a doctor.

In WA the standard of care to be met by health practitioners is set out in section 5BP of Civil Liability Act 2002 (WA). The standard of care required is the standard of care that, at the time the service is provided, is widely accepted by peer professional opinion as competent professional practice.

In assessing whether a medical practitioner has met the standard of care required by section 5BP of the Civil Liability Act 2002, clinical practice guidelines may be introduced as evidence of the appropriate standard of care, but they will not be determinative of that standard. The extent to which a court will rely on a guideline will depend on its quality, the reliability of the medical and scientific evidence on which the guideline is based, as well as the level of acceptance and use by clinicians.

Expert evidence continues to play an important role as guidelines do not cater for every eventuality and most fail to give guidance on patients who do not fit into the accepted norm. If you act outside a guideline, however, you could be exposed to the possibility of being found negligent unless you can provide a relevant reason, such as the specific condition of the patient.l References 1. Women’s and Newborns’ Health Network Policy for publicly funded homebirths including guidance for consumers, health professionals and health services February 2012.

2. A guide to the development, implementation and evaluation of clinical practice guidelines: NHMRC 16 November 1998; page 51

A Bevy of Budget Beauties Budgets provoke a mass of press releases from vested interest groups, so much so that some providers have taken to summarising responses. Take the Australian Healthcare & Hospitals Association. Its May 11 slant on budget responses included: AMA President Dr Steven Hambleton saying government had spared health from broad funding cuts; the National Rural Health Alliance saying rural and remote areas had good news on dental care, aged care and disability services; the RDA saying the medical workforce crisis in the bush had been ignored.

14

The AGP Network chair was saying the Medicare Local program had been short changed; the RACGP saying most of the issues in its pre-budget submission had been ignored and the Australian Diagnostic Imaging Association saying it welcomed MBS requirements that imaging needs a qualified radiographer.

Then the Catholic Health Australia said the 200 sub-acute beds it was promised as part of the COAG health reform agreement would not happen; the Public Health Association was pointing to thrifty savings in Medicare rorts, private health insurance

for natural therapies, and cosmetic surgery rebates; the Pharmaceutical Society saying the uncertainty of wide-ranging budget cuts was dispelled.

A happy customer, the Consumers Health Forum, was saying the budget delivered on key promises in dental, disability and aged care; and the Australian Nursing Federation saying government was moving to fix Australia’s under-resourced aged-care sector.

Just another day in politics. l

By Dr Rob McEvoy medicalforum

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We reserve the right to cease offering these products at any time without notice. Income Protection/Life Insurance is distributed by Experien Insurance Services Pty Ltd (Experien Insurance15 Services) medicalforum which is an authorised representative of Financial Wisdom Limited. AFSL 231138 (AR No.320626). Experien Insurance Services is part owned by Investec Professional Finance Pty Ltd.

Have You Heard?

in Russia and Europe and also in Greece where it has recently acquired a generics maker for $550m. Teva Pharmaceutical Industries Ltd. in Israel is the world’s largest generic drug manufacturer ($13b last year).

The Asia-Pacific operations of Actavis are run from its manufacturing facility in Jakarta, Indonesia, with offices in Adelaide and Melbourne.

Immunise and innovate WA GP Dr Alan Leeb will take part in judging five $20,000 Sanofi Pasteur VaxiGrants awarded to vaccination providers with bright immunisation ideas to improve uptake and decrease wastage (closes September). Alan is no stranger to immunisation innovations. He is involved in Health Department immune surveillance as a sentinel practice, which has found that adults reacted just as much to the CSL flu vaccine (without the same ramifications).

He has developed software that sends an automated cheerio SMS post-vaccination and prompts the patient to report any side effects. Responses are re-merged with his database, leading to non-responders and ‘yes’ responses being phoned.

Workcover workings After legal advice WorkCover WA will no longer, even with the consent of the patient, supply information to employers and prospective employers in relation to workers’

Rural push oversubscribed compensation claims histories. The workers’ comp body has also set up eLodgment, an online alternative to lodging applications for conciliation by mail or in person. Supporting documentation can also be sent securely and applications can be tracked online as well.

Lawyers and agents can also view the status of multiple conciliation applications.

University of WA had 66 applications for its 7 places allocated by DoHA for the John Flynn student rural placements. Students will be matched to mentors from late in July, with first placements to begin in December or January. ACCRM is still interested in finding mentors for selected students to help develop the future rural and remote workforce.

Generics big business

Good luck with that

US-based Watson Pharmaceuticals Inc. is buying Switzerland’s Actavis Group for $5.6b. Both are generics manufacturers with Watson’s profits boosted in December by its generic version of Lipitor. The company expects $5b revenue this year. Privately held Actavis operates in more than 40 countries.

Watson is looking forward to a higher profile

The DoHA-funded NPS is turning to Facebook to sign up “antibiotic resistance fighters” who must pledge three things - don’t expect or ask for antibiotics for a cold or flu, take prescribed antibiotics as directed, and always practise good hygiene.

NPS says if 35,000 Australians join the fight (antibiotic prescribing reduced 25% in five

BreastScreen WA achieves milestones in 2012 BreastScreen WA’s commitment to women undergoing screening mammograms continues to break new ground in 2012.

Innovative digital mammography software developed

by BreastScreen WA has improved image transfer times with external radiology clinics and enhanced communication between clinicians.

The use of digital mammography in all metropolitan clinics since early 2011 has also increased BreastScreen WA’s screening capacity. For the first time ever, more than 100,000 women have been screened in a 12-month period. Medical Director Dr Liz Wylie also credits GP referrals as key to achieving this milestone.

Over 1.3 million examinations have been performed by BreastScreen WA since 1989 and the service has just been awarded a further four year accreditation by BreastScreen Australia.

Remind eligible women to telephone BreastScreen WA on 13 20 50 to book a free screening mammogram appointment.

www.breastscreen.health.wa.gov.au

DOH23344 APR ‘12

BreastScreen WA provides a free screening service to women aged over 40 years with no breast symptoms and specifically targets women aged 50 to 69 years.

Delivering a Healthy WA 16

medicalforum

years) it will bring Australian antibiotic usage in line with other OECD countries, or we could run out of effective antibiotics by 2030 if nothing is done. There are prizes for joining up friends. The hard truth is doctors have been overprescribing for years and it is taking stewardship programs in hospitals and consumer campaigns like this to get us motivated towards reversal.

Alcohol dependence help A brief guide to the assessment and treatment of alcohol dependence has been produced by Next Step Drug and Alcohol services. Doctors and nurses called upon to provide withdrawal treatment are the target audience, with essentials on history,

examination, investigations, observations, treatment and relapse prevention covered.

Go to www.dao.health.wa.gov.au, enter “health professionals” in the search box and select the top clinical guideline link or obtain a printed copy from Mr Craig Carmichael, craig.carmichael@health. wa.gov.au or 9219 1896.

Why so long coming?

Opportunistic screening and prevention are promoted in general practice all the time, so steps to do the same in a Kimberley ED is welcome news. Within the ED, nurses assessed 178 asymptomatic young people aged 16-34 years who attended ED for nongenitourinary complaints that were not medical emergencies –116 were tested, with 14 individuals were found positive for STIs (10 chlamydia, 9 gonorrhoea and 5 both).

A further 29 contacts were identified of which 12 tested positive for STIs, including syphilis. The Kimberley region has just 2% of the WA population but is responsible for 37% of WA’s incidence of gonorrhoea. There are inherent treatment problems but using this existing resource to screen young men in particular is a good start, maybe rolling out to other rural hospitals.

Get oldies off pills Oldies are on too many pills, they say. But are they really better off if you stop them?

The UWA Centre for Health and Ageing aims to find out by selecting older people at high risk of adverse drug reactions from aged care facilities in Bunbury, Busselton and Geraldton. The study will gradually reduce and withdraw only medicines not benefiting the participants or those causing significant side-effects (a hard call, mind you). Then, all will be revealed, under strict medical supervision.

Go the distance reap the rewards the satisfaction of providing health and medical services to rural communities professional support through training, medical indemnity and other incentives generous remuneration packages and attractive conditions.

Visit www.health.wa.gov.au/doctors4ruralWA for more details of the incentive packages that are available. Then email doctors4ruralWA@health.wa.gov.au or phone 08 9223 8589. medicalforum

“Work as a GP in country WA is enjoyable and there is a team of doctors in the practice.

The community really appreciates what you do and you become part of it.”

Dr Nicholas DuPreez

DOH12078C FEB’12 MEDICAL FORUM

Come and practise medicine in rural Western Australia and you will get:

17

Financial Planning

Different Strokes for Different Folks When it comes to clever financial planning and investments, imagination is the key.

We talk to three medicos with very different portfolios. Dr Mike Daly, Dr George Crisp and Dr Ian Bernadt all have their passions and they have made them work for their future.

Mike Daly trained in the UK, came to Perth in the late 1960s and built up a practice in Bedford with Vietnam veterans as a client base. He now works part-time with Medicare Private and is looking n Dr Mike Daly and wife Vicky n Dr George Crisp forward to enjoying the fruits of his “I’m not entirely enthusiastic about piles investment portfolio by spending more of paper and BAS statements. I take an time with his grandchildren, travelling interest in our self-managed super fund and watching cricket at the WACA. but I’ve got zero expertise and, as for the “I’m in my late 60s and my wife and I have been thinking about retirement for quite some time. None of us can be experts at everything and I think, generally speaking, doctors over-estimate their investment expertise. I’m sure there are some who are very good at it but the vast majority are probably a bit like me – quite good at earning money but not all that good at investing it.”

As Mike suggests, when you have neither the interest nor the expertise it’s absolutely imperative to have someone you can trust to fine-tune your investment portfolio.

day-to-day practicalities, I just haven’t got the time. We’ve been working with a financial planner and he’s been a life-saver for us. Financial planning is an increasingly complex area and there are changes all the time so it’s really important to have a good relationship with an investment expert. It gives you trust, confidence and peace of mind.”

And when you throw something like the GFC into the mix it really gets complicated.

“If I’d been in charge when the bottom started falling out of global investments during the GFC, I’m sure I’d have made

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n Dr Ian Bernadt

decisions that I’d regret later on. The GFC was new territory for just about everyone. It’s vital to plan for retirement and medicine can take up a lot of time and energy. And it’s an area that we, as doctors, ignore at our peril.”

Dr George Crisp, from Onslow Road Family Practice, is one doctor who takes an intense interest in his investment portfolio.

“In 2005 I changed my superannuation to a company that invested in ethical funds.

I’ve also closed a bank account because that institution had major investments in the coal industry and any shares with links to mining companies have gone. I’ve kept some shares based in Perth, so that I can attend shareholder meetings and ask questions. It’s a good way to stay informed and exert some influence.”

The real test for the ethical investor is the balance between a potentially lower rate of return and a socially worthwhile outcome.

For George Crisp, that’s an easy choice to make.

“I definitely put social and environmental issues above financial gain. By investing in a company you’re enabling that company to do business so it’s not just a question of the products, it’s also the consequences of making them and you have to take some responsibility for that. We’ve already seen changes in corporate culture. Look at Nike, for example. When people became aware of the working conditions in their factories Nike changed their behaviour.”

George Crisp, unlike Mike Daly, severed ties with his financial adviser.

“I was getting financial advice but I stopped because they kept trying to persuade me to invest in companies I wasn’t comfortable

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medicalforum

with. A bit of research doesn’t go astray.

We’re all time-poor to a certain extent, but you can get a pretty good idea what’s happening. Amnesty International and Greenpeace put out company alerts and they have an annual list of the world’s 500 worst companies.”

George is a member of Doctors for the Environment and stood as a Greens candidate in the seat of Curtin at the last Federal election. His passion for community engagement underpins his investment philosophy.

“This highly individualistic approach to both the practice of medicine and investing doesn’t work well. I think one of the reasons that mental health is such an issue now is because we’re much less integrated as a society,” said George.

One Perth medico with a highly colourful investment portfolio is ENT specialist Ian Bernadt. Ian, who has a room named after him at the Art Gallery of WA, is a passionate collector of Aboriginal art. And it all started when he was a young boy growing up in South Africa.

“I was given a present of a Japanese woodblock print for my tenth birthday.

That piqued my interest and I learnt to identify the signatures of the artists. Here in Australia indigenous art became a genuine art movement in the 1970s and before that it was really tribal art, bark and cave paintings and similar material. Art for art’s sake really began in Papunya in the Northern Territory.”

Ian says Aboriginal art is a wonderful social and cultural investment but is a little more equivocal when he casts a financial eye over his collection.

“These paintings tell stories going back thousands of years about initiation ceremonies, hunting and some pretty sexy stuff as well. It’s a very important part of Australian history. The Cultural Gift program is a scheme where you can donate artworks to registered institutions, the paintings are valued and then you can claim it as a tax deduction. I wouldn’t recommend it to everyone as a financial investment. In fact, it’s probably better to invest in bluechip shares.”

As far as making a profit from his passion, Ian is cautiously optimistic.

“The indigenous art market is soft at the moment, but I think it will pick up again.

For anyone thinking about investing in this area it can certainly give you a lot of pleasure but you have to do your homework.” l

By Mr Peter McClelland

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19

Policy

diabetes/impacts/ where some interesting new facts are interspersed with the obvious (but bearing in mind it is pitched at health consumers). There are over 30 different committees strutting their stuff at this website, not just diabetes, from MyHospitals to maternity data, with a wealth of information graphed and tabled for the brave enquirer.

More recently, there has been some controversy over general population screening for diabetes, as opposed to screening those believed, for targeted reasons, to be at risk.

The GPs say population screening with a blood test is the way to go. They are probably overwhelmed by the recommendations of academics who come down in favour of screening those uncovered at risk using a score of 12 or more on AUSDRISK questioning (try Googling that and see where you end up), or by going straight to a fasting blood sugar (tested on two occasions unless diabetes obvious) for people regarded as very high

medicalforum

risk due to PCOS, past CVS event, or past gestational diabetes.

When it comes to prevention of diabetes, both exercise and obesity (particularly abdominal obesity) get the big drum. That’s one form of prevention. Doctors like to cut it fine though.

Currently, a number of screening programs

Health consumers now need a health coach to encourage them to comply, and that is going to have to be someone they respect, probably their GP, nurse or pharmacist. are being recommended to government, which is willing to listen if people can prove screening is cost-effective (i.e. spend to save money, overall). Health consumers now need a health coach to encourage them to comply, and that is going to have

to be someone they respect, probably their GP, nurse or pharmacist. And they have a choice of taking either their prostate, vein, breasts, cervix, eyes, skin, faeces, urine or private parts to the appropriate health professional – a full-time job for some health consumers.

While the profession and government grapple with the best way to deal with chronic disease management, the average person with diabetes is easily buried in a mass of programs, past and present, that fail to cut to the chase as far as they are concerned. If we are going to enlist them in self-management, and heaven knows we need it while resources are stretched, some decent one-on-one coaching at the formative stages is needed. As a profession, we have discovered much the same with most chronic diseases, with pain management being the best example. The next question is how do we do it? l

By Dr Rob McEvoy

21

Guest Column

Tackling Chronic Disease

W

Dr Will Thornton uses his knowledge of UK primary care to highlight potential solutions for those of us managing chronic disease.

hen I went to school, ‘chronic’ meant ‘terrible’ and I’m wondering if ‘chronic disease management’ went to my school too? I returned to Perth from the UK two years ago having worked as a GP just outside London. Their system of patient care, known as Quality Outcome Frameworks (QOF), outlined what needed to be done in a capitation system of primary care where every patient had a nominated GP.

certifications and is ultimately responsible for the patient’s health. Most importantly, that doctor is responsible for the patient’s chronic disease management.

However, the Australian fee-for-service model struggles to adequately manage chronic disease. The advantages of our health system over the embattled NHS are clear but it seems strange that we embrace the failures of the UK system.

With insufficient appropriately experienced practice nurses who could co-ordinate and complete the requisite plans and recalls, this leaves the future somewhat unclear.

GP registrars complete training with an understanding of care plan principles, yet many experienced GPs are frustrated and disillusioned with the current situation.

What’s gone wrong?

For example, the failed UK Darzi clinics have been rebadged as ‘Super Clinics’ in Australia and are yet to prove themselves.

Furthermore, the Primary Care Trust funding model of the UK – recently re-moulded back into a system known as Consortia Funding – strongly resembles our Medicare Local model. Hopefully, ours will prove to be more successful than theirs.

What does work superbly in the UK is having a nominated GP. A patient has one doctor assigned to his/her care, who receives discharge summaries, dispenses scheduled medications, completes

In Australia, care plans are not the panacea they were intended to be. They are overused by some GPs for ‘sausage factory’ remuneration and, consequently, are of little use to the patient. Other doctors do a good job of managing the complications and co-morbidities but don’t bother with the required administration and paper-chase.

All physicians in Australia share the frustrations of multi-listed patients with partial medical histories at a number of different surgeries, not to mention doctor-shoppers and the breakdown in communication between secondary and tertiary care.

The Patient Controlled Electronic Health Records (PCEHR) may well be a cause for optimism. If patients had a nominated GP, there would be an incumbent responsibility on that doctor to monitor a patient and the

clinician would receive an item of service in parallel with other consultations. This would ensure the continual updating of patient records, with drug allergy status, past medical history and medication list attached to other consultations.

Most critically, it would be a wonderful opportunity to review current Care Plan status for chronic disease management, which would readily fall within the remit of a practice nurse. Appropriate remuneration is obviously essential. It would be a highly cost-effective item of service compared with the current system. Furthermore, a Practice Incentive Payment could be provided to those practices with a designated percentage of patients with complete and updated records.

It’s not too difficult to look after the health of a defined demographic – your own patients – but it’s impossible to look after everyone else’s at the same time.

ED. Will Thornton lives in the Perth Hills and works in the Wheatbelt and the Kimberley as a GP and in emergency medicine. He is involved with teaching medical students and GP registrars. He was trained in the UK GP Vocational Training Scheme and worked in a paediatric palliative hospice for several years before returning to WA. l

Making Good CoNeCTions The twin CoNeCT programs, which have been operating in the North and South Metropolitan Area Health Services for more than 12 months appear to be living up to the promise of reducing unnecessary presentations to Emergency Departments by patients identified as ‘higher users of unplanned hospital care’.

While the program will be evaluated later this year, early figures are promising.

They show that six months prior to the program, there were 298 presentations (now recognised as CoNeCT patients) to EDs with 142 admissions and those figures have fallen to 169 and 50 six months after its instigation.

CoNeCT services include: • Linking patients, carers and families to appropriate health or community care 22

services (such as in-home care, transport, respite, finding a GP, after hours medical support, day activities, independence aids, financial counselling, drug and alcohol support) • Facilitating communication between health-care providers (eg between hospital specialists and GPs).

• Following-up hospital discharge plans to ensure that planned appointments and treatment plan changes occur.

• Supporting patients, carers and families to make decisions about future care and accommodation.

• Accompanying patients to key medical appointments (for example, where cognitive impairment or mental health issue may impact on their ability to represent themselves, provide an accurate

history or understand recommendations made).

• In-home chronic disease selfmanagement support.

• Contributing to care and discharge planning by the treating team for CoNeCT patients who do need to come back to hospital.

Case management is provided by nurses, occupational therapists, physiotherapists, social workers and pharmacists.

CoNeCT is midway through a 12-month evaluation, which will include consideration of cost savings. l

medicalforum

Beneaththe Drapes u WA anaesthetist and pain specialist, Dr Lindy Roberts, is the new president of the Australian and New Zealand College of Anaesthetists (ANZCA). Dr Roberts is a staff specialist in anaesthesia and pain management at Sir Charles Gairdner Hospital, where she was until recently the director of the acute pain service.

Dr Roberts, 47, assumed the role on the final day of the ANZCA annual scientific meeting in Perth last month. u Dr David Blythe has been promoted to Executive Director, Fremantle Hospital and Health Service. He has more than 20 years of medical and health service leadership with both national and international experience. He has been member of the Fremantle Hospital and Health Service since 1998. Dr Blythe has held numerous executive positions including Clinical Director of Critical Care and Director of Clinical Services. u Dr Joe Kosterich is the new WA Medical Director for the Australian Locum Medical Service. u Dr Andrew Papa-Adams is the new CEO of Oceanic Medical Imaging.

u UWA’s Burn Injury Research Unit A/Prof Hilary Wallace has received the Endeavour Executive Award for 2012. The award will enable her to gain experience in working with local organisations in Nepal and to develop a burn prevention program. Nepal is rated amongst the top 10 countries for burn incidence and mortality.

Perth businessman Peter Prendiville to its Board. Mr Prendiville is chairman of Prendiville Enterprises, which includes Sandalford Wines and the Rottnest and Cottesloe Beach Hotels. He is also the Commissioner of Tourism WA and the Deputy Chancellor of Notre Dame University.

u Prof Helen Milroy, the nation’s first Aboriginal psychiatrist, has recently been appointed to WA’s new Specialist Aboriginal Mental Health Service. She is also the Director of the Centre for Aboriginal Medical and Dental Health at UWA.

u Prof Bryant Stokes will chair the Governing Council of the South Metropolitan Health Service. Professor Stokes holds three professorships at WA universities, headed the State Neurological Service for 15 years and was the State’s Chief Medical Officer from 1995 to 2001.

u Anatomical Pathologist, Dr Ross Glancy retired from Fremantle Hospital after 29 years of service. He will take up a part-time position at the UWA School of Pathology and Laboratory Medicine. u Mr Ray Glickman has been reappointed CEO of Aged Care provider Amana Living for another five-year term. He has headed the not-for-profit business for the past eight years and is also chair of Aged & Community Services WA.

u The new head of the Governing Council of the North Metropolitan Health Service is Mr Rob McDonald. He is also the Director of the Centre for Cerebral Palsy. u Dr Rosanna Capolingua, will chair the Governing Council of the Child and Adolescent Health Service. Dr Capolingua is a GP and the current Chair of Healthway.

u WA’s largest private health care provider, St John of God Health Care, has appointed

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23

Feature

Nepal Challenges Young Doctors to New Frontiers Medicine may be practised very differently in Nepal but it was an inspiration two young Perth doctors.

Earlier this year two intrepid PGY2 doctors, Sara Damiani and Leanne Heredia, took themselves off to Nepal to treat patients in public and private hospitals and to learn a lot about medicine and themselves along the way.

insert the endoscope with the patient gagging as their loved ones stood and watched while he checked for ulcers. And the next patient was standing in the doorway taking off his shoes! The same endoscope is used for the morning list with an alcohol and Dettol wipe-down in between patients.”

Dr Sara Damiani is not the typical UWA graduate. She hails from California where medicine is a postgraduate degree and she wasn’t even sure if it would be the career for her.

“Both my parents are surgeons so I knew what I was getting into. I heard about the undergraduate programs in Australia and was accepted at UWA. It all happened very quickly and the next thing I knew I was on a plane to Perth. I completed my n Dr Sara Damiani with orphans degree in 2010 and did a year as an intern at Fremantle Hospital last obstetrics/gynaecology or maybe even work year. I’d always thought about going on to a with the Red Cross. Nepal was a humbling surgical specialty, but after Nepal that’s all experience, I’d never seen poverty like that. changed,” said Sara.

And the outpatient clinics were out of this And it wasn’t only Nepal that’s made Sara think twice regarding her career direction.

The largest state in Australia played its part too.

“I spent some time in rural WA as a medical student and found that very fulfilling. Now I’m leaning more towards general practice,

world!”

Some of Sara’s recollections are a mixture of shock and awe.

“I followed a gastroenterologist around for a morning and timed him. It took him seven minutes to take a brief patient history,

Sara and Leanne were based at the Himal Hospital in Kathmandu, a private institution with specialties ranging from general medicine to dermatology and dentistry.

“The ED had four beds, ICU six and the medical and surgical wards had about six patients in each room.

The doctors spoke Nepalese to their patients and wrote their notes in English – very impressive! There were signs everywhere about using hand sanitiser but there was none in sight. And gloves seemed to be a rarity.”

The trip wasn’t all medicine, there was stunning scenery and cultural insights along the way.

“After it rained the dust would settle and the mountains were absolutely spectacular.

The local people, particularly outside Kathmandu, were so friendly. We were often asked to come into a family’s home, a

Medicine, Ethics – a Student's Perspective The University of Notre Dame and the Knights of Malta have combined forces to award 23-year-old Ms Jessie Chennell the prestigious Ethics Prize. Both philosophy and ethics are core units in the medical degree at Notre Dame, a fact recognised by the Order of Malta, which is one of the world’s oldest Catholic charities.

“I was really honoured to receive the Order of Malta prize. It’s awarded for the best essay by a medical student in the Ethic’s

course and I wrote mine on the debate surrounding abortion. A lot of people shied away from the topic because it can be quite contentious but I think that whole area of individual autonomy is so important. I tried to present both sides of the issue but argued for a woman’s right to choose,” Jessie said.

Being a doctor has been a lifelong aim of Jessie’s though some dancing was involved.

She went to Perth Modern School on a dancing scholarship but it was a focus on helping people that sent her first to Curtin where she did a BSc then to the medical school at Notre Dame.

“There’s great diversity among the Notre Dame students with a 50:50 gender split

and I’m one of the youngest. We had a trip to the wheatbelt in first year and then to Fitzroy Crossing and Derby the following year. It gave me a real insight into another side of medicine, the sort of things you just can’t get out of a text-book.”

Jessie is on rotation at the Rural Clinical School, in Bunbury.

“I delivered my first baby and that was something I’ve been looking forward to for a long time. This placement has given me some experience with patients who’ve died and I found that quite difficult. We’re taught coping skills that help and, in some ways, it’s one of the components of the job that makes it such a privilege.”l

By Mr Peter McClelland 24

medicalforum

Dr Leanne Heredia grew up in Perth, studied medicine at UWA and completed her internship at Fremantle Hospital and she says she’s heading towards a career as a GP. She was drawn to Nepal because she thought she could do some good.

n Dr Leanne Heredia at the children's hospital

one-room shack, and share a cup of tea. We stayed in an orphanage with eight children and breakfast and dinner were provided.

The chicken we had on the last night was the best I’ve ever had! We also had a small dumpling called a Momo which was made from water-buffalo.”

“It’s one of the poorest countries in the world with an estimated 18,000 people per doctor. It’s so rewarding to do something worthwhile in a developing country and I loved the natural beauty. We rowed across the Phew Tal River and trekked through the mountains to the World Peace Pagoda.

The people are friendly and humble and it made me realise just how lucky we are in Australia,” said Leanne.

Leanne, like Sara, had moments of absolute disbelief at some of the treatment practices.

Sara has a message for her colleagues considering a similar trip.

“Stepping out of your comfort zone makes you realise your limitations as a junior doctor. If you’re unsure about career direction it can help there, too. And I really appreciate things like clean running water, electricity and toilet paper a lot more now.”

medicalforum

“Speculums and pap smear spatulas were dipped in Dettol in between patients. Blood stained gloves were washed, hung out to dry and used again. The children’s hospital featured 8-10 children in one room with no isolation for those with infectious diseases.

Sometimes families would bring in their own food and bedding for the patient.

There were times when our stomachs churned as we battled to grasp what we were seeing.”

The trip to Nepal has inspired Leanne to practice medicine in developing countries in the future, but her career direction has a focus closer to home.

“It’s a wonderful thing to assist overseas, but I can’t help but thinking about the health of Aboriginal people. In so many ways it’s similar to developing countries.

There’s still a lot of work to be done right here at home in bridging the gap. I’d really like to incorporate Aboriginal Health in my future specialty as a GP. l

By Mr Peter McClelland

Help Needed

n Dr Heredia shares a meal with children

Hollywood Private Hospital is helping Leanne and Sara collect medical equipment for Nepal. If you can help, contact Adrian Conti Margo, Conti-MargoA@Ramsayhealth.com.au.

25

Spotlight

Fighting for Rebecca Mediation and an apology would have made the world of difference for disability campaigner Maria Sorgiavanni and her daughter Rebecca. know that someone cared, that someone hadn’t forgotten about Rebecca. It doesn’t matter how many years go by, it never stops hurting.”

Maria Sorgiovanni, disability campaigner and WA State Finalist in Australia’s Local Hero awards has a story to tell. Given the concern shown by respondents in the April ‘Trust Me, I’m a Doctor’ E-poll, it’s a story worth listening to. Her youngest daughter Rebecca is 28 years-old with profound physical and intellectual disabilities. One day she said, ‘Mum, where are all my friends?’

Maria had a long, hard think about that question and decided to do something about it.

“Rebecca needed 24-hour care, she needed showering and dressing and she still does.

There’s no way in the world she’ll ever be independent. She has physical and intellectual impairments but she knows what’s going on and she wants to do what other people do. So in 2000 I decided to set up the Swan Friendship Club at Rebecca’s school. It was a big success … we had a basketball club, music and drama nights, sausage sizzles and cake stalls. After that, we opened the Swan Friendship Café in 2007. It’s a professional café with paid employment for people with disabilities and it’s a great way to make their lives more rewarding.”

Rebecca’s case reinforces the healing power of appropriate mediation and an apology.

“There was an incident at the hospital shortly after Rebecca was born and she developed hypothermia and hypoglycaemia.

Maria has turned around an initially bleak prognosis for her daughter.

n Photo: Courtesy Echo Newspaper

Her disabilities stem from that and I spent 12 years going to lawyers and doctors before the legal case was finalised. It was settled out of court, but by that time I was ready to take anything because I just didn’t have any fight left. They just wore me down. And no one apologised, no one ever said sorry.”

There are two sides to the medical coin, a fact that Maria willingly acknowledges.

“An apology would’ve made a big difference, but if it hadn’t been for some of the doctors at PMH then Rebecca wouldn’t be here at all. In the ICU team I got to know Dr Pemberton, Dr Walsh and Dr Christie very well. In fact, I was giving a talk to Rotary – they were kind enough to provide funding for a cash register in the cafe – and this man who looked vaguely familiar came up to me. ‘Do you remember me, I’m Dr Christie?’ he said and added, ‘How’s it really going?’ It was wonderful to

“In the early stages she was on very high doses of epilepsy medication and that’s stabilised now. When Rebecca was born they told me that she would never walk, never talk and never have a normal life. I was determined to prove them wrong. She was walking before she was 18 months and I had her toilet trained by the time she was 2 ½. If they gave me an OT program and suggested 30 minutes, I’d do it for three hours.”

Life still throws up its challenges for Maria and her family.

“Once you get a payout the system doesn’t want you anymore. If I hadn’t battled through the courts for Rebecca I’d be entitled to Disabilties Services Commission (DSC) funding but now if I need anything they charge me a fee.”

“You have to have a loud and squeaky voice and you have to make a noise if you want to get anything done. The last thing I’d like to say is that, in some ways, the parents suffer far more than the child. To have to watch your child struggling in these situations is not easy. No amount of financial compensation can make up for that.”l

By Mr Peter McClelland

The Business Side of Primary Health Care The business of corporate general practice is booming in WA. Medical Forum went on the trail for this update of the big players in WA. Independent Practitioner Network (IPN)

Primary Health Care

The company was established in 1999 as a small group of medical centres known as Foundation Healthcare. In 2002, the company was renamed as IPN and was listed on ASX. It acquired Endeavour Healthcare and Gemini Medical Services then was, itself, acquired by diagnostic giant Sonic HealthCare Ltd in 2008. In 2010 IPN bought out the Prime Health Group. The IPN network now has more than 190 medical centres around Australia with 32 medical practices in WA from Jurien Bay in the north to Wagin in the south. There are onsite pathology collections in all but six centres including four Clinipath offices.

According to an investment presentation to the ASX in April this year, Primary Health Care (not including ex-Symbion smallerscale centres, clinical trials and head office) experienced a 11.5% EBITDA growth for 2011 and a half year 2012 revenue growth of 11.7%. Its EBITDA revenue for full-year 2011 was $140m and its GP headcount has increased from 501 to 766 in the past four years. It has 87 medical centres across the country, but the marketing spokesperson in Sydney did not respond to our requests for WA figures.

26

Healthscope Healthscope Medical Centres own and operate 60 medical centres across Australia including 12 centres in WA and six

Molescan skin clinics. The company was subject of a $1.7 billion takeover by private equity investors 18 months ago and the new CEO Robert Cooke has since undertaken a strategic review of the company's struggling pathology arm, resulting in the divestment of its Tasmanian assets and a new $20m contract in New Zealand.

Kinetic Health Kinetic Health owns nine GP Clinics in WA in such diverse places at the Perth Airport to Newman, Pannawonica and South Hedland in the north. Kinetic was the result of a merger of Gemini Medical Services and Prime Health Group and has a national network of wholly owned medical clinics, occupational health services in remote as well as metropolitan locations.l medicalforum

News

Collaboration a Move Forward in Palliative Care UWA medical students and student nurses from University of Notre Dame will now be able to learn about of palliative care within both an inpatient and class-room setting with the recent opening of a dedicated learning hub adjacent to Bethesda Hospital’s Palliative Care Unit.

The project, which has been funded by Health Workforce Australia, has been devised by UWA’s School of Population Health in collaboration with the School of Nursing and Midwifery at Notre Dame and Bethesda Hospital.

A/Prof of Palliative Care at UWA, Dr David Thorne, said it was an enormous privilege for students to learn at Bethesda’s 23-bed Palliative Care Unit.

Medical students will be clinically placed at the unit in Year 6 and will be supported by hospital staff, a nurse practitioner and a palliative care physician.

A web-based, interactive learning program has been devised and installed in the learning hub.

While the placement is only a small part of the medical students’ final year of study,

SKG Radiology Currambine bulk bills pensioners and healthcare card holders for all Medicare rebatable items.

n Rosemary Saunders, left, Dr Neale Fong, Yasmin Naglazas, Jim McGinty, Dr David Thorne, Prof Ian Puddey, Premier Colin Barnett and Prof Selma Alliex at the opening of the new palliative care learning hub at Bethesda Hospital.

Dr Thorne says students are encouraged to return to the website regularly during the 6th year.

“These students will confront patients many times in their professional lives who will need the help of a palliative care specialist.

At Bethesda’s Palliative Care Unit students will at least experience one-on-one with a patient and their family where they can

learn skills of how to talk to patients about an illness that is coming to an end.”

“It’s giving students a chance to have those conversations.”

He said the learning hub would also be a resource for staff at the Bethesda Palliative Care Unit so they could keep updating their skills. l

SKG Radiology is set to open a brand new branch in Currambine.

The practice will be offering the following premium services: ULTRASOUND X-RAY CT (128 Slice) DENTAL X-RAY (OPG)

Sexuality

Care for Those Under the Rainbow The Freedom Centre has become a ‘safe space’ for gay and lesbian young people and it’s having positive health spin-offs.

The Freedom Centre (FC) opened in Northbridge in the mid-1990s under the banner of the WA AIDS Council after courses to promote good sexual health, positive self-esteem and peer support for gay men was such a success. The FC has been providing a ‘safe space’ for young people who are same-sex attracted or sex and/or gender diverse ever since.

Dani Wright has been with the FC since 2005, first as a volunteer and then as its co-ordinator and says the centre has a peer-support, recreational and educational function as well as referring people to linked professional services such as the AIDS Council, Youth Link and Headspace.

“We provide a safe ‘social space’ and we make sure no one is being excluded or feels uncomfortable. It’s so important to reduce social isolation because a lot of mental health issues and psycho-social problems stem from that. And doctors need to know that negative experiences from society at large, and that includes some within the medical profession, means that some of these individuals are reluctant to seek help.

Inclusivity is essential, one in 10 people are same-sex attracted or gender diverse so there’s a real need for doctors to have the latest information and referral options.

Poor health outcomes stem from stigma and discrimination.”

Dani conducts a one-hour presentation called Supporting Same-Sex Attracted and Gender Diverse Young People to fifth year medical students.

“But there’s only so much I can cover. It’s important to remember that trans and intersex individuals have to engage with a medical system that often doesn’t receive any specialist training in these areas. WA is a conservative state and both NSW and Victoria are much better resourced compared with us but, having said that, there’s no peer-based suicide prevention service for Lesbian/Gay/Bisexual/Trans/ Intersex (LGBTI) community over east either.”

Vanessa Watson is a clinical psychologist at Youth Link, specialising in mental health services for at-risk youth. She has a particular interest in the psychosocial issues concerning LGBTI individuals who often experience barriers in accessing mainstream services.

“The LGBTI community is a particularly vulnerable group. They have a much higher rate of self-harm, depression, substance abuse and suicide. There’s also family and medicalforum

n Ms Dani Wright

peer rejection that can lead to homelessness.

Research shows that these multiple risk factors are a direct result of stigmatisation and discrimination.”

And as Vanessa points out, entrenched social stigma often leads to negative perceptions of health-care providers.

“There’s apprehension about the sort of care they’ll receive when accessing health services. In addition, some health practitioners may not have had sufficient training to be confident in responding sensitively to these issues. Trans and intersex people have additional medical needs requiring specialised knowledge and understanding. A really useful and practical step is to display LGBTI health information and ‘Safe Space’ messages in clinical environments.”

n Dr Andrew Wenzel

Dr Andrew Wenzel, Manager of Headspace in Albany, says knowing how to access health care is an issue that a lot of young people struggle with.

“If you want to go and speak with a doctor because you’re not sure about your sexuality, that’s doubly difficult. It’s very easy to become marginalised, especially in a regional setting when there isn’t the same LGBTI presence as there is in larger metropolitan areas.”

“There’s a steady demand from the LGBTI community in Albany and it’s important

for us to provide a service that’s responsive to gender and sexuality issues. We’re well aware that young people are less likely to respond to someone who’s overly paternalistic or judgmental, so we have a network of gay-friendly doctors.”

As Andrew points out, there are both regional and economic influences impinging on the delivery of health care in a regional centre such as Albany.

“It’s sheer weight of numbers really. It comes down to a cost-benefit analysis in regional areas and the health system isn’t particularly proactive in identifying special areas of need. The health of the LGBTI community is both an area of specialty and a marketing opportunity. I’d like to see WA move towards the Victorian model where there’s a Gay and Lesbian Health Authority within the public health system. It would be good to see the WA government address this area with more focus.” l

By Mr Peter McClelland

Fact Box Useful contacts for doctors: Gay and Lesbian Community Services for information on • Training Courses • Counselling/Advice • Contact Lists City West Lotteries House, Room 1, 2 Delhi St, West Perth. Phone 9486 9855 www.glcs.org.au Regional contact Headspace Albany Cnr Aberdeen St and Serpentine Rd, Albany.

Phone WA 9842 9871 www.headspace.org.au/headspace-greatsouthern 29

News

Divided, the Complaints are Conquered Collaboration between the Health and Disability Services Complaints Office (HaDSCO, formerly the Office of Health Review) and the Australian Health Practitioners Regulation Authority (AHPRA) is apparently streamlining the complaints process since legislation came into effect 18 months ago.

In October 2010, the Health Practitioner Regulation National Law, came into effect and it impacted on the way in which complaints regarding registered health practitioners were handled and processed.

All complaints are now discussed at a monthly meeting of HaDSCO and AHPRA and decisions are made as to whether a complaint is best handled by HaDSCO which operates as an impartial resolution service for complaints, the bulk of them relating to communication issues, fees and procedures. In some instances a complaint may be managed by both agencies. AHPRA will take any concerns about the conduct, health and performance of registered

practitioners to the Medical Board, which may in turn refer on the more serious matters to the State Administrative Tribunal (SAT).

complaint resolution. A complaint can be lodged by the service user or a nominated representative, for example, a family member, carer or guardian.”

It was revealed in the 2010/11 annual report that HaDSCO had dealt with a total of 2033 complaints, 601 against medical practitioners and medical practices, 460 against the public hospital system and 109 in the private hospital system. The number of complaints in all these areas had increased from the previous annual report.

One of the key changes for registered practitioners employed by government agencies is that HaDSCO may now need to communicate directly with the practitioner rather than their employer in the first instance.

A spokesperson said HaDSCO reviewed and reported on the causes of complaints, resolved complaints through conciliation and negotiated settlement, undertook investigations, suggested service improvements and advised service providers about effectively resolving complaints.

“In the first instance, HaDSCO encourages complaints to be raised with the service provider. Offering the provider a chance to address the issues, usually results in quicker

If HaDSCO receives a complaint that relates to a registered practitioner, the Office will write to advise the practitioner that a complaint has been received and explain that AHPRA must be advised. Once it has been determined which agency is most suitable to manage the complaint, HaDSCO will write to the practitioner again to advise them of the decision.

If HaDSCO continues to manage the complaint it will be managed often through the employing agency such as a hospital or clinic. If AHPRA manage the complaint it will liaise directly with the practitioner. l

FPWA Sexual Health Services Unplanned Pregnancy

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Medical risks counselling Psychological counselling for women with unplanned pregnancy Post termination counselling Counselling for partners and significant others FPWA offers counselling that is non-directional and options based.

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medicalforum

Clinical update

Tips for reducing opioids D

By Drs Stephanie Davies, Eric Visser, Roger Tan, and Nick Cooke

ose reduction for patients on high dose opioids (>120 mg oral morphine eq/day) should be a routine therapeutic aim. Why? NHMRC Level I evidence of benefit from opioid analgesia for the treatment of chronic non-cancer pain is at best ‘equivocal’ in terms of pain relief or improved patient function. The risks, however, are significant – dependence and diversion, opioid induced hyperalgesia (worsening pain and increased doses), hormonal suppression (testosterone, oestrogen, cortisol), osteoporosis, and the wellknown side-effects of sedation, confusion, constipation, and respiratory depression.

Initial assessment

Assess the pain diagnosis – is it ‘plausible’ or have things become more complex over time (disease progression, neuropathic pain, tolerance, hyperalgesia, psychosocial issues)?

Assess the psychosocial status (yellow flags), including issues that arose before or at the time of pain onset or subsequently.

Are there risk factors for opioid or substance abuse/addiction?

Is the patient taking opioids for pain and distress (chemical coping), which requires a clinical psychologist or drug and alcohol team?

Is there a risk of diversion?

Things to highlight during patient discussion • Long term risks. Addiction, tolerance, hyperalgesia, adverse neuro-hormonal effects (low testosterone), osteoporosis, lifestyle restrictions, and effects on the brain (amygdala and pre frontal cortex function) with worse pain outcomes over time.

• Dose reduction is therapeutic. Mostly, it improves the quality of pain relief by reducing opioid-induced hyperalgesia.

• Opioids are not forever. Even if prescribed long-term, regular review is always required.

• Active pain management strategies are key to planned dose reduction.

Ways of presenting these ideas to patients include: “A gentle reduction in your pain medication dose is needed over the next 6-12 months to improve your pain, physical function and quality of life, and to reduce the risk of serious side effects. We are doing this with your best interests in mind. We will help you with this but you must be actively involved.”

“Six to 12 months allows time to complete this medication reduction program without causing stress or withdrawal symptoms, but we can’t leave it to the last minute.”

“We will no longer be able to authorise your medications and will not be able to prescribe them if you haven’t made any progress in reducing your pain medications and improving your function within 12 months.”

Tips to reduce the opioid dose Agreed goals or ‘contracts’ for opioid dose medicalforum

reduction can be mapped out for patients (see www.dao.health.wa.gov.au) • Commence dose reduction by ~10% per fortnight (very modest goal). Provide patient information.

equivalents. If your patient over medicates (self-adjusts doses, takes too much despite advice, etc.), use daily dispensing.

Tips for opioid dose control: • No early scripts.

• Mathematically scripting the lesser amount e.g. oxycontin 80mg bd to 80mg am and 70mg pm for 2 weeks (no increase in prn), next fortnightly script is oxycontin 70mg bd and so on.

• Keep the opioid dose less than 120mg oral morphine equivalents per day.

• A 30% reduction (or more) in opioid dose over 6-12 months is an acceptable modest target. Do not precipitate opioid withdrawal by progressing too fast.

• Patients reduce their dose surprisingly well; at times they will request a short respite, to adjust; this is not unreasonable.

• The last 30% is the hardest to wean, so you might have to go slower. Many patients will not completely cease their opioids, but will be on substantially lower doses.

• Consider using ‘anti-hyperalgesics’ (such as duloxetine, gabapentinoids or clonidine) or multimodal analgesia (such as paracetamol, tramadol, NSAIDs with PPI) to help with dose reduction.

• Consider Opioid Rotation if progress proves difficult (see table 1 in May 2012 Medical Forum, Page 38) • The patient must engage in active pain management strategies and make progress in improving function, quality of life, work, recreation etc. Keep a diary of activities. Patients should complete a pain education course such as STEPS (Fremantle Hospital and Perth North Metro Medicare Local). Use resources such as clinical psychology, physiotherapy, drug and alcohol services to help with dose reduction.

At 12 months, if dose reduction and functional goals are not met (or earlier, if substance abuse is indicated or dose reduction proves difficult) withdraw support for continued opioid authority.

Patients need to be referred to Next Step Drug and Alcohol Services.

Dose control as a strategy Rapid opioid dose escalation (‘tolerance’) is not inevitable in the treatment of chronic non-cancer pain – only 30% of patients exhibit this, even less in the elderly. Most patients stay on a steady dose, below the ceiling of 120mg per day morphine

• Limit the number of tablets by defining pick-ups from pharmacy e.g. ‘daily’ for dose control or ‘weekly’ for security or safety issues at home. Specify on the script how the pharmacist dispenses.

Avoid injectable opioids (particularly pethidine). Risks are local and systemic infection, and rapid fluctuations in blood levels (from “high" to “low”) creating a cyclical “push” for the patient to seek more opioid.

• Avoid prescribing large amounts of fastacting (short half-life) ‘prn opioids’, as they have a higher risk of abuse.

• Consider the transdermal route (buprenorphine) – less easy to ‘fiddle’ or ‘take a few extra’. Swap old patches for new at the pharmacy, for patients at risk of diversion.

• Consider once-daily pharmacy dispensing (and supervised administration) of hydromorphone MR (note, if dispensed more than a few doses and patients take too many at one time, hydromorphone MR could be more hazardous).

• The ultimate means of ‘dose restriction’ is daily dispensing of sublingual buprenorphine/Suboxone or Methadone via Community Program for Opioid Pharmacotherapy (C-POP) or NextSTEP (now known as Community Drug Services).

Special Note Oxycodone/naloxone CR (Targin™) appears to be a method of limiting injection abuse and diversion, particularly oxycodone CR. However the adverse effects of diverted high-dose IV naloxone (up to 20 mg per tablet) has not been clarified and may be hazardous ‘Snorting’ Oxycodone/naloxone CR to ‘by-pass’ the naloxone, may still result in a variable systemic naloxone effect (bioavailability ~7-35%). If opioid injection abuse or diversion suspected refer to NextSTEP as Targin™ is not recommended for this purpose.

31

Support Group

Helping Stem the Diabetes Epidemic DiabetesWA is the go-to organisation for information and resources to help patients with diabetes to live a better life.

DiabetesWA is the peak body in the state for diabetes resources and education in WA, and with the increased incidence of the condition, its role is ever-evolving.

The group has been supporting West Australian families affected by diabetes since 1965 and it now represents more than 13,000 emmbers who are affected by or at risk of developing the condition. It provides diabetes-related products to help people manage the condition and is also a source of support and educational services to make living with diabetes easier as well as offering resources for health professionals.

It also provides information through its own magazine, e-newsletters and website www.diabeteswa.com.au.

The organisation drives fundraising campaigns to support research and programs, including prevention campaigns for type 2 diabetes aimed at the wider community. Its main sources of funds are Government contracts and grants.

Diabetes WA and the health-care professions Diabetes WA administers the National Diabetes Services Scheme in WA, so it works with most pharmacies to ensure the supply of diabetes-related products.

It also provides training and resources to diabetes educators, GPs and other health professionals so they are able to refer their diabetes patients to DWA’s educational programs and resources.

It also helps a number of independent support groups, made up of people living with or affected by diabetes, across the state. These groups can be found on the DWA website at www.diabeteswa.com.au

Diabetes WA works with educators, endocrinologists and GPs as well as associated health professionals in podiatry, optometry, exercise physiology, dietetics, cardiology, etc.

DiabetesWA Fact Box

Achievements

Contact: 8.30am-4.30pm, weekdays

Diabetes WA helps more than 100,000 people with diabetes who are registered on the National Diabetes Services Scheme to access life-saving products and services.

3/322 Hay St, Subiaco WA 6008 Phone: 1300 136 588 info@diabeteswa.com.au www.diabeteswa.com.au

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32

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medicalforum

Clinical update

Diabetes and cancer: the good, bad and uncertain I

By Dr Joey Kaye, Endocrinologist, Hollywood Private Hospital Mob 0425 000 833

n people with diabetes, cancer is increasingly recognised as both a co-existent disease and frequent cause of death8, with cancer-specific risks higher in diabetic patients.

Understanding the epidemiology and biological mechanisms underlying cancer risk is critical for effective prevention and treatment. Most importantly, substantial benefit is gained in diabetes, vascular disease and cancer by reducing obesity with healthy lifestyle changes such as diet, physical activity and reduced smoking and alcohol intake.

Diabetes and cancer incidence A large observational study of a German insurance database1 in 2009 indicated an increased risk of cancer when one particular insulin analogue was used to treat type 2 diabetes. Whilst the statistical validity of the study has been questioned, it focused attention on the underappreciated link between type 2 diabetes (T2DM) and cancer, an association that has since gained considerable strength. Moreover, it appears that those with diabetes have a significantly worse prognosis compared with non-diabetes.

In addition, specific glucose lowering therapies have also been linked with cancer incidence and outcomes.

Numerous observational studies have shown an association between obesity, insulin resistance, hyperinsulinaemia (endogenous and exogenous), diabetes and cancer. The strength of the relationship, however, is sitespecific, with the strongest relationship being with liver and pancreatic cancer (although this may be related to the metabolic effects of the tumour increasing diabetes risk).

Endometrial, breast, colorectal, bladder, Non-Hodgkin’s lymphoma and renal cell cancers are about 20-40% more common in T2DM. On the other hand, prostate (possibly due to lower testosterone levels in men with T2DM) and lung (possibly due to the inverse relationship between smoking and weight) are about 10-20% lower2.

It is important to appreciate the limitations of the available studies, most of which are retrospective, observational studies with the potential for significant bias, and the difficulties in discerning the relationship between two complex, multifactorial diseases that share common risk factors.

Diabetes and cancer outcomes A pre-existing diagnosis of diabetes is associated with an approximate 40% increase in all-cause mortality in diabetics with cancer at any site3. A recent meta-analysis suggests four distinct patterns of associations between cancer outcome and pre-existing diabetes4: 1. Increased incidence and increased mortality (colorectal, breast, endometrial, NHL and kidney).

medicalforum

2. Increased incidence but no effect on mortality (pancreatic, hepatocellular).

3. Decreased incidence but increased mortality (prostate).

4. No effect on incidence or mortality (ovarian).

In addition, the uptake of cancer screening (especially breast and cervical) is lower amongst diabetics and who therefore tend to present with more advanced disease.

There is also evidence that cancer therapies are modified for people with diabetes, as they are for other chronic diseases, and that the presence of diabetes and its related complications may increase the risk of adverse cancer treatment outcomes including drug toxicities (for example dexamethasone) and surgical complications4,5.

Mechanisms of cancer risk Mechanisms are still undetermined but several possibilities include hyperglycaemia, inflammation, direct and indirect effects of insulin, and the effects of specific glucose lowering therapies.

Insulin and Insulin-like Growth Factor-1 (IGF-1) are related molecules that activate tyrosine kinase receptors and mediate either glucose lowering (insulin) or cellular growth and differentiation (IGF-1) through different second messenger systems. Insulin can activate the IGF-1 receptor directly, but also stimulates IGF-1 production by the liver. Numerous cancers express IGF-1 receptors and both insulin and IGF-1 have been shown to accelerate the growth rates of various tumours. Obesity and T2DM involve a state of insulin resistance and subsequent compensatory hyperinsulinaemia directly stimulates IGF-1 receptors and increases hepatic IGF-1. It is likely similar effects occur from exogenously administered insulin or insulin secretagogues, whilst agents that improve insulin sensitivity may reduce the effects6.

studies do support the association between cancer and both endogenous/exogenous insulin and sulphonylureas. The relationship with the thiazolidinediones is uncertain, although recent reports note an increased risk of bladder cancer with pioglitazone2.

The risk with incretin-based therapies is highly controversial at present, although overall there appears to be little supportive evidence2.

Importantly, there is increasing evidence of lower risk with metformin. This includes reduced cancer rates with in-vivo studies as well as observational clinical studies of patients treated with metformin compared with other glucose-lowering therapies. In patients treated with combination therapies, metformin appears to abrogate the increased cancer risk associated with insulin and sulphonylureas7.

References 1. Hemkens L, Grouven U, Bender R et al. Risk of malignancies in patients with diabetes treated with human insulin or insulin analogues: a cohort study. Diabetologia 2009: 125 (9); 1418-44 2. Giovannucci E, Harlan D, archer M et al. Diabetes and Cancer. A consensus report. Diabetes Care 2010: 33 (7); 167485 3. Barone B, Yeh H-C, Snyder C et al. Long-term all-cause mortality in cancer patients with pre-existing diabetes mellitus. A systematicreview and meta-analysis. JAMA 2008: 300; 2754-64 4. Johnston J, Carstensen B, Witte D et al. Diabetes and Cancer (1): evaluating the temporal relationship between type 2 diabetes and cancer incidence. Diabetologia 2012 DOI 10.1007/s00125-012-2526-0 5. Renehan A, Yeh H-C, Johnson J et al. Diabetes and Cancer (2): evaluating the impact of diabetes on mortality in patients with cancer. Diabetologia 2012 DOI 10.1007/s00125012-2525-1 6. Gallagher E and LeRoith D. Minireview: IGF, Insulin and Cancer. Endocrinology 2011: 152 (7); 2546-57 7. Currie C, Poole C, Jenkins-Jones S et al. Mortality after incident cancer in people with and without type 2 diabetes.

Impact of metformin on survival. Diabetes Care 2012: 35 (2); 299-304 8. Thompson A, Di Angelantonio E, Gao P et al. Diabetes mellitus, fasting glucose and risk of cause-specific death. N Engl J Med 2011: 364: 829-41

This clinical update is supported by an independent educational grant from Hollywood Private Hospital.

Glucose lowering therapies Initially, one analogue insulin was thought to be associated with higher cancer rates but subsequent studies do not identify any one agent as carrying a greater risk. However, the

33

Clinical update

PIVET MEDICAL CENTRE Specialists in Reproductive Medicine & Gynaecological Services

By Assist/Prof Kym Guelfi PhD, School of Sports Science, Exercise and Health, UWA.

Medical Director Dr John Yovich

FERTILITY NEWS

Andrology: Immotile Cilia Syndrome Dr Anne Jequier Consultant Andrologist at PIVET This condition, previously known as Kartagener’s syndrome or the Immotile Cilia syndrome but now known as Primary Cilial Dyskinesia (PCD) is a rare but well recognised cause of infertility in the male.

It is an autosomal recessive disorder that may be found in around 1 in 32,000 to 1 in 50,000 individuals. A number of abnormal genes have been identified with this condition but so far none have been found to relate consistently with this disease.

All movement of both cilia and spermatozoa is due to the presence of an internal structure known as the axoneme.

This structure is present in all cilia and is also in the tails of all spermatozoa. Structural abnormalities of the axoneme will result in loss of movement of both sperm and cilia.

Each axoneme consists of 9 pairs of contractile fibres and a central pair.

These are known as ‘doublets’ and are joined by structures known as dynein arms.

Normal cilia (A) and cilia representative of Primary Cilial Dyskinesia (B).

In this condition, these dynein arms are absent and this results in the loss of movement of all cilia, the most important of which are those in the bronchial tract. There is also no movement in the tails of the spermatozoa. Thus the major symptoms of this condition are bronchiectasis, sinusitis and infertility. There may also be situs inversus.

The best treatment of the infertility caused by this condition is IVF and ICSI, particularly using Pentoxifylline, a sperm stimulant initially reported from PIVET (Yovich et al, 1988 Fertil Steril). The results are fairly good and due to the rarity of this condition, the likelihood of a partner carrying the risk would be remote hence offspring will be normal.

The diagnosis should be considered in all patients with bronchiectasis and non-motile spermatozoa.

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

34

Influence of exercise over gestational diabetes T

he Cycle Study* is examining whether a 14-week supervised home exercise program, commencing at week 14 of pregnancy, can reduce the incidence and severity of gestational diabetes mellitus (GDM) in women with a prior history of the condition.

Effects on fitness and mobility, weight gain, psychological wellbeing and rates of medical intervention during labour are also being examined. Around 200 Perth women are being recruited into the program, which if shown to be effective, has the potential to prevent obesity and type 2 diabetes (T2DM) in future generations.

Gestational diabetes GDM is relatively common, affecting up to 1 in 12 pregnant women in Australia, particularly women who are overweight or obese. For those with a history of GDM in a previous pregnancy, the risk of recurrence may be as high as 69%.

The condition usually manifests at 24-28 weeks of pregnancy due to a pronounced peripheral resistance to insulin and impaired insulin secretion, resulting in elevated blood glucose levels.

Women developing GDM are at an increased risk of many adverse health outcomes including complications with delivery, and are 7 to 8 times more likely to develop T2DM in subsequent years. For the child, there is increased risk of neonatal complications and increased risk of obesity and T2DM in later life.

Given the benefits of exercise for decreasing the risk of insulin resistance and T2DM in non-pregnant populations, exercise may be a promising strategy to prevent GDM.

Exercise and diabetes Observational research suggests that regular maternal exercise is associated with an approximate halving of the risk of GDM. However, there is a lack of randomised controlled studies investigating this issue.

Women enrolled in The Cycle Study have a 50:50 chance of being randomised to either an exercise program, or standard antenatal care (control group). Those allocated to the exercise intervention have a stationary bike delivered to their home at 14 weeks of gestation and are visited three times each week by an exercise physiologist to conduct supervised training sessions. The supervised home program overcomes many of the exercise barriers related to transportation, child care issues and lack of support and continues until week 28, when the women are tested for the recurrence of GDM. References available on request. *ED. Women less than 14 weeks gestation who have had GDM in a previous pregnancy, can be referred to the study on 9340 1705 (see www.thecyclestudy.com.au). Major sponsors are the Women’s and Infants Research Foundation, Telethon and the NHMRC. medicalforum

Guest Column

Diabetes, a Patient Perspective Barbara Daniels reflects on the help she has received, offers insights into personal and community attitudes, and the changes needed for future diabetics.

M

y heart murmur meant I wasn't able to climb mountains and having only one kidney meant that kidney infections were fairly frequent. Having two uteri did cause a particularly horrendous pregnancy and a couple of miscarriages before I was able to have my two children (and I am very thankful medical practices have changed dramatically since then). But in 1986 I was diagnosed with Type 1 Diabetes and this did change my life.

• Diabetes was a huge problem, especially in indigenous and some ethnic populations, so we worked to develop the highly successful "Don't Ignore Diabetes" media campaign to raise awareness.

At the time I was a young mum, a teacher, a fit, active person who loved travelling, playing sport and doing arts. I was in total shock I'm not sure why, as diabetes is all through my family. I knew very little about it and when I learnt the longterm consequences I was horrified.

• The need for constant reinforcement of information was recognised as essential so short courses and things like shopping trips were organised.

I have a great GP. In fact he was diagnosed with diabetes four years later and we have travelled the journey together. This is the key to coping with chronic long-term conditions – having a doctor you respect.

My GP referred me to Diabetes WA and again, luckily, they were running a sixweek intensive program called "Living With Diabetes". It explored testing blood sugar levels, foot care, eye care, diet, exercise and care plans and it involved my partner. Best of all it was free (but subsequent programs offered were well out of the financial reach of many people with diabetes).

A long time ago I decided I would do my best to manage my condition but not allow it to rule my life. So I altered my diet but still went out to restaurants and had small amounts of my favourite foods. I increased my exercise but in areas I enjoy and I made sure I took my medication and worked out a care plan with my doctor.

I was able to keep my condition in check apart from a few minor hiccups usually related to stress and so far have not suffered any of the nasty complications.

In 2000, a group of consumers at Diabetes WA formed the Consumer Reference Group and I chaired it for the first five years when we dealt with issues raised by members: • Doctors who were not helpful – at the time many doctors were not up to speed with the latest research. We worked closely with one of the divisions to examine the language used by doctors when discussing the initial diagnosis with patients.

Changes needed in the health system • Education programs at diagnosis and regularly for review – low cost (preferably free) and including partners or carers.

Education encourages people to take control of their own health.

• Transition programs for adolescents entering the adult health system. Mentoring programs at a younger age are very successful.

• Cheap medication and aids. Many sufferers have multiple co-morbidities and many are on pensions.

• Costs created problems for many – we heard of people not visiting their doctor or taking medication as prescribed because they couldn't afford it.

• Country areas had unique problems, mainly those of access, with technology helping but not the complete answer.

Pregnancy, childbirth and menopause.

Three of dozens of reasons why your patients might wet their pants today.

If you have patients with leaky bladders or other symptoms, we can help. Bladder problems are very common, affecting thousands of people, especially women who have had children. Your patients may be eligible for free treatment if they have a pensioner or healthcare card.

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I was lucky! I have a great GP. In fact he was diagnosed with diabetes four years later and we have travelled the journey together. This is the key to coping with chronic long-term conditions – having a doctor you respect.

• We became aware of the unique problems of adolescents, especially in transitioning from the child to adult health systems. Many were influenced by peer pressure and even in denial, which often led to non-compliance and adverse events. So we helped finance the children's camps and mentoring program.

For a free consultation with a trained nurse ask your patients to call 1300 787 055 or visit www.continenceandyou.org.au.

• Don't assume technology is the total answer – nothing beats a real person to discuss things with.

medicalforum

35

Clinical update

Diabetic maculopathy

By Dr Brad Johnson, Ophthalmologist, Edgewater Tel 9301 0060

D

iabetic retinopathy is the most common cause of blindness in working–age Australians. Diabetes can affect the eye in numerous ways but maculopathy is the most common means by which vision deteriorates (fig 1). For many years the primary treatment of this disease was photocoagulation (laser) therapy, however this usually does not result in vision improvement, rather a slowing of vision deterioration. This article looks at what interventions make a difference and includes recent advances in the treatment of diabetic maculopathy.

Medical therapies remain important Many studies have shown that strict longterm control of blood sugar levels and blood pressure can slow the progression of both diabetic maculopathy and retinopathy.

Managing dyslipidaemia, renal failure and anaemia can also help slow the progression.

Smoking increases the risk of progression of diabetic eye disease.

Fenofibrate appears to slow the progression of maculopathy and reduce the amount of laser treatment required. These affects appear to be independent of its lipid lowering ability, and as such, one may consider using

it in patients with a ‘normal’ lipid profile, or in conjunction with other lipid lowering medications, if deemed safe.

Retinal photocoagulation (laser) Retinal laser has been used for many years and remains the mainstay of treatment for diabetic macular oedema not involving the central macula. It has been shown to reduce the risk of vision deterioration by 50% compared with sham. Unfortunately, it does not tend to improve vision – rather, the aim of therapy is slowing the decline. It is decreasingly being used for patients with oedema involving the centre of the macula.

n Fig 2. OCT scan pre and post treatment,

demonstrating reduction in macular oedema following intravitreal bevacizumab.

Recent randomised controlled studies have shown that anti-VEGF agents are superior to photocoagulation in terms of visual acuity gained. They also have less ocular complications than intravitreal triamcinolone.

Intravitreal pharmacotherapies Over the last decade, triamcinolone injected into the vitreous cavity has been used in the management of diabetic maculopathy. It is effective in reducing the oedema associated with diabetic maculopathy, however it has a relatively high complication rate (due to cataract formation and intraocular hypertension) and therefore tends to be used as an adjunctive therapy only.

n Fig 1. Retinal view of diabetic retinopathy and maculopathy.

Late last year, the TGA approved the use of intravitreal ranibizumab for the treatment of centre-involving diabetic maculopathy and the drug is now considered the gold standard for treatment of center-involving diabetic macular oedema. Generally, patients need to have repeated intravitreal injections to maintain visual acuity gains (see Fig 2). n

Anti-vascular endothelial growth factor agents, such as bevacizumab (Avastin®) and ranibizumab (Lucentis ®), have been in common clinical practice for several years.

VEGF is released from affected retina and is a major contributor to macular oedema.

Declaration: This clinical update is supported by an independent educational grant to Medical Forum from the Eye Surgery Foundation.

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37

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medicalforum

Clinical update

The lack of dizziness: bilateral vestibulopathy T

Dr Vincent Seet, Neurologist and Neuro-otologist, SCGH, Nedlands. Ph 9346 3333

he complaints of dizziness and vertigo have an estimated community prevalence of 22.9% and incidence of 3.1% per annum, with about half vestibular in origin. However, a subgroup of those with definite vestibular pathology can be misdiagnosed or suffer delays in diagnosis beyond 24 months – those with bilateral vestibular loss (bilateral vestibulopathy), where vertigo (i.e. spinning or another illusion of motion) is absent and in whom standard neurological examination that ignores four key steps will completely miss the diagnosis.

Suggestive history Bilateral vestibulopathy affects both sexes equally with mean age of about 60 (range 12-98 years). Patients typically present with ataxia worsened by darkness or uneven surfaces (i.e. where there is loss of visual and proprioception cues).

They do not have symptoms of cerebellar disorders or peripheral neuropathy (e.g. dysarthria, upper limb incoordination, distal limb numbness) yet may find it necessary to use a walking aid for a gait ataxia that remains unexplained.

About half the patients voluntarily complain of oscillopsia. A common description of this is the bobbing of the horizon or an inability to read road signs during locomotion, which reflects dysfunction of the vestibulo-ocular reflex and is similar to walking and looking at the environment through a camera. However, patients with a slowly progressive course and elderly patients who move slowly with limited head movements, may not complain of oscillopsia.

While patients with bilateral vestibulopathy do not complain of vertigo, one third have a past history of vertigo.

Key examinations There are four key examinations for bilateral vestibulopathy, used in combination: 1. A tandem Romberg’s test. The patient is asked to place one foot directly in front of the other and then close the eyes. A positive test equates to a prevented fall in less than 6 seconds. This test is sensitive but not specific (i.e. it is also positive in cerebellar, peripheral nerve and central gait disorders such as Creutzfeldt-Jakob disease and Friedreich’s ataxia).

2. The dynamic visual acuity test. Static binocular visual acuity is first tested using a standard eye chart, then repeated while moving the head horizontally at 2 Hz and 30 degrees to either side. A loss of 3 or more lines is a positive test and suggests impairment of the vestibuloocular reflex (e.g. patients with acute bilateral vestibular loss often do far worse than the loss of 3 lines whereas patients with complete unilateral vestibulopathy score normally).

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3. The fundoscopic (vestibulo-ocular reflex) VOR test. The patient is asked to fixate on a target. Using an ophthalmoscope, the examiner observes for any slip in the optic disc during small head oscillations. In normal individuals, there is no movement of the optic disc during head movements. There is very low rate of false positives with this objective test.

4. Head impulse test. During visual fixation, the patient’s head is moved rapidly 20 degrees to either side.

Impairment of the vestibulo-ocular reflex is confirmed when there is a catch-up or corrective saccade back to the fixation target. There is no corrective saccades in patients with a normal VOR, as it is a very fast reflex at 10 ms compared to 100 ms for the visual system. In bilateral vestibulopathy, corrective saccades towards the target are visible with head movements to either side. (Avoid this test in patients with significant cervical pathology).

disease, meningoencephalitis and sequential vestibular neuritis, which account for a further 25%.

Why is diagnosis important? Diagnosis of bilateral vestibulopathy should lead to prompt general treatment such as vestibular physiotherapy and falls prevention. It will help the clinician avoid the common mistake of prescribing vestibular suppressants to a patient with bilateral vestibulopathy. It avoids the damaging misdiagnoses of a psychological disorder such as malingering or normal ageing. And it offers up treatment of the underlying cause in many cases, with genetic implications in some cases (e.g. spinocerebellar ataxia), and legal ramifications in others (e.g. gentamicin ototoxicity).

Table 1. Causes of bilateral vestibulopathy Cause

Percentage

Idiopathic

47-50%

Ototoxic antibiotic e.g. gentamicin

13%-19%

Vestibular tests

Meniere’s disease

7%-12%

The gold standard test for bilateral vestibulopathy is now the rotational chair test. It negates the various disadvantages of caloric testing (i.e. technical and anatomical factors), with no dependence on satisfactory heat transfer to the horizontal canal, an ability to test frequencies ranging from 0.01Hz to 1.28 Hz (compared to 0.003 Hz only) and it is also useful for monitoring progress over time.

Meningoencephalitis

2-5%

Sequential vestibular neuritis

4%

SCA-3, SCA-6, EA-2, MSA

1-4%

Systemic autoimmune disease

1-3%

B12/folate deficiency

2%

Trauma

1-2%

Creutzfeldt-Jakob disease

1%

Cogan’s syndrome

1%

Vestibular evoked myogenic potential (VEMP) is useful in some patients who have suspected bilateral vestibulopathy and normal caloric test. While the caloric and rotational chair tests assess function of the horizontal canals and the superior vestibular nerve, VEMP is able to assess the function of saccule and inferior vestibular nerves.

Familial

1%

NF-2 bilateral acoustic neuroma; Superficial siderosis; Otosclerosis; Alcohol; Posterior circulation ischaemia; Bilateral chronic otitis media

<1% each

Computerised dynamic posturography, dynamic visual acuity and head impulse tests are also available.

Aetiology vs treatment Ideally, the identification of bilateral vestibulopathy should include the diagnosis of the cause but as Table 1 shows, among the variety of causes, ‘idiopathic’ makes up the majority (50%). Other important causes include drug ototoxicity, Meniere’s

SCA = Spinocerebellar ataxia, EA = episodic ataxia, MSA = multiple systems atrophy Suggested reading Zingler VC, Cnyrim C Jahn K Weintz E, Fernbacher J, Frenzel C, Brandt T, Strupp M. Causative, factors and epidemiology of bilateral vestibulopathy in 255 patients.

Ann Neurol 2007;61:524-532.

Kim S, Oh YM, Koo JW Kim JS. Bilateral vestibulopathy: Clinical characteristics and diagnostic criteria. Otology and Neurotology 2011;32:812-817.

Author competing interests: No relevant disclosures.

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Clinical update

Pancreatic cancer: reason for more hope T

By Dr Andrew Dean, Oncologist, SJOG Subiaco Tel 6465 9200

he most common perception of pancreatic cancer is of a disease of little hope, with very few treatment options and a dismal prognosis. Is this actually so? Recent local and international data challenge this idea and suggests that the tide may well be turning.

For many years, there was really only one effective chemotherapy for unresectable pancreatic cancer – weekly gemcitabine, which produced a life expectancy of approximately six months. Since 2009, oxaliplatin with 5-fluoro uracil (5FU) showed some benefit and, subsequent addition of irinotecan showed further improvement

Results too good to be true?

At the American Society of Clinical Oncology meeting 2009, it is astounding that a presentation by Dr Daniel Von Hoff (Scottsdale, Arizona), which demonstrated amazing results with a new chemotherapy approach, did not attract a fanfare. This was possibly because the results were so good that nobody believed them.

Dr Von Hoff’s study demonstrated an exceptional response to gemcitabine and nab-paclitaxel (AbraxaneTM). Ca19.9 tumour marker dropped in >90% of patients, 78% of patients showed a response on PET and 23% exhibited a complete PET response. Median survival was >12 months in metastatic disease.

The mechanism of this success is thought to be the overexpression of a protein trap called SPARC (secreted protein acid rich in cysteine) found on tumour cell membranes, which traps human albumin, probably a ‘feeding’ mechanism to provide protein to the tumour. Complexing the chemotherapy

n Fig1. Pancreatic tumour SPARC expression is linked to drug response.

agent paclitaxel to albumin results in a 30% increase in chemotherapy concentrations found in tumour cells.

Interestingly, the response rate of 90% parallels the incidence of SPARC overexpression found on pancreatic adenocarcinomas (see Fig1).

Australian anecdote supportive The first Australian patient to get this new therapy in September 2009 was Mrs MT, a 72-year-old with advanced pancreatic cancer who had progressed on gemcitabine.

She had severe abdominal pain, resistant to opioids and had failed a coeliac plexus block. She had become very debilitated (making it dubious whether she was well enough to actually have treatment) but was insistent on trying the new therapy. Her pain improved after the first weekly dose, she became functional after the second, went home after the third and was back at work after the sixth.

Her CT scan immediately prior to treatment and after 3 months is shown (see Fig 2), and she remains alive and completely disease free to this day.

Growing evidence of efficacy I recently analysed the data of the first 63 patients treated in Perth at two centres.

This showed that 81% of patients given the combination of gemcitabine plus nabpaclitaxel responded, with 10 achieving a complete disappearance of tumour on PET or CT. Median survival time was over 12 months, compared to 3 months if untreated and 6 months if given gemcitabine alone.

Interestingly, 23 patients had locally advanced unresectable disease and of these 8 became operable and were able to undergo successful pancreatic resections.

One patient had complete pathological response at operation with no evidence of any residual tumour. All of these patients currently remain alive, with 7 still being free of disease.

This data will be presented at ASCO 2012 and essentially supports Dr Von Hoff’s findings. There are currently two major studies underway in Perth. One is a phase 3 study comparing standard gemcitabine to gemcitabine plus nab-paclitaxel and the other study will look at whether chemotherapy with gemcitabine plus nabpaclitaxel given before surgery improves the resectable rate of pancreatic tumours and hopefully the cure rate.

We are all eagerly awaiting the results of the ongoing phase 3 trials of this therapy to see whether this will give us a new gold standard. Until then, it is fair to say we can have a more optimistic outlook for pancreatic cancer treatment.

n Fig2. Mrs MT: CT scan pre and post treatment.

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Declaration: Dr Dean has served on the advisory board for Specialised Therapeutics Australia.

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Clinical update

Surgical management of colorectal liver metastases I

By Dr Krishna Epari, Upper GI-Hepatobiliary Surgeon, SJOG Murdoch & Fremantle Hospital

n colorectal cancer, liver metastases are present in 25% of cases at diagnosis, and even after resection of the primary this figure increases to 50% within five years. While the liver is often the first site of metastases, it is the only site of metastases in one third of patients. Advances in palliative chemotherapy have increased the median survival to over 24 months, however, tumour progression ultimately occurs. In searching for cure, surgical resection is a consideration as up to 20% of patients have surgically resectable metastases and for them, five-year survival outcomes of 20-60% can be achieved. This article covers some important patient considerations.

Imaging and staging A high quality triple phase CT scan will detect most liver lesions and is always the most appropriate initial staging investigation.

Trans-abdominal ultrasound is good at differentiating solid from cystic lesions but lacks both sensitivity and specificity.

Whole body Fluoro-18-deoxyglucose (FDG) positron emission tomography (PET) identifies metabolically active tumour deposits and is particularly useful for detection of extra-hepatic disease. It is less sensitive for smaller lesions (< 1cm diameter) and post-chemotherapy (due to suppression of metabolic activity).

The liver has an amazing capacity for regeneration. Up to 70-80% can be resected in a normal healthy liver, or up to 50-60% in patients with cirrhosis, steatohepatitis, steatosis or chemotherapy-induced liver disease.

Relationship to chemotherapy

When the predicted future remnant liver volume (FRLV) is inadequate, there are several techniques that can help increase the FRLV, decrease the risk of liver failure and make resection feasible.

Chemotherapy can make some borderline cases resectable by allowing more liver to be preserved and to obtain clear margins whilst preserving vital vascular structures. This must always be balanced against the risk of chemotherapy-induced liver disease that increases operative morbidity and mortality, especially with more extensive resections.

Preoperative embolisation of the right or left branch of the portal vein is a radiological

MRI has the best specificity for characterising liver lesions due to their different pathognomonic features. It is usually able to distinguish common benign lesions such as simple cysts, haemangiomas, focal nodular hyperplasia (FNH) and hepatic adenomas from malignant appearing lesions, including metastases.

The diagnosis of liver lesions can be made in most cases with imaging alone. Biopsy is not recommended in potentially resectable cases due to a 20% risk of seeding rendering the patient incurable! Staging laparoscopy with laparoscopic ultrasound can identify low volume or peritoneal disease and may avoid unnecessary laparotomy in 10% of cases.

Surgical considerations Advances in surgical technologies over the last decade (e.g. ultrasonic dissection, vessel sealing energy devices, staplers, tissue glues) have advanced major liver surgery by minimising intraoperative haemorrhage and extending the boundaries of resection.

Enhanced recovery protocols – targeted fluid management, regional analgesia, early feeding and mobilisation – have shortened the average length of stay to 5-7 days for open surgery, with emerging laparoscopic resection offering further advantages.

Multiple, large and even bilobar metastases are no longer considered to be contraindications provided they can all be completely resected whilst preserving an adequate remnant of liver to maintain normal function. Extrahepatic disease is not a contraindication if all the site(s), such as lung, can also be completely resected. medicalforum

n Colorectal liver metastases visualised before laparoscopic resection.

procedure used to induce atrophy of the diseased side and hypertrophy of the future remnant liver before major resections.

Staged resection for extensive bilateral disease clears one side of the liver and allows some regeneration before further resection.

Staged resections may be combined with embolisation.

Local thermal ablation with radiofrequency or microwave probes can be used in conjunction with surgery to treat difficult to reach lesions, whilst preserving vital normal liver tissue.

Preoperative chemotherapy may decrease disease volume allowing more liver to be preserved converting inoperable or borderline cases to resectable (“downsizing”).

Minor liver resections can be safely performed during primary bowel resection.

Major resections are best performed separately to avoid compounding morbidity (sometimes only a few weeks apart, if recovery is uncomplicated).

Chemotherapy is the only treatment that targets systemic micro-metastatic disease.

Use of peri-operative chemotherapy with liver resection has been shown to improve survival by around 25%.

A period of chemotherapy can select out non-responders or those who progress rapidly to inoperable disease, thereby avoiding major surgery. On the other hand, operable disease could become inoperable by delaying surgery. Smaller lesions may disappear (complete radiological response), which presents a problem given that at least 80-90% will eventually recur. It is essential to have high quality imaging before starting any chemotherapy so that the full extent of disease can be assessed – and so these metastatic sites can be included in any subsequent resection, should surgery be performed.

Multidisciplinary Team Approach There are many factors to consider and weigh up, which is why it is recommended that all patients with potentially resectable liver metastases are reviewed together by all involved – liver and colorectal surgeons, radiologist, medical and radiation oncologists. There is no general consensus for the optimal timing of chemotherapy for initially resectable metastases and treatment plans must be individualised, according to circumstances.

Follow-up surveillance After potentially curative resections of primary and/or metastatic colorectal cancer all patients should remain under surveillance as further resection may be possible with similar survival outcomes. WA Health guidelines recommend checking CEA levels every three months and a CT scan every six months for the first two years, followed by CEA levels every six months and CT scan annually, for five years.

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Cycling

Free – Wheeling Freedom Sarah Hedges and Tom Walwyn have just ridden along the spine of America and blogged about their adventures – every inch of the way.

Medical nomads Sarah Hedges and Tom Walwyn are passionate believers in living the life they want to live. It’s a philosophy that’s taken them from Hobart to Edinburgh, Newcastle-Upon-Tyne, a short stint in Liberia and then on to Darwin and Fremantle.

On their latest trip they cycled from Canada to Argentina and their superb blog, bicyclenomad documents the adventure in words and pictures.

“I’ve always enjoyed long-distance walking and I’d intended to do the Continental Divide Trail through the USA and Mexico.

Tom’s really into bikes so this trip was something we could do together. We’d both just finished our specialist training (Sarah, anaesthetics, and Tom, paediatric oncology) and didn’t have long-term jobs so we thought we’d do this trip and see how far we got. We ended up at the bottom of Argentina,” Sarah said.

Sarah has always been a woman on the move.

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“I went to school here in Perth and did medicine at UWA, but I was born in the UK and had lived in Queensland, NSW and WA by the time I was seven. I’ve certainly bounced around a bit, in fact I’ve moved every year since finishing university in 1996. As specialists that may change because we’re more likely to get long-term contracts.”

And that’s what’s happened. Tom has just secured a five-year contract as a paediatric oncologist at PMH and, as Sarah points out, it’s a big change from the simple life of two wheels on a road somewhere.

“Being back in Perth feels strange and in many ways, I really didn’t want it to end.

Life is so complicated in the West and the bike trip was so simple. It was just eat, sleep and ride the bike. I miss that.”

There were a few exciting moments on the trip, thankfully none of them serious.

“We had our fair share of D&V on the road which is to be expected in South America.

But there was nothing worse than that and we didn’t have to do the doctor thing and look after anyone else. One night in northern Mexico we woke up to the sound of the tent being unzipped in the middle of the night. Whoever it was disappeared.”

The Great Divide cycling adventure was, in Tom’s words, a ‘natural gap between finishing Fellowship training and longer-term medical jobs.’ But the blog, documenting the trip in words and pictures, had an entirely different genesis.

“The blog was originally for our mothers who, naturally enough, had a vested interest in knowing we were still alive. But we’re actually missing the blog now and even thinking of going back and filling in some of the gaps. We’d always wanted to do a significant tour and that just morphed into a trip along the spine of America. It did take a bit of courage, we went away without jobs to come back to,” Tom said.

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Cycling

Tom and Sarah have always been medical nomads. They’ve never lived anywhere for more than 18 months and, as Tom suggests, the discipline of medicine is an integral part of life on the road.

“The trip was a huge step sideways and it just became our normal life. We’d wake up in the morning, have breakfast and cycle. It took quite a bit of self-discipline and having done medical training and postgraduate exams helped with this. I think medicine tends to attract people who impose a routine on themselves. We were very much into the experience as well, but both of us felt we hadn’t done a day’s work unless we clocked up six hours on our cycle computers.”

In a way, Tom’s parents launched him on his medical trajectory towards his current position as a paediatric oncologist at PMH. “Both my parents were teachers and the only advice they gave me was ‘don’t

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become a teacher’. I wanted to do something science-based with a people focus because I really thrive on personal contact.

I did my university training in the UK and worked in New Zealand and Australia, in fact Sarah and I met on our first day at work in Hobart in 2003. I’d seen some photos of Tasmania in a rock-climbing magazine and it looked very appealing.”

Tom’s the first to admit that the nature of his current five-year contract will have its own demands and rewards.

“Paediatric oncology is a confronting area at times, no parent goes into the treatment of an oncological condition without thinking, ‘my child’s going to die.’ And there are some occasions when that happens and we’re not expecting it. Having said that, we have an overall cure rate of 75-80% which is very different compared with adult oncology or palliative care. We say to our young patients, ‘this is something we can deal with and we expect to cure you’. I haven’t

been a consultant long enough to know if I’ve got the true feel for it but I’m very satisfied at the moment.”

Tom, like Sarah, believes in living a life less ordinary.

“The message I’d give to my medical colleagues is ‘if you’re thinking of doing it, then do it!’ It’s too easy to become institutionalised within the practice of medicine.

In Scotland, for example, a substantial proportion of the people we worked with grew up in Edinburgh, went to school and university there, maybe did a six-month stint somewhere else and then hoped to get a consultancy position back in Edinburgh.

Our medicine has always had a real multinational flavour and the cycling trip added to that.”l

By Mr Peter McClelland 45

Car Review

Loving the Open Road

Dr Daryl Sosa and Dr Peter Bradley spent the weekend putting the sporty new Lexus GS350F through its paces.

The new Lexus GS350 F Sport arrived in Australia last month replacing the outgoing GS300 and it fits between the IS 350 and the Lexus IS F. The 350 weighs in with a 3.5 litre Direct & Port injected quad valve, naturally aspirated DOHC V6 mated to a six-speed clutchless sequential semi-automatic transmission, which is lifted from the IS 350 and tweaked to produce 233kW and 378Nm torque (up 27% and 22% respectively).

al alloys, low profile rubber and neat rear three-quarter view combined with excellent build quality this $110K luxury sports sedan is desirable. There is even “self-healing paint” with selected exterior colours. I wish my daughter’s new Lancer had that!

It hosts a multitude of performance and handling upgrades designed to upstage its natural competitors from Audi, BMW and Mercedes … at a significantly lower entry fee.

The F Sport features 19-inch dark-coloured titanium alloy rims shod with staggered 235/40 and 265/35 Bridgestone tyres and upgraded 356mm ventilated two-piece front rotors. Exterior body enhancements include a redesigned front bumper that’s loosely derived from the “LFA supercar’s” DNA and a discrete rear lip spoiler and lower diffuser.

The new look has polarised opinions. The aggressive “manta ray“ front bumper treatment doesn’t quite match the conservative rump – it’s a bit like wearing fishnets to a funeral: you might think it looks sexy, but most will think you’re a bit out of place!

Other than that, the side profile, individu48

Slipping into the cabin, the firm, contoured leather seats are supportive and very comfortable, even on extended journeys. The new stitched leather dash has crisp, linear styling and the Display and Operation zones ooze class. This is punctuated by a small, central analogue clock forged from a single billet – very chic.

The central 12.3-inch LCD multimedia screen outguns the BMW’s 10.2 in size but its Satnav is not as detailed, and we couldn’t work out how to get rid of the split screen

Nav/radio view. DAB+ Digital audio is fed to a 17-speaker Mark Levinson system.

Even the air conditioning features Nano Technology moisturising!

The orange Heads Up Display (HUD) projected above the steering wheel was a little distracting despite having some manual adjustment. The Active Cruise Control employs a forward-sensing radar to adjust automatically the GS 350s speed if a vehicle is detected ahead in the same lane. Theoretically this is a safety aid but in practice it’s annoyingly sensitive with it often overreacting and retarding the cruising speed too much.

Other safety features include a Pre-Collision Safety System, Blind Spot Monitor, Tyre Pressure Monitor and 10 SRS Airbags.

The aggressive styling is supported by Lexus Dynamic Handling (LDH), an integrated system controlling electric-assisted power steering, Adaptive Variable Suspension (AVS) and Dynamic Rear Steering (DRS).

The rear wheels are steered in opposing directions to the front wheels up to 80km/h then in the same direction above 80km/h. VDIM 5 is a stability control program that incorporates traction control, Electronic Brake-force Distribution (EBD)

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Car Review

and the DRS/VGRS (steering). These systems improve high-speed handling and stability and reduce the turning circle to 10.8m.

Having said that, the initial turn-in is a bit vague but the four-wheel steering really helps the car to track through fast-sweeping bends and sharpens the F sports slalom times over lower-spec models.

Manual sequential gear changes can be performed with either the steering wheel-mounted shift paddles or the transmission shift lever in the centre console using the Sports Program Direct Shift (SPDS) lifted from the Lexus IS F. You can select your driving mode – Normal/ Eco, Sport or Sport+. The Sport mode enhances throttle and transmission control, while Sport+ changes both engine/drivetrain and suspension parameters for increased dynamics and performance. Once again, our regular passenger, Steph, felt a bit “seasick” with the Normal/ Eco mode though felt much better in Sport+.

The GS350 suffers from a common complaint we have with most of the performance-oriented clutchless, semiautomatics – they’re all a bit nervous on part-throttle and initial braking, which can make car parks and traffic jams more annoying. It also suffers a bit from the familiar 6-cylinder engine noise at moderate revs.

Where the 350 F Sport really comes into its own is out on the open road. Pete took the Lexus on a quick blast to Jurien Bay and

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then to York for the annual motorcycle festival. After the mandatory pies and sauce on Avon Tce listening to TC (“Top Cop or The Commish”) O’Callaghan rocking the bikers in the main street, we decided to head back along the Great Southern Highway towards

Overtaking was a breeze, aided by nearly 400Nm of torque and the seamless gear changes. This was definitely the Lexus's realm.

The Lakes, comfortable in the knowledge that Karl & Co were usefully occupied back in town.

Sticking the boot in generated a deepthroated growl as the double-injected V6

unleashed its 300+ Hp, a couple of quick blips on the downshifter and the fun started. Overtaking uphill was a breeze, aided by nearly 400Nm of torque and the seamless gear changes. This was definitely the Lexus’s realm and if you spend a lot of time driving in the country or even cruising up and down the freeway, then this vehicle demands serious consideration.

Fuel consumption for the weekend with a mix of city and country roads and with some relaxed and other times spirited driving was about 11.5 l/100km – a reasonable result.

The new GS350 F Sport is a substantial step forward for Lexus in its quest for impact in the luxury (sports-oriented) sedan market. While it’s not designed to rival the BMW M3, Mercedes AMG or Audi RS, it certainly represents stylish luxury, performance, safety and finesse at a modest cost.

49

Photo Competition

1st

Wild times & FUN times Have camera, will travel and when you do, you capture some spectacular moments. Pictures for this month’s competition came in all shapes, sizes and subjects, just like the topic Wet ‘n Wild. And there was some distance travelled to bring these pictures to you – from the Antarctic in the south to arctic Norway with Australia’s outback and the African savannah in between.

Dr Susan Downes, who has spent a lot time working in the north of the State, is the winner of this month’s competition for her stunning picture of “Desert Storm”, taken from a small plane while trying to get back to Newman from Punmu in the Western Desert one evening after three days of clinics in various desert communities.

2nd

Second was Gary Dowse’s “Frozen Waves” in the Antarctic was second. He took this picture of rafted sea-ice (where actions of tides, currents and wind act on the sea-ice to break it up and push it back together) near Mawson Station, Antarctica, while he was there for a year in 2007 as Station Leader.

Third place went to Dr Julia Charkey-Papp for her picture of the partly frozen Dragan River in Transylvania, which she took on her Canon Powershot SX1IS camera on Boxing Day 2011, while holidaying in Romania.

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3rd medicalforum

Photo Competition

1

2 3

4

6 5 8

Runners up

NEXT THEME: The Human Face Get your pictures in by July 10 to be published in the August edition of Medical Forum.

1 Aurora Borealis by Dr Charles Crompton, taken near Tromso, in arctic Norway in March this year on an Olympus E510 DSLR 25mm f2.8 ISO 400 10 seconds.

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2 Dr Charles Armstrong’s painterly photograph of the Orkney coast was taken on Olympus e-620 with 50mm lens, iso 100, f/6.3, 1.320.

3 Joondalup Physicians practice manager Jo Marks’s picture of her husband reliving his childhood at Adventure World.

4 Dr Cathy Irvin was at the Broome zoo when she captured this saltwater crocodile lazing beside the pool. Salty has pride of place on Cathy’s living room wall where it gets lots of comments.

5 Clive Addison’s water baby. Who’s looking at whom?

6 Dr Janina Anderst captured this herd of elephants making a border crossing from Botswana into Namibia over the Chobe River.

7 Cool, wet and wild were in the swimmers’ minds at Tolmer Falls in Ltichfield Nastional Park in the Northern Territory and captured on camer by Dr Farhat Mahmood.

8 Dr Vijith Vijayasekaran’s a frozen Niagara Falls from the Canadian side of the falls.

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8 51

You speak often how your mother and grandmother introduced you to food and flavour. Tell me a little more about these women.

Celebrity

GC: Two women who would do without the shirt on their back to put up great food. Their passion for great produce and food that filled you heart and soul was their mantra. I love their hospitality.

They fill the hearts of people with happiness through great food and love.

Where did they grow up? What food did they grow up cooking?

When did your family settle in Australia?

GC: They were born in Cyprus and they grew up eating Greek Cypriot cuisine – a cuisine influenced by the Ottomans. They settled in Melbourne and it has been home for the last 40 years.

How important is tradition to first and second generation Australians?

GC: Tradition is a gift at birth. It’s an idea, a belief, a ritual.

It reflects time passing through the year. For me it’s the smells of raisins and cinnamon during Easter time; meats slowing cooking over coal over Christmas. It is the best – I love all these things and I am proud to pass it down to my son. And food is the centre piece to cultural values. It brings us all together as one. It’s about sharing and experiencing.

How hard is it to get ingredients in Australia?

GC: It’s not hard at all. You just need to be in touch with what is happening out there. But try to use local and native. And don’t be afraid to try.

When the family gets together, do they let you cook? What do they say about your cooking?

GC: No, I don’t cook much. I prefer to let my mum and my mother-in-law do that. I love their cooking.

The food scene in Australia has changed so radically in the past 20 years, describe what it means to have a life in food in Australia in 2012.

GC: I am part of a diverse cooking culture where everything and anything goes. We are so spoilt for great chefs, great food and great service. We are so lucky.

Your own restaurant business has grown exponentially in the past decade, do you still get a chance to roll up your sleeves and do service?

GC: Yes. I have to. The Press Club (in Melbourne) is my baby and my flagship. I always wear my chef’s jacket. It’s who I am and what I know. I must lead from the front but sometimes helping the kitchen hands wash is OK – I do that too. I never forget where I started from.

How do you keep yourself in touch with that wonderful, calm focus that comes with cooking?

GC: Calm?! I am running a hundred miles an hour every day. I dream all the time and want to be better every day. Food is my life!

MasterChef is back on our screens, what impact has this show had on the Australian food scene?

10 minutes with...

George Calombaris George Calombaris was a respected chef in Melbourne until a little show called MasterChef made him a national treasure. Here he talks about the food of his childhood and the women who cooked it.

GC: Well for me it has changed the way young Australians eat.

Kids now know where carrots come from and that chickens have feathers. It’s exciting! MC is about people’s stories and how they want to change their lives with food. They dream and we believe.

Real people, real food.

How do you keep a healthy weight with your lifestyle?

GC: Hmmm not sure I am that healthy. But I can say I only eat real food. No fast food or inferior product – that means I eat butter not margarine.

What will you be doing at the Good Food and Wine Show in Perth in July?

GC: I’m very excited about coming to Perth. I am bringing with me a couple of my chefs, one of whom is a Perth boy and was a chef at Andaluz. Brenton Pyke is my head chef at The Little Press and Cellar. My show at the GF&WS is all about the growing Family Tree. How life influences my food and my experiences.

Chefs are the new rock stars, can you play guitar?

GC: HMMMMM. The difference between chefs and rock stars is rock stars do maybe six to 10 concerts a month. Chefs do 1 concert for lunch and 1 for dinner every day. Every service in my kitchen is a concert. We must perform.

When you close your eyes, what do you smell?

GC: LIFE. I am so blessed to be alive and to do what I love. I was born a cook and I will die a chef.

What would be your last meal?

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** George Calombaris will be in Perth next month for the Good & Wine Show. See the competitions page for your chance to win double passes.

GC: No such thing as a meal. It would be a symposium of dishes.

By Ms Jan Hallam

Food Festival

n Iain Lawless at a cooking class and, right, Marianne Kempf and the long table lunch at Mundaring Truffle Festival.

Culinary Olympics with Black Gold the Prize They may smell like old footy socks and ugly to boot but there’s no denying that truffles make foodies go weak at the knees and you’ll find several thousand of them wobbling around the annual Mundaring Truffle Festival at the end of July.

Truffles are colloquially known as black gold – and for good reason – French truffles sell for about $2000 a kilogram, while local varieties, of which there are growing numbers, command anywhere between $1600 and $1800 a kilogram.

Scores of celebrity chefs will come out to play with the black fungi at this year’s festival. At the same time as our Olympic athletes will be competing in London, local chefs will match their truffle skills against a French team at long table lunches held on July 28 and 29.

Sydney-based French chef Guillaume Brahimi joins forces with fellow French ex-pats Alain Fabregues (of Loose Box fame, and who also has a trufferie at Toodyay) and Emmanuel Mollois (of Choux Pastry and ABC TV show Po’s Kitchen) for the Long Table Luncheon on Sunday.

The wildly entertaining Iain Lawless (Kitsch Bar and Lawless Cooking School) and the impeccable Marianne Kempf (Gala Restaurant) will be on the team to prepare the Long Table Luncheon for 200 on the Saturday.

Iain is ready to roll up his sleeves and have some fun and while he seems laid back and yet to decide what he will prepare for the chal-

medicalforum

lenge, he comes with a hefty weight of experience behind the pans.

He’s soon to open a bar in Oxford St, Leederville, specialising in all things French.

His early thoughts? “I’m thinking of a hot dog, just for fun. But whatever I choose to cook, you can be sure there will be plenty of truffles.

I’m not into waving a little truffle over food, you’ve got to taste it.”

Marianne will be doing her tried-and-acclaimed truffle ice cream matched with a hazelnut brownie, quince and truffle meringue.

She and husband Hans do regular truffle dinners at their Applecross restaurant when truffles are in season, sourcing them from France and locally, including Oak Valley in Manjimup, the official truffle supplier for the festival.

Other celebs to watch out for are Anna Gare, Herb Faust, Rockpool’s Dan Masters and local boy made huge, Nino Zocalli.

Ticketed events include the Long Table Luncheons at $175 a seat, and a truffle masterclass including a three-course lunch prepared by Brahimi, Fabregues and Mollois for $190 a head. l

By Ms Jan Hallam

** Look out for your chance to win entry tickets to the Mundaring Truffle Festival in the July edition of Medical Forum magazine. ** Mundaring Truffle Festival, July 28-29, 10am-5pm.

Tickets from BOCS. 53