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Contents

March 14 25

14

22

18

26

FEATURES

NEWS & VIEWS

14

3

18 22 25 26

Online Appointments – Right for You? Dr Rob McEvoy Athletes Battling the Bottle Mr Peter McClelland Pitch for Best and Brightest Ms Jan Hallam Eyes Fixed on Rural Needs Trailblazer: Dr Sean Stevens Ms Jan Hallam

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13 20

LIFESTYLE 40 41 42 43 44 46 48 49

Four Wheels to Happiness The Long Way Home Helen Reddy – Hear Her Roar Wine Review – Turkey Flat Dr Louis Papaelias Travel: Kalgoorlie – the Pit, the Pubs and the Golden Mile The Funny Side A Creative Vision for WA Competitions

23 24 27 28 30 38

E-POLL/EVENTS 3 45

MAJOR SPONSORS medicalforum

Editorial: Dollars and Sense Letters: More Stroke Studies Needed – Prof Daniel Fatovich Response – A/Prof David Blacker Incentive Scheme Will Help – Ms Jonine Collins Stroke – Calling the Ambulance – Prof Ian Jacobs Standards Define Profession – Dr Mike Civil Public vs Private – Who Pays? – Mr Roger Cook Have You Heard? Younger Stroke & Communication Beneath the Drapes Rural Clinical School Validates! Dr Kathleen Potter – Prescribing Quality not Quantity Bust Back in Family Hands Current Science is Future Art Don’t Panic, Read the Manual

e-Poll: Health Insurers & Doctors; Costs and Consumers Conference Corner

1


PUBLISHERS Ms Jenny Heyden - Director Dr Rob McEvoy - Director

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ISSN: 1837–2783

John Alvarez Cardiothoracic Surgeon Peter Bray Vascular Surgeon Joe Cardaci Nuclear & General Medicine Chris Etherton-Beer Geriatrician & Clinical Pharmacologist Philip Green General Practitioner: Rural Mark Hands Cardiologist

ADVERTISING Mr Glenn Bradbury advertising@mforum.com.au (0403 282 510)

Clinical Contributors

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

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

DR ROB PAUL 33 Bladeless Cataract Surgery

DR KEITH HOLT 34 Arthroscopy of an Arthritic Knee?

TIM 35 MR BARNWELL Ruptured ACL, What Now?

MS JO BEER 35 Diet and Cardiovascular Risk

Supporting Clinical Editor Dr Joe Kosterich (0417 998 697) joe@mforum.com.au 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 Thinking Hats

2

TIM 36 DR GATTORNA Sudden Cardiac Death in Young Athletes

DR PETER STEELE 37 Concussion 38 CLIN/PROF HARVEY COATES Management

Innovations in Tissue-Engineered Myringoplasty

PROF PAOLO 39 FERRARI Kidney Exchange: Solution for Some

Guest Columnists

MITCH 10 MR MESSER Consumer Partnership, Really?

HELEN 28 MS BROWN Beat the Heat – Plant Trees

MS JUDI MOYLAN ALEXIUS 29 National 31 DR TAYLOR JULIAN Focus Needed for Diabetes

Brave New World

‘Doctors vs the Pace of Change’ Five days until the next...

Doctors Drum Breakfast

WHERE Observation Rendezvous WHEN Wednesday March 5, 7.15-8.45am FREE Breakfast supported by our Sponsors Slater & Gordon, Fertility North and Medical Forum WA

Go to: www.doctorsdrum.com.au or scan the QR link to register and see who’s on the panel medicalforum


Editorial

h Marc

By Dr Rob McEvoy Medical Editor

ll o P e

Dollars and Sense

e-Poll Facts: 158 responses from General Practitioners (42%), Specialists (42%), Doctor in Training (8%) and Other (8%). GP-Specialist differences in responses are outlined as footnotes. As the health cake shrinks, everyone is circling for a slice. Government has a lot on its plate. Longstanding industries are folding leaving the unemployed joining the growing number of aged, unwell people looking for assistance. Rather than an orderly prioritising of health we are in for a bunfight. Doctors as lobbyists tend to behave as uncompromising craft groups, rather than pitch in for the collective good. I’m pessimistic, unless we can find some exceptional leaders who can think and act outside the box. Fragmentation leaves primary care the most vulnerable and Government can use Medicare to get at GPs. The $6 fiasco is an example of where things are heading. While the majority of our surveyed doctors agree a price signal is important (see e-Poll results), this was bad policy that affected the most vulnerable as well as the ‘bottom feeders’, those who exploit. Then doctors, who just see privately insured patients and charge large gaps as well, were saying how damaging the $6 price signal was going to be for disadvantaged GP patients. Is that a mixed message? Around this time, an SBS program reminded me that, “Injustice happens when good people do nothing”. The profession’s dilemma is how to mobilise the altruists, ignore any self-serving opportunists, and reclaim some of the high ground in our community. As it’s all about money, we’ve asked some money questions in this e-Poll. If our respondents are anything to go by, doctors are undecided on many money issues. I hope that relatively unshackled private practitioners volunteer cost-saving efficiencies, simply because most acknowledge that health consumers are hurting. We didn’t have room to display it here but 44% of polled doctors disagreed that big hospitals like Fiona Stanley were the best use of health resources (19% took the opposite view while 37% were neutral). Given the IT problems FSH is experiencing, it is interesting that 61% of doctors said medical technology would not provide answers to cut overall health costs. O

We’d like to hear from you. Scan the QR code and leave your comment at www.medicalhub.com.au medicalforum

Health Insurers & Doctors

Q

As health cost pressures increase, private health insurers are contracting with corporate GP practices to give preferential treatment to their insured clients. Stated aims are to promote the benefits of health insurance or reduce the payout for treatment to those with chronic health problems, both through improved care. Please respond to these statements... Statement

Strongly Disagree Neutral Disagree

Agree

Strongly Agree

These two things should be targeted in those with health insurance.

9%

22%

41%

23%

5%

If costs end up controlling clinical decisions this is a necessary step.

23%

33%

14%

23%

6%

Insurers might dictate clinical care in particular situations.

4%

13%

11%

46%

25%

This is no different, in essence, to ‘no-gap’ products for specialist services.

9%

22%

33%

30%

6%

Clinical independence can no longer be justified at all cost. (1)

18%

27%

12%

34%

8%

Government could benefit under this arrangement from fewer hospital admissions.

6%

26%

35%

28%

4%

This is the most appropriate way to reduce the cost burden of private health insurance “frequent flyers”. (2)

13%

34%

37%

14%

2%

ED. (1) Although viewpoints seemed polarised on this statement, specialists were in strongest disagreement (25% ‘strongly disagree’ vs 13% of GPs). (2) GPs were more strongly against this idea (52% said ‘disagree’ or ‘strongly disagree’ vs 38% of specialists).

Costs and Consumers

Q

Government has flagged that out-of-pocket consumer health costs, in one form or another, are likely to be introduced as a way of keeping demand down and making the system more ‘user pays’. Please respond to the following… Statement

Strongly Disagree Neutral Disagree

Agree

Strongly Agree

There is a real need for health consumers to receive some sort of ‘price signal’.

3%

6%

10%

62%

19%

Excessive servicing by doctors is a big part of the problem.

10%

39%

17%

27%

6%

Unnecessary demand by patients is a big part of the problem.

3%

15%

15%

51%

15%

Patients with health insurance already complain about the cost of gap payments when seeing a specialist.

2%

5%

9%

63%

21%

Public hospitals should no longer be places for automatically ‘free’ health care. (1)

12%

28%

13%

33%

13%

Premiums for private health insurance must go on rising. (2)

6%

36%

26%

30%

2%

ED. (1) Disagreement levels were not significantly different between GPs and Specialists but specialists were less neutral and more in agreement with this statement (52% vs 42% of continued on pagevs 4 25% of GPs. GPs). (2) The same for this question where 42% of specialists agreed 3


Letters 4USPLF.BOBHFNFOU

More stroke studies needed Dear Editor, Medical Forum [February edition] presented a prothrombolysis view of acute stroke treatment. Emergency physicians around the world, including Australia, have a different interpretation of the research on this subject, which is why it has not been adopted as a standard of care in emergency medicine. For a treatment to be scientifically proven there needs to be replication of the studies, elimination of bias and healthy debate. This has not occurred for stroke thrombolysis, which is a great shame for our stroke patients. Active debate continues in the international literature. Interested readers are referred to the independent review that concludes “no benefit found” (www.thennt.com/ nnt/thrombolytics-for-stroke/). The BMJ published a debate on this subject (by Western Australian authors; 2013) and conducted an unscientific poll won by the ‘con’ side, 54%-46%, so concerns do not represent a “fringe” view. When thrombolysis was studied for AMI, it took studies on 60,000 patients to work out that thrombolysis prevents deaths, but only in STEMI (about 5% of all MIs). Every type of thrombolytic that was studied worked, and the earlier it was given, the better. Interestingly, the one that caused the most intracerebral haemorrhage was tPA. What follows is an incomplete summary of the issues. Things you need to know about the stroke thrombolysis studies: 1. There are 12 important studies: 10 were negative (i.e. thrombolysis did not work) and of these, four had to be stopped early because of harm i.e. they were killing people. So far, they have only studied about a sixth of the number of stroke patients compared to the AMI studies. 2. This is a completely different situation to the MI studies, where it worked in every study and every drug they tried worked. 3. The two ‘positive’ stroke studies (i.e. suggesting a statistical benefit) have been widely criticised because of their scientific flaws. One looked at giving tPA within three hours of the stroke (the NINDS-2 study, which had 333 patients). Interestingly, the first part of this study (NINDS-1) found no benefit in the first 24 hours. The other study (ECASS 3) looked at giving tPA from 3-4.5 hours after the stroke. This second study also has some major problems. 4. The biggest flaw in these two “positive” studies is an imbalance in baseline stroke severity. The placebo group were sicker, with more severe stroke; the tPA group 4

If Mum or Dad Had a Stroke...

Stories by Dr Rob McEvoy

were less sick and had milder strokes so were favoured with respect to outcomes. 5. This study was re-analysed later. If tPA really worked to improve the outcomes in stroke, then you would expect a much larger improvement in outcome over time, compared to the placebo group. This was not the case – the apparent difference after treatment could be simply attributable to the baseline differences in stroke severity between groups. Much debate and different post-hoc analyses have reached different conclusions. The only solution is to replicate the study in a way that avoids baseline imbalances in stroke severity. 6. All studies show that tPA causes intracerebral haemorrhage, in about 6% of patients. It is strange to advocate a treatment that can cause a (worse) stroke, when the evidence for benefit is so unreliable. 7. The largest study on thrombolysis in stroke (2012) was an open label study, inherently favouring tPA, yet this again was a negative study i.e. tPA did not work in terms of the study’s primary outcome (alive and independent at six months), and confirmed the increase in early deaths with tPA. 8. In AMI, after studying 60,000 patients, every study showed that the earlier the drug was given, the better. The majority of stroke studies do not show this effect, including the Cochrane review and the (largest) international stroke trial of 2012. So time is not brain. The reason for this is unclear, but may be because the patients who get to hospital earlier are somehow different to the ones who arrive later. 9. Patients who received tPA in the registry reports do worse than placebo in ECASS 3. Finally, the updated meta-analysis published by Wardlaw (2013) no longer shows a statistically significant benefit for alive and independent for the 3-6 hour time frame. This may represent regression to the mean as sample size increases. Considering that thrombolytic trials for AMI eventually enrolled 140,000 patients, rather than the ~3500 tPA patients in the Wardlaw meta-

analysis, this should serve as an additional warning of the inadequacy of the current evidence. So why is this being pushed so hard? Probably because we really want it to work (like steroids for spinal cord injury, now discredited) and the everpresent intervention bias in medicine. Unfortunately, many pushing this treatment have conflicts of interest with the drug manufacturer (see BMJ). Patients and society expect that an offered medical treatment has passed the test of science, which requires elimination of bias, healthy scientific debate, and replication. Replication means repeating the study that suggested a statistical benefit, to see if we can get that result again, which would make it more believable. This replication has not happened for stroke, but needs to, if we want to maintain our trust in medicine. Prof Daniel Fatovich (RPH), Prof Simon Brown (RPH), and A/Prof Stephen Macdonald (Armadale Health Services) References available on request.

RESPONSE: Dr David Blacker Drs Fatovich and Brown have been raising these issues regarding stroke thrombolysis for many years, and clinicians consider these problems with each acute stroke patient they treat. Emotiveness surrounding this has not been productive. As with many medical issues, the data, and clinical decisions are not always clear cut. The statistical and design aspects of the trials have long been debated, and there are different interpretations. Stroke trials are extremely difficult undertakings, and the patient population and pathology is vastly more heterogenous than with ischaemic heart disease. It is unrealistic to ever expect similar numbers of stroke patients to AMI patients in any trial. More letters P6 medicalforum


Letters Continued from P4 I don’t expect there will be any “replication� of early trials, because of the difficulty, expense and a feeling in the stroke research community that tPA works, and a discomfort about randomising to placebo. Furthermore, treatment strategies in these studies are more than 20 years old, and do not incorporate modern neuroimaging. My interpretation of the literature is summarized below: t "OZUSFBUNFOUCFOFGJUPGJOUSBWFOPVT tPA is highly time dependent. A pooled analysis of available trials has showed a reasonably impressive benefit for treatment commenced within 90 minutes, moderate benefit for within 180 minutes and modest benefit up to 4.5 hours. I am unimpressed by the data from ECASS3 (3 to 4.5-hour window), and as Drs Fatovich and Brown point out, the data for 3-6 hours really does not suggest benefit. t 5IFSJTLPGIBFNPSSIBHJDUSBOTGPSNBUJPO with deterioration must be considered with each encounter. This is less time dependent, and may be more influenced by other factors such as stroke severity, blood pressure and blood sugar levels. Although tPA-related haemorrhage results in an early increase in mortality, the 3-6 month mortality tends to “even out�. The task clinicians face is to match risk versus benefit with the individual patient, and convey this to patients and their relatives before making a decision. I totally agree that more study is required, but that should not deny patients the option of having tPA, especially where experienced stroke physicians have been involved. Apart from the risk of haemorrhage, my other concern about tPA is that in many patients, especially those with a large thrombus burden, it is just not effective enough. We need something better! As a way forward, I suggest the following. t $PODFSUFEFGGPSUUPSFEVDFPOTFUUP treatment time, since benefit will remain critically time dependent. Early symptom recognition, pre-hospital ambulance assessment, and service organisation are all important. t %FGJOJOHUIFQBUIPQIZTJPMPHZVTJOH advanced imaging to identify vascular occlusion and the state of the brain parenchyma. Whilst “time is brain� is important, many stroke patients may not benefit from early tPA because they have a large thrombus burden, poor collaterals and an adverse metabolic state; whereas others who have more favourable circumstances could still benefit from later treatment. The START-EXTEND study is exploring such a strategy by using advanced imaging. t 3FEVDFUIFSJTLPGIBFNPSSIBHJD transformation. The ENCHANTED study is exploring a reduced dose of tPA, along with blood pressure parameters 6

with a view to improving safety. My study, WAIMATSS, uses intravenous minocycline to reduce tPA-associated haemorrhage (as shown in animal studies). t 8PSLPOBMUFSOBUJWFBOUJUISPNCPUJD medications; Tenecteplase appears promising but others should be developed. t 8PSLJOOFVSPQSPUFDUJPO QPTTJCMZFWFO revisiting previously unsuccessful agents, tried again in an earlier time window, combined with thrombolytic drugs. t $POUJOVFESFGJOFNFOUPGUISPNCFDUPNZ and other mechanical strategies such as sonothrombolysis, to enhance vessel recannalisation. In summary, there is much to do, but tPA at present may still be useful, and should not be dismissed on the basis of being “pro� or “con�. A/Prof David Blacker, Neurologist and Stroke Physician ED. While we argue about the efficacy of thrombolysis using TGA-registered tPA, a Melbourne group say they have uncovered a safer drug that is administered at lower systemic doses because of improved targeting for clot lysis by linking it to a human platelet antibody. Meanwhile it is not all gloom and doom in the stroke world in WA: the Health Department has recently funded a 0.3 FTE position for a director of state stroke services, Dr Andrew Wesseldine, after networks produced the Model of Stroke Care; WACHS has established rural stroke care co-ordinators in several country areas over the past 18 months; the Osborne Park (Dr Andrew Granger) and Rockingham (Dr Bhaskar Mandal) Stroke Units have both been recognised for their good work; and Winthrop Prof Graeme Hankey continues as a stroke researcher and editor of Stroke journal.

Incentive scheme will help Dear Editor, The latest National Stroke Foundation Audit of Australian hospitals has revealed that stroke unit access in WA remains alarmingly low with 65% of patients unable to gain access to care that is proven to save lives and money. A shortage of stroke unit beds and poor service coordination are key barriers to patient access. Provision of stroke unit care has, undoubtedly, the greatest impact on stroke patient outcomes and is far and away the most important stroke treatment available in Australia. The unfortunate reality is that costs associated with identification, treatment and ongoing management of stroke will continue to blow out in WA while access to this life-saving treatment is so poor. Fortunately, there is good news with signs the WA Government is committed to implementing key measures that are likely to improve stroke care standards in the state. Introduction of an incentive scheme for stroke unit care, through the Activity Based Funding model, is also a great initiative, which should drive improvements in access to stroke unit services. PMs Jonine Collins, WA Executive Officer, NSF ED. Stroke recovery responds best to a multidisciplinary approach. While 14% of acute stroke patients admitted to hospital die in hospital (9% within seven days), about 20% of stroke victims are suitable for thrombolysis, More letters P8

Star

Joke Miss Beatrice, the church organist, was in her 80s and had never been married. She was admired for her sweetness and kindness to all. One afternoon the vicar came to call on her and she showed him into her quaint sitting room. She invited him to have a seat while she prepared tea. As he sat facing her old Hammond organ, the young minister noticed a cut glass bowl sitting on top of it. The bowl was filled with water, and in the water floated, of all things, a condom! When she returned with tea and scones, they began to chat. The vicar tried to stifle

Better

than a Flu Shot! his curiosity about the bowl of water and its strange floater, but soon it got the better of him and he could no longer resist. ‘Miss Beatrice’, he said, ‘I wonder if you could tell me about this?’ pointing to the bowl. ‘Oh, yes,’ she replied, ‘Isn’ t it wonderful? I was walking through the park a few months ago and I found this little package on the ground. The directions said to place it on the organ, keep it wet and that it would prevent the spread of disease. Do you know I haven’t had a cold or the flu all winter.’ medicalforum


Dr Boon Ham Perth, WA

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Letters Continued from P6 and the rest do better if assessed and treated by expert groups. While hospitals appear the best place for Stroke Units, early discharge will see many patients in the community. Investment in community-based rehabilitation services becomes important, given the relatively high rates of recurrence for survivors of both stroke and TIA and the late improvement that is possible, thanks to neuroplasticity.

Stroke – calling the Ambulance Dear Editor, As described in Medical Forum, stroke is a time critical medical emergency. Ambulance services are acutely aware of this and have processes to ensure time to acute stroke care is minimised. In collaboration with stroke physicians and the Department of Health, St John Ambulance has implemented a “pre-hospital stroke bypass guideline” which allows patients meeting specific clinical criteria to be taken to a hospital that has an acute stroke service. Currently, these are RPH, SCGH, Fremantle and Swan District Hospitals. Calls to the service are managed through a structured system, which ensures essential information about the patient and call location is obtained, for timely dispatch of an ambulance. Paramedics arriving on the scene assess the clinical status of the patient and commence treatment. Part of the assessment process is to ascertain if the patient is, or highly likely, to be suffering a stroke. This involves assessing the patient’s vital signs, blood sugar level, conscious state and applying the FAST criteria. Where two of the three FAST criteria are present, the patient’s blood sugar level is within normal limits and onset of acute symptoms is less than three hours, patients are transported to a those hospitals with an acute stroke service. Ambulance paramedics also pre-warn the Emergency Department of their imminent arrival to further reduce delays in receiving time critical interventions. From the perspective of St John Ambulance the effective management of acute stroke requires a system-wide approach in which initiating an effective pre-hospital response is crucial in improving patient outcomes. Professor Ian Jacobs, Clinical Services Director, St John Ambulance

Standards define profession

Public vs Private – Who Pays?

Dear Editor, I was interested to read the recent opinion poll [February edition], which sought the thoughts of GPs on the RACGP Standards for general practices (4th edition) and the related accreditation process. The RACGP appreciates any feedback from the profession on this issue. It is important to note that the development of professional standards is a defining characteristic of a profession and assists RACGP in gaining recognition of general practice as a defined specialty. I see through your poll results that some respondents have a negative perception of the Standards and their role in improving the quality of health care provided in general practice. The RACGP strongly believes that the Standards provide a template for quality care and risk management in Australian general practice. Whilst acknowledging that there is a worldwide lack of theoretical evidence for standards for primary healthcare, the RACGP aims to ensure that the Standards reflect contemporary general practice and pave the way for quality improvement and innovation. To achieve this, the Standards are developed by the profession for the profession with the development process overseen by a committee of experts – the majority of whom are GPs. Indeed, the development of the 4th edition Standards was informed by a comprehensive consultation process that included feedback from nearly 700 individuals and organisations and field testing with 200 practices. The RACGP believes that those practices which then choose to become accredited against the Standards are showing their patients that they are serious about providing high quality, safe and effective care to standards of excellent determined by the general practice profession. The RACGP regularly reviews the contents of the Standards to ensure that they are reflective of contemporary general practice. The College is working with the University of NSW to determine the extent to which accreditation in Australia leads to improved organisational performance, quality of care and patient satisfaction. It is hoped that this continuing research will provide more relevant evidence on practice accreditation. I encourage any member of the profession to email standards@racgp.org.au if they have any suggestions for future editions of the Standards.

Dear Editor, The Barnett Government loves privatising public services. It’s driven by a hardcore conservative ideology promoting privatisation on the basis that it provides better services and value for money. That’s not always true. Privatisation often doesn’t improve services – just look at our prison transport system. And it’s increasingly apparent that the privatisation of Fiona Stanley Hospital (FSH) is emerging as a costly exercise. The privatisation of hospital services at FSH in 2011 was accompanied by claims that it would save the taxpayer ‘hundreds of millions of dollars’. It was also claimed that the innovations brought by the private contractor would improve patient services, particularly with the introduction of a paperless patient e-record system. These claims have not been realised. The mid-year review of public sector finances reveal that the Barnett Government will pay Serco $261,000 a day or $118.8m between now and March 2015. And that’s to run a hospital with very few patients. Furthermore, the Serco contract allows the private operator to start billing the Government from the scheduled date of opening (April 2014) rather than the actual delayed date of opening. This is like an episode of Yes, Minister – a shiny new hospital, no troublesome patients and the taxpayer footing the bill. The excess money paid to Serco would have been far better spent paying for the extra floor needed at the New Children’s Hospital. And the claim that the privatisation of FSH would lead to a paperless hospital is a hollow one – it’s not going to happen by the government’s own admission. There has been confusion between Serco and the Health Department regarding the compatibility of computer systems and the end result has been a massive blowout in costs and timelines. The Barnett Government’s privatisation agenda is unravelling. It has been exposed as costly and inefficient and it will be WA patients and taxpayers paying the price. Mr Roger Cook, Opposition Health Spokesman

Send in your letters by March 10 to editor@mforum.com.au

Dr Michael Civil , Chair, National Standing Committee, Standards for General Practice, RACGP

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Incisions

Consumer Partnership, Really? Doctors Drum explored partnerships between GPs and specialists. Mr Mitch Messer wonders where the health consumer fits in. It’s time for the medical profession to walk the walk, not just talk the talk! As a health consumer advocate I have long heard the rhetoric about consumers being at the centre of everything health professionals do. It seems to me, though, health professionals are making all the decisions and designing the system to suit their needs. When they believe they are finished, they finally talk to consumers and say ‘Do you want that in black or white’ as if that is meaningful consultation. Partnership is still a long way off in many parts of the health system. Many health professionals battle to partner with each other let alone the ‘patients’ they are dedicated to helping. This leads to consumers facing a labyrinth rather than a system that has been designed to help them easily navigate through what are often difficult and emotionally charged times. They are given referrals from one place to another, often with very little information about whom the ‘next’ person is or even what

may happen when they get there. For those with complex or multiple conditions, it can feel they are on a treadmill without an off switch! Some may feel this is OK for those who have only intermittent interactions with health professionals. However, as our population ages and we are faced with increasing complexity, it could be a slippery path that leads to poor outcomes and many people being shuffled from one appointment to another, with little understanding of what is going on or when, if ever, they will be allowed off the treadmill. It is time to stop and take stock. We need to begin the work of truly seeing each other as partners. After all, we all want the same outcome. Instead of surveying patients about how satisfied they are with the service they receive, perhaps we need to start asking patients to be involved in helping to design the services provided; to bring the users of services in at the beginning and have them involved throughout the process. Initial

discussions through to service/system design, build/implementation, delivery and review. I have been talking about this for years and I always hear, ‘That would be too slow’. Surely it would be better in the long term to get it right, even if it takes a little more time, rather than having to ‘retrofit’ or redesign a service. Sadly, consumers are often faced with services that operate inefficiently and chew up more resources and put everyone off side! Let’s change the paradigm and seek true partnerships. Health professionals have skills we all need, consumers have experience and knowledge that can help develop and design services that work. Imagine a health system that works for all of us, rather than a system that leads to a constant battle between winners and losers. O ED: Mitch Messer is a long-time consumer advocate and is member of the South Metropolitan Health Service Governing Council, President of Cystic Fibrosis Australia and member of the WA Drug Evaluation Panel among other positions.

Fertility North Making dreams come alive Since the clinic’s inception in 2002, Fertility North has been located within the state of the art Joondalup Health Campus and is a refreshing alternative to the crowded city clinics. In our 11th year of practice the clinic is excited to be relocating to a brand new custom built facility within the newly developed private hospital at JHC in 2014. Each of our patients experience personalised treatment with a high level of clinical contact from both our specialists and clinical support staff. This ensures we deliver the highest level of quality care in an ongoing, supportive and compassionate environment. Dr Vince Chapple Medical Director Qualifications MB, BS (London) FRANZCOG MRepMed

Dr Jay Natalwala Clinical Director Qualifications MB, BCh (UK) DRCOG FRANZCOG MRepMed

Dr Gian Urbani Fertility Specialist

Dr Santanu Baruah Fertility Specialist

Qualifications MBCHB, MMED(O&G) FRCSC, FACOG, FRANZCOG

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

Both Dr Santanu Baruah & Dr Gian Urbani are also able to see Fertility North patients from their Attadale consulting rooms.

Suite 213 Specialist Medical Centre, Joondalup Health Campus, Shenton Avenue Joondalup WA 6027 North of the River (08) 9301 1075 | South of the River (08) 9317 8220 Fax (08) 9400 9962 | Email admin@fertilitynorth.com.au

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Have You Heard? Back to Third Med School? Doctor numbers have hit the headlines again, but this time it may spark genuine debate on the Curtin proposal for a third medical school, which would be situated in the eastern suburbs and offer an undergraduate degree. [Former WACHS chief now health consultant] Dr Felicity Jefferies’ report for Curtin University on the state of the WA medical workforce got a lot of press at home and nationally with the headline “1000 doctors short in Western Australia and its set to worsen”. Not that it’s news for those in rural areas but the loud opposition to another medical school has made decision-makers nervous. The Jefferies report may change that. There is cautious support from the State Government but silence from the Feds. The momentum will need to continue if Curtin is to get the politicians to toe the line.

Rethinking training strategies Now a partner in Healthfix Consultancy, Dr Jefferies’ report also questions the ethics and economy our heavy reliance on Overseas Trained Doctors to fill the services gaps. With WA having the highest percentage of OTDs in Australia and doctor numbers still falling short in rural and outer metro areas, time is ripe for a strategy change. The report called for a comprehensive workforce review and a plan that involved medical students, interns and vocational training programs. The news was welcomed by WAGPET Chair Dr Damien Zilm who said that having enough doctors in the right locations was essential, adding the review would require “cross-sector collective action”.

month he completed his last anaesthesia list at the hospital and another doctor had also resigned after “feeling poorly appreciated for a long time.”

Cardiologist spending spree Phylogica Ltd (ASX: PYC) recently responded to a share price query not long after Perth cardiologist Bernard Hockings underwrote a $6m rights issue and acquired a reported $1.78m in shares. This increased his company stake to 22.5% and secured him a position on the board. PYC is a biotech company that provides peptide drug discovery services to the pharmaceutical industry using their Phylomer peptide libraries and proprietary screening capabilities. Founder and current CEO Dr Richard Hopkins is from the Telethon Institute for Child Health Research. PYC lists Genentech (Roche Group), MedImmune (AstraZeneca), Pfizer and Janssen (Johnson & Johnson) as partners.

Fuel to the statin fire? The ACCC is taking action against Pfizer Australia for alleged anti-competitive conduct – misuse of market power and exclusive dealing in relation to its supply of atorvastatin to pharmacies (Pfizer’s generic, post Lipitor). Before patent expiry in May 2012, Lipitor was a statin on the PBS, with annual sales exceeding $700m. The ACCC alleges that Pfizer offered significant discounts and the payment of rebates previously accrued on sales of Pfizer’s Lipitor, conditional on pharmacies acquiring a minimum volume of up to 12 months’ supply of Pfizer’s generic atorvastatin. Prior to Pfizer’s loss of patent protection, other generics suppliers were prevented from making competing offers.

GPs fight back

Troubles in Paradise When Medical Forum contacted Esperance GP, student and registrar mentor and Esperance Hospital stalwart Dr Donald Howarth about his involvement with Rural Health West over his 19 years in the Far South Coast town [see P25], he hinted at troubles in paradise with tensions mounting between some GPs and the hospital administration. Donald describes his frustrations at what he sees as attempts to “run a minimalist medical service at a minimalist cost”. He hopes this won’t be a repeat of the Kalgoorlie experience that saw GPs lose their hospital rights, leading to an exodus of 13 GPs. He said GP retention in remote and rural areas was simple – engagement with patients in hospitals. Last medicalforum

they still have to take a paper script to their pick-up pharmacy? eRx developers have got Medical Director to print scripts that include a QR code for the eRx Express App. The patient forwards the script to their preferred pharmacy which pays $50 a month to join up and carry the receiving eRx Express Q software on a Windows Surface RT tablet. GPs must be registered to use ePrescribing through eRx Script Exchange. This IT experience appears to originate from the Malouf Pharmacy Group of 18 pharmacies in Queensland.

The RACGP has hit back at the report that pharmacists should conduct preventive health checks. Fragmentation of care was one argument, as was a poorly directed investment of $75m when the RACGP had evidence for effectiveness of health checks in general practice. They argued that in a 19-minute consultation (rebated $36.30 by Medicare) the GP can weigh, take blood pressure, measure blood glucose and cholesterol, take an appropriate history and produce a management plan. The college is talking patient safety and quality of care. Government is listening to anyone who will save them money.

e-Script via Queensland The website blurb said “put a pharmacist in your phone with eRx Express[…] order your scripts anywhere anytime”. We downloaded the App and gave it a test drive. After entering our WA postcode we were offered a pharmacy in NSW. If this is all about convenience for the patient, why do

$6 worth of confusion Thanks to feedback from a GP, we discovered that Medical Forum was not the only media outlet to wrongly report that the (rubbery) proposal for GPs to collect $6 during bulkbilled consultations would not apply to concession cardholders. We joined ABC TV, the Brisbane Times, Channel 7, and even Dr Mal Washer in a Medical Observer report. None mentioned the RACGP fears that the current $6 incentive payment to bulk bill would be morphed into this scheme. The media frenzy around the Griffith by-election where former AMA president Bill Glasson was having a second tilt at the seat may have influenced things.

Midland looks for workers SJGH Midland and Fiona Stanley Hospital recruiters will be going head to head over the next few months with the announcement that Midland will kick off its search for 1000 employees this month. It has 18 months [the hospital is due to open November 2015] to fill clinical and non-clinical positions and the first phase will target existing Swan District Hospital and St John of God Health Care staff. O

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Primary Care

Online Appointments – Right for You? Online appointment systems may be the way of the future but there are pitfalls and practices need to ask some hard questions, Dr Rob McEvoy reports. Patients can book standard appointments online using one of 20 or more systems available today. But can all save busy practices time and money? Some are aimed primarily at patient convenience and suit start-up practices looking to fill appointment times. Some can be considered an in-house way of better managing the existing patient population and freeing up staff. Don’t be frightened to shop around or move to another system as your needs change. If successful, around a quarter of standard appointments will be booked online so you need to consider how you will market this to patients. Essential ingredients appear to rely on seamless integration with existing software (no double handling) and include: t J1IPOFBQQGPSCPPLJOHT  t QBUJFOUTDBOCPPLBOEDBODFMTUBOEBSE appointments without reception staff involvement, t TFMFDUJPOPGBQQPJOUNFOUTPQFOGPSPOMJOF bookings is easily adapted to particular doctors and times. Here are some considerations after you have answered the most important question, ‘Would your patients and practice benefit from an out-of-hours online booking system?’

Can you ‘train’ patients away from their inevitable abuse of appointment scheduling (e.g. booking standard appointments that should be longer), and does the vendor show you the most effective ways to do this (given that triage by the receptionist is no longer possible)? Can patients directly cancel their booked appointments (thereby freeing the appointment for someone else)? How will you deal with late cancellations and no-shows?

Practice Efficiency Can you reach a point where 25% of all standard appointments are booked online without reception involvement, because that’s the point at which staff time savings probably accrue. Can you tailor online bookings for each of the practice doctors; are blocks of appointments easily offered; are doctor standard appointment intervals easily adjusted; can doctors bar bookings from new patients?

Does the system allow recalls to be easily sent as a customisable email or SMS to patients who are, in turn, encouraged to book via your online service? Are risks of downtime and alternatives covered? Check if practice management software integration is of high standard (both software vendors are working together); how regular upgrades are done; and does the system depend on a stable and fast internet connection? What extra staff training is needed, if any? Remember, you will still need reception staff to triage urgent and longer appointments.

Telstra Branches Into Health It’s all about integration to create efficiency. Telstra, as a telecommunications provider, is building capacity in the health sector under head of Health, Shane Solomon, spending over $100m in its drive to become a major player in Australia’s healthcare technology market. It has recently invested in community pharmacy e-script vendor Fred IT, which is part owned by the Pharmacy Guild of Australia.

Australian government’s personally controlled e-health record (PCEHR) seem to be the focus. This was highlighted by Telstra’s $10.4m investment, along with Seven West Media, in online appointment booking system HealthEngine (with WA’s Dr Marcus Tan as CEO) and e-health operator IP Health. Linkage between hospitals, medical centres, pharmacies, and health professionals are seen as forerunners to better ways of serving patients and providing care coordination.

This follows Telstra Health’s acquisition of the health division of Database Consultants Australia (DCA) last October. DCA is said to provide IT services to over 12,000 GPs, 170 aged and community service providers, and 20 other health service outlets.

Solomon is reported as saying dysfunction in home health and aged care leads to preventable hospitalisations and premature entry to residential aged care. He said these markets are most amenable to eHealth, which will be music to government ears.

Connectivity and electronic health management systems that include the

In a report in PulseIT last November, Mr Solomon apparently told investors that

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health was huge and growing, and eHealth could fix major problems in the system, for which connectivity was important. Pharmacy, health information, messaging, home healthcare and telehealth and consumer self-service were areas targeted with deliberate intent. Of course, Telstra has the telecommunications network. Telstra is also investing in US and Canadian software. It has signed an exclusive fiveyear deal with UK healthcare data analytics organisation, Dr Foster – an agreement said to provide insights to assist with patient treatment and care across Australian hospitals by analysing data collected. In the IT world, anything is possible, and some of it is probable. O

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Primary Care Caution for The Future Patient Handling Do you need to fill appointment slots with new patients ‘of convenience’, that is, increase productivity by growing your practice, OR Do you want a system that encourages regular patients to rebook with their usual doctor or, as a minimum, with your practice? Is patient payment requested up front (many refuse to hand over credit card details) or is patient registration onerous (which might discourage same)? Does the system offer online patient appointments at alternative practices to yours (which may encourage your patients to doctor shop and reduce your continuity of care)? How is your patient demographic data stored, who has access to it under the vendor’s Privacy Policy, how easy is the access, and is all this documented in the Terms of Service? Does your contract with the vendor allow them to ‘market’ directly to your patients?

Patient Convenience Does it send an automated reminder to patients for their booked appointment? When and how often? Can appointments be booked via either a home workstation or an App on a mobile device (e.g. android or iPhone)? Can this be done with new patients by registering online using a mobile device? Are mobile device bookings easy to make, and is the name of the patient’s usual doctor offered in preference when rebooking? Can scripts be requested in the same way, is it more convenient for patients than your current system, does it allow doctors to indicate if they take script requests in general, will comply with a particular request or prefer an appointment made by the patient (sent via an automated customised email)?

Other checks you can do If you need to, use free trials to compare a couple of systems. Read the ‘chat’ on the software vendor’s online forum, if they have one. Talk to practice managers already using an online appointment system, bearing in mind their use may be different to what you intend. Try vendor websites for 1stAvailable, Appointuit, HealthEngine, Clinic Connect, DocAppointments and HotDoc (with some said to be more patient than practice-centric). l

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For one US example of how online bookings can work, albeit in the US health system where patients do not need GP referral to book specialists and health insurers hold sway, see ZocDoc.com. Their terms of use, particularly paragraph 7 (www.zocdoc.com/ terms), which when considered with clauses 11, 12, 13, 17 and 19 of their Privacy Policy, may appear disquieting to Australians. Do they herald things to come in Australia?

QR link to www.zocdoc.com/terms If Australia’s intended PCEHR and national provider data are integrated, and if integration with online scripts occurs, or if referrals of convenience to specialists occurs (now more possible with national registration), then the health consumer will hold most of the cards and government has a wealth of data mining potentially available to it. GP practices may have difficulties with online systems they feel are not built with their patients in mind. In effect, the gatekeeper role of the GP gives way to consumer convenience and market forces. Specialists may become overloaded and costs may be an issue if consumers come more often via someone other than their ‘usual’ GP. Clinical networks and feedback to a referring GP may be replaced by consumers requesting that the specialist does not inform their ‘usual GP’ out of embarrassment. CASE REPORT: St Francis Medical Family GP is a new practice in Subiaco with a pharmacist as director, situated alongside a pharmacy. Currently four GPs, who also work at other practices, are listed as working there. The practice website has a HealthEngine booking frame imbedded in it. This could give a new patient the impression they are booking through the practice when in fact they are registering their details through HealthEngine. What happens to their personal information?

any personal information to H.E. via the Website, you consent to H.E. using that personal information lawfully at its sole and absolute discretion, including for the purposes of providing promotional and marketing materials by other means.” The important question is who are health consumers providing the information to, the GP practice or HealthEngine or both? The St Francis Medical web privacy statement says it collects patient information “for the purposes of conducting and improving our business as a health services and products provider, and online retailer. Our server may collect and log information (but isn’t limited to) your IP addresses, time visited, location (country/city), and other information you entered in the form fields.” For the booking system to function, booking information from patients has to pass from HealthEngine to the practice. GPs may also question if this system promotes consumer referrals of convenience to see specialists. As we go to Press, HealthEngine lists a comprehensive range of specialists, from whom we chose ‘Geriatricians, Perth’. When we clicked in random on northern suburbs geriatrician Dr X, we were taken to a screen that asked “Need a Referral from a GP to see Dr X?” and below on the same screen were nearby general practices, with appointments to book, presumably to get a referral. Certainly, we were told by a receptionist when we phoned one of the practices we could “get a referral to any doctor” using their online booking system – we just had to attend an appointment with one of their doctors first. When we spoke to the practice manager, she was unaware their practice was part of any referral arrangement with HealthEngine. The online appearance of their listing suggested the practice had paid for a ‘featured’ listing on HealthEngine, to be listed ahead of other practices in that area. l ■ ”Need a referral from a GP to see Dr X” Names hidden to protect privacy

Whilst booking, you can check a box to “receive relevant notifications, updates and offers from HealthEngine.” On the same form HealthEngine answers its own question ‘How private is my information?’ by saying HealthEngine only uses the contact information for making that booking, secure web technology is used and “we won’t contact you for marketing purposes, sell, trade, or give away your information”. Without that opt-in checkbox ticked, progressing with booking specifies the user agrees to the “terms of use” for the HealthEngine website, which say in part, “In specifically and knowingly providing

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Primary Care

GP’s Online System in Action What does a GP from Romania and an attempt at ideal online appointment system have in common – read on. DocAppointments has been in development for nearly four years using the skills of Dr Calin and Mrs Anita Pava, a husband and wife team in Devonport, Tasmania. He is one of three GP principals in a 16-doctor practice and she is a graphic and web designer. Romanian-born Dr Pava’s motivation is clear: “We looked at what was on the market and none fitted my purpose, so we surveyed patients, talked to doctors, and built a system that would satisfy both and the practice could afford. I like making my practice as effective as possible – a better service to the patient and a better lifestyle for the staff. I managed to move two receptionists to chronic disease management. Patients are reminded about their health assessments and asthma clinics etc, and I can pay more money to staff and take more holidays.” Their website suggests that while general practices may be the centrepiece, telehealth consults and pharmacy site indicators are part of their marketing strategy. Dr Pava told Medical Forum that DocAppointments is designed for general practice and currently handles about 30-40% of standard appointments at his practice. Longer appointments are still triaged by reception. Patients login via the practice website, which is where patient education begins. “Everything comes down to the patient’s education. When patients register for our system it is made clear that it caters for 15-minute appointments only and they must ring for a longer appointment. By making 80% of appointments available online, reception has more time to listen and schedule the remainder appropriately.” Their system needs to be installed on the practice server. It is integrated with Best Practice, Pracsoft, Zedmed, Practice 2000 and Stat (which together comprise about 98% of the market). Patients register with the practice (via the DocAppointments server in Melbourne), and are added to a database that links to the practice. The practice manager has an admin panel that can be logged into for practice statistics and newsletter broadcasts among other tasks. His criteria for an ‘ideal system’ from the doctors’ perspective include: t 4FBNMFTTJOUFHSBUJPOXJUIFYJTUJOH practice management software “so nobody knows it is there”. t "TNBOZBQQPJOUNFOUTBTQPTTJCMF 16

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booked online, to freeup receptionist time and create savings. 5IFQBUJFOUIBTUIFBCJMJUZ to cancel appointments without having to ring. "MMPXEPDUPSTUPUBLFOFX patients or restrict online bookings to their existing patients only. 5IFQSBDUJDFTQFDJGJFT which appointment blocks are for online bookings and can override should reception want to book a particular space; confirmation emails to patients can be customised by the practice. *ODFOUJWFGPSQBUJFOUTUP make an appointment with their own doctor, or within the practice (for better continuity of care). 1BUJFOUTIBWFBDDFTTUP online bookings.

Doctor shopping happens just as easily in Devonport as it does in Sydney, according to Calin, so he has firm views about booking systems that offer patients an array of practices. “As a doctor, I don’t want my patient to make an appointment with another practice just because the time is more convenient.” He said systems built mainly around consumer choice are for places like city practices that are not choosy about who they take. But will some patients go for this convenience every time? “It all depends on how the practice is managing their appointments. We tell practices of the strategies to get the best out of their systems. We recommend all practices make a block of appointments for each doctor, which opens at 5pm the night before. In my practice, the receptionist does this just before she closes up.” While designing his appointment system, Dr Pava had a few surprises. First, was the spectrum of age groups using online bookings, including an 80-year-old woman who rang her daughter in Queensland to arrange the booking! Next was the growing use of mobile devices, for which DocAppointments has written its own free iPhone and android App. “About 50% of patients are booking using a mobile device, depending on the type of practice and its location. In Devonport, most book via the internet but one user in Canberra

QTasmanian GP Dr Calin Pava

had about 3000 patients register via mobile devices soon after they installed it.” He says other development milestones were: t #FJOHBCMFUPNJNJDBQQPJOUNFOU durations in the practice management software for each doctor. t 1FSTPOBMJTFEBVUPNBUFEFNBJM notifications of appointments booked. t 1BUJFOUTDBOOPXSFRVFTUTDSJQUTBOE they have a waiting room iPad that is connected to the server so patients who arrive can notify reception via the iPad, without pestering a receptionist. He said being prepared to customise their system has attracted some practices, which has included rebranding their mobile device App. “Other practices requested employer registration so they can make multiple appointments for injured or workers compensation patients. That was a significant advantage for companies who could jump online and find appointments at one practice rather than ring four different practices.” He charges the practice a flat fee, whereas some go on patient usage (registrations). His no-show rate is 0.3%. His system works if the practice has satellite locations linked to a central server. They have IT companies doing the installation and after that, most updates are onto their server in Melbourne. “All DocAppointments is doing is allowing information to go out or in. All we do is look at the practice management software for the empty appointment spots.” O

By Dr Rob McEvoy medicalforum


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Sport & Alcohol

Athletes Battling the Bottle Alcohol and fired up athletes in the cauldron of competitive sport is a volatile cocktail which raises questions about alcohol sponsorship and the lack of support for our sporting heroes. A recent literature review by Sports Medicine Australia (SMA) revealed a significant link between alcohol consumption, sports participation and violence. Medical Forum spoke to people with differing levels of involvement, from the lead author of the report to a retired AFL footballer who had a well-publicised struggle with alcohol and violent behaviour. It is a controversial topic and one that not all local sports physicians or teams were comfortable talking about to Medical Forum.

The Research The principal author of the SMA review, Anders Sonderlund, said that the culture of some sporting contexts could be a catalyst for poor behaviour but the broader picture was more complex. “There’s plenty of anecdotal evidence that this relationship [alcohol, sport and violence] does exist. Yet one might also expect that playing sport – a combination of physical coordination and good health – would be a protective factor against excessive alcohol consumption. It’s an interesting paradox.� “But there’s no denying that the social environment entrenched within a particular club makes players conducive to this type of behaviour.� And, as Anders points out, there are often competing interests at the corporate sponsorship level.

Take Home Points In a national survey of sports clubs: t POFJOGJWFDMVCNFNCFSTDPOTVNFPS  NPSFESJOLTJOBOJHIU t PGNFOBOEPGXPNFOBHFE  ESJOLBUMFWFMTLOPXOUPIBSNMPOH  UFSNIFBMUI t PGDMVCNFNCFSTBHFEBSF  ESJWJOHIPNFBGUFSGJWFPSNPSFESJOLT t        

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“There have been recent violent incidents involving prominent athletes, but overall I think the situation is improving. However, the alcohol sponsorship of many sports – both amateur and professional – doesn’t help the situation. Yet again, it highlights the paradox of sporting participation and alcohol abuse.� The wider sociocultural pattern of drinking is a significant factor and there are some salient differences. “Australia, as with many Nordic and Northern European countries, has a predisposition towards binge-drinking. This is vastly different to a Mediterranean culture in which alcohol consumption is not done for the sake of inebriation but as an integral part of normal social activities.� “It’s obvious to everyone that binge-drinking is closely linked with poor health outcomes and alcohol-related violence.� “One of the most effective ways of addressing the problem is to engage prominent players,

both past and present, to spread the message that a sensible approach to alcohol is worth aiming for and that a drink in an appropriate social setting is quite OK.�

Effects on Players Former Fremantle Docker and St Kilda footballer Heath Black, by his own admission, had a fearsome reputation – both on and off the field – and says QHeath Black it’s no surprise that players struggle to cope in the cauldron of the AFL. “They’re high-octane individuals. There’s a craving for that adrenalin high you get on the football arena. One way to bring back a sense of normality is to use drugs and alcohol inappropriately and that increases any inherent predisposition towards violent behaviour.� medicalforum


h Marc

“I know what makes me tick these days. I’m pretty competitive on the golf-course and I’ve just bought a motocross bike. I’ll always need something to replace the high of football and I don’t want it to be alcohol.” Heath now works with the Australian Cricket Association (ACA) conducting player workshops and mental health seminars. “I’ve changed codes and it’s quite different with the cricketers because the issues tend to revolve around alcohol rather than drugs. Perhaps it’s something to do with the game of cricket and its own history and traditions. A player is on tour, away from home, nicks a ball and is out for a duck. He’s back in the room, drinking alone and that starts a negative spiral.” “I do think that the culture within major sporting clubs is changing, although there’s always that tension when alcohol sponsorship is part of the equation. Illicit drugs still pose a big problem and it’s vital we educate young players regarding potential pitfalls. The overall remedy has to be player-driven.”

Alcohol Promotion in Sport Public health campaigner Prof Mike Daube is a long-standing advocate for a shift in the culture of drinking in both a social and a sporting QMike Daube context. He reserves his strongest message for high-profile sporting teams and their governing bodies. “The issue of sport and alcohol is a big challenge for the authorities concerned. They have a clear duty of care to the players and, coupled with that, they should be doing everything they can to turn that negative culture of drinking around. They have to face it head-on and take it seriously.” “And, if you take the case of Rugby League (NRL), you’d have to ask yourself if they’ve even begun to address this in an appropriate manner. It’s worth underscoring the fact that a culture of alcohol is, essentially, a culture of alcohol and violence. The SMA review isn’t saying that alcohol sponsorship is responsible for violent behaviour but the literature does show that players in sports with heavy alcohol endorsement are more likely to engage in antisocial activities.” “What these reports are saying is that if you’re trying to change the culture of drinking then you shouldn’t be sending your players out as mobile billboards for alcohol.” medicalforum

“One of my favourites is Ricky Ponting at a press conference in London in the 1990s. Andrew Symonds was being sentt home for alcohol-related misdemeanours rs and there was the Australian captain wearing a VB cap! And if you compare that with the WACA, who won’t accept alcohol sponsorship, and the way they handled the recent Tom Triffitt affair [who was charged with stealing and wilful damage after drinking heavily]. They suspended his contract with the Western Warriors and that sends a very clear signal.”

The Club Perspective

QDamien de Bohum

The Football Federation Australia (FFA) was one of the few sporting associations willing to speak with Medical Forum.

“FFA and Professional Footballers Australia conduct a series of education and development programs across the Hyundai A-League competition,” said league chairman Damien de Bohun. “These sessions discuss alcohol, illicit drugs, ASADA’s anti-doping program and match-fixing. We also make the FFA code of conduct very clear to ensure our players are well aware of their responsibilities as professional athletes.” Psychologist Dr Jo Mitchell is the Wellbeing Manager for the AFL Players’ Association and focuses on providing practical support strategies QJo Mitchell for players both past and present. “We’re committed to looking after the best interests of these sportsmen, not only as players but also as human beings. They’re dealing with thought patterns such as, ‘am I good enough?/can I do this?’ They think, feel and behave just like all of us and the programs we run aren’t all that different to those in a community setting,” Jo said.

ll e-Po

Sport and Promotion S

Q

Take promotions out of sport and Australians would be healthier.

Strongly Disagree

5%

Disagree

32%

Neutral

32%

Agree

25%

Strongly Agree

6%

ED: The 158 GP and specialist respondents might reflect the split community attitudes to commercial promotions in sport. Slightly more doctors (37%) were unconvinced that promotions of sporting events had adverse effects on Australians’ health overall, than those who did (31%). We did not ask specifics about product promotion vs sports participation.

have the knowledge that they can go outside the framework of the football system.” “And for a GP who might be treating an AFL player, it’s important that they’re aware of the range of support services – financial, legal and medical – provided by the Players’ Association.” “It’s important for doctors to ask direct questions regarding the ‘elephant in the room’. GPs are usually very good at reading the subtext during a consultation but it’s well known that men, and young men in particular, are reluctant to ask for help. They may well be angry, depressed and using alcohol inappropriately but be highfunctioning in other areas.” Jo also reaffirms the need for players to look after each other and speak openly about pressures and temptations when playing at the elite level. O

By Mr Peter McClelland

“But, having said that, it’s important we have counselling staff who understand elite sport, both its pressures and its opportunities. We’ll often liaise with the club doctor but it does happen that a player prefers to consult his own GP. That level of independence is imperative, players need to 19


Stroke Management

Younger Stroke & Communication Younger stroke survivors like Ms Barbara Cafagna say they have more trouble with diagnosis and rehab than many older stroke patients. It is four years since Kalgoorlie woman Barbara Cafagna suffered a stroke two weeks shy of her 35th birthday and she has only now regained the confidence to pick up her life and return to work full time as a travel consultant. “The only thing that my doctors can put my stroke down to was the [contraceptive] pill even though they won’t openly say that. There was nothing else in my history.”

The general practitioners She relates 4-5 weeks of worsening headaches during which time she saw four doctors visits and was treated for sinusitis and tension headaches, eventually being referred to a physiotherapist. With hindsight, she feels things dragged on unnecessarily. “Looking back, I truly believe that things would have been different had I have been listened to in that first consultation. Even a simple question like, ‘Do you often get headaches?’ could have started a conversation that may have raised some alarm bells.”

She now strongly advocates an early MRI, even for young people, and when we explained that GPs cannot order an MRI easily, she was unwavering. “Yes, but I nearly died; and I had progressively worse headaches for five weeks. When someone who rarely goes to the doctor sees four of them [at the same clinic] within the space of five weeks, and nothing is working…at no point was I asked if there was a history of stroke or TIA in my family. I think there has to be more of a conversation with patients.” “My usual GP, and he’s brilliant, would have said there is something not quite right as my symptoms got worse. Unfortunately, he was away, and he knows me well.” With hindsight, Barbara presented as a ‘stroke in evolution’, a worsening venous sinus thrombosis and she needed someone who could see the big picture.

left side and was veering off to the left when driving my car. I still had the excruciating headache in the front right of my head.” Imaging done during the first ED visit [a CT, we believe] failed to reveal any thrombosis and because she did not fit the typical stroke profile, her symptoms were explained as dehydration and perhaps as a spinal problem, and she was sent home. “By the Friday, a week after leaving Joondalup Hospital, I think I had the real stroke. It wasn’t a normal headache, I had never suffered migraines, and the morning I went to the doctor, I didn’t know where anything was and things were starting to droop on the left side.”

The Hospital ED

“Luckily the doctor I saw said I was having a stroke and her sister had very similar symptoms [see Medical Forum, February edition]. She wrote a letter to the hospital so it had some idea.”

“I ended up going to Joondalup Hospital about the beginning of week five – I was starting to get weakness and tingling in my

She was urgently sent to Joondalup Hospital with neurological symptoms, headache and vomiting.

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medicalforum


Frustration and stress were growing. She remembers a discussion around thrombolysis. Barbara’s sister got quite upset and her partner sought advice from a friend of a GP. Things started to move along and at some stage an MRI was done, the diagnosis made and she was started on heparin. “After 11 hours of being moved around within the ED, I was finally moved into a room on the ward. My partner and sister were still battling with staff at the nursing station. The process of transferring me to Sir Charles Gairdner Hospital had begun. If it had not been for my sister and partner, I would not be here today.” QMs Barbara Cafagna

“Even when we went to Joondalup I waited an hour before I went into Emergency. It was such an ordeal – the time delays were caused because people could not see what was happening. I couldn’t sign my own name even though I could see my signature in my head. I wasn’t given anything in Emergency for quite some time.” “I’m really grateful I had my sister and my partner there because they were the ones who were getting things done. They were trying to initiate a dialogue with ED staff as to what the next step was for me, but it was difficult as no one seemed to know what to do.”

The Stroke Unit Barbara was transferred to the SCGH Stroke Unit after two days, and was there for two weeks while her anticoagulants were stabilised. [Medical Forum was told it was the predominance of sensory symptoms during her presentation that fooled everyone.] “I would have to give a bouquet to the registrar who was working under Dr William Carroll. She was absolutely brilliant – she kept us informed but, more importantly, she took the time to ask us if we had any questions or concerns. She even took a phone call from my parents who

were travelling around Europe while all this was happening. It was her reassurance that made the difference.” Barbara said she continued to suffer headaches and left-sided weakness for the next two to three months. “For me it was more not having the emotional side cared for. Once I was on heparin and then warfarin I was able to recover quickly compared to other stroke survivors.”

Stroke SAFE ambassador “I was completely unprepared for my life after my stroke. Emotionally, I was a wreck. I became very fearful and I thought I was ‘losing it’ for no reason at all.” “It was that lack of support. Upon discharge, it would have been good to have a conversation with someone where they said, this is the Stroke Helpline, this is who you call for counselling, and this is where you can go for help.” “My confidence hit rock bottom and it’s only just coming back now after four years thanks to the Stroke SAFE ambassador training.”

continued on page 29

smithcoffey

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Feature

Pitch for Best and Brightest New name, new digs and a new director – the Perkins Institute for Medical Research has entered a new era. This month the doors officially open on the WA Institute of Medical Research’s new headquarters at Sir Charles Gairdner Hospital. It is to be now known as The Harry Perkins Institute of Medical Research named after its inaugural chairman and the legendary Wesfarmers identity.

and facilitating a better integration into the health system than we currently have,” he said. “And that’s not to the detriment of basic discovery, because without basic discovery we might as well pack up and go home.”

It’s been quite a journey since 1998 when Wesfarmers kicked in the first $5m to get WAIMR off and running at the Royal Perth Hospital research facilities.

“Without research there would be no new drugs, no new treatments. It is expensive – it could be as much as $1.1b investment that’s come from one basic discovery. And only about one in 10,000 of those discoveries actually get to the bedside but that’s not a reason not to do the discovery work, it means you have to be very rational about how you invest your research dollars.”

With a $100m injection from the WA taxpayers and the University of WA, matched by a further $100 QHarry Perkins from the Federal Government in 2007, the vision of Harry Perkins is complete, with the new stateof-the-art facilities at SCGH bustling with activity, to be followed mid-year by the opening of a centre at Fiona Stanley Hospital. With the RPH facility still operating, the Perkins institute will have three tertiary campuses giving it strong clinical links, which its new director, Prof Peter Leedman, is keen to see flourish. Integration was Peter’s key message, when Medical Forum caught up with him. “The institute has done a lot of discovery work in the past 16 years but I don’t think we’ve been as integrated in the health system as we could wish. I’m still a clinician with a patient list so I know how important it is for the Perkins institute to translate some of our basic discoveries towards the bedside.” Peter Leedman wears many hats. He’s an endocrinologist albeit with a reduced clinical load and director of a juggernaut research institute, overseeing the development of its commercial arms, such as the awardwinning Linear, of which he is chairman. Late last year, Linear, which was established in 2010, won the Premier’s Award for Excellence at the Industry and Export Awards as one of only five early phase clinical trials facilities in Australia, with 24 beds. It has contracts with Top 10 Big Pharma companies and Fortune 500 biotechnology companies. The exciting thing for Peter is the institute’s close connection to hospital-based principal investigators and their patients. “Having three hospital sites is a brilliant way of increasing recruitment into clinical trials 22

He is ever-aware of the cynicism that pervades the profession about research, but he is defiant.

“And it can take a long time. There’s no quick fix that consumers and Government always want so much. We are progressing a cancer therapy that last year was granted a full US patent after seven years. It’s a long journey but it is a discovery we can support all the way to the bedside. Of course, not all trials will be from our own discoveries but that’s not a reason not to be passionate about research.” “Research is a great thing for health care. I had an amazing meeting recently about a patient who had one type of cancer in the middle part of his thyroid and an aggressive type had invaded the nodes. That’s the type of patient we can study, take the cells into the lab and ask interesting questions and hopefully find answers.” “It’s the sort of research you can do if you’re a well-integrated system with clinicians asking a lot of interesting questions of scientists and scientists asking questions of clinicians. That’s a really rich mix.” Business savvy is also a big part of the game and while the institute relies on grants from the usual sources – NHMRC grants, government support, philanthropy and fund-raising [one of its key events, Ride to Conquer Cancer, which raised $5.2m last year, takes place on March 16-17], Linear is expected to pull its weight. Being a full-profit operation in a not-forprofit organisation, Linear’s earnings will be ploughed back into the institute. Peter said that Linear had created 32 full-time jobs in its three years of operation. “That’s a substantial contribution to the landscape,” he added. But while Linear has the potential to pull in big business and create jobs, equally important, in Peter’s mind, is its and the

QPerkins Institute Director Prof Peter Leedman

institute’s contribution in retaining and attracting the best research and clinical minds to WA. “The Perkins ‘mother ship’ in Nedlands has platforms of technology that will allow us to do some pretty cutting edge research, enabling Perth to grow as a research centre. We do discovery well, we do translation in some areas really, really well and we’ve got brilliant databases here, through Raine and wonderfully collated government health databases, which researchers can tap into. It is an attractive place for keen researchers.” “Currently Perkins has 150 clinical trials active at any one time with about 80 new trials a year. Of those 70% are Pharma g sponsored the rest are investigative.

h Marc

Medical Research

Q

ll o P e

WA taxpayer investment in medical research should be increased.

Strongly Disagree

2%

Disagree

7%

Neutral

27%

Agree

51%

Strongly Agree

13%

ED: It looks like the campaign for more research dollars gets a big thumbs up from more than two thirds of the 158 GP and Specialist respondents to our e-Poll. medicalforum


X Fiona Stanley Hospital Appointments: Dr Gavin Coppinger is Medical Co-Director Service 2; Dr John Keenan is Deputy Director Clinical Services ; Dr Matthew Wright is Head of Haematology; Prof John Olynyk is Head of Gastroenterology; Prof David Fletcher is Head of General Surgery; Dr Annette McWilliams is Head of Respiratory Medicine; Dr Stephen Fenner is Head of Psychiatry; Dr Mark Monaghan is Head of Emergency; Dr Janine Spencer is Head of Paediatric Medicine; Dr Gargeswari Sunanda is Head of Obstetrics and Gynaecology; Dr Alex Swann is Head of Anaesthetics; Prof Gareth Prosser and Prof Piers Yates are co-heads of Orthopaedic Surgery; Prof Michael Stacey is Head of Vascular Surgery; Dr Stephen Wright is Head of General Medicine. X Dr Danel Conradie and Dr Victor Tan are new associate members of the WA Faculty board of the RACGP. Danel is an IMG representative and Victor a Registrar representative. Prof Tom Brett, Dr Jamil Khan, Dr Kiran Puttappa and Dr Mahinda Yogam retired from the board at the last FGM. The research focus is on the killers – CVD and breast and prostate cancer, though we are slowly moving into poorer prognostic cancers such as head and neck cancers where breakthroughs could be meaningful globally.” To be meaningful locally, Peter says it’s a fairly simple answer – integration. “If you have a health system that doesn’t have a rich integration of clinical trials in the hospital sector, you end up with a place that lacks vitality with lacklustre doctors and consultants. Standards drop and you become a place young doctors want to leave.” “Similarly, if you don’t have rich integration of discovery, you get second class researchers and the whole system suffers. We could import all the technology and have no research and in 15 years’ time the entire system – the innovation and clinical sectors and health delivery sector – will be much worse off and we will all pay as patients.” “That’s the answer to the naysayers. It’s as simple as that.” O

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23


Training

Rural Clinical School Validates! The road has been long for the Rural Clinical School of WA but the hard work looks as if it’s starting to pay off. Winthrop Professor of Rural and Remote Medicine at UWA, Dr Geoff Riley AM, is pretty pleased that their figures (Med J Aust 2014; 200 (2): 104-107) show students who go through their Rural Clinical School (RCS) are nearly four times more likely to end up in rural practice. Mind you, the RCS experience still only results in 15% of their graduates choosing a rural career. Any increase is vindication of the efforts Geoff and QDr Geoff Riley AM his team have put into this scheme, believing from personal experience it would work. “I agree that 15% doesn’t seem like much but it’s a good result. We knew that it was never going to 60 or 80%. But over time the current numbers will wash through and start making a real difference,� he said. “We have 83 students out there in 2014 but because the lag time between leaving RCS and gaining Fellowship [independent practice] may be

eight years minimum, it will be in the next 5-10 years that it will start to be noticeable in the bush,� Geoff said. Better access to more interesting clinical work under experienced mentors is a pleasant surprise for many RCS undergraduates. Additional non-teaching influences that might affect outcomes in coming years include: t 68"TXJUDIJOHUPBQPTUHSBEVBUFDPVSTF – older women seem more attracted to the bush (reason unknown); t 3$4EJEOPUSFBDIDBQBDJUZVOUJM t UIFFYUSBDVSSJDVMBSSJDIOFTTPGUIFSVSBM experience – could attract more students ambivalent about their rural urges; t BOEBDIBOHFJOUIFQPMJUJDBMTQFOE “They tell us that the committed teaching and teachers, access to lots of patients, hands-on experience, greater responsibility and the broad range of problems tackled are attracting students to RCS. We are fortunate in being able to reproduce the best way of learning clinical medicine, that is, an apprenticeship, guided and monitored with better quality feedback than happens elsewhere. It’s just about the ideal system.�

“What will get them back is ‘country’. The special places, special recreations but mostly community, and learning to be part of it – getting to know people, good relationships and so on. With ongoing funding on the line, RCSWA can at last say it is an effective rural workforce strategy. RESULTS: The study looked at 1017 UWA medical graduates who had completed Year 5 medical school between 2002 and 2009. Of these, 258 had attended the RCSWA (195 from urban backgrounds), and of these, 14.9% were working as rural doctors between four and 11 years after graduation, compared with just 3.8% of controls. Commentators seemed most impressed with the ability of RCSWA to influence those from an urban background almost as much as those from a rural background. Where to from here? “Well, further growth mainly. We have just established Northam this year and the next will probably be Merredin if the WACHS investment in Merredin continues.� O

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medicalforum


Feature

Eyes Fixed on Rural Needs As Rural Health West gets ready to celebrate 25 years, the need for a coordinated response to the rural medical shortage continues. This year Rural Health West turns 25. It’s a significant milestone for any organisation but especially so for one forged in the desert that was rural and remote WA health in the 1980s. When the then Health Minister Barry Hodge charged Prof Max Kamien in 1986 to investigate ways to recruit and retain doctors for the country, only 282 were working in rural and remote WA. For Prof Kamien, the purpose of the review was always clear. He wrote: “This report may seem to be about doctors but it is really about the medical care of people in rural communities… They deserve the same quality of basic medical care available in the urban areas.” With a $2m grant from the Lotteries Commission, Rural Health West – then known as WACRRM – was born. Medical Forum spoke to a veteran rural doctor and a junior doctor about their experiences with the organisation and the key words were focus on service – to doctors and rural communities, the same priorities as 25 years previously. It is at the forefront of why veteran GP Dr Donald Howarth moved from Adelaide to set up practice in Esperance 19 years ago. And largely why he has stayed. “We were aware there was funding from WACRRM to move to Esperance. We did a reconnaissance and signed up. Then the checklists arrived – they thought of everything, from what I needed to work in the hospital to logistical support.” “It struck me back then that this was a focused, organised mob that worked as a team. There was nothing like that in NSW where I had done the bulk of my work till then. There are a lot of bureaucracies who could learn a lot from the way Rural Health West goes about its business.” “In my 19 years here, I’ve seen the tide of recruitment turn – we have 12 GPs here and registrars and students are coming to the town and witnessing a really functional medical community and hopefully they will say they’d like to stay.”

and remote medicine, are procured with the help of Rural Health West, which also offers courses in skills training and professional educational at special events or by telehealth. Doctors’ partners are also looked after. At the junior end of the scale, Fremantle intern Dr Jasmine O’Neill has become a Rural Health West junior ambassador after a stint as student secretary of the Spinifex club [established by WACRRM] and has participated in the Rural Clinical School which took her to south to Albany and Denmark to Kununurra, Wyndham and Halls Creek in the far north. The former radiographer from Melbourne is committed to a being a doctor in a small community and believes many of her contemporaries are becoming increasingly interested in a rural general practice career. For the current CEO Ms Belinda Bailey, recruitment and retention programs are the core focus but always in the context of the needs of the rural communities they service. Work with the Aboriginal health sector is an area Belinda says has seen significant gains, particularly recruitment of doctors and locums to the Aboriginal Medical Services and the organisation is now working with their business support services. “That’s core to our future, maintaining and building those partnerships and relationships particularly in Aboriginal health,” she said. “Rural Health West does that really well. We have our fingers in a lot of pies and by being involved we are able to join up all the dots

QDr Donald Howarth, with inset Ms Belinda Bailey (top) and Dr Jasmine O’Neill

and get the whole picture, that’s really critical. That’s what’s going to be really important in the future.” With a number of players now working in the rural training area, the danger is duplication. Former Director of Rural Health West and WA Country Health Service, now an independent consultant, Dr Felicity Jefferies, said communication and relationship building were vital, and something she believe the sector did well. Belinda said there was plenty of work for all the agencies to do in this area without duplicating. “It’s about tolerance and patience and working together. But you can’t just be nice to one another, you have to have plans and strategies and implement those strategies then measure your outcomes. That’s what we do.” O

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Trailblazer

GPs the Agents of Change As pressure mounts on the health care system, the role of the GP will be crucial. It will be a challenge, says Hills GP Dr Sean Stevens, but with vision and planning it can be met.

M

ead Medical, which has sites at Kalamunda and Forrestfield, was announced the country’s best general practice at the RACGP’s national conference late last year. It was a vote of confidence for the large team of doctors, nurses, administrators and practice staff involved but it also gave Medical Forum a chance to catch up with one of the eight associates of the practice, Dr Sean Stevens, for his insights into what makes his practice tick efficiently. “Communication is particularly important. Mead has 20 doctors, 12 nurses, six administration staff and 30-40 receptionists over two sites. Some of our GPs do procedural work – obstetrics, anaethesia and surgery. They don’t spend a lot of time in the office so meetings are vital. We’ve had to formalise the structure so

QGP Sean Stevens

we have a practice meeting once a month, executive meeting once a fortnight, and a strategy meeting every six months.” “We also have an extremely good practice manager, Dot Melkus, who takes a huge administrative burden off our shoulders.” Sean, 43, has been at Mead for the past 12 years, though the practice was established in 1956 by Dr James Jamieson who started the practice in a room at the back of his house when Kalamunda was still considered a country town. It was 10 years before he sought a partner. Times have changed – for everyone involved in general practice. As health resources get squeezed, the system is looking for a miracle to come from general practice. Sean reckons resourc properly, it will cope, too, if it is resourced the right systems are in place and people are well trained. “I think it will happen but it will take time. The training of general pra practitioners and moving towards models of integrated care de need a dedicated lead clinician to coordinate. That’s wh what will make differ the difference. ” “In Austr Australia, we began Collabo a Collaborative scheme work really well, that worked GP paid time to giving GPs work out outside of face-toface cons consulting to share im and implement ideas p system and plan ch change. It’s a t tragedy that funding was withdrawn from it. The Collaborative model is a long-term proposition but it is the type of thing that will drive system change from the grass roots up.” “It’s still going but in a m much reduced c capacity and wit without the invo involvement of enou motivated enough practi practices, Australia

26

will never achieve a critical mass to make it work. What we did see was some impressive improvements in focused areas such as blood pressure and cholesterol targets, but it’s difficult to sustain if your clinical lead doesn’t have the dedicated time to work on them.” Training is another of Sean’s passions. He is the head of GP training at Mead and won the GPET Australian GP Supervisor of the Year award in 2006. He knows the power of a good mentor. He was inspired by his supervisor Dr Peter Wallace at the Forrest House Medical Centre in Pinjarra where Sean trained and subsequently stayed on and practised until 2002. “Primarily I’m a clinician … I love general practice. If I won Lotto tomorrow, I’d still practise as a GP. It’s the long-term connection and communication with people I love most. The trust patients show in their GP is humbling and that is what makes the job so rewarding.” But Sean is also a man of his time and that time insists on business savvy and organisation so more can be achieved with less. After he did his GP training he did a business diploma to help him draw some lines for himself. “One of the most useful lectures I’ve ever been too was on time management and the importance of prioritising because it is very easy to get caught up in everyone else’s pressures and expectations.” “My father was a rural doctor in Albany who was very committed to his work and his patients and I saw, growing up, the respect people had for him. It inspired me to become a doctor. He also worked phenomenal hours. The next generation doesn’t want to do that and with good reason.” “Family is important to me. I have a wife and young children – I want to be a good husband and father to them as well as a good doctor to my patients. I don’t want to miss my kids’ childhoods.” “Doctors generally put a lot of importance on their job; it defines them, in a way, and it’s an easy trap to fall into. I fall into it myself. It’s really important to visualise what you want from your life – your family, your friends, your work and yourself. Each of those four areas need time and effort.” “I don’t succeed in this, but I try! I have my systems.” O

By Ms Jan Hallam

medicalforum


Aged Care

Prescribing Quality not Quantity GP Dr Kathleen Potter’s research into medication use in ACF residentss poses many added questions that she discusses with Medical Forum. Medical Forum asked Kathleen: Is her research attempt to lower medications simply returning ACF residents to their non-compliance levels that we assume were the norm while living in the community? “I would hope we are doing things more logically, by weighing up the risk-benefit analysis, whereas their decision [to discontinue a drug at home] might be based on finances, how they feel on the day and which coloured pills they don’t like,” she said. The elderly living in the community may be good at picking medications that give side effects but they are often not aware of long-term benefits from compliance. She has noticed that a minority improve after entering aged care facilities. Why? Is it medications? “Some people make a dramatic improvement after entering a residential aged care facility – medications, better diet, stop drinking, better nursing care – it may be multifactorial, which hints at why it is so difficult to do research. They don’t tell their doctor about nonadherence while in a community setting.” “Many have cognitive impairment and are unable to make their own decisions, and as soon as someone else is making decisions, it becomes more complicated as to what is in someone’s best interests.” As a profession, we see a lot of effort getting doctors to prescribe. Her work in aged care facilities suggests we should be doing the opposite. “The only counter information is the NPS, so the information we are receiving is powerful – it’s part of the culture that if you are prescribing you are doing your job well. You see it with your colleagues – the reaction to a new problem is to prescribe something. It takes time and energy not to prescribe. There is a real issue with the fee-for-service system in ACFs when people have complicated problems that require time to sort them out.” This doesn’t mean that you are able to withdraw most medications for someone without running into problems. In fact, her experience proffers a cautious approach. “Slowly, slowly is my advice – stop things slowly and review things one at a time. And review them frequently. I would like to see more frequent reviews of medication in the elderly or when someone comes with a new symptom. Look at their current medications, rather than prescribe something to treat that symptom.” Avoidance of both overprescribing and cascade prescribing bring up quality-of-life issues, which Kathleen suggests is how we medicalforum

ircumstances have changed, and the elderly in aged care facilities (ACFs) are averaging 10-14 medications. When someone enters an ACF, compliance may jump from less than 50% in the community to about 100% as nursing staff dutifully hand out medications. Side effect risk may increase, along with “cascade prescribing”, where further prescribing aims to combat a symptom that is an unrecognised drug side effect. And with around 80% of ACF patients now with dementia, many cannot relay their experiences accurately. Government has a cost saving agenda, so it is timely the profession, charged with acting in the patients’ best interests, looks at the issues. Dr Kathleen Potter is researching how to safely reduce medications in ACFs. Her data collection is incomplete but she understands the issues.

C

should consider our interventions among residents in aged care facilities.

between ‘the lesser of two evils’, fall while on anticoagulants vs increased risk of stroke.

“If you took a person without dementia in their sixties into a nursing home and sat them for a day to watch people being fed, moved to a flotation bed, having their continence aid changed, most people would say they would rather die before they get to that state.”

Another is persistence with Alzheimer’s medication during deterioration. “Larger trials in huge populations suggest that once mini-mental state examination score falls below about 10 you are not achieving any benefit at all.”

While earlier ‘living wills’ may take care of what happens with superimposed acute illness in those without the mental capacity to decide, the use of long-term medication raises other concerns. “One of the issues I’ve had is assessing whether someone deteriorates as part of medication withdrawal or as part of their illness. I think there is a lot of room for improvement and we are veering on the overmedication side.” She gave examples, starting with statins. She points out there is very little benefit regarding primary prevention if prescribed over the age of 75. “You are not extending their life and there is not much evidence of improved quality of life if they have not had a past vascular event,” she said. This dilemma comes into sharp relief for someone on anticoagulants for risk of stroke who is also experiencing falls. Kathleen said cost and inconvenience to the patient often means the reason behind falls is not fully investigated and the prescriber must choose

“Panadol Osteo tds is commonly used and often not required as frequently or at all. Regular review is required with the aim of maximising quality of life for people in their final years. Quality not quantity – controlling symptoms and reducing any side effects and giving them the best years you can,” she said. Among the 25% or so of patients who are ‘low care’ are those with strong opinions who may disagree with attempts to withdraw long-term medication. And for residents with family making decisions, there is a moral hazard in getting another opinion when they are paying pharmaceutical bills. “Generally, they want the best for their relative and do feel they are taking more medications than are required. However, sometimes relatives have trouble deciding, so you can’t put it on them.” For her study she enrolled 30% of eligible residents from ACFs in Dongara and Geraldton. She believes their medications should be reviewed every six months. O

By Dr Rob McEvoy 27


Guest Column

Beat the Heat – Plant Trees The urbanisation of Perth is robbing the city of its natural climate control – trees. Curtin academic Ms Helen Brown says that development practices must change.

T

he link between extreme heat and health is well established and plans to manage such events are dealt with in detail in the State Emergency Management Plan for Heatwaves, released in late 2012. However, global climate change is not the only factor to influence future exposure to extreme heat in cities. Urban areas are typically warmer than surrounding rural areas because of the

urban heat island (UHI) effect. Urbanisation typically results in a reduction in vegetation, an increase in the amount of built surfaces (that tend to store heat) and an increase in man-made heat, mostly from motor vehicles and air-conditioning. With the population of Perth expected to double in the next 40 years and a strong policy of urban consolidation, the potential

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for UHI effects is clear. Unlike global climate change, the extent of UHIs is determined by actions and decisions at the local level. Recent research at Curtin’s School of Public Health focused on the loss of tree canopy, which is a significant contributor to the creation of UHIs. One of the research findings was that current practices and policies related to trees are more likely to exacerbate the anticipated effects of climate change in Perth. For example, while a clear target has been set for urban density, there is no target or monitoring of tree canopy levels. The complete removal of trees during redevelopment is a decision that is routinely made by private land-owners and developers. With few restraints on their removal or incentives to retain or incorporate trees into urban design, the practice is likely to continue. The outcome will be less resilience by people to the impacts of future heatwaves and higher temperatures – an outcome at direct odds with the need for climate change adaptation and that has implications for the health sector. In addition, reducing the tree canopy will affect shade, air quality, water quality, physical activity and mental health. Trees work hard for our health and wellbeing and it will ultimately cost us if we don’t recognise their value and protect them in our urban environments. The causes and potential solutions for UHIs are well-documented and the need for action is clear. This does not mean that the solutions are simple. State and local government, the private sector and the community all have a role to play and a responsibility to bear. How to best manage trees during a period of rapid growth will require collaboration from everyone. The future of our city, as captured by the Directions 2031 vision is for “a world class liveable city: green, vibrant, more compact and accessible with a unique sense of place.” A significant amount of effort and support is channelled into the achievement of the ‘more compact’ element of this vision. While the benefits of reducing the significant health, environmental and economic costs associated with urban sprawl are clear, care must be taken that the potential costs of a ‘more compact’ city such as tree canopy loss and the UHI are not overlooked. To do so would place the health and well-being of Perth residents and the broader vision of a world-class liveable city at risk. O

medicalforum


Guest Column

National Focus Needed for Diabetes Diabetes has been on Ms Judi Moylan’s radar for the 10 years she was in politics. As she’s national president of Diabetes Australia, her voice is still being heard.

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ecognition of the global challenge posed by diabetes led to a unanimous United Nations resolution in 2006 declaring November 14 World Diabetes Day. The seriousness of diabetes as a modern day scourge was highlighted by Kofi Annan, when he reminded his audience that diabetes kills more people worldwide annually than HIV/AIDS, tuberculosis and malaria combined.

Such a message six years after the Resolution should serve to stiffen our national resolve to do better. How Australia should confront the challenge is a matter of much debate in the medical community. There is consensus, however, on the need to re-energise the commitment of all governments, state and federal. The deadly political inertia of a hung parliament over the past three years has done little to progress one of the most pressing public health challenges on our watch. As the nation continues to be confronted by burgeoning health costs and fiscal constraints, the new government will need to retrieve the crucial mantra that ‘nothing succeeds like prevention’. It is both the best medicine and the best politics. It is also the least costly.

Stroke Signs Missed continued from page 21 “I was able to speak with a stroke survivor, the first person I’d ever spoken to since my stroke! He shared his struggles with me and it was only then I realised I wasn’t the only one to have these feelings. You go through a grieving process for your old life.” “Doing presentations as a Stroke SAFE ambassador in the Goldfields is my therapy now. You have to develop a sense of humour because stroke is such a heavy word.” She is concerned that the oral contraceptive pill she was on is still on the market. Her doctor in Kalgoorlie won’t prescribe it unless patients particularly ask. Incidentally, she does not think any of her doctors, including the neurologist, has put in an adverse drug report to the National Prescribing Service. She now takes aspirin daily. O

By Dr Rob McEvoy medicalforum

The prevalence and cost of diabetes was outlined last year by Baker IDI. It projects a diabetic population of up to 3 million over the age of 25 years by 2025. Tragically, Australia has not had a coherent diabetes policy for years. In 2007, the Council of Australian Governments (COAG) committed to a diabetes prevention program, targeting the 40-49 year age group through the general practice network. The commonwealth’s contribution of $103 million was to be matched by an equal contribution by state and territory governments. Labor scrapped the commonwealth’s commitment in late 2011. By way of contrast, various state governments continued to fund diabetes prevention programs. The Victorian Government’s Life! Program continues to show the way with over 30,000 Victorians at high risk referred into structured, evidence-based courses. Following recommendations by the National Hospital and Health Services Commission in 2010, the federal Labor government had committed $436 million to a Coordinated Care for Diabetes program. A political decision to cut this funding and replace it with a $30 million pilot study was disingenuous in the extreme. This small-scale pilot study was subsequently promoted as a newly funded diabetes initiative and rebadged as the Diabetes Care Project.

Coalition policy announcements before last year’s election offer hope with commitments to strengthening primary care with a clear clinical priority to diabetes prevention and management, restoring the independence of the Pharmaceutical Benefits Advisory Committee and the integrity of the Pharmaceutical Benefits Scheme. A return to a system of listing of new medications, free from political interference, is of vital importance. It is axiomatic that governments need to be more concerned about the cost of diabetic complications from undiagnosed, untreated and poorly treated diabetes, than about the cost of efficacious medications. Most welcome is the Health Minister’s pledge to develop a new national strategy that will include state governments and peak bodies including Diabetes Australia. However, this will all require more than endless political confabulation. The implementation of effective policy grows more urgent by the day. We dare not fail. References on request O

ED: Ms Moylan retired from federal politics at the last election. In November, she was appointed Independent President and Chair of Diabetes Australia.

John Back in Family Hands

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n March, 2012, Medical Forum helped E/Prof Max Kamien to establish the identity of a bust of RACGP stalwart Dr John Bamford. Just to remind readers, the ‘mystery’ bust was discovered during the clean-up following the sale of the Claremont Community Health Centre. While there was a school of thought that it was the late Dr Bamford, identification could not be confirmed, even by Dr Bamford’s wife, Jean, or his practice partner Dr David Watson. But a careful comparison of the bust with a portrait of Dr Bamford hanging in WARACGP College House, showed enough similarities to give the bust a name. The bust has been living in Max’s garden awaiting Bamford connections to lay claim to it. Well, Max reports that Dr Bamford’s son, Mike, and his children have taken the bust back to their Kingsley home. “There is still a medical connection since Mandy Bamford is the daughter of Dr Peter

QThe bust of Dr John Bamford back home with son Mike, left, grandsons Jake and Josh and Mike’s daughter-in-law Mandy.

Silberstein, a West Australian pioneer of paediatric neurology, and the brother of Dr Nick Silberstein, a long serving procedural GP in Mt Barker who joined Médecins Sans Frontières and worked for six years as a medical coordinator in a variety of hazardous developing world locations.” O 29


News & Views

Current Science is Future Art Art from living tissue may be a confronting issue for some but a thought-provoking reminder about medicine and its practice. A research laboratory and an art studio may appear to be odd bedfellows. But, as the Director of SymbioticA at UWA, Professor QProfessor Oron Catts Oron Catts, argues, the convergence of the biological arts with the life sciences explores profoundly relevant issues for doctors.

Q(Main Photo) Victimless Leather – A Prototype of Stitch-less Jacket grown in a Technoscientific “Body”; Biodegradable polymer skin and bone cells from human and mouse. Q(Below Inset) Pig Wings The Chiropteran Version; Pig mesenchymal cells (bone marrow stem cells) and biodegradable/ bioabsorbable polymers (PGA, P4HB) All images courtesy of the Tissue Culture & Art Project (Oron Catts & Ionat Zurr)

“There’s a growing interest in this area and meaningful engagement with medical professionals is both necessary and valid. We’re trying to reaffirm that advances in biological engineering require some degree of reflection by both researchers and doctors into the deeper implications of their clinical practice.” “We’re using living tissue as a form of artistic expression and, hopefully, provoking questions about all forms of medicine and its applications. The work we’re doing represents a major shift in this area. As artists we’re imagining new possibilities and presenting them in a cultural context.” Oron and SymbioticA work within the Department of Anatomy at UWA. It’s a continuation of fruitful relationships with some of the most prestigious medical faculties in the world. “I spent a year collaborating with Harvard Medical School which was highly productive. We presented material with the Head of Surgery at medical conferences. Some people were surprised at what we were doing and I guess sculptures of living tissue can be quite confronting.” “Nonetheless, it’s important to remind both scientists and doctors of the sociocultural aspects of their activities.’ “We’re all aware that medical technology allows a heart to exist outside the body and stem cells to grow body parts. There’s a positive and important functional aspect, but it should also provoke questions about what it means to be alive and the fact that some of these concepts are malleable.” Oron agrees that an ageing population and related issues will broaden the debate and doctors, particularly those just beginning in the profession, will ultimately engage with areas of increasing complexity. “Transhumanism [a fundamental shift in the human condition utilising emerging medical technologies] is an expanding field in the US, exploring the subtle differences between 30

the treatment of disease and the condition of old age.” “It’s important for doctors to gain a well-rounded view of an inherently diverse profession. Things aren’t always what they seem. One such case is the French surgeon, Dr Alexis Carrel, who was a pioneer of tissue rejection and cell regeneration in the early 1900s. Unfortunately he was also a racist and a eugenicist who supported the use of the gas chamber in Vichy France.” “Despite winning the Nobel Prize, his work has, understandably, slipped from the historical record. It’s safe to say that cultural amnesia is not unknown in the world of science.” The exhibitions and workshops of SymbioticA aim to reinforce a broader view of the human body and suggest to clinicians that the significance of medical intervention goes much deeper than merely treating a condition.

“Medicine is inextricably entwined with philosophical and sociocultural issues. It wasn’t all that long ago when premature babies were ‘exhibited’ in amusement parks. At Coney Island’s Dreamland they lay in incubators next to the bearded lady and the strongest man in the world. In the early 1900s, as far as hospitals were concerned, these babies weren’t regarded as human.” “I’d really like to emphasise that the artistic expression of SymbioticA is just another way of looking at some of the more challenging and ground-breaking developments in medicine.” O

By Mr Peter McClelland ED: SymbioticA Symposium will be held in Perth next year in October. medicalforum


Guest Column

Brave New World SCGH resident Dr Alexius Taylor Julian heads the clinical reference group, Junior Doctors in Health Information and looks forward to a technological future.

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hey’re on the way! Two brand new centres in the form of Fiona Stanley Hospital and Perth Children’s Hospital plus a secondary institution at Midland Health Campus. There are going to be some big changes in how we deliver health care and the tools we use to achieve that.

Fiona Stanley will have wi-fi coverage and identification cards will not only give access throughout the hospital but also provide staff with a quick way to log on to computer terminals. And this extends to patient entertainment systems. They’re no longer just a TV and media outlet but also a system allowing doctors to display test-results and x-rays to patients. The new technology embraces mobile devices so clinical staff can review information on the move rather than stuck at a computer terminal. We know there’s an appetite for these innovations – about 70% of junior doctors indicated they would be happy to carry a tablet device.1 You only have to browse through an App store to see the latest medical technology. There are Apps which allow iPads to capture ECGs over Bluetooth and store them on remote servers. There are eye charts, assessment tools and medical calculators and radiology imaging viewers. This will be revolutionary in the way we measure, communicate and store information. It’s an increasingly mobile workforce, too. Junior doctors are spread over numerous sites and different parts of the state and the need for readily accessible information has never been more important. Imagine if an intern in Port Hedland could send a live ECG to the tablet of a cardiologist in Perth. If we are going to capitalise on these advances we need to take long, hard look at the way we do things. ‘That’s the way we’ve always done things’ just isn’t good enough anymore. WA Health is looking at system redesign. One project found a mean delay of 180 minutes between completion of radiological imaging and review by the treating team due to the absence of automatic notification.2 We need to cultivate a culture of innovation and we must invest in these new frontiers of medical technology. And we’ll need to take some calculated risks, too. (Not with patient safety, of course!) Ingenuity and risk go hand-in-hand. References: 1. eHealth Survey of WA Health JMOs 2011 – Junior Doctors in Health IT Clinical Reference Group 2. Chandratilleke and Honeybul. Modifying Clinicians Use of PACS Imaging. Journal of Digital Imaging December 2013, Volume 26, Issue 6, pp. 1008-1012 O

ED: We fully understand the enthusiasm for hospital IT innovations amongst new doctors. Doctor comment at a recent Doctors Drum was that poor communication between hospitals and community doctors currently impedes patient care, and should also be the focus of IT innovation. As an example of what can be done, Medical Forum has been approached by the developers of the excellent web-based imaging prompt for doctors (www.imagingpathways.com.au), to say they are developing desktop software that offers decision support during daily workflow for community doctors. This includes pre-filled radiology request forms when the GP chooses to order particular imaging. They would like GP feedback now, during development (Felicity.Millman@health.wa.gov.au, 92442198) medicalforum

PIVET MEDICAL CENTRE Specialists in Reproductive Medicine & Gynaecological Services

FERTILITY NEWS

by Medical Director Dr John Yovich

“Thank you; we got there in the end.” … with Growth Hormone Happy mum Wendy with baby Zoe born 19 September 2013, is so pleased that she is keen to let me tell her story. Wendy was aged 30 and husband Peter was 36 when they commenced trying for pregnancy. They were referred to PIVET as a Happy mum Wendy with baby Zoe healthy couple with unexplained infertility 14 months later. All initial investigations including AFC, serum AMH and HyCoSy for tubal patency testing were DOOQRUPDO6SHUPSURÀOHVZHUHDOVRSHUIHFWO\QRUPDODFFRUGLQJ to current, exacting WHO criteria. In the IVF programme, Wendy responded well initially with a good number of blastocysts arising. Published PIVET data shows that such a couple have a 7580% chance of live-birth from a single TVOA (egg collection procedure) – ref Stanger & Yovich 2013; follicle recruitment determines IVF productivity rate via the number of embryos frozen and subsequent transfers. RBM Online 27, 286-296. However Wendy had 4 TVOA procedures and 6 FETs without any sign of implantation. Further investigations including Vitamin D testing and searching for Natural Killer cells were all normal. At this stage AFC and AMH showed the ovarian reserve ZDVGHSOHWLQJDQGWKHDQGURJHQSURÀOHZDVUHGXFLQJ:H introduced our “famous” DHEA trochéts as well as a course of Growth Hormone according to our previously published schedule – ref Yovich & Stanger 2010. Growth Hormone supplementation improves implantation and pregnancy productivity rates for poor-prognosis patients undertaking IVF RBM Online 21, 37-49. GH appears to improve egg quality and Zoe resulted from an immediate single fresh blastocyst transfer!

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medicalforum


CLINICAL UPDATE

Bladeless cataract surgery

By Dr Rob Paul, Ophthalmologist

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ith over 20 million cataract operations performed worldwide, the introduction of femtosecond lasers into cataract surgery has taken the procedure to a new level.

Traditional cataract removal first uses microsurgical blades to enter the eye, manual creation of a capsule opening with a needle, and break-up of the affected lens using phacoemulsification (high frequency ultrasound; requiring more energy for denser cataracts).

Of course complications still occur. In the early days of this technology, a cluster of unforeseen capsule ruptures occurred due mainly to surgeon inexperience and imperfect imaging systems. Software and imaging upgrades have reduced such problems.

As one of the biggest advancements, these procedures are now performed within about 20 to 30 seconds using the femtosecond laser (first performed in 2008 in Budapest). The laser creates a near perfect, round opening in the anterior capsule by dissecting it with a spiral laser pattern (capsulotomy), through which the surgeon simply removes the capsule tissue.

At the Eye Surgery Foundation the LensX© laser, one of 15 machines in Australia, is in a dedicated laser room next to the operating theatre. I believe the use of the laser during this procedure will become more widespread as surgeons and patients realise the clear benefits, although patients must first decide if the out-of-pocket expense of $800-$1000 is acceptable.

QIncision and capsulotomy placement of LensX© laser.

QOcular CT image of a cataract

The laser replaces the most technically challenging part of the surgery. For the less experienced cataract surgeon, being able to precisely create a well-centred capsulotomy is critical, which may prove to be the greatest advantage of laser-assisted cataract surgery. The femtosecond laser also assists fragmentation (breaking up) of the cataract by applying pulses to the lens in a predesigned pattern, which then allows the surgeon to use current technology to remove the lens matter. This additional step is quicker and applies less energy, making the overall procedure safer and less traumatic to the eye, with expected reduction in postoperative swelling and faster visual recovery.

References: 1. Nagy Z, Takacs A et al Complications of femtosecond laser-assisted cataract surgery. J Cataract Refract Surg 2014;40:20-27. 2. Takacs A, Kovacs I et al. Central corneal volume and endothelial cell count following femtosecond laser assisted refractive cataract surgery compared to conventional phacoemulsification. J Refract Surg 2012;28:387-391 3. Roberts TV, Sutton G, Lawless M, Bali SJ, Hodge C. Surgical outcomes and safety of femtosecond laser cataract surgery; a prospective outcome of 1500 consecutive cases. Ophthalmology 2013;120:227-233 O Declaration: Eye Surgery Foundation supports this clinical update through an independent educational grant to Medical Forum. Author: No competing interests.

Supporting Ophthalmic Research, Education and Overseas Projects

EYE SURGERY FOUNDATION Our Vision Is Improved Vision After 18 months of expansion, the Eye Surgery Foundation amalgamated two buildings and re-commenced surgical procedures in November. The new day hospital is twice the size – four operating

theatres, a dedicated Laser room with a Femtosecond Laser, two recovery rooms, large reception, and a spacious staff room. The hospital is managed by Perth Eye Centre P/L.

Dr Ross Agnello Tel: 9448 9955 Dr Malcolm Burvill Tel: 9275 2522 Dr Ian Chan Tel: 9388 1828 Dr Steve Colley Tel: 9385 6665 Dr Dru Daniels Tel: 9381 3409

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E: info@eyesurgeryfoundation.com.au 42 ORD STREET WEST PERTH WA 6005 33


CLINICAL UPDATE

Arthroscopy of an arthritic knee?

By Dr Keith Holt, Orthopaedic Surgeon, Perth Orthopaedic and Sports Medicine Centre

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rthroscopy can be helpful in an arthritic knee when there are symptomatic meniscal tears, or mechanical problems such as loose bodies that are catching. Unfortunately, cleaning up areas of wear generally does not help, and indeed, it often aggravates the symptoms. An MRI is the key investigation to define the pathology and, in particular, look for and/or exclude a stress fracture to the underlying bone.

Who benefits most?

Hence, if the symptoms are unchanged at say five weeks, the patient should be reassured that in the next 2 to 3 weeks they will most likely improve, and that it will happen quite suddenly. Thereafter, a return to normal activity is possible, albeit with an emphasis on low impact exercise.

Those with locking, jamming or catching may benefit. The benefit here is a resolution, or diminution, of the mechanical symptoms, not pain relief, and rarely a loss of swelling. This must be clearly understood by the patient. A meniscal tear may produce exactly the same pain as an arthritic area on the same side of the joint so that in a chronically painful arthritic knee the cause of the pain may be hard to determine. In the acute situation however, a patient with mild-tomoderate osteoarthritis who presents with a sudden onset of joint line pain, and who has marked tenderness right on the joint line, most likely has had an episode of acute meniscal failure. If this is confirmed with an MRI scan, an isolated resection may benefit the patient by removing the meniscal element to the pain.

Sub-chondral stress fractures The commonest misdiagnosis, as isolated pathology, or in association with a meniscal tear, is a sub-chondral stress fracture, particularly when osteoporosis is present. Where the soft articular surface becomes

FACTS: PONDER POINTS 3FDFOUFWJEFODFTVHHFTUTUIBUy t "SUISPTDPQJDEFCSJEFNFOUPGBO  BSUISJUJDKPJOUJTOPUHFOFSBMMZVTFGVM t "SUISPTDPQJDXBTIPVUEPFTOPU  SFEVDFQBJOPSTXFMMJOH t 4IBNBSUISPTDPQZ NBLJOHQPSUBMT  CVUOPTVSHFSZ JTBTHPPEBTUIF  SFBMUIJOH t %FHFOFSBUJWFNFOJTDBMUFBST JG  MFGUBMPOF FWFOUVBMMZEPBTXFMMBT  XJUISFTFDUJPO

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Bone density assessment should be undertaken.

Investigations worn there is a decrease in stress absorption with impact loading. This alone can lead to a stress fracture. If degenerative meniscal failure supervenes, then even less impact absorption results and the risk of stress fracture increases. Sub-chondral stress fractures are not uncommon, and need to be looked for, particularly in the elderly. They frequently present acutely, in conjunction with a meniscal tear. Despite the coalescence of the pathologies, it is often the stress fracture, not the meniscal tear that is most symptomatic. Meniscal resection in this situation reduces further any impact absorption, increasing stress on the bone and making the fracture worse. Treatment of the stress fracture requires an accurate diagnosis (MRI) followed by appropriate activity reduction for about eight weeks. This may include time on crutches or similar. Fracture symptoms do not slowly improve. They get better suddenly when the fracture finally heals.

Plain x-ray is very important for overall assessment. An additional 20° weightbearing PA film is most sensitive for joint space narrowing. MRI is the investigation of choice to refine the diagnosis. It can visualise stress fractures, underlying bone oedema, and arthritic cysts. It can also detect relatively common conditions such as ACL degeneration (with or without ganglion formation), which can be symptomatic in this population. [CT arthrogram is probably inappropriate as a refining investigation because it does not show enough pathology and there is a moderate radiation exposure.]

Additional treatment To re-emphasise, arthroscopy should be reserved for mechanical problems and residual, symptomatic, meniscal tears. Osteotomy to correct mal-alignment (varus or valgus), thereby permanently unloading an arthritic compartment, may be appropriate in active individuals under 60 years. If the arthritic part of the knee is judged to be the patello-femoral (not tibio-femoral) joint, patella re-alignment and/or lateral release may help. Where the arthritis is advanced at presentation, it may be better to go direct to replacement rather than via a series of minor procedures that have little prospect of success. A plain x-ray may be all that is required for that diagnosis. O

Declaration: no author competing interests.

medicalforum


CLINICAL OPINION

Ruptured ACL, what now? By Mr Tim Barnwell, Sports Physiotherapist

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35-year-old amateur footballer presents with a swollen left knee after pivoting and twisting at a game on the weekend; there was a snapping sound, then no pain, but by nightfall his knee had swollen dramatically; a typical story of anterior cruciate ligament (ACL) rupture. As well as referring or arranging MRI to confirm the diagnosis, it is worthwhile determining if circumstances favour a non-surgical approach. In some cases, conservative rehabilitation of the knee may give an acceptable outcome long term, or at worst, delay reconstruction 6-12 weeks.

The factors considered most important in opting for conservative treatment are: t *TUIF"$-SVQUVSFJTPMBUFE 4VSHFSZJT more likely if there is other associated knee injury t )PXVSHFOUJTSFUVSOBOEIPXPMEJTUIF patient? A return to competitive change of-direction sport may necessitate ACL reconstruction immediately, as typical recovery from this surgery is around 12 months, and a 6-12 week delay may

be unacceptable especially to the younger athlete. However, time in rehabilitation may be what is required to consider long term sporting options, particularly in older patients, where improved strength and joint control may lead to acceptable stability without reconstruction. t 3FUVSOUPUPQMFWFMDPNQFUJUJWFTQPSU It all depends on what stress the person wishes to place on their knee after recovery (e.g. senior grade rugby forward). At this point, evidence suggests a patient cannot return to top level competitive sport without a reconstruction. Of course, ACL reconstruction can address later instability should surgery be delayed. In practice, around 50% of amateur athletes who undergo knee reconstruction are hesitant to return to their pre-injury sport for fear that they may injure the knee again. For many years it has been believed that joint stability must be returned quickly to minimise the risk of meniscal injury and the development of early osteoarthritis.

ACL research is now suggesting that the extent of OA and risk of meniscal injury is the same between groups of people who have had a reconstruction and those who have not, so perhaps a delay in reconstruction is not as detrimental as initially thought. Conservative rehabilitation focuses on quadriceps strengthening, neuromuscular retraining, range of motion exercises and functional training. Noticeable benefit appears at between six and 12 weeks. It remains good practice for all elite sports people to undergo ACL reconstruction following a rupture. References available on request O

Declaration: No competing interests.

ED Advice from our Advisory Panel has stressed the importance of early accurate diagnosis and treatment, particularly of haemarthrosis, multi-ligament injuries and intra articular fractures.

Who to believe?

Diet and cardiovascular risk By Jo Beer, Senior Dietitian and Diabetes Educator. Tel 0403 938 747

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ardiovascular disease (CVD) remains the leading cause of death in Australia. The key causes are well established and include hypertension, hypercholesterolaemia, poor fruit and vegetable intake, obesity, low activity levels, alcohol and smoking. To counter these, efforts have focused on lifestyle management and cholesterol reduction through medications such as statins. Differing viewpoints have suggested that statins are both over and under prescribed, but a healthy diet should be followed by all.

Despite this, current recommendations have recently been vigorously challenged, with suggestions that the role of dietary cholesterol in heart disease has been misrepresented. Last year, lawyer and author David Gillespie provoked debate with his book Toxic Oil, stating that saturated fat and cholesterol do not cause CVD but that the dietary villains are polyunsaturated fats, including vegetable and seed oils. However, Gillespie has been highly selective in the literature he uses. He also fails to adequately consider whether the fat has undergone processing and the quantity being consumed.

Competing points of view

Populist publications such as Sweet Poison and I Quit Sugar have stressed harmful effects of sugars on health. This appears to be a gross extrapolation from somewhat limited evidence that refined carbohydrates and high glycaemic loads may adversely affect CVD. Conversely, some evidence does suggest that diets high in fibre and whole grains are beneficial to cardiovascular health.

Evidence based healthy eating guidelines have been produced by numerous eminent organisations with broad support for a ‘Mediterranean style’ diet. These guidelines have been derived from methodical analyses of peer-reviewed literature with, for instance, the latest Australian Dietary Guidelines from the NHMRC involving analysis of over 55,000 pieces of evidence. medicalforum

Nutritional science is constantly evolving and must embrace legitimate challenges and criticism. However, it is important not to lose sight of known facts and to avoid extremism. To assist in educating and informing patients, the Heart Foundation’s on-line question and answer position statement on fats, nutrition and heart disease is highly recommended. Sound evidence continues to support a Mediterranean style diet that is primarily plant based, high in fibre and includes a wide variety of fruit, vegetables, legumes, whole grains and nuts. The main added fat should be olive oil, with protein supplied by moderate portions of meat and regular intake of fish, cheese and natural yoghurt. This will naturally provide a diet that is low in harmful saturated fats and trans fatty acids. Diet is one aspect of lifestyle change that is needed to reduce CVD risk. Your patients should also aim for an ideal weight, exercise regularly and not smoke. Specifically tailoring dietary recommendations to an individual’s living environment, medical needs, culture and lifestyle will help with their motivation, compliance and ultimate success in combating CVD. See www.eatforhealth.gov.au O Declaration: Author has no competing interests. 35


CLINICAL UPDATE

Sudden cardiac death in young athletes

By Dr Tim Gattorna, Cardiologist, Electrophysiologist, Western Cardiology

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udden cardiac death (SCD) in young athletes is an unexpected and tragic event that inevitably leads us to ponder how we can prevent future episodes. Each year, it happens to an estimated 2-4 young athletes out of every 100,000; males twice as often, with ethnic variation.

Aetiology Most events are due to malignant ventricular tachyarrhythmias. Age is also a primary determinant of cause, with atherosclerotic coronary artery disease occurring predominantly in athletes older than 35 years. Inherited or other acquired cardiovascular abnormality occurs predominantly in athletes under the age of 35 years (see Table).

Pre-participation screening (PPS) The dilemma with SCD in young athletes is that the majority of events occur without antecedent symptoms and with unremarkable cardiovascular examination. Strategies for the prevention of SCD in athletes are endorsed by sports governing bodies, but mandatory cardiovascular screening is rare. PPS usually involves a detailed history and physical examination with further evaluation if indicated.

Suggested Algorithm for Evaluating Athletes for SCD

Symptoms such as pre-syncope, syncope, chest pain, palpitations, dyspnoea or a family history of SCD or abnormalities detected on physical examination require urgent referral for further evaluation.

HISTORY

Role of the ECG

EXAMINATION

Incorporating a routine ECG improves efficacy in identifying conditions capable of causing SCD. However, regular, intense exercise changes the heart physiologically (“athlete’s heart�), leading to diagnostic uncertainty; the magnitude of changes is influenced by age, sex, body surface area, sport undertaken and ethnicity. These changes can be identified on ECG and echocardiogram and it is important to distinguish this from other potentially pathological conditions capable of causing SCD. Referral to a cardiac electrophysiologist or sports physician with expertise in this area is recommended. O

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TABLE: COMMON CAUSES OF SUDDEN CARDIAC DEATH IN YOUNG ATHLETES Structural Abnormalities

Electrical Abnormalities

Acquired Abnormalities

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medicalforum


CLINICAL UPDATE

Concussion management

By Dr Peter Steele, Sports Physician

C

oncussion is a disturbance of the brain’s ability to acquire and process information after trauma. Current consensus favours a disturbance of brain function rather than a structural injury. Though most concussions resolve spontaneously in 7 to 10 days it is not a benign injury.

Return to sport before full recovery increases the risk of a further more severe concussion or post-concussion syndrome. There is also growing concern regarding links between repeated head trauma and long-term risk of depression and dementia (chronic traumatic encephalopathy).

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It is an important condition to recognise in both professional and amateur sportsmen. Major sporting codes have tightened rules on concussion management and this increased awareness has filtered down to amateur and under-age sporting competitions.

The SCAT3 checklist can be a helpful symptom checklist and prompt for carers monitoring recovery. Designed for health professionals, it includes a page of information for the athlete and carers – things to watch for.

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The gentle recovery

Management of known concussion is both physical and cognitive rest – no reading, computer, electronic games, minimal TV and for children, no school. Of course, no return to sport the same day, as a minimum.

The player with more severe symptoms on game day will usually be assessed further in hospital to exclude pathology such as intracranial bleeding. A player presenting with focal neurological deficit will need imaging. Concussion symptoms can also mask co-existent periorbital fractures, occult cervical spine fractures or jaw fractures.

History After the game day, players usually present with a parent or friend who can help with the history and provide an objective report of events, particularly the nature and severity of the blow to the head. Concussion symptoms include headache, blurred vision, memory loss, dizziness, nausea/vomiting, excessive fatigue or not “feeling right�. Signs noted by observers may include – unresponsiveness, fit/seizure after hitting the ground, tonic/clonic movements of upper limbs, poor balance,

Once symptom-free at rest, activities can be slowly introduced. A progressive return to work or school may be needed if symptoms are slow to improve. confusion/disorientation, slurred speech or facial injury. Find out what management occurred on game day. If the symptoms were mild, was the patient allowed to play on? Were there any further injuries or knocks to the head? Did the symptoms change or worsen through the day? Factors associated with a higher risk of complications and needing longer recovery include:

When symptom-free and doing nonphysical activities, exercise can be slowly introduced. Initially this should be activity like light jogging that does not raise the BP or heart rate significantly. Response should be monitored over 24 hours. The player needs to remain free of symptoms as the level of exercise is progressed. For contact sports a session of controlled contact should be completed before being cleared to return to competition. O

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Preparing for Hospital

QProf Dorothy Jones

medicalforum

The Health Department has produced a video aimed at giving patients practical information about hospital admission. Going to Hospital has been developed for use on Patient Entertainment Systems and GP clinic waiting rooms, offering information ranging from what to bring and how to get there, to informed consent and medication safety. It also encourages people to see their GP after discharge for continuity of care. HoD’s Prof Dorothy Jones said the video gave patients the chance to consider things ahead of their admission, so they felt better prepared. Going to Hospital can be viewed and ordered at www.healthywa.wa.gov.au. O

37


CLINICAL UPDATE

Innovations in tissueengineered myringoplasty

By Clin/Prof Harvey Coates AO, Paediatric Otolaryngologist

T

hings have come a long way since the first attempt at repair of a Tympanic Membrane Perforation (TMP) in 1640 by Banzer, using pigs’ bladder as a lateral graft. Myringoplasties have evolved from using rubber disks and cork plasters (19th century) to the latest silk fibroin scaffolds and genetically engineered growth factors. A traumatic TMP often regenerates spontaneously, but only heals in two layers, where the absence of the central, firm and elastic layer, can lead to retraction pockets and cholesteatoma. The regular myringoplasty uses either a fascia graft or tragal cartilage, and the most common approaches are transcanal, endaural or postauricular. This surgery requires theatre time, sophisticated equipment and general anaesthetic. Furthermore, outcomes are variable and inconsistent. Recently, however, Prof Shin-ichi Kanemaru (University of Kyoto) has used tissue-engineering techniques, applying a genetically engineered basic fibroblast grown factor (b-FGF) to gel foam sealed with tissue glue (TisseelŽ). This form of myringoplasty requires only local anaesthetic (or brief general anaesthetic in children) and about eight minutes operating time.

to determine the most effective technique in repairing chronic TMP in a population of adults and children; this includes the use of an innovative silk fibroin scaffold (TymPaSilŽ) and a collagen scaffold (CelgroŽ). All these techniques implement regenerative tissue-engineering as a treatment alternative to invasive surgery and present numerous advantages – safety, surgical time (reduced by a factor of 10) and costeffectiveness. Potential problems, although highly unlikely, include cholesteatoma formation, b-FGF oncogenic potential, viral transmission with TisseelŽ (despite safe use in 5.0m surgical procedures worldwide). In early January we performed our first procedure using TymPaSilŽ scaffold in combination with b-FGF. The child was operated under general anaesthesia and the surgery was completed within eight minutes. We are reporting for the first time, success in implementing this innovative technique in repairing TMP (Picture 1).

Using this technique, our group with Prof Gunesh Rajan (UWA, Fremantle Hospital) reports an overall success rate in patient terms of 83% after a single treatment in adults, with similar success rate in children, although children required 1.3 treatments on average. The reduction in the success rate in children is due to postoperative infections or non-compliance with water precautions.

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We hope to answer important questions regarding the future of myringoplasties: t 8IBUJTUIFBQQSPQSJBUFBHFGPS5.1 repair, particularly in Aboriginal children?

Don’t Panic, Read the Manual L ike airline pilots, anaesthetists and surgeons are helped by checklists at critical points in operations and handovers. In a way, it has always been the case, with scrub nurses carefully counting instruments prior to ‘touchdown’.

QDr David Borshoff

38

Now anaesthetists and their technicians or ‘co-pilots’, have a formal set of crisis management checklists, thanks to The Anaesthetic Crisis Manual. Its author and publisher, Perth anaesthetist Dr David Borshoff, has recently returned from the US where he has been espousing the virtues of crisis checklist use. The US is

QNew Tissue engineered myringoplasty using b-FGF + TymPaSiLÂŽ. A) TMP pre-op B) Two weeks post-op; healing tympanic membrane.

A

B t )PXIFMQGVMBSFUPQJDBMTMPXSFMFBTF antibiotics in the middle ear, as well as intramuscular ceftriaxone, intra operatively? The outlook for tissue-engineered myringoplasty is bright, and once the optimal scaffold and growth factor combination is established, it will enable us to make major inroads into the large number of Australian patients who have chronic middle ear disease with perforation (estimated at over 100,000). O

Declaration: Author has no competing interests.

where Gawandes’s Surgical Safety Checklist took off and now the same Harvard study group has shown superior clinical performance using checklists in simulated operative crises. It makes sense really – some people need guidance or cognitive aids in potential panic situations. It’s all about patient safety. “I set up my own publishing company to produce the manual exactly the way I want. The Australian Society of Anaesthetists has endorsed the project and is looking to promote it as a standard in all operating theatres.� he said David hopes to see the manual attached to all anaesthetic machines in Australia, NZ and internationally. SCGH, RPH and JHC already have them in place as well as some UK and US hospitals. (See www.theacm.com.au) O

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Innovation

Kidney Exchange: Solution for Some As Nephrology head at Fremantle Hospital, Prof Paolo Ferrari is busy, particularly since live donor kidney exchange has become more popular. Kidney donation requires an organ donor. In effect, that means one of two possibilities; either someone on life support who tests ‘brain dead’ and has relatives in agreement (deceased donor) or a healthy relative or friend who agrees to have one of their kidneys removed to help someone on dialysis (live donor). For the latter, incompatibility can be a barrier to transplantation. That is where the kidney paired donation (AKX) program in Australia steps in. The program started in WA in 2007 and is now national and run by Prof Paolo Ferrari as the Australian Paired Kidney Exchange (AKX) program. AKX matches living donor-recipient pairs. That is, someone wants to but cannot donate a kidney to someone else (relative or friend usually) because of blood group or tissue type incompatibility. QProf Paolo Ferrari AKX finds a reciprocal pair in the same boat, and they exchange organs. With the alternative being dialysis or join the queue for a deceased donation, this is a no brainer for some people. “Factors that prevent tissue compatibility have not declined in importance. In fact, the number of patients who have HLA antibodies has probably increased. Previously they were not considered for transplantation because there were no means to offer this option. Also, more patients are listed for second, third, fourth kidney transplant,” Paolo explained. There have been over 175 pairs referred to the AKX registry for the quarterly matching

rounds. The computer algorithm does not use conventional tissue matching but instead uses a virtual cross-match integrating modern HLA technology, which is said to be far superior to the matching approach still used in allocating deceased donor organs (and might have something to do with the involvement of 2012 Nobel Prize Winner for economics, Alvin Roth). Information is obtained by blood test. “Compatibility is determined by looking at the blood group of donor and recipient and HLA antibody in the recipient compared to HLA antigen in the donor. In the matching, a recipient with HLA antibody specific to donor’s HLA antigen (donor-specific antibodies=DSA) will not be matched to that donor but will be matched to a donor against whom they don’t have DSA,” he explained. In effect, they ignore HLA matching so the degree of compatibility is irrelevant, as long as DSA are avoided. If DSA are avoided there is no need for plasmapheresis or stronger

immunosuppression, which is one of the major advantages of the exchange program. This makes AKX particularly good news for kidney failure patients who might otherwise miss out on a kidney transplant even from a deceased donor, due to their high level of antiHLA antibody to most prospective donors. “In practice a recipient with broad sensitisation – HLA antibody against over 90% of the population – will end up with a good match anyway,” Paolo said. Donor screening is very strict to ensure donated kidneys are good quality, there is no hanky panky (no buying a kidney from a deceased Chinese prisoner!) and donors are psychologically and medically suited. Pairs who participate in the exchange program have to sign an agreement, which among other things includes preservation of confidentiality and anonymity. They can’t make themselves known to others. Variations on a typical ‘two couples’ arrangement include someone donating without a reciprocal relative, or three couples in a swap, resulting in three donor kidneys flown to transplant units around the country – that’s six operations coordinated together on the same day. Around 80 kidney transplants have happened so far – over 10% all live donor kidney transplants in Australia – with a planned collaboration with New Zealand. As a renal physician, Prof Ferrari is acutely aware that diabetes and hypertension cause 60% of end-stage kidney disease. His ‘top three’ things for prevention are: “stop eating junk food, do some exercise, and cut down on the booze”. O

By Dr Rob McEvoy

Listen up, by the book ENT Surgeon Harvey Coates, see his clinical column opposite, has just published a fresh 2000 copies of the updated 2013 Aboriginal Ear Health Manual, sponsored by Telethon. If you have anything to do with helping Aboriginal kids overcome this problem [see Dr Deborah Lehmann’s story, December edition], the manual is not only a ‘labour of love’ by those involved, but it also offers practical explanations for important concepts, with heaps of pictures and illustrations. It has proven its worth with both national and international uptake. To obtain your free copy contact harvey.coates@uwa.edu.au

medicalforum

39


Classic Cars

Four o t s l e e Wh

s s e n i p Hap Two classic veteran doctors show Medical Forum their amazing classic car collections.

Vascular surgeon Dr John Teasdale is a serious collector of vintage automobiles but for him, it’s as much about the original owners as the vehicles themselves. i5IFSFT B SFBM TFOTF PG UIF QBTU XIFO ZPVSF ESJWJOH UIFTF DBST "T POF PG NZ TPOT TBZT  AZPV HFU UIBU GFFMJOH UIBU UIF PSJHJOBM PXOFS NVTU IBWF IBE XIFO UIFZ XFSFJOUIFDBS*UTHPUOPUIJOHUPEPXJUI TQFFEPSQPXFSBOEDFSUBJOMZOPUIJOHUPEP XJUIPXOJOHTPNFTPSUPGTUBUVTTZNCPMw i*SFBMMZFOKPZXPSLJOHPOUIFDBST5IFZIBWF BDIBSBDUFSBMMUIFJSPXO

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40

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QDr John Teasdaleâ&#x20AC;&#x2122;s special babies: Buick â&#x20AC;&#x2DC;53 Skylark (main) and, below left, his â&#x20AC;&#x2DC;historicâ&#x20AC;&#x2122; VW Convertible

QDr Frank Wilsonâ&#x20AC;&#x2122;s speed machines: Alpha Romeo; HQ Holden (left)

Long Road Leads Home

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By Peter McClelland

In 2008, the Perth International Arts Festival brought a powerful play that lifted the lid on the brutalities of modern warfare. Black Watch was written and produced by the creative team at the National Theatre of Scotland who gathered ďŹ rst-hand accounts from soldiers from the famed Scottish regiment of the same name who had returned in 2004 from a particularly vicious campaign in Iraq. /FYU NPOUI  4ZEOFZ 5IFBUSF $PNQBOZ CSJOHTTPNFUIJOHFRVBMMZNPWJOHCVUDMPTFS UP IPNF XJUI OPU POMZ UIF WPJDFT CVU UIF QSFTFODF PG "VTUSBMJBO TPMEJFST XIP IBWF SFUVSOFE GSPN *SBR  "GHIBOJTUBO BOE &BTU 5JNPS The Long Way Home is a special collabora UJPO XJUI 45$ BOE UIF "VTUSBMJBO %FGFODF 'PSDFBTBDUPSTBOETPMEJFSTQSFTFOUTUPSJFT PGUIFIPSSPS UIFQBJOBOEUIFDBNBSBEFSJF PG BDUJWF TFSWJDF BOE JT UIF PGGJDJBM TUBSU PG UIFDPNNFNPSBUJPOTPGUIFDFOUFOBSZZFBS PG8PSME8BS*

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41


Music

r e H r a e H oar R Helen Reddy:

The wo woman who sang the soundtrack of a ge generation heads to town to sing to th that hat generation’s grandchildren.

Not too many people on the planet can boast of having written and sung an anthem that defined a generation. Australia’s Helen Reddy can. Her 1972 worldwide hit, I Am Woman, may have shot her US music career into the stratosphere but it also became a catchcry for a social and political movement that rocked the establishment to its core. It’s almost impossible to conceive the women’s movement of the ’70s without that song playing in the background. )FMFO  OPX   BOE IJUUJOH UIF SPBE GPS B OBUJPOBMUPVSPG"VTUSBMJBXJUIBTUPQJO1FSUI PO "QSJM   TQPLF UP Medical Forum about UIPTFEBZTBOEXIBUUIFZNFBOUPXPNFO PGUIFOPXHFOFSBUJPOoUIFHSBOEEBVHIUFST PGUIFXPNFOTIFTBOHGPS i5IJOHT UFOE UP DIBOHF FWFSZ  ZFBST 8IBUFWFSXBTIJQBOEGBTIJPOBCMFUIJTZFBS JT PVU OFYU ZFBS  CVU UIF XPNFOT NPWF NFOU PG UIF T MBJE UIF HSPVOEXPSL BOE XFWFTFFOBMPUPGDIBOHFUBLFQMBDF TPNF TVCUMF PUIFSTOPURVJUFTPTVCUMFw

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By Ms Jan Hallam

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Wine Review

You Can Taste

Turkey Flat History

2013 Turkey Flat Rose

By Dr Louis Papaelias

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In 1847, shiraz vines were planted near Bethany Creek in the central Barossa by Johann Fiedler, a Silesian refugee seeking escape from the religious persecution taking place in Germany at that time. It was called Turkey Flat because of the large number of native bush turkeys (Australian Bustards) in the area. By 1865 the property was acquired by the Schulz family, in whose hands it has remained ever since. In addition to maintaining the vineyard, the Schulzes opened a prosperous butcher shop which, now restored, serves as the cellar door sales and tasting area.

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2012 Cabernet Sauvignon $PNJOHGSPNUIFZFBSPMEVOJSSJHBUFEWJOFZBSE UIJTXJOFIBTBOBQQFBMJOH MJOHFSJOHTBWPVSZRVBMJUZUIBUDBMMTGPSBHPPEBDDPNQBOZJOHNFBM*UBWPJETUIFPGU TFFOPWFSSJQFTXFFUOFTTUIBUDBOPDDVSXJUI#BSPTTBSFET5IFSFJTSFGJOFNFOU BOEDPODFOUSBUJPOXIJDIXJMMLFFQGPSNBOZZFBSTJOUIFDFMMBS

WIN a Doctor's Dozen! Which Turkey Flat wine comes from the unirrigated vines of the 160-year-old vineyard? Answer:

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

ENTER HERE!... or you can enter online at www.MedicalHub.com.au!

QOwner Christie Schultz

medicalforum

Competition Rules: One entry per person. Prize chosen at random. Competition open to all doctors or their practice staff on the mailing list for Medical Forum. Competition closes 5pm, March 31, 2014. To enter the draw to win this month's Doctors Dozen, return this completed coupon to 'Medical Forum's Doctors Dozen', 8 Hawker Ave, Warwick WA 6024 or fax to 9203 5333.

Name:

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

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

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

Please send more information on Turkey Flatâ&#x20AC;&#x2122;s offers for Medical Forum readers.

43


Travel

QThe Exchange Hotel sits alongside the once-booming Kalgoorlie Miner newspaper offices.

QRed earth and the movement of gravesites following infrequent downpours are some cemetery features.

Kalgoorlie K Kalgoorli l liie â&#x20AC;&#x201C; the Pit, the Pubs and the Golden Mile Take the Prospector for a round trip experience and step back in time, away from the madding crowd.

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QLawyers and doctors go back a long way.

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By Dr Bullion

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medicalforum


Conference Corner

QIf you tour the Superpit be prepared to feel insignificant amongst the scale of things.

Dates: Venue: Website:

Rural Health West Annual Conference and Trade Exhibition 2014 March 15-16 Mar Pan Pacific Perth www.ruralhealthwest.com.au

Dates: Venue: Website:

Royal Australian & New Zealand College of Psychiatrists Annual Congress May 11-15 Perth Convention and Exhibition Centre www.ranzcp.org

Dates: Venue: Website:

Rural and Remote Retrieval Conference 2014 May 15-18 Karijini National Park www.ruralhealthwest.com.au

Date: Venue: Website:

Western Australian Drug and Alcohol Symposium June 23-25 Esplanade Hotel Fremantle www.dao.health.wa.gov.au

Dates: Venue: Website:

Aboriginal Health Conference 2014 July 5-6 Parmelia Hilton Perth www.ruralhealthwest.com.au

Dates: Venue: Website:

Perth GPCE July 26-27 Perth Perth Convention Exhibition Centre www.gpce.com.au

nce C o n fe re s e Packag E BL AVA IL A

ENQUI

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NOW!

CONFERENCE WITH

A DIFFERENCE

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medicalforum

Treat your conference with a memorable and truly unique experience T : +61 8-9292 5161 | E : functions@rottnestlodge.com.au www.rottnestlodge.com.au

45


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I dream of a better tomorrow ... where chickens can cross roads and not have their motives questioned. â&#x20AC;&#x201C; Rocky the Rooster

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Ancient

Anecdotes

From FFro ro om Dr Dr John John oohhhnn Qu Q Quintner uint iinntne nner err

From: Letter to a Physician by Alton Ochsner, 1954.. The reason for the decrease in cancer of the lung after aff tteer afte er the tth he age a ge ag of fifty-five is, I believe, due to the fact that the heart earrt an aand nd bl bblood bloo loood vessels of heavy smokers are also subjected to the n noxious ooxxxio iioous us eeffects f fec ff ects cts ts ooff cigarette smoking, particularly nicotine, and thatt aass a re rresult esu ulltt ooff tth the he detrimental effects on the heart and blood vessels, llss, s, a lla large arg rge pr rge p proportion rop poorrtion tion ti on of individuals develop heart disease and coronary r y thrombosis tth hrroom mbboosssis iiss aand nd n d do do not live long enough to develop cancer of the lung. un ngg. g. 46

medicalforum


CT radiation figures weâ&#x20AC;&#x2122;d like you to notice we include a radiation dose estimate on every 128 Slice CT scan report

Imaging Central is an independent radiology practice delivering the same dose reduction technology as Princess Margaret Hospital for Children: SaďŹ re Iterative Reconstruction CARE Dose kV CARE Dose 4D Adaptive Dose Shield

Australian Adult MDCT DRLs - (95% Cl) (Dose Length Product, mGy.cm) 1200

1200

1000

1000 900

800 700

In 2011, the Australian Radiation Protection and Nuclear Safety Agency conducted the Australian National Diagnostic Reference Level Survey. The data established a measure of multi-slice detector CT doses for current diagnostic imaging practice in Australia, allowing individual practices to compare their doses against those of their peers.1 At Imaging Central, it is easy to compare our dose achieved with others as we include it on every CT report.

1 Australian Government, Australian Radiation Protection and Nuclear Safety Agency., viewed 29th Jan 2013 http://www.arpansa.gov.au/services/ndrl/index.cfm 2 Imaging Central Practice Reference Level Dose measured from Oct - Dec 2013

600

600

450 400 388

210

200

0

389

154

Head

149

Neck

Chest

National Dose Reference Levels

Head to our website for more information about our dose reduction technologies

114

Abdo Chest Lumbar Pelvis Abdo Pelvis Spine Imaging Central

.

p: 9284 6900 f: 9284 2955 w: www.imagingcentral.com.au a: 345 Stirling Highway, Claremont 6010


Arts Investment

A Creative Vision for WA With the squeeze on Government funding, arts organisations are increasingly looking at private philanthropy, including State-owned institutions such as the Art Gallery of WA. The Art Gallery of WA (AGWA) is the central hub in Perthâ&#x20AC;&#x2122;s artistic wheel. Its director, Dr Stefano Carboni, has a passion for Islamic art and a commitment to making the gallery more engaging and accessible to those who own it â&#x20AC;&#x201C; the people of WA. i'SPN B CSBOEJOH QPJOU PG WJFX "(8" IBT BMXBZT CFFO LOPXO BT UIF 4UBUF "SU $PMMFDUJPO*DIBOHFEUIBUUPYour$PMMFDUJPO CFDBVTF XFSF HSPXJOH BT B NVMUJDVMUVSBM DJUZ BOE * XBOU UP GPTUFS UIBU GFFMJOH PG JODMVTJWFOFTT 5IFSF BSF XFMM PWFS  NJM MJPO QFPQMF IFSF OPX BOE XFWF TIBLFO PGG UIF JEFB PG 1FSUI BT B EJTUBOU PVUQPTU PG "OHMP$FMUJD MJGF 5IF DJUZ JT HSPXJOH JO DPOGJEFODFw i8F IBWF BO BNCJUJPVT QSPHSBN MJOFE VQ GPS UIF OFYU GJWF ZFBST BOE XFSF XPSLJOH IBSEUPCSJOHQVCMJDBOEQSJWBUFTUBLFIPMEFST UPHFUIFSUPDSFBUFUIFHBMMFSZPGUIFGVUVSF 1FSUITNBKPSBSUHBMMFSZOFFETUPCFQSPQ FSMZGVOEFEw 1SJWBUF QIJMBOUISPQZ JT OPU BT XFMM EFWFM PQFE IFSF DPNQBSFE XJUI &VSPQF BOE UIF 64 CVU  BDDPSEJOH UP 4UFGBOP  UIF TJUVBUJPO JTJNQSPWJOH i2VJUFBMPUPGEPDUPSTBSFGPVOEBUJPONFN CFSTPGUIF(BMMFSZ CVUQSJWBUFQIJMBOUISPQZ IBTCFFOMBSHFMZDIBOOFMMFEJOUPUIFIFBMUI  FEVDBUJPOBOEDPNNVOJUZTFDUPSTXJUIUIF "SUTCFJOHTPNFXIBUOFHMFDUFEw i8" JT POF PG UIF XFBMUIJFTU TUBUFT BOE UIFSF BSF TPNF FOMJHIUFOFE QIJMBOUISPQJTUT MFBEJOH CZ FYBNQMF 5IF HFOFSPTJUZ PG UIF .D$VTLFS 'PVOEBUJPO BOE "OESFX 'PSSFTU BSF TJHOT UIBU 1FSUI JT NBUVSJOH BOE * XPVMEIPQFUIBUJOBEFDBEFXFMMCFMFBE JOH UIF OBUJPO " IFBMUIZ  XFMMTVQQPSUFE BSU HBMMFSZ JEFBMMZ OFFET  HPWFSONFOU GVOEJOH DPNCJOFE XJUI  QIJMBOUISPQZ BOE CFRVFTUT QMVT POHPJOH DPNNFSDJBM SFWFOVFw i* DBNF UP 1FSUI GSPN UIF .FUSPQPMJUBO .VTFVN PG "SU JO /FX :PSL  XIJDI JT B QSJWBUF PSHBOJTBUJPO PXOFE CZ B #PBSE PG 5SVTUFFT5IFZFYJTUBMNPTUFOUJSFMZPOQIJ MBOUISPQZ BOE JG ZPV GBODZ ZPVS OBNF PO B

48

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By Mr Peter McClelland

h Marc

The Arts and Health h

ll o P e

Q

Artistic endeavours eavours are as important to the health of a community as prevention and treatment of illness.

Strongly Disagree

7%

Disagree

42%

Neutral

28%

Agree

20%

Strongly Agree

3%

ED: With nearly half the respondents disagreeing with the proposition and less than a quarter agreeing with it, it may take some time for the arts community to convince those in the cost-pressured health system the value of the arts for their and their patientsâ&#x20AC;&#x2122; health and wellbeing. medicalforum


Competitions

Entering Medical Forum's COMPETITIONS is easy! Simply visit www.medicalhub.com.au and click on the 'COMPETITIONS' link (below the magazine cover on the left). CITROร‹N PRESENTS

Movie: The Grand Budapest Hotel )FSFT BOPUIFS DSB[Z XPOEFSGVM QJFDF GSPN EJSFDUPS 8FT "OEFSTPOXJUIBDBTUIFBWZXJUITUBST JODMVEJOH3BMQI'JFOOFT  "ESJFO #SPEZ  8JMMFN %BGPF  +VEF -BX BOE 5JMEB 4XJOUPO "U JUT DFOUSF JT (VTUBWF ) 'JFOOFT  B MFHFOEBSZ DPODJFSHF BU B GBNPVT &VSPQFBO IPUFM CFUXFFO UIF XPSME XBST  BOE ;FSP .PVTUBGB UIFMPCCZCPZXIPCFDPNFTIJTNPTUUSVTUFEGSJFOE In cinemas, April 10

Movie: The Invisible Woman 5IJT JT BO BEBQUBUJPO PG BXBSEXJOOJOH CJPHSBQIFS $MBJSF 5PNBMJOT BDDPVOU PG UIF SFMBUJPOTIJQ CFUXFFO ZPVOH BDUSFTT /FMMZ5FSOBO 'FMJDJUZ+POFT BOEXSJUFS$IBSMFT%JDLFOT 3BMQI 'JFOOFT 5FSOBOTTUPSZIBTCFFOBMMCVUFSBTFEGSPNUIFIJTUPSZ CPPLT VOUJM CSJMMJBOUMZ CSPVHIU CBDL UP MJGF CZ 5PNBMJO 'JFOOFT EJSFDUTUIJTGBTDJOBUJOHGJMN In cinemas, April 17

Movie: Chinese Puzzle 'JSTUJUXBT#BSDFMPOBGPS5IF4QBOJTI"QBSUNFOU UIFO-POEPO BOE 4U1FUFSTCVSH GPS 3VTTJBO %PMMT  BOE OPX FJHIU ZFBST MBUFS  $รESJD ,MBQJTDI UIJT UJNF XJMM UBLF IJT DIBSBDUFST UP /FX :PSL $JUZ BOE 1BSJT 5IFZ BSF MJUUMF HSFZFS  IBWF LJET CVU UIF TUPSZ JT BT DPNQFMMJOH BT FWFS 5IJT UIJSE PQVT XJMM HJWF 3PNBJO %VSJT  "VESFZ 5BVUPV  $รDJMF EF 'SBODF BOE ,FMMZ 3FJMMZ UIF DIBODF UP NFFUBHBJO In cinemas, April 17

Concert: Helen Reddy )FSIJUTPOH*"N8PNBOXBTUIFBOUIFNGPSBHFOFSBUJPOPG XPNFO BOE IFS PXO DBSFFS JO UIF 64 GPSHFE B QBUI GPS FWFSZ "VTUSBMJBO FOUFSUBJOFS BGUFS IFS )FMFO 3FEEZ XBT UIF GJSTU "VTUSBMJBO UP XJO B (SBNNZ "XBSE  IPTU IFS PXO UFMFWJTJPO TIPXBOEIBWFUISFF/VNCFSIJUTJOUIFTBNFZFBSJOUIF64 )FSFJTBSBSFPQQPSUVOJUZUPTFFIFSQFSGPSNJOQFSTPO Crown Theatre, April 17 at 8pm

CELEBRATING 25 YEARS Gold Sponsor

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Movie: Alliance Franรงaise French Film Festival *GZPVMPWFDJOFNB ZPVBSFCPVOEUPMPWFUIFFYRVJTJUF WBSJFUZPGUIF'SFODI'JMN'FTUJWBM XIJDIDFMFCSBUFT JUTUIBOOJWFSTBSZUIJTNPOUI&WFSZZFBSUIFGFTUJ WBMPGGFSTGJMNTGVMMPGSPNBODF GBSDFBOEESBNBBOE UIJT ZFBS MPPL GPS B UFSSJGJD MJOFVQ PG EPDVNFOUBSJFT BT XFMM 5IF GFTUJWBM PG 'SFODI DVMUVSF JT CSPVHIU UP "VTUSBMJBCZUIF"MMJBODF'SBOรŽBJTFJOBTTPDJBUJPOXJUI UIF 'SFODI &NCBTTZ $JOFNBT JOWPMWFE BSF $JOFNB 1BSBEJTP  /PSUICSJEHF -VOB PO 49  'SFNBOUMF BOE 8JOETPS$JOFNB /FEMBOET In cinemas, March 18 - April 6

Doctors Dozen Winner Bunn Shiraz a Joy JOF%PDUPST 5IFEFMJDJPVT #VOO8 1FSUI (1 SUI /P JT %P[FO XJOOFS  BO JEFBM *UT y ara Sah i ran Dr Ind DPOUBJOT JU F BVT EP[FO GPS IFS CFD  GBWPVSJUF IFS PG FT UBH WJO F UISF J TBZT CPUI WBSJFUZ  TIJSB[ *OESBO WFBTUSPOH IB BOE VTC FSI EI TIFBO OUI TIF NP YU /F JOUFSFTU JO XJOF GUFSUIFJS HB LJO MPP WF MFB PO XJMMCF IF #BSPTTB IFSIVTCBOE IFBET UPU UXPZPVOHTPOT XIJMF JO QB UIF TF FB FMQ MMI XJ 7BMMFZ5IF#VOOTIJSB[

Theatre: The Long Way Home 3FUVSOFE"VTUSBMJBO%FGFODFQFSTPOOFMUFMMUIFJSTUPSJFTPGXBS JOBTQFDJBMDPMMBCPSBUJPOCFUXFFOUIF4ZEOFZ5IFBUSF$PNQBOZ BOE UIF "VTUSBMJBO %FGFODF 'PSDF 5IFTF  NFO BOE XPNFO KPJO BDUPST UP DSFBUF B VOJRVF FYQFSJFODF GPS BVEJFODFT BDSPTT UIFDPVOUSZJOQFSGPSNBODFTUIBUNBSLUIFTUBSUPGUIFDFOUFOBSZ DPNNFNPSBUJPOTPG8PSME8BS* His Majestyโ€™s Theatre, April 11-12

WINNERS FROM THE DECEMBER ISSUE The Rocky Horror Show โ€“ Musical Theatre:%S$ISJT(VOOFMM Dr Seussโ€™ Cat in the Hat โ€“ Childrenโ€™s Theatre: %S5POZ-PVSFOTFO The Railway Man โ€“ Movie:%S3JDIBSE#FOTUFBE %S.JDIFMMF#FOOFUU %S,BUSJOB(V[EFS %S.BZ"OO)P %S,BSFO1SPTTFS %S&SJD,IPOH %S/BSFMMF7VKDJDI .S3BZ#BSOFT .T(BCSJFMMB5BMMNBO %S)FSUIB$PMMJO Horrible Histories: Awful Egyptians โ€“ Childrenโ€™s Theatre:%S5BOZB4UPOFZ %S.PIBO+BZBTVOEFSB The Book Thief โ€“ Movie:%S4UFQIFO3PESJHVFT %S)FMFO4MBUUFSZ %S%FSFL+PIOT %S/JDLZ&OEBDPUU %S4UFQIFO"EBNT %S"OHFMP$BSCPOF %S*BO8PPE %S#PFZ-FOH-PZ %S3PCFSU8FFEPO %S.BSJB1PXFS

medicalforum

Review The Illusionists: Reviewed by Dr Mandy Croft (1 %S .BOEZ $SPGU IBE OFWF S CFFO UP B NBHJD TIPX  TP XIFO TIF XPOUJDLFUTJOMedical Forum UPTFF5IF*MMVTJPOJTUTBUUIF$SPXO 5IFBUSFJO+BOVBSZ  TIF XFOUXJUI BOPQFONJOE4IFBMTPXFOUXJUI IFSZFBSPMEEBVHIUFSo BOE BTF WFSZQBSFOUBOEBDUPS DBOBUUFTU UIBUTUIFIBSEFTUBVEJFODF PGBMM#PUINPUIFS BOEEBVHIUFSMPWFEUIFTIPXi5I FSFXFSFUSJDLTUIBUZPV XFSFMJUFSBMMZHPJOHAIPXEJEUIFZEP UIBUyUIFJMMVTJPOJTUT XFSFTPHPPEBOEUIFTIPXXBTTP TMJDL w.BOEZTBJEi*U XBTBMTPWFSZGVOOZ1VSFFOUFSUB JONFOUw

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medical forum GENERAL EMG Machine (Keypoint Medtronic) portable Fully computerised (Toshiba), complete with Cart & printer and all necessary software. Used minimally ie. as new Cost $28,000 Sell $12,000 ono Phone 9381 9934 or 0431 369 292

FOR LEASE MURDOCH Murdoch Specialist Centre, brand new stylish large rooms. Please email you interest to admin@sleepmed.com.au WEST LEEDERVILLE Sessional rooms available, mornings or afternoons. Close proximity to SJOG. Ample parking (12 bays) Contact Liz 0438 924 710

MURDOCH New Wexford Medical Centre â&#x20AC;&#x201C; St John of God Hospital 2 brand new medical consulting rooms available: t TRNBOETRN t %VFGPSDPNQMFUJPO.BSDI t DBSCBZQFSUFOBODZ Lease one or both rooms. For further details contact James Teh Universal Realty 0421 999 889 james@universalrealty.com.au WEST PERTH t .PEFSOVQNBSLFU.FEJDBM3PPNGPS lease (16sqm) t 4VJU.FEJDBM4QFDJBMJTU%STBOEPS allied health t -BSHFSFDFQUJPO XBJUJOHSPPN BMGSFTDP area, shared with existing clinic t 1SFNJTFTMPDBUFEJO8FTU1FSUI t 4LJO.BOBHFNFOUBOE$PTNFUJD  Medicine Clinic operate in the same building t 1BSLJOHBWBJMBCMF CBZ

Phone: (08) 9481 3366 Email: louise@alnour.com.au

AVELEY Suitable for dental practice and/or allied health services (eg. Physiotherapy, Psychology, Podiatrist, Radiology etc). Medical centre located in the same building. Located in a fast growing community beside a shopping centre, close to secondary schools, primary schools, church and Child Care Centre. Contact: 0400 814 091

WEST LEEDERVILLE

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FOR SALE 2 MEDICAL SUITE(S) 10 McCOURT STREET WEST LEEDERVILLE 2 x 61sqm medical suite(s) with two car bays each. New carpets & paint work and ready for immediate occupation. GORDON TUCKER R/E 0408 093 731 gtrealestate@iinet.net.au

PSYCHIATRIST WANTED

Doctors Consulting Suites. Part or Whole Building (up to 250 sq m) Onsite Parking Easy Access to Freeway and Bus/Train Services Phone 9380 6457

MURDOCH Brand new Medical Suite for Lease at the new Wexford Medical Centre. 106 sqm, complete fit-out and one car bay. Ready to lease by June 2014 Please contact: reception@ccwa.net.au BEACONSFIELD Opportunity to lease recently renovated rear building adjacent to established medical practice. Approx 100sqm total which includes 2 large consulting rooms with shared reception area and toilet with onsite pathology collection centre. In prime location on South Street, with close proximity to St. John of God Murdoch, Fiona Stanley Hospital & Fremantle Hospital. Contact E-Mae Lim 0423 282 762 / 9335 9884 SUBIACO Fully supported Sessional Suites available in modern office - Churchill Avenue. Good sized consulting rooms, reception and waiting area. Parking space included. Phone: Lorraine 6380 1441 for further information or Email: admin@mercyanaesthetics.com.au SHENTON PARK Fully supported consulting room for lease. One or two consulting rooms, waiting room and secretarial area. Available between 1-4 sessions a week. Easy access and plentiful free parking for staff and patients. Tel: 0400 810 953 or 0458 700 151

BIBRA LAKE - Psychiatrist wanted Are you intending to start Private Practice? This is a sheer walk in! Part time, sessional or full time - all enquiries welcome. Furnished consulting rooms available at: Bibra Lake Specialist Centre, 10/14 Annois Road, Bibra Lake WA 6163 Existing private psychiatrist one day a week at this location. 7-day pharmacy and GP surgery next door are added advantages. 5 minute drive to St John of God and upcoming Fiona Stanley hospital. Phone Navneet 9414 7860

URBAN POSITIONS VACANT FREMANTLE General Practice in Fremantle requires VR GP FT or PT for privately owned family practice. Accredited, computerised with full-time Nurse support. Phone: Practice Manager 9336 3665 BALLAJURA Northern Suburbs: DWS Area: Ballajura Permanent/part time GP wanted Ballajura Medical centre Mixed billing, busy practice, nursing staff, Best Practice, lots of potential. Female GP will be preferred 0488 222 238/chibilitism@yahoo.com

MANDURAH Mandurah coastal lifestyle 40 minutes from Perth. VR non VR doctor required short term or long term. No weekends or after hours. Good remuneration. Clinic has full time nurses, pathology, psychology, hearing centre, dermatologist and orthotics. Contact practice manager Elaine 9535 8700 Email: elaine@mandurahdoctors.com.au

LANGFORD (Qualifies as DWS) Langford Medical Centre is looking for a full time GP to commence in Feb/March 2014. We are a modern, well equipped, accredited mixed billing practice. Situated south of the river, Langford is one of the closest practices to the CBD that still qualifies as a district of workforce shortage. For confidential enquiries please contact PM Rita on 9451 1377 SORRENTO V/R GP for a busy Medical Centre in Sorrento. Up to 75% of the billing Contact: 0439 952 979 FREMANTLE Fremantle Womenâ&#x20AC;&#x2122;s Health Centre requires a female GP (VR) to provide NFEJDBMTFSWJDFTJOUIFBSFBPGXPNFOT health 1or 2 days pw. It is a computerised, private and bulk billing practice, with nursing support, scope for spending more time with patients, and provides recently increased remuneration plus superannuation and generous salary packaging. FWHC is a not-for-profit, community facility providing medical and counselling services, health education and group activities in a relaxed friendly setting. Phone: 9431 0500 or Email: Diane Snooks - director@fwhc.org.au or Dawn Needham clinical-manager@fwhc.org.au

Reach every known practising doctor in WA through Medical Forum Classifieds...



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APRIL 2014 - next deadline 12md Friday 14th March - Tel 9203 5222 or jen@mforum.com.au


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medical forum

HILTON GP. Wanted / Sessional/ P/Time VR. GP. to join 25yrs established General Practice in the Hilton area; (1T"DDSFEJUFE$PNQVUFSJTFEXJUI fulltime nurse support. Service growth potential. Contact Practice Manager on 9337 8899 JOONDALUP CANDLEWOOD MEDICAL CENTRE GP required to join our friendly team for After Hours work immediate start Weekdays 6 â&#x20AC;&#x201C; 9pm and Saturday 12 - 5pm Very Attractive remuneration Privately owned, AGPAL accredited general practice Fully computerised Contact Michelle 08 9300 0999

WOODLANDS Woodlands Family Practice Great opportunity for FT/PT VR doctor in a well-run, newly extended, inner metro, mixed billing, privately owned practice. Call Dr Mary McNulty or Dr David Jameson, 9446 2010 or email laura@wfpwa.com.au

NORTH PERTH View Street Medical requires a GP F/T or P/T. We are a small, privately owned practice with a well-established patient base, computerised & accredited with nurse support. Ring Helen 9227 0170 MANDURAH GP required for established, accredited Practice. Large client base, newly renovated, private practice. Well-equipped medical centre staffed by experienced Registered Nurses. Generous remuneration. No DWS please. No on-call. Contact Ria 9535 4644 Email: mandmedi@wn.com.au MT HAWTHORN Mt Hawthorn Medical Centre requires a PT/FT VR GP to join our privately owned practice with a well-established patient base, computerised & accredited with nurse support. A monetary incentive after 12 months service with us. Phone Rose 9444 1644

Osborne City OSBORNE CITY OSBORNE CITY MEDICAL CENTRE requires a GP. Flexible hours, excellent remuneration. Modern, predominantly private billing practice with full time Practice Nurse. Fully computerised. Please contact Michael on 0403 927 934

NORTH BEACH Close to the beach! Opportunity for a P/T or F/T GP to join our privately-owned practice. Flexible hours and mixed billing. "OJOUFSFTUJOXPNFOTIFBMUIBO advantage. On site pathology, psychologist and nurse support. Please contact Helen or David 9447 1233 to discuss or Email: reception.nbmc@ bigpond.com

KARDINYA Kelso Medical Group requires P/T GP (DWS after hours only). This long established privately owned and managed mixed billing practice offers great opportunity for doctor with interest in CDM and minor surgical procedures. Located in Kardinya in newly refurbished premises with onsite pathology and allied health with growing patient base. $VSSFOUMZTVQQPSUFECZ(1TBOE3/T www.kelsomg.com.au Please call 0419 959 246 for further information.

PALMYRA Palin Street Family Practice requires a full or part-time VR GP. We, at this privately owned fully serviced computerised practice enjoy a relaxed environment with space and gardens. Earn 65% of mixed billings. For further information call Lyn on 9319 1577 or Dr Paul Babich on 0401 265 881.

CLOVERDALE PT/FT VR General Practitioner required for established practice. Predominantly bulk-billing, Full-time RN. Non-Corporate Medical Centre situated in a Medical Complex. Located next door to Chemist, Physiotherapist and Pathology. Remuneration of 65% of income. Phone Anne 0421 128 144 GIRRAWHEEN Doctors required for The New Park Medical Centre Girrawheen. Opened in February 2014 - we are seeking '5BOE15(1TUPKPJOUIFUFBN Enquires to Dr Kiran on 0401 815 587 Email: kiranpkumar@hotmail.com NEW PRACTICE - Inner Northern Suburb Located in an inner northern suburb, approximately 5 mins from the CBD. In a prime location on a main road, with good exposure and ample parking at the front and rear. Also next door to a 7-day pharmacy. With recent retirements in the area, this is the perfect opportunity for an enthusiastic GP or group of GPs. Generous percentage offered and interest in ownership considered. Administrative and nursing services will be provided, along with pathology collection on-site. Opening April 2014. Call 0414 287 537 for details. KOONDOOLA VR GP required for a well-established, privately owned, purpose built practice with onsite pathology and pharmacy. DWS status. Please email groupmanager@westnet.com.au

We make Aged Care work for GPâ&#x20AC;&#x2122;s Medical Practitioners for Aged Care (MP+AC) is seeking doctors to join its team providing medical services to residents of various Residential Aged Care Facilities throughout the Perth metro area. Our efficient service delivery model NBYJNJTFTUIFEPDUPSTFBSOJOHQPUFOUJBM t 'MFYJCMFTFTTJPOT.POEBZUP'SJEBZ t (SFBUBENJOTDIFEVMJOHTVQQPSU t 3FNPUFMPHJOUPQBUJFOUSFDPSET t 3/QSPWJEFECZ.1 "$UPBTTJTUEPDUPS t #FUUFSVUJMJTBUJPOPGEPDUPSTUJNF t 1BZNFOUPGHSPTTSFDFJQUT t &RVJUZJOWPMWFNFOUQPTTJCMF For more information or confidential discussion about work options please contact Rollo Witton â&#x20AC;&#x201C; Chief Executive Officer - MP+AC Tel. 9389 8291 or Mobile 0417 921 632 or Email: rollo@mpfac.com.au BALGA Balga Plaza Medical Centre has now opened in the Balga Plaza shopping centre and is steadily growing. We are in the process of expanding, and looking for enthusiastic GPs to be part of this exciting process. Generous locum percentage offered and interest in ownership considered. Contact - balgaplazamedical@gmail.com Phone: 0427 794 419 PERTH CBD Full and part time VR GPS to join our busy inner city practice located in the Hay Street Mall. Non corporate, mainly private billing, accredited, fully computerised with full admin and nursing support and on-site pathology. Flexible hours and high earning potential for suitable candidates. Please contact Debra on 0408 665 531 to discuss or Email: drogers@perthmedicalcentre.com.au MOSMAN PARK Full or Part time GP wanted. A rare opportunity to join a friendly, noncorporate, fully computerised practice in Mosman Park. Hours and days flexible. Remuneration - 70% of gross billings. Tel: Tabs on 9385 0077

PERTH GP Opportunity Do you enjoy travel? Are you looking for an alternative to General Practice? Travel Medicine may be for you. t 5SBJOJOH1SPWJEFE t (PPEJODFOUJWFT t &YDFMMFOUUFBN t &TUBCMJTIFEOBUJPOBMOFUXPSLPGUSBWFM clinics providing excellent support t 4FTTJPOBMIPVST t 0OHPJOH&EVDBUJPOJTFODPVSBHFE t 5SBWFMNFEJDJOF5SPQJDBM.FEJDJOF Occupational medicine We require: GP â&#x20AC;&#x201C; VR an advantage. Team Player Send resume to anthony.pace@medibankhealth.com.au BENTLEY Rowethorpe Medical Centre is a nonprofit, friendly practice seeking a part time GP to provide visits to our onsite residential aged care facilities. Practice-based consultations are also available. t 'VMMZDPNQVUFSJTFE t /FXMZSFOPWBUFEQSFNJTFT t .PEFSOFRVJQNFOU t 0OTJUFQBUIPMPHZ t )PVSTUPTVJUZPV For enquiries, please contact Jackie on 6363 6315 or 0413 595 676 BULL CREEK PT/FT VR GP required for Accredited, Privately owned, Friendly Family Practice. Please call â&#x20AC;&#x201C; 9332 5556

WEST PERTH FT GP required for our friendly, accredited and fully computerised general practice. Our busy practice serves a young, professional demographic as well as providing specialist sexual health services. With one of our doctors moving on this provides an exciting opportunity for an enthusiastic practitioner to join our practice with an established patient base. VR with interests in family planning and sexual health preferred. Contact Stephen on 0411-223120 Email: stephen@westperthmedicalcentre.com.au

NEDLANDS Full time or sessions available for VR GP in non-corporate family practice. Predominantly private billing, weekends optional. Close to UWA in shopping centre, in the process of being accredited. Full time practice nurse, care-plans, immunisation, ECG/Spiro. Please contact Suzanne at 9389 8964 or Email: nedlandsdoctor@yahoo.com.au

APRIL 2014 - next deadline 12md Friday 14th March - Tel 9203 5222 or jen@mforum.com.au


medical forum VR GP Required for NEW PRACTICE located in an ASGC-R2 location east of Perth. This brand new practice is the perfect opportunity for a GP to work in the inner regional area of Perth located approximately 45 mins from the CBD. This large community with no current TFSWJDJOH(1TJTMPDBUFEOFYUEPPSUPB busy pharmacy and can accommodate 2 GVMMUJNF(1T Admin and nursing services will be provided along with pathology onsite. Relocation incentive may apply to this location. For more information please call 0419 959 246 Email: admin@ppdgroup.com.au THORNLIE VR GP required for an AGPAL accredited, computerised, non-corporate practice. Full time nursing support. No after- hours. Friendly support staff. Rapidly growing patient base. Outer Metro Visa 457 sponsors. Excellent remuneration and conditions. Contact: 9267 2888 / 0403 009 838 Email: thornliemedicalcentre@hotmail.com

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Are you looking to buy a medical practice? As WAâ&#x20AC;&#x2122;s only specialised medical business broker we have helped many buyers find medical practices that match their experience.

DUNCRAIG DUNCRAIG MEDICAL CENTRE requires a female GP (existing patient base as Lady Dr moving to Albany) Flexible hours, excellent remuneration. Modern, predominantly private billing practice with full time Practice Nurse. Fully computerised. Please contact Michael on 0403 927 934 Email Dr Dianne Prior: dianne@duncraigmedicalcentre.com.au

You wonâ&#x20AC;&#x2122;t have to go through the onerous process of trying to find someone interested in selling.

To find a practice that meets your needs, call:

Brad Potter on 0411 185 006

Youâ&#x20AC;&#x2122;ll get a comprehensive package on each practice containing information that you and your advisers need to make a decision. Weâ&#x20AC;&#x2122;ll take care of all the bits and pieces and youâ&#x20AC;&#x2122;ll benefit from our experience to ensure a smooth transition.

Suite 27, 782 - 784 Canning Highway Applecross WA 6153

Ph: 9315 2599 www.thehealthlinc.com.au

Are you a general practitioner looking for a tree and sea change opportunity? A fantastic opportunity is available for a general practitioner who would like to operate their own practice and have time to enjoy the beautiful surrounds of this wonderful location. Walpole, located in the beautiful south west, is a small inclusive and supportive rural community surrounded by stunning national parks and peaceful inlets. Servicing a permanent population of around 700, the practice would operate three days per week, providing plenty of time to enjoy the relaxed lifestyle. The GP Clinic is located within a community health facility. Equipment, practice support and housing may be provided by negotiation.

If you are interested in this unique opportunity contact Rural Health West today! E recruit@ruralhealthwest.com.au T 08 6389 4500 W www.ruralhealthwest.com.au

APRIL 2014 - next deadline 12md Friday 14th March - Tel 9203 5222 or jen@mforum.com.au


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85% take home,

Lucrative opportunity, modern practice in friendly town Take this excellent opportunity to operate your own general practice in a newly refurbished accredited medical centre in the friendly, picturesque town of Corrigin. The successful candidate will receive comprehensive general practice business support through an innovative initiative of the surrounding Shires. Support includes assistance with recruitment, accounting, IT, human resources, service coordination and corporate services. The Corrigin Shire provides a house, car and practice infrastructure. Candidates may also be eligible for payments through the Southern Inland Health Initiative. For further information please contact Rural Health West on 08 6389 4500 or email recruit@ruralhealthwest.com.au quoting RHWCOR1.

www.ruralhealthwest.com.au

enjoy flexible hours, less paperwork, & interesting variety...

Equipment Provided - WADMS is a Doctors’ cooperative Essential qualifications: s General medical registration. s Minimum of two years post-graduate experience. s Accident and Emergency, Paediatrics & some GP experience. så så så så

Fee for service (low commission).så Non VR access to VR rebates. 8-9hr shifts, day or night. så Bonus incentives paid. 24hr Home visiting services. så Interesting work environment. Access to Provider numbers.

Contact Trudy Mailey at WADMS

(08) 9321 9133

F: (08) 9481 0943 E: trudy.mailey@wadms.org.au www.wadms.org.au WADMS is AGPAL registered (accredited ID.6155)

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

APRIL 2014 - next deadline 12md Friday 14th March - Tel 9203 5222 or jen@mforum.com.au

Supplement your income: Are you working towards the RACGP? – we have access to provider number for After Hours work. Are you an Overseas Trained Doctor with permanent residency and working toward RACGP? - we have access to provider number for After Hours work.


medical forum

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Specialists – opportunity for easy private practice in Fremantle! Ellen Health (Ellen Street Family Practice) will be moving from 59 Ellen Street Fremantle, to the beautiful old Beacon Theatre - 69 Wray Avenue (corner Hampton Road), Fremantle, co-located with pharmacy, pathology and allied health. Doctor-owned and managed, Ellen Health is a multi-disciplinary team, providing excellence in health care. We invite specialists to join the team, offering an instant referral base with our established general practice, and with the ease and comfort of fully serviced new rooms.

We are recruiting specialists and VR-GPs now. Enquiries to Dr Catherine Douglass 0421 520 767 www.ellenhealth.com.au

ARE YOU

READY FOR

A CHANGE?

Looking for dedicated GP’s and Specialists who love the South West and want to stay – move across to our state of art practice – we have oodles of space. You can have your own room. Excellent working conditions with limited after hours needed through Bunbury After Hours GP Clinic. Contact Dr Brenda Murrison for more details!

9791 8133 or 0418 921 073

COMPRESSION GARMENTS

Are your patients at risk from travel? t Long distance travel increases deep vein thrombosis (DVT) risk. Seated immobility is a common cause of venous embolism (clot). Commonly called “Economy Class Syndrome”, this can occur after journeys by car, bus, train or air. t Symptomless DVT affects up to 10% of long distance travellers. t Wearing graduated compression stockings reduces DVT risk by 68% VENOSAN® compression garments can help: t Travel socks reduce DVT risk and swelling of the ankle and feet on long journeys (a minimum of 20mmHg compression is recommended to be effective).

Travel Socks SOCKS | STOCKINGS | ARMSLEEVES S Simple preventative measures include: t Wear proper and correctly fitted medical graduated compression socks. t Compression arm-sleeves are recommended for patients travelling post breast cancer treatment. t Certain medical conditions or medication may increase risk of blood clots or there may be contraindications for wearing compression. (eg. diabetes). Only wear on Doctor advice.

Looking for a sea change? We may have the job for you. If you have finished your GP training or looking for a subsequent term placement or an experienced GP looking for a change for the better, phone Jill on 08 97521133 or email

t Stay hydrated – drink plenty of water and other non-alcoholic drinks. t Do not over-eat. t Exercise your legs. t Wear loose fitting, non-restrictive clothing.

jill@busseltondoctors.com.au. Busselton is located on the pristine shore of Geographe Bay in the Margaret River Wine Growing region, just a short 2 hour drive from Perth.

Your WA Consultant – Jenny Heyden RN

Tel 9203 5544 54 44 4 4 or Mob 0403 350 810

APRIL 2014 - next deadline 12md Friday 14th March - Tel 9203 5222 or jen@mforum.com.au


Medical Forumwa 03/14 public edition  

Western Australia's premier independent monthly magazine for health professionals

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