Calm Waters Our wish for 2016
t Parenting Under Ice t Medical Board Fairness t Midland Public Opens t Clinicals: Adrenal Fatigue, Travel Medicine etc t Christmas Greetings, Letters & Humour
DECEMBER 2015 www.mforum.com.au
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Electioneering or a Sign of Things to Come? One thing Paris has forcefully brought home is that to control the outcome requires a balanced focus on the process. Health is somewhat similar. You have to get the balance right. Too much emphasis on the process and you end up with an unresponsive system plagued by paperwork and protocols. On the other hand, if the profession ignores the integrity of the process, behaviours such as bullying can become part and parcel of how we do things. Thankfully, most in the profession are looking for balance – evidence-based medicine (our process) that leads to measureable health results (our outcomes). To see how this is travelling, we must insist on transparency and accountability. Patient care is what matters most. When we write about fairness and balance in tackling doctors who conﬁne their work to a special interest area (see P18) we always have one eye on the safety of patients. Last edition we wrote brieﬂy about the MDA National Mutual Board elections, with three of the six candidates from WA and all with strong AMA credentials. Given that MDA has done deals with AMA State branches in Victoria and Queensland, MDA doctor owners – less than half are in WA – are entitled to ask how this might impact them. The AMA is a political lobby group among other things. I wrote to all MDA candidates and four responded to my questions about the advantages and disadvantages of an MDA-AMA association. The candidates said the potential advantages were to increase MDA membership, improve collaboration to better protect doctors, strengthen advocacy on key medico-political and medico-legal issues, share resources, experience and knowledge, use the combined ability and inﬂuence of both organisations (e.g. to affect public policy to the advantage of doctors), and to inﬂuence the insurer to protect doctors ahead of containing insurer costs. The boundaries became more blurred as potential disadvantages were discussed. Two candidates said joint members would receive beneﬁt, with one saying it depended on the agreement but it was important that non-AMA members were not disadvantaged. They said potential disadvantages occur if doctors disagree with AMA policy or advocacy and consider the alliance politically motivated. That’s an important point. Can non-AMA members feel reassured they will get the same treatment from MDA as AMA members? Ten days out from this election, the president of the AMA in WA Dr Michael Gannon emailed me (a non-AMA member) and other doctors, imploring us to vote in the upcoming
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election. I wasn’t the only one who, on ﬁrst impression, felt the email had gone to all MDA members. But when I asked Dr Gannon, he didn’t know who the email had gone to. He said he would ﬁnd out and ring me back but didn’t. When I phoned him six days later he said the email had gone to every doctor in Western Australia on the AMA WA database. And the reason they hadn’t applied for the MDA members list was they had so much trouble getting it the last time. If voting patterns repeat themselves and only 10% of MDA members vote, with the three interstate candidates unknown to most WA doctors, the email would not have done the election prospects of the three local candidates any harm. The CEO of MDA thought it was just the AMA in WA lobbying for its people and one interstate candidate Dr Rob McEvoy agreed. Who are we talking about? One of the three WA candidates was the current vice-president of AMA WA, the other a past president, and the other a current AMA Councillor and past president. This might just be electioneering but if this is an example of how the AMA is going to do business with MDA, shouldn’t members have a right to query what is going on? One thing is for certain, legal expenses inﬂuence what Medical Defence Organisation (MDOs) like MDA National do. The AMA in WA perhaps sees the writing on the wall as it is now offering legal costs insurance to its members that will cover, among other things, disputes with Medicare, AHPRA and the Medical Board – all at a $220 discount to AMA members. MDOs are owned by their doctor members who show unusual loyalty for the long term, which may be why they are offered low insurance premiums and various sponsorships when in training, before substantial risks arise. But like banks, MDOs may be set to lose customer loyalty. WA doctors are entitled to ask any MDO if it offers the best cover for their circumstances, if it is leveraging off the strength of existing loyal members to grow business elsewhere, and if it offers timely advice in the form they want. The difﬁculty is getting independent advice from a broker who knows.
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DECEMBER 2015 | 1
December 2015 14
FEATURES 14 Spotlight: Photographer Richard Woldendorp 16 Trailblazer: Dr Tim Chappell 18 WA Case Report: Medical Board 22 Giving Hope to Kids 25 Midland Public Hospital
LIFESTYLE 54 Mongolian Adventure Mr Peter McClelland 56 Laugh Lines Ms Wendy Wardell 56 Funny Side Christmas Sparklers 57 Wine: Dr Louis Papaelias
NEWS & VIEWS 1 Editorial: Electioneering or a Sign of Things to
58 60 61 62
12 37 43 49 51
Come? Dr Rob McEvoy Letters: Bureaucracy’s Priorities on Display Dr Robert Davies Transparency Urgently Needed Dr Michael Marsh United Stand Beneﬁts Members Mr Ian Anderson NDIS Must Have Sector Input Ms Julie Waylen Carers Have Rights Ms Rosie Barton Ageism – One ‘Ism’ Too Many Dr Penny Flett Collaborative Research Is Key Dr Tom Brett Early Diagnosis, Better Outcomes Ms Catherine Greenway
Travels Tales: Dr Simon Moss, Dr Ross Agnello, Mr Lindsay Green Messiah #130 Ms Jan Hallam Social Pulse: Rural Health West Competitions
Christmas C hririsstm Greetings Gr G reetinngg Christmas Greetings Feature pp27-36
Feature Fe F eattuure
Have Your Heard? Dr Serge Toussaint: Sharing Wisdom Beneath the Drapes Anaphylaxis Tips Surgery to Art Gallery
MAJOR SPONSORS 2 | DECEMBER 2015
Dr Smathi Chong Fever in Travellers – When to Investigate
Dr Rachel Hughes WA Youth Cancer Service
Dr Brett Sillars “Adrenal Fatigue”
Dr Camile Farah Oral Cancer
Dr Peter Burke Meningitis Vaccination in Travellers
Dr Kate Borchard Scarring Alopecia in Women
Dr Alan Donnelly New Approaches To Psoriasis
Premier Colin Barnett opened the SJG Midland Public Hospital, which plans to service 75% of local residents in its 307 beds. The expected 102,000 outpatients and 60,000 ED patients in the ﬁrst year may see a glimpse of the nearby GP Superclinic, which was taking advantage of the opening with prominent signage. The nearby proposed Curtin Medical School was also mentioned. New Federal Assistant Minister for Health Ken Wyatt represented the feds who came up with half the development funds and the hospital just happens to be in his seat of Hasluck. Both he and Kim Hames said the privatepublic partnership would bring local people (which includes a quarter of Perth’s Aboriginal population) the quality of private hospital service in a public hospital. Everyone hopes it can live up to the hype.
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Anonymous Ice Addiction Can Be Helped
Mr Jason Micallef Planning for Innovation in Health
Ms Amelia Harray Healthy Eating Good for the Planet
INDEPENDENT ADVISORY PANEL for Medical Forum John Alvarez (Cardiothoracic Surgeon), Peter Bray (Vascular Surgeon), Chris Etherton-Beer (Geriatrician & Clinical Pharmacologist), Joe Cardaci (Nuclear & General Medicine), Alistair Vickery (General Practitioner: Academic), Philip Green (General Practitioner: Rural), Mark Hands (Cardiologist), Michele Kosky AM (Consumer Advocate), Olga Ward (General Practitioner: Procedural), Piers Yates (Orthopaedic Surgeon), Stephan Millett (Ethicist), Kenji So (Gastroenterologist) MEDICAL FORUM DECEMBER 2015 | 3
Letters to the Editor
Bureaucracy’s priorities on display
work in the public hospital system, I eventually forced a hearing with the Medical Board. They found in my favour as all patients had excellent outcomes. No restrictions were placed on my registration by AHPRA, which remains today.
During this whole episode, my appeals to relevant people in high public life led to the matter being referred back to the original source and the basis of my complaints remained uncovered. In my case, I couldn’t have persevered without my Medical Defence Organisation, partly because of the costs involved.
So the Sir Charles Gairdner and Osborne Park Health Care Group have announced their new “high-level Strategic Plan”, outlining their “Vision”, “Motto”, “Values” and “Mission” following input from “focus groups”, a “values survey” and a “strategy day held in July”. Meanwhile none of my dictated outpatient letters to General Practitioners and other referring doctors had been typed at Sir Charles Gairdner Hospital for a year. I feel that I am trapped in an episode of Utopia. Dr Robert Davies, urologist, West Leederville
From my harrowing experiences I concur that the appointment of practitioners on these boards needs to be open to scrutiny and they should have training in the investigative and forensic nature of medical complaints. Dr Michael Marsh, General Surgeon (ret), Floreat ........................................................................
Transparency urgently needed
United stand beneﬁts members
I commend the editorial Should Doctors Worry? (November edition).
We appreciate the story on the upcoming MDA Mutual Board election (MDA National Election and AMA Alliances, November).
The various committee members of AHPRA, Medical Boards, Medical Appeal Panel Committees, Clinical Review Panels, and Solitary Investigators are from a select group of medical practitioners who control who is appointed to these committees. Being recognised leaders in their particular ﬁeld of medical practice does not necessarily mean they have highly developed skills in investigative techniques when assessing complaints against their colleagues. After a series of events that spanned four years and followed a complaint about my
DISCLAIMER Medical Forum is published by HealthBooks as an independent publication for the medical profession in Western Australia.
The statement that “all MDOs are ﬁnding it hard going under the ﬁnancial burden that AHPRA and the new National Law have created” is perplexing and risks misleading readers. MDA National enjoys a strong ﬁnancial position, including our recent result for the 2014/15 ﬁnancial year, which enables us to invest in the scale and quality of the services we provide. In addition, we enjoy a strong culture of compliance, meeting the requirements of all regulatory stakeholders in our industry and working with our members to assist them to practise safely within their own regulatory framework. We believe that Australia’s MDOs understand that we share a competitive market, and that doctors choose their MDO based on the ability of each to support their needs and protect their interests and promote the medical profession.
Mr Ian Anderson, CEO, MDA National
We also appreciate the reference to our new strategic alliances with several of the State AMAs. MDA National promotes safe medical practice by informing, educating and supporting our members through a variety of channels, including our industry alliances. We believe a signiﬁcant part of our organisation’s success is our collaborative approach with like-minded membership organisations. This includes various colleges, societies and associations, and therefore extends well beyond the State AMAs.
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.
We believe we can achieve better outcomes for our members and the broader community when we work collaboratively.with like-minded organisations.
This includes supporting our individual members if they need to respond to investigations initiated by AHPRA.
Let's just say that on this day, a million years ago, a dude was born who most of us think was magic. But others don't, and that's cool. But we're probably right. Amen.
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NDIS must have sector input Dear Editor, The disability sector faces substantial change and is at a critical juncture as we look ahead to the rollout of the National Disability Insurance Scheme. This transition must be successfully navigated if the potential of the NDIS is to be fully realised. Representing 105 disability service providers across WA, National Disability Services is uniquely placed to advocate for an NDIS model based on the core principles of choice, control and subsidy for people with disability. continued on Page 6
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4 | DECEMBER 2015
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Letters continued from Page 4 In our Pre-Budget Submission, we urged the State Government to commit to a rollout of the NDIS across WA with these principles at the forefront. Experience over many years has shown that local management results in good and sensible outcomes. It is vital that the NDIS be designed so that decision-making and accountability is from the citizens it impacts, giving them the strongest inﬂuence on the conditions that make up their lives. To ensure sustainability, it must give people with disability and the disability services sector a strong voice in the practical design of the NDIS. NDS WA is supportive of the unique NDIS trial arrangements in WA involving the NDIA model in the Perth Hills and the NDIS My Way model in the Lower South West and Cockburn/ Kwinana. The evaluations of these two trial sites can inform the transition to the NDIS, which should also be supported by credible evidence-based data and underpinned by comprehensive engagement with the disability services sector and people with disability. NDS WA recommends that the State Government develop a Disability Services Industry Plan and establish a NDIS Sector Innovation Fund to build a strong disability services sector that provides choice. The NDIS is a huge reform but its shape and form must meet the needs of people with disability in WA.
Carers have rights Dear Editor, I read with interest, (In It Together Until the End, November) Firstly, it was pleasing to know that WA Health consulted with carers and consumers before discussing end of life choices and planning at a clinical senate debate. The opportunity for clinicians to hear real stories and gain insight into the issues carers face when their loved one is admitted to hospital is a step in the right direction towards closing the communication gap between medical staff and carers. This lack of communication is an issue often raised by carers. It is understood that the clinicians are the experts in terms of medical knowledge and needs of the patient. The carer may not know the aetiology or the pathophysiology of the patient’s illness, but they do understand the impact it has had on them and often know the best way to approach the patient and provide them with care and support. They are also more familiar with the patient’s needs and behaviours. If there is an Advanced Health Directive in place, it is very likely that the carer has been involved in the process and is aware of the patient’s treatment preferences. To supplement the article, we would like to note that including the carer in the patient’s
Ms Julie Waylen, NDS WA State Manager
care and/or end of life plan is a requirement by law. The Carers Recognition Act (CRA) requires that the views and needs of carers are taken into account when decisions are made, along with the views, needs and best interests of the people receiving care. Carers should be included in end-of-life conversations, no matter how difﬁcult, as it is both the constitutional right of the carer and helps their grieving process and future wellbeing. Ms Rosie Barton, Programs Manager, Carers WA ........................................................................
Ageism – one ‘ism’ too many Dear Editor, Ageism, like any other ‘ism’ is a consequence of collective human judgement of the value of ‘others’ (Do Human Rights have a Use-By Date?, November). Young people, old people, poor people, disability pensioners, refugees, anyone in a nursing home – in fact any group of people who are categorised, homogenised and then stereotyped. Overt or insidious, ‘isms’ are alive and well. It takes much effort to persuade society to come understand an ‘ism’ – and relinquish it. It is so easy to accept ‘ism’ behaviour, conﬁdent continued on Page 8
The one thing women don’t want to ﬁnd in their stockings on Christmas morning is their husband. Joan Rivers
Something in the Country Air When it comes to medicine Michiel Mel would like the handlebars to be turned in a more collaborative direction. I really love being a rural GP in Boyup Brook because… you don’t have to ‘behave’ like a doctor. It just doesn’t feel like like ‘work’ when I’m working. If I hadn’t done medicine I think I’d have been a very good … landscape gardener. It would be very nice to work outside a bit more and it’s a highly creative way to make a living. When I’m not working I really enjoy… mountain biking. I love my carbon-ﬁbre bike! When I’m pushing the pedals I feel great and I ﬁnd that
6 | DECEMBER 2015
I can work through things in my mind at the same time. It’s a great social activity, too. One of the things I’d like to do is … work in a health setting that brings everyone together on the same page – and that includes politicians, health bureaucrats and policy makers. We’re not pulling in the same direction at the moment and it can be very tiring.. A ﬁlm I watched recently is … Wolf Creek. It was pretty scary and my wife, Linda, wanted to stop watching it. We ended up skipping bits but we did make it through to the end.
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Letters continued from Page 6 that you are the ‘normal’ one, and ‘others’ are not, and can therefore be judged and treated differently. The concept of Ageism is a little odd because most people love, respect and enjoy their parents and grandparents. This personal connection with an old person is at odds with our collective behaviour. Moreover, every one of us is ageing, every day. How can we, intelligent beings that we are, behave as if we are somehow not part of this inevitability? Population ageing is a new world-wide phenomenon, with many implications-not only rising demand on our health and social systems, but also on structural economic issues. So ageism is really not acceptable. If we are all to look forward to a longer and healthier life than previous generations, we must come to grips with making our world one for all of us to enjoy, whatever our age. Age is the new ‘black’, as fashionistas might say. Take the time to understand and relate to every patient, consider how you would want to be treated if you were that patient, and behave accordingly. The presence of dementia is no excuse for a different attitude; it just takes a little more skill and effort to get it right. And while we are about it, no more ‘isms’!
to be treated. In such situations, the value of teamwork including support from fellow doctors, nurses, allied health professional and, yes, medical students, can play a pivotal, collaborative role. Notre Dame Fremantle endeavours to raise the proﬁle of medical students and GPs in primary care research by encouraging an active hands-on approach in the research process and by recognising their contributions as authors in publications (BJGP 2012, Annals of Family Medicine 2013, BMJ Open 2014 and J Co-morbidity 2014). Recent inter-university collaboration between four WA primary care research units and RACGP WA has shown considerable potential in positioning the specialty as a major research collaborator in the future. Medical students who have collaborated with us on various research projects invariably produce positive outcomes from their research experiences with many progressing to complete their honours program in the area. One single research experience may whet an appetite if given a chance.
Prof Helena Liira raises some interesting points about medical student research (Seeing the World with Fresh Eyes, November). In an ever changing health environment, the potential for medical students to receive broad-based exposure to a wide range of health conditions becomes an essential part of their training. General practice is recognised for its ability to provide students with broad-canvas experience of facing undifferentiated presentations and offers a very different clinical exposure to tertiary level subspecialties where the majority of patients will have roughly similar conditions and health issues. For some students, this can be a challenging experience but it provides them with an unrivalled opportunity to experience the myriad facets of disease presentation – the organic and the functional, the social determinants of health, the biological, the psychological as well as the social aspects. The ability to deal with uncertainty is a key part of medical training. As we age, diseases rarely come in single entities and guidelines for single diseases are often inappropriate when the multi-morbid individual shows up. Such presentations are rarely packaged into neat, convenient diagnoses just waiting
8 | DECEMBER 2015
Issues that impact on early development such as sleep and feeding can be identiﬁed early and addressed in speciality clinics offered by Ability Centre. Early detection of cerebral palsy and contemporary early intervention practices are key contributors to positive long-term outcomes for children with CP and their families. Ms Catherine Greenway, GM, Therapy and Health Services, Ability Centre ........................................................................
Early diagnosis, better outcomes
Ability Centre offers thorough assessment and the option of services in the home, reducing the barriers of travel. With three major therapy hubs across greater metropolitan Perth and a regional support program, the organisation’s commitment to choice and freedom to access the best supports possible is apparent.
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Dr Penny Flett, CEO, Brightwater Care Group
Collaborative research is key
of ‘group’ established at PMH is not lost and the overlap and consistency allow strong relationships to ﬂourish, which beneﬁt the child and empower the family.
We welcome your letters and leads for stories.
It was with interest I read A/Prof Jane Valentine’s clinical column on early diagnosis of Cerebral Palsy (November edition). The time between a parent’s suspicion that not everything is as it should be with their child and a diagnosis, is a time of immense stress and enormous grief. It is when families are most vulnerable because they are not yet engaged with a community service provider and the future is unclear.
Please keep them short. Email: firstname.lastname@example.org (include full address and phone number) by the 10th of each month. Letters, especially those over 300 words, may be edited for legal issues, space or clarity. You can also leave a message, completely anonymous if you like, at www.medicalhub.com.au.
The earlier the detection of Cerebral Palsy in a child by diagnostic identiﬁcation methods such as GMs and neonatal imaging, the sooner the needs of the child can be met and the family can be supported. There are a diverse range of agencies equipped to help but with a team of specialist paediatric therapists, psychologists and social workers, Ability Centre has a comprehensive support package and having established links with PMH, the transition from the sense
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By Dr Smathi Chong Clinical Microbiologist & Infectious Diseases Physician
Fever in Travellers When to Investigate Western Australians are great travellers with Bali considered one of WA’s ‘northern beaches’. Herein lies some of the risk – travels to destinations that may be too familiar.
fever is perhaps the commonest laboratory identiﬁed cause of fevers in WA returned travellers. Most are acquired in Bali. Although not endemic to WA, GPs should be familiar with the infection as there are about 500 cases diagnosed per year in WA (dengue and chikungunya illnesses, both due to mosquito borne viruses, were mentioned in a previous Medical Forum article).
Fever in travellers can go unnoticed unless medical practitioners enquire about travel history in someone presenting with fever. The patient, considering it irrelevant, may not volunteer this information, especially when the incubation period of some infections can be many months. Obviously, the differential diagnosis changes signiﬁcantly, and patients need prompting about the importance of posttravel fever or other symptoms, even at the pre-travel consultation.
Malaria is very rare in travellers to Bali but travel to other islands may expose them. Infection is not excluded by a history of malaria prophylaxis while visiting endemic areas. Travel to Papua New Guinea and sub-Saharan Africa would be the commonest destinations for malaria.
The main concerns in a returned traveller with fever are to exclude a life-threatening, highly communicable, or treatable illnesses. Most are infections, and although the list of possible causes is too long for this article, Malaria, Typhoid and Dengue are three major considerations.
Other infections that may be diagnosed on serology, including Rickettsial diseases – especially patients returning from a safari to South Africa with a fever, spotty rash with or without an eschar. If a generalised rash is present, PCR (throat swabs, urine and blood) for measles and rubella would be recommended. Contact with fresh water, including ﬂoods, would prompt investigations for Leptospirosis.
Fundamentals of the history Any detailed history and examination includes the speciﬁc details of the travel, the history of the illness including characteristics of the fever, and associated symptoms like rash, gastrointestinal or respiratory symptoms or arthritis. The travel history seeks to assess risks for certain diseases like geography (e.g. malaria), pre-travel vaccinations, adherence to prophylaxis and other preventative measures. Assessment of risk also takes account of activities (e.g. sexual exposure, healthcare tried, exposure to freshwater or caves), food intake (e.g. raw meat or unpasteurised milk), or animal contact. Known incubation periods can rule out certain conditions. Laboratory testing
Serology tests have to be speciﬁed but tests for Dengue would generally be recommended for travellers to most countries in the tropical and subtropical zones of the world. Dengue
At least two sets of blood cultures before antibiotics would be important for diagnosis of enteric fever (Typhoid & paratyphoid) and other bacteraemic infections. Typhoid serology is less useful.
Less common causes of fever in a returned traveller include sexually transmitted infections like acute HIV or syphilis. Getting assistance
Laboratory investigations often form part of the assessment of a febrile returned traveller. Any traveller to a malarial area, regardless anti-malarial prophylaxis, requires malaria ﬁlms – in anyone with at least a moderate risk, three sets of ﬁlms over 24-48 hours is recommended. Basic tests should generally include a full blood count, liver enzymes and renal function.
Stool culture for bacterial pathogens and evaluation for ova and parasites may help, especially where there is diarrhoea. Travel is also a good way to contract or spread respiratory viral infections! For example, travel to the Arabian peninsula (e.g. for the Haj) may result in MERS-CoV (Middle East Respiratory Syndrome Coronavirus) infection – unwell patients should be referred to a public hospital and the emergency department forewarned.
så !SKåABOUTåAåTRAVELåHISTORYåINåPATIENTSå presenting with fever. så #AREFULåTRAVELåHISTORY åILLNESSåHISTORYåANDå examination help in diagnosis and in directing appropriate investigations. så !åFEBRILEåTRAVELLERåTOåAåMALARIAåENDEMICåAREAå should be considered to have malaria until proven otherwise. så $ENGUEåISåAåCOMMONåCAUSEåOFåFEVERåINå travellers from WA, especially to Bali, with a short incubation period, usually less than a week.
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Frequent evaluation is important until a deﬁnitive diagnosis is made and appropriate treatment started, or the patient is deﬁnitely improving. Discussion with your local Clinical Microbiologist or Infectious Diseases physician helps direct testing and further management. The very young and those with multiple comorbidities or who are immunocompromised should have a lower threshold for close evaluation and inpatient management.
Ice Addiction Can Be Helped The father* of a former â€˜iceâ€™ addict talks of the nightmare his family lived through and the lessons learned from helping his daughter. I have three daughters â€“ my middle daughter is a rehabilitated Ice addict. Her path to methamphetamine addiction was not all that unusual. She started smoking marijuana at age 16 and by the time she was in her early 20s (she is now 25) she was addicted to Ice. I was unaware of how deep her problems were until I moved in with my older daughter to help out with her young son while she went to work. Her sister was living with her at the time. I saw close up the dramatic changes in her, her aggression and difďŹ cult general behaviour -so difďŹ cult, in fact, that my older daughter asked her to leave. She went to stay with her younger sister and within a few days was asked to leave there too. Her situation was graphic and dramatic but she was in denial and felt out of reach to me, her mother (my ex-wife) and her sisters. The man she lived with was a drug supplier and her life was spiralling out of control but it wasnâ€™t until she hit rock bottom that she came to me in total despair saying, â€˜Dad I need helpâ€™. We knew little about methamphetamine and it was frightening. More than the shock headlines, we found Holyoake and the Next Step program on the internet. She agreed to Next Step where clinicians saw her and talked her through options. She decided to go into residential rehab and we all decided to go to family counselling at Holyoake in Midland. I joined the family group and was desperately trying to ďŹ nd the best way to support her.
Waiting for her, the problem became very clear â€“ two hoursâ€™ therapy out of 164 hours in a week meant time back on the streets socialising with the same people and facing the same temptations. After rehab she signed up for Holyoake counselling. I would take her for her hourlong appointment and sit in the park opposite reading the paper until sheâ€™d ďŹ nished. Weâ€™d then have a bit of lunch before I took her back for a group session. She would make her own way back home after that. Waiting for her, the problem became very clear â€“ two hoursâ€™ therapy out of 164 hours in a week meant time back on the streets socialising with the same people and facing the same temptations. There had to be a better way. I understand the constraints of ďŹ nance but I also saw this real problem of disengagement. My personal counsellor at Holyoake, hearing me talk of these things, asked me if I wanted to be involved in ďŹ nding a solution. Thatâ€™s how I became a consumer advocate in a local drug action group that is hoping to establish a community garden to engage recovering addicts. We hope the garden will be operational by March or April next. It will allow people a place to do something; get their
hands dirty, watch things grow and talk to each other about what theyâ€™re going through. Thereâ€™s a lot of beneďŹ t in those things. My daughter has been clean for 18 months. She has a new partner and they have just had their ďŹ rst baby. Her sisters, mother and I are all a part of her life. We are fortunate. The recent government campaigns have done nothing but frighten people and make the stigma of methamphetamine addiction so much worse for the users and for their families trying to help them. I understand how difďŹ cult it is for emergency staff to deal with extremely agitated drug addicts. But rather than spend on advertising campaigns that donâ€™t address the problems faced by addicts and those around them, Iâ€™d like to see campaigns that give people information on how to access the services we have. There is a lot more help out there than I ever imagined but if it werenâ€™t for the internet I wouldnâ€™t have known where to start. The media also must recognise that headlines about â€˜ice epidemicsâ€™ and â€˜ice agesâ€™, while attracting readers, are also wrong. Methamphetamine use in Australia, while deeply worrying, has a stable number of users; itâ€™s the drug that has become much more potent and dangerous. Getting serious about tackling this problem is all about community education and rehabilitation and supporting drug users in practical ways. There is help out there. ED: * The writer has asked to remain anonymous to protect his familyâ€™s privacy.
Ice â€“ The Stats Current government policy on Ice is being driven by statistics collected from the 2013 Household Survey and the 2012/13 Australian Crime Commissionâ€™s Illicit Drug Data Report. Here are some of the WA statistics from the IDDR. sĂĽ #ONSUMERSĂĽĂĽARRESTSĂĽnĂĽĂĽWEREĂĽMALE
sĂĽ 7HILEĂĽNOĂĽRISEĂĽINĂĽMETHAMPHETAMINEĂĽUSEĂĽINĂĽ 2013, use of powder fell from 51% in 2010 to 29% in 2013; while the use of ice rose from 22% to 50%. Use increased in daily or weekly use (from 9.3% to 15.5%). Among ice users there was a doubling from 12.4% to 25%
sĂĽ ĂĽ ĂĽUSEDĂĽMETHAMPHETAMINEĂĽINĂĽ the last 12 months
sĂĽ 3EIZURESĂĽKGĂĽINĂĽTHEĂĽPERIODĂĽPURITYĂĽ ranged from 76% to 89%
sĂĽ 4HEĂĽAVERAGEĂĽAGEĂĽOFĂĽUSERSĂĽWASĂĽĂĽINĂĽ ĂĽ compared with 28 in 2013
sĂĽ 0RICEĂĽĂĽSTREETĂĽDEALĂĽĂĽORĂĽ ĂĽ a gram (these ďŹ gures are for non-crystal form)
sĂĽ 7!ĂĽHADĂĽTHEĂĽHIGHESTĂĽNUMBERĂĽOFĂĽMETH amphetamine users in the country (3.8%)
The National Household Survey: sĂĽ 4HEĂĽNATIONALĂĽPERCENTAGEĂĽOFĂĽ)CE3PEEDĂĽUSESĂĽ has risen .1 of a percent from 2% in 1993 to 2.1% in 2013; the highest usage was recorded in 1998 (3.7%)
sĂĽ -ETHAMPHETAMINEĂĽWASĂĽTHEĂĽSECONDĂĽMOSTĂĽ nominated drug of concern for the general community
Yearly Total Metropolitan ED Attendances for stimulants including methamphetamine, ecstasy, MDMA, amphetamine and other psychostimulants (excludes cocaine for the period 2010/11 - 2015/16). The data does not capture speciďŹ c methamphetamine diagnosis, however amphetamine diagnosis is captured and collated. Financial Year
Source: Health Department of WA
10 | DECEMBER 2015
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DECEMBER 2015 | 11
Have You Heard?
Stormy times for GP training Last edition we reported the Federal Government ﬁnally giving the nod to WAGPET’s tender to deliver GP training in WA next year. However, the community residency program, which was rescued from oblivion by the State Government this year, has been axed. The lack of appropriate provider numbers just made it too difﬁcult to continue – a major blow as it was an effective promotion for general practice. WAGPET’s difﬁcult 12 months was summed up by CEO Dr Janice Bell in the latest newsletter: “The calm before the storm doesn't begin to describe the time since May 2014… but it has been – among other things – a time of considered reﬂection and re-evaluation. The general practice training world has changed nationally, perhaps irrevocably, in ways we are only now beginning to fully countenance.” 160 registrars start their training in the New Year.
Cost cutting to the bone The Federal Government’s euphemism for cost slashing, ‘efﬁciencies’, has the potential to
drive a stake through the heart of the Aboriginal Community Controlled Health Services by slashing the salary support of GP registrars. Docs working in ACCHS have their salary paid for up to three years but a new draft policy seeks to reduce that to just 12 months. As the the Aboriginal Health Council of WA’s chair Michelle Nelson-Cox said, without that salary certainty, few docs will commit to working in regions that need them the most. This could kick off as soon as January 1, Kimberley AMS says it could lose 15 of its 18 doctors who were due to start training next year.
has become an issue for the relatively young patients affected. Early detection remains the key to a better prognosis and MelanomaWA says staying informed and feeling conﬁdent is important. Their Support Pack includes info on support services from them and other organisations – connecting patients to available melanoma-speciﬁc services. As well as education about prevention at schools etc, the organisation is involved with rural GP training that encourages the use of dermatoscopes. Phone Clare on 0403 829 796 to order a sample pack (www.melanomawa.org.au).
RACGP proﬁle change
With WA GP Dr Tim Koh recently appointed national chair of the RACGP Council and Mandurah GP Dr Frank Jones heading into his second year as RACGP President, Sandgropers are well represented in the college. Frank, who still manages 4-6 sessions per week in his practice, is keen to lift member engagement through better use of social media and state faculties. Not before time, in our view – trying to ﬁnd local GP stories in WA is too difﬁcult. As government tries to rein in health costs, the MBS rebate freeze, better chronic disease funding, quality of care, accreditation and GP advocacy are in full focus. The plan is to make the RACGP a voice to be listened to. Increased relevancy and responsiveness is needed.
Remember Hospital in the Home through GP divisions? The idea was to prevent unnecessary expensive hospital admissions by treating some conditions at home - anticoagulation for VTE, IV antibiotics for some infections, hyperemesis gravidarum and iron infusions for anaemia. It turns out that these savings are chicken feed compared to what can be gained from early discharge and ED referral for nursing at home or in secondary hospitals – the expanded Silver Chain Home Hospital is servicing RPH and FSH (and has employed Dr Daryl Kroschel as FT medical director), while SCGH still has its own HITH program. It costs about $750 a day to occupy a tertiary hospital bed.
Pooling melanoma resources
A doctor messaged us via our website, complaining of up to ﬁve-minute delays on the Authority Prescriptions phone calls. An appalling waste of time, they said, wondering if it was on purpose to reduce authority scripts by getting doctors to tire of waiting and hang
MelanomaWA is positioning itself as the go-to organisation for those diagnosed and their families. Melanoma prognosis has improved markedly with different immune-mediated treatments (drugs and vaccines). Their cost
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up. They wondered why the lack of trust to authorise repeats without calling and why an online system for authorities didn’t exist. When we contacted the Department of Human Services they were apologetic and said the average wait time for the ﬁnancial year so far was 42 seconds. There were logged problems on November 17 and 18 –carrier issues, urgently rectiﬁed. The spokeswoman also reminded us the Pharmaceutical Beneﬁts Advisory Committee recently stopped repeat prescriptions for some PBS subsidised antibiotics.
Oral cancer robot Hollywood hospital has four ENT surgeons offering trans-oral robotic surgery for head and neck cancers, courtesy of the latest generation da Vinci surgical robot. It goes with dexterity and improved visualisation, where no surgeon’s hand can (easily) go, for removal of tongue base and oropharyngeal cancers. The use of a robot in these cramped quarters has decreased operative time and the operators say improved recovery times and clearance margins. Contentious areas remain radiotherapy, neck dissection and disease control. HPV related oral cancer is likely to persist for a generation until the HPV vaccine program kicks in.
Hacked! It happens to the best of us. You may have received a request from Dr Steve Wilson to transfer some money to him in South Cyprus as he had lost his personal belongings and needed assistance. We hope you didn’t end up cabling money to him via Western Union, as that may be the last you will see of your money. Steve had his Gmail and Yahoo email accounts hacked.
Hunt for GP obstetricians WACHS is planning to re-open the obstetrics unit at the Northam Hospital and is keen to hear from procedural GPs interested in going on the roster. The unit faltered in July after the retirement of long-serving Northam GP obstetrician Dr Colin Smyth but demand in the district is the impetus for its resurrection. It is now looking to fully staff a 24/7 level 3 maternity services, including emergency caesareans. There are 21 shires surrounding Northam with an estimated combined population in 2013 of 22,679. Average total births per annum to women resident in the potential Northam
Hospital maternity service catchment area for the decade 2003-2012 was 496. Of these, 14% (68p.a.) were to women resident in shires more than two hours' drive, 29% (145p.a.) between 1-2 hours’ away and 57% (283p.a.) within an hour's drive of Northam. Population projections give an estimated average population growth of about 2% p.a. over the next 10 years. The nearest maternity service to Northam is the SJG Midland Public Hospital, 79km away. A spokesman for WACHS says the search for well-skilled GP proceduralists at Northam is going hand in hand with hospital redevelopment including improved theatre facilities.
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DECEMBER 2015 | 13
Seeing With an Artist’s Eye Richard Woldendorp’s photographs of West Australian landscapes are often taken from an aeroplane, but his connection to the land is deeply personal.
The stunning photographs of Richard Woldendorp look a lot like like paintings and that’s hardly surprising. Richard studied sketching and commercial art in Holland before picking up a camera to create evocative aerial images of the West Australian landscape. “The image has always been very personal for me, and particularly so with the photographic work I’ve done with the Aboriginal people of the Pilbara region. It struck me that they weren’t concerned with a measure of the land but rather an experience of country.” “I remember spending time with an elder named Toby Thomas walking along the Kimberley coast and it was obvious that his relationship with the land is all about features. Aboriginal people are not concerned with distance, for them it’s all about describing and recognising things that are important. It’s the same for me, too. It’s all about the landscape.” “I think my photographs have the same sort of ‘feel’ and I’d deﬁnitely describe my style as ‘painterly’. I love reading about painters and I’d have to say I’ve got more artist friends than photographers.” “It’s so important to enrich one’s outlook by embracing different points of view.” Richard, born in 1927 in Ultrecht in The Netherlands between two World Wars, came to Australia in 1950. He is the ﬁrst to acknowledge that he’s had a fortunate life.
14 | DECEMBER 2015
“I spent three years in the army in Indonesia as a young man and I still remember being struck by the incredible tropical diversity. It made me realise that you have to look intently at what’s around you because it’s a beautiful and complex world out there.” “That’s one reason I decided early in my career to be a freelance photographer and not base myself in a studio. I wanted to have the freedom to explore and interpret in my own way. I’ve been very lucky in many ways because three things came together at the same time that had positive spinoffs for me. The SLR camera made taking photos so much easier, the quality of the ﬁlm improved markedly and, particularly after WWII, it was just so easy to jump on an aeroplane.” “Aerial photography became so much simpler and that’s been wonderful for me.” Nonetheless, Richard suggests that while new technology and the digital age have opened up new possibilities, there have also been a few dents to the creative process. “We’ve got perfection now, fabulous colour and people taking photographs on their mobile phones. But in the early days there was a stronger ﬂow from beginning to end and there’s a bit of that missing now. It was a bit like making a sketch, a slow process that was quite involved and something that had to be learned before you got it under complete control.”
“The camera I use now is a Canon 25D and I did my last book, Out of the Blue, with that and two lenses. I ﬁnd that the simpler it is the more I can concentrate on actually ‘seeing’ what’s in front of me. Some people are very good on the technical side, extreme close-ups and high deﬁnition and it’s certainly a good thing that the vast potential of the camera is well utilised.” “There’s a lot that can be done with digital technology and creative talent will always take photography to new and interesting levels. I’ll admit that I’m not as technically skilled as I’d like to be but, for me, it’s always been the excitement of discovery in the image itself.”
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DECEMBER 2015 | 15
Passion for People and General Practice ‘People person’ is a phrase bandied about without any regard for its actual meaning, but in the case of Cloverdale GP Dr Tim Chappell, it captures him perfectly. When you speak to Dr Tim Chappell, it doesn’t take long to realise he has a genuine affection for his patients. In conversation he describes them as “tremendous”, “fascinating” and “riveting” and you get the sense that along with their medical history, he could also give you their entire life story. It is this affection for people which saw him make a last-minute switch from the specialist pathway to general practice. After unexpectedly ﬁnding himself accepted onto a general physician training program, the idea unsettled him.
compassion and communication – into those he teaches. If a doctor is failing, he says, it is usually in one of those three areas. His teaching experience goes beyond his practice doors. He regularly lectures for WAGPET, has been a guest lecturer at Notre Dame University and UWA, and has taught a medical course to occupational therapists. His dedication to the next generation of doctors surely had a part to play in Fulham
disintegrated, I think we will see improvements for general practice. Patient expectations change when they pay. Patients expect more, much more, and they listen.” However, he warns aspiring GPs about the challenges of paperwork and policy and the damaging effects it can have on individuals and the profession at large. “A lot of the paper work belies – underneath it – a lack of trust. That the doctor is not going
“I would wake everyday thinking, ‘what is wrong with the world? The sun is out, it’s beautiful outside, the coffee is on...oh that’s right, I’m on the general physician training program. I have to get off that’,” he said. “A physician once said to me: ‘We want serious people, we don't want people ending up as poets after all this training’. Not that I’m not serious, but one of the troubles with specialty work is that it doesn’t leave much time for development of any other part of the person you are.”
Dr Tim Chappell (inset) and with colleague Dr Michael Kurian.
Patient-centred care Despite hearing a “truckload of negative information” about general practice, he realised he was a natural GP. “I love listening to people’s stories and ﬁnd the relationship with the patient the most rewarding thing. I saw that general physicianship wasn’t going to give me that and general practice was.” It isn’t just his patients he has a passion for. Since he was a resident at Royal Perth Hospital he has put his hand up to teach and mentor younger doctors. For him, part of the joy of teaching is seeing “the penny drop”. “I enjoy seeing people learn more and gain conﬁdence. Registrars and medical students also give back to us. We learn from them – they keep us on our toes and are always introducing new things.” “I do put energy into teaching. There are teaching sessions every Tuesday morning at 8am and I supply the coffee. I try to address the blanks, talk about the issues. I make sure there is formal time – you can’t do it at lunch time.” “I want my students to succeed; I want them to start up their own practices.” Teaching is vital More than just ﬁlling in the blanks, Tim also tries to instil the three Cs – competency,
16 | DECEMBER 2015
Medical Centre being named the 2013 WA General Practice Education and Training Practice of the Year. He has high hopes for the next generation. The future of general practice is in the hands of some “outstanding doctors” who are driven, engaged and far less cynical than their predecessors. A change in how hospital doctors regard GPs is also creating more excitement about the ﬁeld.
to do the job. It just creates less focus on the job at hand. I think it is a danger – it becomes so regulated that a doctor is unable to practise good medicine because there is so much other stuff to do.” Tim has been at the Fulham Medical Centre in Cloverdale for 15 years, the past six years as one of the practice partners. Prior to this he spent three years as a GP in the Pilbara port town of Dampier.
“Emergency departments see a lot of bad general practice, just from the nature of the beast. Either the patient isn’t helped or they are sent in inappropriately or something hasn’t worked. In hospitals you don’t get to see the positive side of general practice,” he said.
“Hospital doctors are expecting more of general practice and I think that is great. They are expecting us to look after diabetes, emphysema, asthma, so general practice skills are increasing, not decreasing.”
“I had one of the women at the checkout say to me, ‘How was your holiday Dr Chappell?’ I thought to myself, I don’t recall telling you I was going on holiday,” he said.
Time to value GPs The gradual shift away from bulk billing is another reason to be excited. Like many GPs, Tim believes the system grossly devalues general practice. “When people get to the point where they can’t charge $5, you just think wow, they are valuing their professional opinion at less than a cup of coffee. Now that is slowly being
In a small town, knowing everyone becomes inevitable which, for Dr Chappell was the best (and sometimes the worst) part of the job. He recalls a time when he knew everyone in the shopping centre, including the tourists.
When he isn’t teaching or attending to patients, Tim indulges his other love – writing. He already has one book to his name, and is now ﬁnalising his second – a book for young adults. The subject is close to home about quokkas escaping from Rottnest Island. Tim describes it as an epic adventure and a “cross between Watership Down and The Lion, The Witch and the Wardrobe”.
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“Deﬁciencies Not A Competency Issue” when they failed, at major cost, no independent analysis was available for all to see.
The Medical Board (MB) has the power, without notiﬁcation, to independently initiate an investigation if it believes the way the doctor practises is or may be unsatisfactory (see sample letter, from another case, opposite). No patient complaint is required as a trigger. In this case, the MB sought to deregister this doctor by showing them to be incompetent, the reason the matter was taken straight to the State Administrative Tribunal (SAT).
Using FOI, we have learnt that Prof Bernard Pearn-Rowe (BPR) was paid $23,017 to prepare one pivotal report for the MB and received more to appear in court, while lawyers prosecuting the case were paid $48,352 by AHPRA. We note it took two years before SAT gave its judgement, during which time administrative costs for AHPRA and the MB would have accrued. The doctor’s MDO said it spent about $250,000 defending the case and was not awarded costs as the court was not persuaded that the MB unnecessarily prolonged the length of the proceedings.
This may be a good thing as we have more chance of learning from a ﬁnal judgement in public view, than if the practitioner’s health, performance and conduct were reviewed by a MB performance review panel. The doctor’s Medical Defence Organisation (MDO) had tried unsuccessfully before trial to negotiate settlement. After a ﬁveday hearing, SAT in WA dismissed an application by the WA Medical Board to deregister this doctor. Why did the Medical Board fail in its attempt? It appears this case failed for these reasons. The MB attempted to judge this general practitioner with a special interest (GPwSI) as if they were a generalist, when they knew the practitioner conﬁned their work to a special interest area. In fact the MB (presumably in a way that safeguarded the public) had a year earlier set up the framework for this to happen. The framework was not on trial. The medical practitioner and his livelihood were. It probably comes down to how restrictive is your interpretation of an “approved registration standard relevant to general registration in the profession” under National Law. The judge in this case said GPs with special interests could conﬁne themselves to their special interests, and still practise legitimately.
This practitioner saw patients with particular health problems, having worked solely in specialised ﬁelds for up to 20 years. Referrals were mainly by word-of-mouth. Remuneration was about the 50th centile for general practitioners. Medicare item numbers used were those of a non-vocational GP, with a higher proportion of longer consults because of the nature of the work. Patients included elite sportspeople, difﬁcult-to-treat chronic pain patients, and medical colleagues. The doctor used general practice skills when other problems known to inﬂuence the conditions treated, were encountered. Who paid the price? The Medical Board of Australia alleged this doctor was unable, due to a lack of medical knowledge and skill to practise safely and competently as a general medical practitioner. They sought to remove the doctor’s livelihood, in effect saying the doctor’s conduct was serious enough to warrant such action, and
Additional information about BPR’s extra court appearance fees were withheld by AHPRA (a decision upheld on FOI appeal, partly for commercial reasons), which we ﬁnd a bit ironic given that AHPRA is funded by registrants’ fees, the same registrants who are expected to offer patients open informed ﬁnancial consent. Moreover, the WA ofﬁce of AHPRA declined to say how many times BPR has appeared as an expert witness or panellist since this case. Much hinges on how BPR was briefed by lawyers, information we were unable to obtain. When on FOI appeal we cited a Privacy Commissioner’s determination in favour of accessing the brieﬁng notes given by the legal ﬁrm to BPR, pointing out such notes were also not subject to legal professional privilege, our request went begging. We were told how to appeal under FOI to the Melbourne ombudsman (must do so within 60 days, cost $385, with an expected six-month delay due to the backlog).
The Practitioner Comments Overview “I estimate the cost to the taxpayer of my investigation (HIC plus Medical Board) to be of the order of $500,000. In the beginning I Dr Anywhere told the HIC I worked in a restricted area of practice. In the end I was deemed competent to continue my work as long as I advised my patients that I worked in a restricted area of practice. The only change was that I now, as I should have done always, report to the patient’s GP of my input.”
18 | DECEMBER 2015
The Medical Board “The Medical Board’s action was to seek to deregister me because I was not competent in all aspects of general practice. The judge said it would be a case he would think long on as the outcome would affect other doctors now working in restricted areas, like Mole Scan, sports medicine, and counselling.” “I can only speculate as to the forces at the top that pushed this action with such great energy.”
Has an injustice been done? The WA Medical Board made its decision knowing these things: så 4HEåPROSECUTEDåDOCTORåHADåNEVERåBEENå visited by a Medical Board representative ve to see them in action with patients. så !FTERåOVERååYEARSåPRACTISINGåINåAåSPECIALå IAL interest area of medicine, only one patient ent had complained against the doctor, a complaint the doctor says the MB had earlier deemed was ‘no case to answer’. r’. så !åYEARåBEFOREåTHISåACTIONåBYåTHEå-" å the doctor had given the MB a written undertaking to conduct patient consultations according to a set of d conditions it speciﬁed, which cemented ere their work in a special interest area. There was no suggestion these undertakings (see next page) had been broken. OF THE så 4HEåPATIENTålLESåTHATåFORMEDåTHEåBASISåOFåTHEå om MB’s and BPR’s opinion were drawn from tor’s a time at least ﬁve years before the doctor’s written undertaking to the MB. så $EREGISTRATIONåISåTHEåHARSHESTåOFåSEVENå options open to the MB in this instance,, and involved bypassing the MB’s own professional standards committee. As far as we know, no one has offered an apology to this doctor since the case. The ir profession might thank the doctor and their MDO for the legal precedent the case has ext produced for those that follow (see inset next page). The All-important Medical Report The expert witness, BPR, prepared the eral report. He was the inaugural chair of General Practice at Notre Dame University during its start-up phase and was awarded a medical professorship by that university. We ut understand that about ﬁve years ago he cut back his work with UND and is now listed as an Adjunct Professor. uded In this case, his costly 25-page report included ht no instance that the presiding judge thought
continued on Page 20
“I agreed to sign a "voluntary undertaking" g" to restrict my practice. I was formally noww doing only what I had been doing for thee last 25 years. I had been recognised by the Medical Board as a GP working in a specialist area. It declared what I had said from the beginning...I was not doing full normal GP medicine.”
DECEMBER 2015 | 19
Medicolegal continued from Page 19
“Deﬁciencies Not A Competency Issue” demonstrated ongoing incompetence by the doctor – just a lapse in note taking, patient history taking and clinical acumen that might have been considered poor practice in some instances, something the doctor admitted to and said in court had been remedied. The lawyers acting for the MB set out 25 grounds for possible deregistration of the practitioner. These largely relied on the report by BPR in which the medical records of 22 patients were referred to. This report was born from a PSR review years earlier that led to a MB complaint, which the doctor under investigation, said the MB was obliged to act on. It led to the “voluntary undertaking” to the MB which the doctor signed a year before this action. According to the judge’s summing up of crucial points that focus on the ﬁve-day SAT hearing, BPR, in court, retracted or signiﬁcantly ‘softened’ his evidence under cross examination (nine times), or was in direct disagreement with the defendant’s expert witness (nine times). During disagreement the judge preferred the evidence of the defendant twice, and the defendant’s expert witness once. At one point, the judge commented that not even experts could agree. In one instance, the defence presented evidence from a patient that refuted one of the MB’s claims. The judge made numerous comparisons between this practitioner and the patient’s usual GP, questioning who bore responsibility for what. In fact, this appears to be a major reason the judge came down in favour of the defendant. Failure to notify the patient’s usual general practitioner or take adequate notes were admitted to and proved by the MB but the judge indicated the MB had insufﬁcient or
How to be a full-time GPwSI Paraphrased below are undertakings very similar to those given by this practitioner to the Medical Board to allow them to practise safely as a GP with a Special Interest. [We believe those points marked ‘#’ would normally be taken care of if the practitioner only sees referred patients.] så 2ESTRICTåPRACTICEåTOåSPECIALåINTERESTå areas (and work in line with any relevant academic college’s teachings); så .OTåCHANGEåTREATMENTSåBYåOTHERåMEDICALå practitioners except those speciﬁed by the Medical Board; så !DVISEåEVERYåPATIENTåTOåCONSULTå their general practitioner about the complaint(s); så 4OåPROVIDEåINåWRITINGåTOåEVERYåPATIENTåANå outline of: o The restricted areas of practice the practitioner works within; o The practitioner’s inability to treat or advise in all other areas; o The requirement to notify each patient’s usual GP. så 0ROVIDEåAåPROMPTåDETAILEDåREPORTåTOåTHEå patient’s GP; and så .OTåTREATåANYåPATIENTSåUNTILåTHEåPATIENTå identiﬁes their own GP.
unsupported evidence to back its assertion of incompetency, that is, that the defendant lacked adequate skill and judgement. While some actions were proved or admitted, the judge suggested these actions were justiﬁable and 11 instances of conduct alleged by the MB were not proved. The judge suggested that the MB might have had a case against the medical practitioner for acting carelessly or incompetently, as a disciplinary matter, for which the MB had the option of assessment. In any event, these were matters SAT considered could be rectiﬁed and had been brought to the doctor’s attention
The Practitioner Comments Errors of Judgement “My main mistake was continuing to work alone without contact with the patient's own GP. The PSR criticised me for that and I immediately corrected this omission.”
is guilty. I calculated the review had cost in the order of $300,000 and like Wayne Swan's mining tax, returned bugger all. All from the investigation of a doctor already cheaper to the system than half their practising colleagues. They reported me to the Medical Board.”
“The legal argument is that if the patient sees you as the person managing their health they may assume you are attending to all things needed for their health.”
“Prof Bernard Pearn-Rowe ‘examined’ files as if I were a full-time normal GP. He did not meet with me. He did not visit my clinic to see me work. His report was used in an attempt to declare me unsafe to practise medicine.”
Conduct of Inquiries “For those of us who have been challenged, the power of the HIC and the Medical Board is frightening.” “In the area of 60 minute consultations they [the PSR] found me guilty in three of the 25 files. They need greater than 10% to be statistically significant. Two files in 25 is not guilty, three files
20 | DECEMBER 2015
“The assumption was made clear to me from the beginning. I was not doing things the same as they did so I was in the wrong and they would drag me through their system until they proved to me that they were right, then they would punish me.” “I believe they expected me to give up. By the time it got to court they were already beaten. It was all so unnecessary, so costly.”
Important lessons from this case så !NYåDOCTORåCANåLEGALLYåPRACTISEåINåAåRESTRICTEDåAREAåOFåMEDICINEå (i.e. specialise) while holding general registration. så 4HEå-EDICALå"OARDåCANåSETåGENERALåGUIDELINESåFORåTHISåTOåHAPPEN å so the public is protected. så )TåISåUNJUSTåFORå!(02!åORåTHEå-EDICALå"OARDåTOåJUDGEåGENERALåPRACTITIONERSå working only in a special interest area as if they should be competent across all aspects of general practice. så $OCTORSåCANåLEARNåMUCHåFROMåCASESåLOSTåBEFOREå3!4åIFåTHEYåAREåFULLYå scrutinised, which in our view, includes brieﬁng notes by lawyers given to ‘expert’ medical witnesses. så 4HEåPERFORMANCEåOFåEXPERTåWITNESSESåACTINGåFORåTHEå-EDICALå"OARDåNEEDå to be value for money. så 4HESEåSTATEDå2EGULATORYå0RINCIPLESåOFåTHEå"OARDSåANDå!(02!åAREåAPPLIEDå in each case: o The organisations operate in a transparent, accountable, efﬁcient, effective and fair way. o The main objective is to have suitably trained and qualiﬁed doctors practise in a competent and ethical manner. o Any action taken is timely and proportionate to the risk to the public. through the PSR’s actions. SAT disagreed with the MB’s assertion in its closing submission that the practitioner could not learn from mistakes. In short, a competency matter did not exist. ED. Anyone researching the precedents of this case may need information that identiﬁes the doctor and the MDO involved. The doctor has agreed to this on merit – please contact Medical Forum if you want further details.
The AMA Federal Council recently said: “…the General Registration category affords medical practitioners ﬂexibility to limit their scopes of practice and/or their amount of practice from time to time during their professional life, and in transition to retirement; and 50 hours per year of self-directed CPD is appropriate to ensure contemporary practice, and affords medical practitioners the ﬂexibility to tailor their own CPD program to their scope of practice.”
By Dr Rob McEvoy
The Legal System “Until the matter gets to court the argument is all about process.” “The lawyers believe that the internal structure of the medical regulation system is fundamentally correct. They have a symbiotic relationship with orthodox medicine. They perhaps see their new client as an ‘unfortunate’ to be guided through the legal minefield and brought home alive with the least number of injuries.” Peer Review “Lawyers can argue anyone who is not practising full time as a normal GP and totally restricts their practice to a special interest area deserves review by a doctor with training in that area. Your lawyer can then stand his ground and remind them that should your request be denied, this will be regarded negatively when it gets to court.”
Medical Experts “The legal team defending an individual doctor has no interest in patient outcomes. That is not their brief. The judicial system, by pitting expert witness against expert witness, exposes the Achilles heel of the investigation system.”
“At one stage the judge commented that it appeared that neither expert was wrong, but that there was clearly a difference of opinion within the profession regarding the management of certain conditions.” “The judge was acceding to the fact that [x] medicine was practised by reputable doctors whose process differed from conventional doctors.”
DECEMBER 2015 | 21
Working Now to Bring Future Hope Early intervention for a child who has suffered abuse saves lives. Parkerville Children and Youth Care CEO Basil Hanna says it is at the heart of its advocacy and therapy programs. Parkerville Children and Youth Care focuses on therapy and care for the most vulnerable ‘high need’ children in our community. Its CEO, Mr Basil Hanna, stresses the need for early intervention and increased awareness of the pervasive and destructive legacy of child abuse. He’s also a ﬁrm believer in the role played by the medical profession. “The kids we deal with are highly complex. I remember an individual who came to Parkerville for help as a young boy. He was in a bad way and probably on a one-way track to prison. He turned 18 last year after being with us for just over a decade and quite recently he walked up and handed me a piece of paper. He’d written, my past deﬁnes me, I’m unseen, unheard, unwanted and unloved… that is what Mr Basil Hanna I am.” “He’d written it many years ago and he was telling us that he didn’t need those words anymore. The building of hope is one of our key values and it saves children’s lives.”
22 | DECEMBER 2015
The nexus between duration of treatment and potential beneﬁts is contentious, particularly in relation to the pervasive psychological damage associated with child abuse. Parkerville, argues Basil, is much more than a circuit-breaker and the long-term beneﬁts are demonstrable and enduring. “One of the problems we face is that the concept of early intervention is not something that’s been attractive to funding bodies, particularly at state and federal level. The end results of our work often remain unseen for many years and, as we know, the real decision makers are politicians and they’re often reluctant to look beyond their term of ofﬁce.” Impacts of abuse “When I ﬁrst came here a decade ago there was a distinct lack of awareness within the wider community regarding the long-standing effects of abuse. Many people didn’t fully understand that the developmental pathways of the brain are often severely impaired and the child can be left with cognitive, social and physical disabilities.” “Without timely therapeutic intervention these young people move into adolescence and adulthood with difﬁculties in forming relationships and underachieving at school and in the workplace.”
Reinforcing this, the Parkerville website contains some confronting and highly realistic material highlighting the entrenched nature of psychological damage. “It’s a strong message and it needs to be because this abuse has ﬂow-on effects and these children carry their problems into their adult lives. On the surface people appear to be functioning well, but inside they’re still carrying a lot of pain. Up until quite recently there was a belief that if you gave them love and care they’d get over their trauma but that’s not the case when the developmental pathways are affected.” “So what we’re saying in website videos such as Inside Out is that what you see on the outside is not necessarily what’s happening on the inside.” Caring for the carers It’s not only the victims of abuse who struggle to emerge from a whirlpool of despair, according to Basil. Clinicians and allied health professionals deal with emotionally distressing material on a daily basis. “Our staff members are exposed to a lot of vicarious trauma – from paediatricians and psychologists to social workers and carers. It’s a signiﬁcant factor and as an organisation we invest in a lot of different strategies to try
and alleviate it. We have a formal supervision process, staff development and provisions in place for people to talk through these issues.” “Every person at Parkerville receives training on the full impact of child abuse. We acknowledge that this is a very difﬁcult ﬁeld to work in.” Most people would agree that Australia has a long way to go before we get anywhere near the level of corporate philanthropy enjoyed by medical institutions in the US. Basil, however, takes a slightly different view. “We were the ﬁrst organisation to receive funding from Lotterywest and we’re talking about a £200 grant in the 1920s! They’ve helped us survive and were also a very important part in the building of the George Jones Child Advocacy Centre (CAC). Telethon has enabled us to have a paediatrician and
you just can’t underestimate the value of that.” “In this town there’s a waiting list of 14 months for a paediatric specialist and we can access one within a fortnight.” Philanthropy with a cause “We needed to raise money in 2009 for the CAC and all we had to sell was our vision. I learnt a lesson about Australians and philanthropy when we had a charity dinner and raised $1.9m in a little over two hours. If you can show people that there’s a tangible way to address a serious issue they’re often incredibly generous.”
Basil sees the medical profession as a critically important way of widening the net of understanding. “It’s vitally important that we keep telling doctors about Parkerville. And as far as them getting involved there’s everything from probono assistance to just getting on our website and having a look at the work we do. There’ll always be a ﬂow-on from that because this is a societal problem and there needs to be increased awareness of this issue.”
By Mr Peter McClelland
“About 80% of our donations come from individuals at functions rather than large corporations. We raised enough money at that dinner to put some away for the next CAC planned for Midland in 2017.”
Christmas Cheers Christmas comes but once a year and Parkerville Children’s Home pulls out all the stops to make sure it’s a lot of fun. Ms Jo Collins, Director, Out-of-Home-Care Services, says the festivities relieve some of the harsh realities faced by the young people involved with Parkerville. “We use a local swimming pool in Mt Helena which is a fantastic location. It’s well supported by the community and last year the Kalamunda Lions Club brought along cooked sausages Ms Jo Collins and hamburgers. One of our carers always dresses up as Santa and one year he turned up in a red Ferrari.” “The time he arrived in a London taxi disguised as Thomas the Tank Engine was pretty special, too.” “Usually we’ll have around 100 children and carers, there are lolly bags, an ice cream truck
and the kids have a ball. It’s also a great way for the carers to catch up with one another.” It can be a ﬁne balancing act to assess the needs of an individual child when the normal supportive parenting structures break down. “We provide about 120 funded places for children who’ve been removed from their parents. Sadly, it’s a repeated pattern of social issues such as poverty, lack of appropriate role models, intergenerational abuse and struggles with drugs and alcohol that impact on highly vulnerable families.” “The decision to remove a child from their home is not taken lightly. Providing a safe environment is the main concern but we’re well aware that, at times, that removal can add to the trauma and compound a very difﬁcult situation.” “I’ve spoken with just as many people who say they are so glad they were placed in fostercare as those who say they wish they hadn’t been removed from their families.” “It’s that million dollar question, is this going to be the right move for a particular child? Do they have the resilience to go on in the
absence of their biological family? We have quite a few indigenous children from the Kimberley. Their ties to country are obviously very strong so once we ﬁnd a safe and stable situation for them we send them home.” “If they’re ﬂoundering because they’ve lost their sense of belonging then all the resources and opportunities we can provide will be pretty ineffective.” Jo points out that, sadly, there’s increasing demand for Parkerville’s services. “We receive referrals from the Department of Child Protection (DCP) for a limited number of funded places. In the last six months we received around 300 referrals and we’re at full capacity at the moment. We can ﬁnd temporary placements but that means moving children here and there which is particularly difﬁcult with sibling groups.” “Not too many potential carers have the required number of spare rooms and most have two working parents. It’s a signiﬁcant ask of the community to provide these services.”
By Mr Peter McClelland
DECEMBER 2015 | 23
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24 | DECEMBER 2015
Midland’s New Health Hub The new Midland Public Hospital will offer high acuity not seen in the district previously with the aim of keeping its community close. seen immediately from opening. These high acuity services will really raise the level of health care in the region.”
Comparisons are odious but almost impossible to resist, particularly when it comes to the weighing up of two major health infrastructure projects opening within a year of each other.
Workforce planning Clinical recruitment is sitting about 85% and when we spoke, Glen was conﬁdent of improving that ﬁgure signiﬁcantly by opening day. The hospital will employ about 1200 people with about half having previously been employed at Swan District Hospital. However, he said some areas were proving more difﬁcult to ﬁll than others.
Fiona Stanley Hospital – at 783 beds – is a titan. With 307 beds, St John of God Midland Public Hospital is a relative minnow. FSH has had titan headaches, while Midland has ﬂown under the radar. Both hospitals share architects and builders. While FSH has struggled at every turn, from construction cost blow-outs, delays and operational problems (mobile phone blackouts to burst water pipes in operating theatres for starters), Midland has been built and commissioned on time, on budget and on song. Medical Forum spoke to SJGMPH CEO Dr Glen Power (PhD) several weeks before the scheduled November 24 opening and, understandably, he declined to comment on FSH but merely said “where there were lessons to be learnt, we’ve been keen to get across those”. Midland differs from FSH in two signiﬁcant ways. Where the state ﬂagship hospital has struggled with an apparent problematic hybrid workforce of public and private, Midland will be wholly administered by St John of God Health Care (SJGHC), which secured the State Government tender to build and run the public hospital for 23 years. Relative independence Dr Power and Mr Ian Anderson (now CEO of MDA National) before him have not only had the responsibilities to construct and commission, but they also have had a freer hand to hire and train the workforce that will suit their contract remit for the Eastern suburbs and Hills. And that’s the second big difference – Midland is a community hospital and bearing witness to this were the 2000 people in the district who came to the open day in September to take a look at their new facility. “There’s a growing sense of excitement in the region because many of the new services at this site will mean many more patients will not need to travel to tertiary sites for treatment. The role delineation of the services at the St John of God Midland Public Hospital, compared with Swan District Hospital, has increased our capacity to treat more people here,” Glen said. “We hope to treat about 75% of the patients from our region.” The region encompasses the four local government areas of City of Swan, Town of Bassendean, Shire of Mundaring and Shire of Kalamunda as well as about 50,000 in the
Midland CEO Dr Glen Power
Wheatbelt resulting in about 280,000 people in the overall catchment. Glen said St John of God Midland Public Hospital is expected to play a substantial role managing secondary referrals from community hospitals in the Wheatbelt, which would make the hospital a health hub for the region. The cultural diversity of the region has also shaped workforce policies and health programs at the hospital. Aboriginal health a priority “A quarter of Perth’s Aboriginal population live in the hospital catchment so we worked hard to create services that reﬂect that with a dedicated Aboriginal health program. We are recruiting the Director of Aboriginal Health at the moment and looking for a medical practitioner to lead our program. There will be distinctive models of care informed by the Aboriginal-controlled health sector.” “We set aside 30 full-time positions for Aboriginal caregivers and we have exceeded that target by about 20%. About 3.5% of the workforce will be Aboriginal, in positions right across the board – medical, nursing, Aboriginal health workers and patient liaison, reception and catering. It not only boosts workforce representation but it ensures that the hospital will have a culturally diverse and competent workforce across all caregiving areas.” Other new services at Midland include critical care and cardiology. There will be 12 critical care beds – six for coronary care and six HDU/ ICU beds. “We will be able to monitor and ventilate patients in the new critical care unit – a ﬁrst for the region. From February, when our Intensive Care Physicians come aboard, we will be able to care for ventilated patients in the unit, with high dependency monitored patients being
“We didn’t anticipate that enrolled nurses would be harder to ﬁnd that RNs, so we have reviewed our assumptions of workforce mixes and modiﬁed those expectations to maintain our overall target which is 1083 FTE for opening.” One of the areas that will be ready for action on November 24 is the 48-treatment-space ED, which Glen says is big enough to manage the estimated 60,000 presentations in the ﬁrst full year of operation, and stand the test of time. No-go procedures Of course, there is the question of the services that won’t be provided at the SJGHC-run hospital which has been canvassed widely in Medical Forum and in Parliament over the past three years. Terminations and contraception will not be delivered at the public hospital but those patients will be accommodated at the Marie Stopes day facility in Midland, or referred to KEMH by their GPs. Glen said most of those procedures were not generally provided for in hospitals such as Midland. “It also needs to be recognised that these procedures were never sought by the State from any of the tenderers in the original RFP phase.” “The number of those procedures conducted at Swan District Hospital was very few; as Midland evolves, it will be providing high acuity services to the region and those procedures are more appropriately dealt with in day facilities.” The hospital opens at a time when the Health Department is devolving its health services and while that reconﬁguration is a subject for another day, the St John of God Midland Public and Private Hospitals – when in full ﬂight with a proposed adjacent stand-alone private hospital and the new medical school to open in 2017 – will be at the heart of an Eastern corridor health facility that will give tertiary sites a run for their money.
By Ms Jan Hallam
DECEMBER 2015 | 25
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s a m t s i r h C s g n i t e e r G
e r u t a e F Best wishes from WAâ€™s Health Professionals
Medical Forum wishes all our readers and supporters a Merry Christmas and a Happy New Year
DECEMBER 2015 | 27
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We sincerely appreciate your continued support and goodwill throughout 2015. We wish you, your staff & your families all the joys of this holiday season on behalf of the Doctors and staff at SKG Radiology.
Dr Sue Ulreich, CEO & Radiologist www.skg.com.au
28 | DECEMBER 2015
gs Featu n ti e e r G s a m st ri h C Dr Corinne Jones To friends and colleagues Thank you for your ongoing supportt throughout the year. Wishing you some happy, shared moments during the Festive Season and all the very best for 2016.
People say I don't write books, I make Christmas presents. Bryce Courtenay
Dr Yovich & his team at PIVET wish you & your families a joyful festive season. We thank you for your continued support.
COMPREHENSIVE SERVICES: CONSULTATIONS FULL NON-INVASIVE CARDIAC TESTING DIAGNOSTIC AND INTERVENTIONAL CARDIOLOGY
The Cardiologists and Staff from HeartCare Western Australia wish our referrers and their support staff a...
Merry Christmas & Best Wishes for a Healthy & Prosperous 2016
We thank you for your support this year and look forward to continuing high quality service to yourselves and your patients in 2016.
ON CALL DOCTOR NORTH OF RIVER: 1300 443 278 SOUTH OF RIVER: 6332 2350
Dr Randall Hendriks Dr Bernard Hockings Dr Mark Ireland Dr Ben King
Dr Donald Latchem Dr Allison Morton Dr Mark Nidorf Dr Vince Paul
Dr Peter Purnell Dr Pradyot Saklani Dr Nigel Sinclair Dr Isabel Tan
Dr Angus Thompson Dr Peter Thompson Dr Alan Whelan Dr Xiao-Fang Xu
heartcarewa.com.au MEDICAL FORUM
DECEMBER 2015 | 29
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30 | DECEMBER 2015
gs Featu n ti e e r G s a m st ri h C
The team at Panetta McGrath Lawyers would like to thank all of our clients for your support in 2015. We wish you and your families all the very best for the Christmas season and prosperity and good health in the New Year.
Dr Phil Daborn A special thank you to all my referring colleagues for your continued support throughout 2015. Wishing you & your families a joyful festive season, and all the very best for 2016.
A lovely thing about Christmas is that it's compulsory, like a thunderstorm, and we all go through it together. Garrison Keilor
We would like to thank our referring doctors, colleagues and hospital staff for your support in 2015. We look forward to working with you and continuing to provide high quality specialist care in the future. Wishing you and your loved ones a safe and wonderful Christmas and a Happy New Year!
Mr Krishna Epari
Mr Alan Thomas
Assoc Prof Mo Ballal
Mr Sanjeeva Kariyawasam
Mr Matt Henderson
Suite 73-74 SJOG Wexfo Wexford Medical Centre 3 Barry Marshall Parade Murdoch WA 6150 T (08) 6189 2500 F (08 (08) 6189 2505 Healthlink uppergiw email@example.com www.uppergiwest.com.au firstname.lastname@example.org
DECEMBER 2015 | 31
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CATARACTS AND GENERAL OPHTHALMOLOGY Dr Phil McGeorge and his team wish you a Merry Christmas and a Happy New Year. Thank you for your support over the last year. We look forward to providing general ophthalmology services to your patients in 2016. For a prompt and early appointment call 9366 1655 or 9366 1744.
Dr Phillip McGeorge MBBS FRACS FRANZCO
Suite 55, St John of God Murdoch Suite 318, St John of God Subiaco
Dr Phil McGeorge and his team extend warm festive cheer to you and your family.
Phone 9366 1655 www.perthlaservision.com.au
32 | DECEMBER 2015
gs Featu n ti e e r G s a m st ri h C Santa Claus has the right ht idea â€“ visit people only once a year.
The Cardiologists and Staff of Western Cardiology wish all a very Merry Christmas and Happy New Year. Thanks to all referring doctors for their support during the year. We look forward to continuing quality care for your patients in the future.
Dr Mark Hands Dr Stephen Gordon Dr Philip Cooke Dr Brendan McQuillan Dr Johan Janssen Dr Paul Stobie Dr Chris Finn
Dr Mini Zachariah To all my referring doctors and colleagues. A Merry Christmas and a Safe & Happy New Year. Thank you for your continued support and I look forward to working with you in 2016.
Dr Eric Yamen Dr Joe Hung Dr Michelle Ammerer Dr Luigi Dâ€™Orsogna Dr Andre Kozlowski Dr Tim Gattorna Dr Devind Bhullar
Warmest wishes, Mini
Mr Marek Garbowski
MBBS FRACS (Vascular) lar)
Vascular & Endovascular Surgeon I would like to extend my warmest greetings of the season, best wishes and health for the coming year to all my referring doctors, their families and staff. Thank you kindly for your outstanding continued support. I look forward to working with you in 2016 in mutually caring for the wellbeing of our patients. Best of health to you all Marek Garbowski & Staff at Perth Vascular Clinic
Perth Vascular Clinic: Suite 218, SJOG, 25 McCourt Street, SUBIACO All enquiries and appointment bookings phone: 9382 9100 www.perthvascularclinic.com.au
DECEMBER 2015 | 33
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Best of health for the festive season
The Executive, management and staff at Ramsay Health Care WA would like to thank our specialists, referring doctors and all of the medical community for their invaluable support throughout the year. We wish you all a safe and happy festive season and a prosperous 2016.
Attadale Rehabilitation Hospital
34 | DECEMBER 2015
Glengarry Private Hospital
Hollywood Private Hospital
Joondalup Health Campus
Peel Health Campus
gs Featu n ti e e r G s a m st ri h C
New Year's Day: Now is the accepted time to make your regular annual good resolutions. Next week you can begin paving hell with them as usual.
Dr Anjana Thottungal
Wishing all my colleagues and their staff a merry Christmas and a very happy New year. Thank you for your continued support over 2015.
Dr Jennifer Martinick
We all at POGU look forward to working with you in the new year.
Wishing my referring colleagues a Merry Christmas and a Happy New Year. Thank you for trusting me with the care of your patients suffering from any type of hair loss. I look forward to working with you in 2016.
Wishes you all a great xmas and happy new year!
WAVC Continues in its tradition of utilising the latest development in non -invasive Vascular Diagnosis & minimally invasive Treatments.
Phone 9279 4333 www.wavascularcentre.com.au
DECEMBER 2015 | 35
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Thankyou for your continued support throughout 2015. We wish you all a very joyful festive season. Warmest wishes Dr Peter Hugo, Dr Aparna Baruah & staff
Clinic will be closed from 24/12/2015 â€“ 04/01/2016
SEASON'S GREETINGS Dr Victor Chan, Dr Belinda McManus and Dr Alida Lancee Wish to thank all GPs who have supported them during the year.
Nanyara Fertility Control Clinic 2 Cleaver Terrace, Rivervale 6103 Tel: 9277 6070
MERRY CHRISTMAS and a HAPPY NEW YEAR to all doctors 36 | DECEMBER 2015
News & Views
Sharing Care and Wisdom It’s a long way from Mauritius to Perth’s Western Suburbs but for Dr Serge Toussaint there’s been an enduring philanthropic link between both places. think there’s great value in developing an ongoing relationship with a family doctor.”
Dr Serge Toussaint has been at the helm of the McCourt Street Surgery for 33 years but his medical practice extends well beyond his own waiting-room.
“The practice I built up is not fully computerised, although I have used a software program for the last decade, but I still reckon I take better notes using a pen and paper.”
“A charitable foundation began in Mauritius in 1968 helping children with serious medical conditions to receive treatment abroad. That, coincidentally, was the same year I won a scholarship to study medicine in London at St Mary’s Hospital.”
“There are distinct advantages in working alone but, ultimately, the buck stops with you. I’ve had a lot of happy moments as a GP and some very sad ones. I’ve seen many people with more than their fair share of major morbidities and you can’t help but wonder at their resilience. And it’s not just medical issues, either. There’s often a high level of adversity in their personal lives. I had one patient who told me that for the last ﬁve years I’d been her only friend.”
“I migrated to Australia in 1974, worked in Wembley and Floreat before taking over the McCourt Street surgery. I’ve just retired and it’s a pretty emotional time for both me and my patients, many of whom are in my ‘40 Year’ club. We’ve all seen each other through some ‘highs’ and ‘lows’ but there’s absolutely no doubt that being able to give that continuity of care has given me great satisfaction as a doctor.” Supporting kids in Mauritius A phone call from the other side of the world provided an opportunity for Serge to reconnect with his Mauritian heritage and, at the same time, provide specialised medical care for disadvantaged patients. “I was contacted in 1990 and asked if I would help to set up a local branch of the charity. After speaking with some prominent members of Perth’s Mauritian community we formed a committee, drew up a constitution and the Children of Mauritius Medical and Surgical Support Association (COMMSSA) was born.” “The children are selected by a panel of Mauritian doctors and we then receive an application before deciding if it’s appropriate to bring them to Perth. The charity’s medical director then approaches hospitals and specialists to coordinate the treatment. Usually the airfares are paid by the Mauritian government and we pick up the tab for the medical expenses.” “We’ve helped approximately 80 children. Initially it was almost exclusively cardiac cases and then we had a number of patients requiring orthopaedic treatment. Surgeons, pathology and radiology services have been very generous by giving substantial discounts and some do the work pro-bono. One ophthalmologist has treated four patients and never charged a cent!” Pressures of going solo Serge, just nudging into his seventh decade and now stepping away from medicine, reﬂects on both the changing landscape for GPs and the privileged glimpses of humanity that a career in medicine can bestow.
“I’ve never felt isolated as a solo GP but I acknowledge that it’s probably asking too much to expect anyone to practise that way in this day and age. I think doctors of my vintage looked at medicine in a slightly different way and that often comes at a cost to your own family. There’s no doubt that the world of a GP has changed a great deal and many people want to see a doctor at short notice and expect to be offered extra services such as the option of seeing a practice nurse. But I
In retirement, Serge has no plans to break out the ﬁshing rods. “We’ve got seven grandchildren and extended family in South Africa and France so sometimes when we go on holiday we don’t tell anyone we’re coming! We’ll be doing a lot more travelling and I’m very interested in languages, particularly French and Creole. I love cooking, too.”
By Mr Peter McClelland
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Planning for Innovation in Health For innovation, small steps are as important as big steps, according to Jason Micallef, Manager for the Institute for Health Leadership (DoH). It has been almost 15 years since Australian hospitals adopted innovative improvement methods from the manufacturing industry in order to improve quality, reduce errors and increase productivity. In many international high performing hospitals these improvement methods, such as lean-thinking, have underscored their clinical excellence and cost effectiveness (e.g. Intermountain, Cleveland Clinic, Virginia Mason). Yet here in WA healthcare improvement efforts remain ad hoc and lack integration with the daily activities in our hospitals and clinics. This prompts the question, “Why haven’t we embedded processes to improve care in a time of increasing ﬁnancial pressures, and a need to deliver more cost-effective care?” The positive news is that more clinicians are asking themselves that same question, as well as “What can I do about it?” Since 2012 junior doctors participating in the Medical Service Improvement Program have led 85 projects across metropolitan hospitals that have improved the safety, reliability and cost-effectiveness of care. Junior doctors are perfectly positioned to lead this work. They are close to the patient, interact with all health
Small but meaningful improvements can inspire clinicians and administrators to think creatively and to challenge the status quo. professions, and interface with myriad ordering, reporting, admission, referral and discharge processes. While complex ‘wicked problems’ consume attention and create anxiety, junior doctors see a multitude of more simple problems that plague patient care, which otherwise go unnoticed – gaps in communication and information and misalignments of how we do things. Addressing these issues requires a minimal investment in staff time but yields immediate results, such as reductions in delays and better use of resources and staff time. As an example one junior doctor estimated $800,000 per year of productive clinical time was lost due to excessive wait times for patients being transferred between two units. These estimates are based on stafﬁng
and equipment costs. The effects on patient experience and outcomes are also signiﬁcant considerations. Staff can work more collaboratively to address small daily operational issues. Although our health systems are complex, many solutions are not. One administrator from a ‘US top 10 hospital’ said there is so much “low hanging fruit improvements” in their hospital that just focussing on big-ticket innovation is only half of the picture. Many high performing hospitals have simpliﬁed their improvement methods, making them less arduous and more easily integrated into everyday hospital activities, with frontline clinicians taking the lead. Finding the best way to deliver timely and costeffective care requires the careful balancing of diverse and sometimes conﬂicting interests, including best-practice evidence, clinician preference and site preference. There is no policy silver bullet or transformative innovation on the horizon to solve the health affordability and quality issues. However, small but meaningful improvements can inspire clinicians and administrators to think creatively and to challenge the status quo. Supporting our clinicians to take small but meaningful steps can only lead to bigger innovations in the future.
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Healthy Eating Good for the Planet Everything is interconnected, so dietitican Ms Amelia Harray says it should come as no surprise that what we eat impacts on environmental sustainability. Reducing our carbon footprint through the food we eat is rarely considered by people when making dietary choices. We know healthy diets are more environmentally sustainable, however, there is limited evidence on how current Australian diets are impacting the environment. Eating a predominantly plant-based diet, limiting intake of particular foods (such as highly processed packaged foods) and avoiding kilojoule consumption above energy requirements, can support both health and the environment. However, we know that many Australians choose foods inconsistent with our national dietary recommendations for good health, with over one third of energy intake coming from junk foods, such as burgers, pies, cakes and sugary drinks. To date most national dietary surveys have collected data on nutrient and food intake but have not collected data on sustainable diets. Research is being conducted to assess how the diets of young West Australian adults comply with a healthy and sustainable diet using a mobile food record application.
Participants in the study are asked to take before and after images of their food and beverage intake. Sustainable dietary behaviours are measured from the food images supplied, including meat and dairy portion sizes, fruit and vegetable seasonality, individually packaged foods, ultra-processed foods and food (plate) waste. Once the images have been analysed, tailored feedback can be provided so people can reﬂect on their use of individual food packaging, the amount of food they waste and how their food choices impact their health and the environment. Future research will explore if feedback on a person’s sustainable dietary behaviours motivates them to choose healthier foods. The research goal is to develop a Healthy and Sustainable Diet Index. This diet quality index will assist in guiding nutrition interventions, population monitoring, informing policy makers, monitoring the effectiveness of programs, and research. The NHMRC’s Dietary Guidelines currently have no direct recommendation encouraging Australians to reduce the carbon footprint
of their food choices, but it does have an appendix on the issue. European countries, such as Sweden, have incorporated sustainable food choices in their dietary guidelines, as have the proposed 2015 American Dietary Guidelines, but we are yet to hear if these will stay. Just as there has been a transition from nutrient to food-based dietary guidelines (as people eat food and not a main of zinc, with a side of vitamin C and a dash of folate), there needs to be a shift in the thinking of consumers, health professionals and policy makers to consider both health and environmental sustainability. Although improved health status is of upmost importance, recommendations must address sustainability to ensure access to an adequate, nutritious food supply for future generations. Australian dietary behaviours need to change on grounds of human health and environmental health. For this to happen, policy makers need to follow in the footsteps of other countries and incorporate sustainable diet considerations into public health policy and our Dietary Guidelines. ED: Amelia Harray is an Accredited Practising Dietitian and researcher at Curtin University.
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DECEMBER 2015 | 39
N E W H O S P I TA L S I T E E X PA N D S PERTH RADIOLOGICAL CLINIC â€™S PRESENCE IN MIDLAND
To complement our community based clinic at Victoria Street Midland, Perth Radiological Clinic is pleased to announce the opening of a new clinic on 24 November, at St John of God Midland Public Hospital. Services offered on site at the hospital include: 1 MRI 1 Low Dose CT 1 Ultrasound including Doppler 1 Nuclear Medicine 1 X-ray Be assured that Victoria Street Radiology will continue to provide excellent radiology services to the local doctors and patients in Midland.
www.perthradclinic.com.au 40 | DECEMBER 2015
Leaders in Medical Imaging MEDICAL FORUM
Keeping it Real Lead Clinician Dr Rachel Hughes shares with readers her enthusiasm for the WA Youth Cancer Service. About 110 young people aged 15-25 are diagnosed in WA with cancer each year and most come to the attention of the WA Youth Cancer Service. Dr Rachel Hughes is the lead clinician. She said that without age-targeted services, these young people run the risk of falling through the cracks. While brain development has reached the point where most 25-year-olds can fully plan and navigate complex health problems, teenagers at the other end of this cohort have quite different needs. The adolescent-young-adult (AYA) group has other sobering features. “It’s an age group that has a more challenging group of tumours with a need for specialised treatment approaches,” Rachel pointed out.
Involvement in decision-making “Young people want to be involved in decision making in any chronic illness. Their priorities are honesty and conﬁdentiality. We recognise that young people are at least partially independent but possibly quite connected to their family.” “How much control over decision making do they want? Perhaps they want conﬁdential time during consultation. Sometimes we have to advocate for them – what they do and don’t want to share? We try and help each family communicate. The onus is on us to be clear around conﬁdentiality.” “Trust is incredibly important. Young people need to understand why we are putting
stage disease with a lot of symptomatology. If the young person is facing a life-threatening illness they still want honesty and assurance that even if things are not going well, we will make as much effort to look after them as if they were getting cured.” Conﬁdence in their doctor being able to control symptoms is important. She said fatigue, both emotional and physical, is the most common complaint. The Youth Cancer Service grew out of a very strong nursing model and now has a network of supporters. Over the last 10 years recognition of clinical gaps in this age group has grown. Survival is improving. Rachel thinks getting young people onto clinical trials will
“A very distinct array of tumours peak in their age group – some of the sarcomas, Hodgkin’s lymphoma, some of the leukaemias – but the most common tumours are melanoma, then gonadal germ cell tumours (testicular and ovarian), Hodgkin’s, and thyroid cancer.” Cancer survival rates “The overall cancer survival for the age group is 85-88%, however, the AYA cohort has peak incidences of some of the high mortality tumours such as the sarcomas and brain tumours, where survival can be lower than 70%. So they are very morbid tumours.” “Something about the biology of young people gives them a poorer survival. We know that some of the AYA leukaemias demonstrate more unfavourable cytogenetic types that beneﬁt from more intensive treatment.” Diagnostic delays also occur more often, for a variety of reasons, some related to a ‘bullet proof’ mentality at this age. “Young people do appreciate risk but are still likely to take risks. They may not see their doctors much and cancers are relatively rare at this age.”
Dr Rachel Hughes, inset, and the WA Youth Cancer Service team
them through this. Their brains are wired to question everything. One of my jobs is to be an extra sounding board on treatments, symptoms and side effects.” “I’m a generalist, so I look at a young person from scratch – what’s affecting their quality of life, so the impact of cancer can be minimalised. The other thing that’s important later is to help them transition out of cancer treatment back into life.” Balancing hope with reality
To improve outcomes, Rachel works with a team of senior nurses, counsellor, youth development ofﬁcer and exercise physiologist to provide psychosocial and general medical support. They work alongside the oncologists and others on the treating teams. Given her unique experience – palliative care physician, rural general practice, sexual health medicine and retrieval medicine – sharing the experiences of young people has been a very worthwhile journey for her.
improve things further. Early referral from GPs for a rare disease means the best information has to get out to GPs. “When someone is referred to our service we get to know them and screen them for psychosocial distress and as soon as we can, we discuss fertility preservation – we bring it up as some young people may not have contemplated having children and we know having cancer doesn’t alter their desire to have children.”
“We are not friends, we are trusted health care professionals, that’s an important distinction. I want patients to come to me when they are worried about something, and I will speak with them honestly and allow them to balance hope and reality. And then we go from there.”
“For example in WA we have a state sarcoma service – working towards a highly specialised, centralised, multidisciplinary management team of surgeons, radiation oncologists and making sure the diagnostic process is ideal. Referral pathways are something we will continue to work on. The other is making sure young people get the best access to supportive care alongside the best cancer care.”
“Enough of my patients go through advanced
By Dr Rob McEvoy
She has set herself clear boundaries around caring.
DECEMBER 2015 | 41
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“Adrenal Fatigue” Patients presenting with an Internet facilitated self-diagnosis of “adrenal fatigue” is an increasing problem for doctors. It is commonly deﬁned as a constellation of symptoms (including fatigue) due to hypo function of the adrenal glands. This apparent adrenal hypo function is a result of chronic stress or illness. Adrenal fatigue as an entity is not supported by conventional medicine including the Endocrine Society. It differs from adrenal insufﬁciency, which is a clear medical entity deﬁned by clinical symptoms, signs and supportive testing. Not unexpectedly there are always borderline cases especially biochemically and clinical judgement is needed. Diagnosis of adrenal fatigue is based on a list of non-speciﬁc symptoms that would capture most of the population and is sometimes supported by cortisol measurements in the saliva or “day curves”. Salivary cortisol is not a validated test outside of screening for Cushing’s syndrome (midnight salivary cortisol).
s At the recent MDA National Board election, Dr Andrew Miller (WA), Dr Robyn Napier (NSW) and Dr Beres Wenck (QLD) were returned. Dr Rosanna Capolingua (WA) was replaced by Dr Patrick Maher (VIC). Dr Keith Woollard (WA) failed to win a seat. s Mr Tim Shackleton has been appointed Chair of the WAGPET Board. Dr Felicity Jefferies and Dr Jonathan Mortimer (GP Registrar Representative) have also been appointed, Dr Andrew Png and Ms June Foulds have stepped down. Former chair Dr Peter Maguire will continue in the position of GP Supervisor Representative on the Board. s Former school principal Mr Colin Pettit has been appointed Commissioner for Children and Young People. Ms Jenni Perkin has been acting in the position for nearly three years after the resignation of inaugural commissioner Ms Michelle Scott. s Prof Wendy Erber has been appointed Dean of the Faculty of Medicine, Dentistry and Health Sciences at the University of WA.
No logic There is good evidence both in experimental studies and clinical practice that adrenal glands hypertrophy in the context of excessive stimulation and do not atrophy. For example, in Cushing’s disease the adrenal glands hypertrophy in response to excessive ACTH. There is no published research supporting adrenal fatigue. On the other hand there is a signiﬁcant body of literature on HPA axis dysfunction in chronic fatigue syndrome (CFS). To summarise; There appears to be mild HPA axis dysfunction and hypocortisolaemia in those with diagnosed chronic fatigue. Whilst causality cannot be inferred from association studies, prospective studies suggest the hypocortisolaemia occurs after the chronic fatigue and is probably a secondary or adaptive response. There is evidence that short-term improvement in fatigue can occur with glucorticoid replacement in some with CFS. These are short-term studies and such a strategy comes with obvious long-term risk. I suspect this is pharmacological (i.e. drug) use of glucorticoids rather than physiological (i.e. replacing what is deﬁcient).
She was head of the School of Pathology and Laboratory Medicine. s HBF CEO Mr Rob Bransby will leave the state’s biggest private health insurer in April to take up the role of chief executive of Perth Racing. s Lifeline WA CEO Ms Fiona Kalaf will leave the organisation in February to become the CEO of Youth Focus. The current CEO Youth Focus Ms Jenny Allen will leave her post at the end of the year. She has been at the NFP since 2000. s Medical student Andrés Noé, 24, of North Perth, has been awarded a Rhodes Scholarship. s Prof Andrew Whitehouse, from Telethon Kids has been awarded a Australian Research Council Discovery Project grant of $415,000 to investigate how fetal hormone exposure and early brain growth support child language development.
By Dr Brett Sillars Endocrinologist Fiona Stanley Hospital
How to approach the patient concerned about Adrenal Fatigue? I tend to stress a couple of points to the patient. Their symptoms are genuine and require explanation but adrenal fatigue is not real. Chronic stimulation (or “stress”) of the adrenal glands causes the adrenals to grow and produce more cortisol, not shrink and produce less. Chronic stress does indeed lead to ill health and this needs to be addressed. I explain that the messages around healthy living on these websites are supported; however adrenal “supplementation” is a waste of their hard earned money. Glucorticoid supplementation comes with signiﬁcant risk and will only worsen the problem due to HPA axis suppression and side effects. References available on request.
Author competing interests – no relevant disclosures. Questions? Contact the author on 61152 6049
s More than $40m in fellowships will be shared among 76 early career researchers working on dementia including Dr Sarah Rea and Dr Kate Smith, both from the Perkins Institute, Dr Andrew Ford, from UWA’s School of Psychiatry and Clinical Neurosciences and Mr Sam Buckberry, from the ARC Centre of Excellence in Plant Energy Biology. s Four researchers at The University of Western Australia have received $2.2 million in Federal Government funding to tackle the causes and impacts of dementia – the second-leading cause of death in Australia behind heart disease. s Mr Peter Kerr has been appointed to the board of Diabetes Research WA as treasurer. He is CFO of Mount Gibson Iron. s The ACCC will conduct a public merger review of the proposed acquisition of Adelaide Pathology Partners (APP) by Sonic Healthcare Limited and its subsidiary, Clinpath Laboratories Pty Ltd, (together, Sonic).
DECEMBER 2015 | 43
We w would like to extend our sincere thanks to all our referrers for your support this year. refer We w wish you ou an and your fam family a wonderful and safe holiday season eason n an and the very b a best for 2016.
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New approaches to psoriasis
PIVET MEDICAL CENTRE Specialists in Reproductive Medicine & Gynaecological Services
By Dr Alan Donnelly Dermatologist West Leederville
Psoriasis is a common skin condition characterised by persistent scaly erythematous patches. Previously considered a disorder of keratinisation with hyperproliferation of the epidermis, psoriasis is now recognised as an immune-mediated genetic disease manifesting in the skin, joints or both.
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Recently, within our PIVET-Curtin collaboration, we have re-examined the LQĂ XHQFHRIVSHFLĂ€FOLIHVW\OHHIIHFWV,QZRUN WKDWH[WHQGVWKH3K'WKHVLVRI'U.DUHQ Clinical -RHVEXU\ZHKDYHUHH[SORUHGWKHLQĂ XHQFHV Professor John Yovich RIYDULRXVIDFWRUVÂ˛FLJDUHWWHVPRNLQJGLHW FDIIHLQHFRQVXPSWLRQDOFRKROFRQVXPSWLRQ DQGVWUHVVERWKJHQHUDODVZHOODVIHUWLOLW\UHODWHGVWUHVV LQERWK PHQDQGZRPHQ.DUHQ conducted her studies DW3,9(7IURPWKH&XUWLQ 6FKRRORI3XEOLF+HDOWK DQGWKH)DFXOW\RI+HDOWK 6FLHQFHV
The most common form is a chronic plaque psoriasis presenting as erythematous scaly plaques. Other forms include guttae psoriasis where small lesions occur particularly after streptococcal throat infections. Flexural psoriasis involves body creases but often well demarginated erythematous plaques occur without associated scale. Pustular psoriasis can be localised to the hands and feet but can involve the whole body. Psoriatic arthritis is the commonest co-morbidity. Psoriasis is also associated with hypertension, hyperlipidemia, diabetes, nonalchoholic fatty liver disease and an increased risk of depression. Traditional treatments for mild psoriasis are topical steroids, vitamin D preparations and topical tars. Topical calcineurin inhibitors like tacrolimus and pimecrolimus can be used for difďŹ cult sites such as intertriginous areas or the face, with phototherapy (Narrow Band UVB) used for more widespread disease. Oral medications like methotrexate, cyclosporine and acitretin are used for widespread or unresponsive disease.
Fig 1. Sarah Firns, MSc student with PIVET-Curtin Research fellow Dr Kevin Keane (left) and PIVET Medical Director Prof John Yovich at UWA Club in October.
New agents Biologics currently available on the PBS, have strict guidelines for use. These medications include TNF-alpha inhibitors etanercept, adalimumab and inďŹ‚iximab. Ustekinumab is a drug that blocks interleukin-12 and interleukin-23. The latest introduction is secukinumab which is an IL-17A blocking agent. Biologics are used long term and at present there seems to be no evidence of any cumulative toxicity or drug-to-drug interactions (which can occur with agents like methotrexate). To obtain the biologic agents, the psoriasis must have a psoriasis area severity index (PASI) score greater than 15. Associated with this, the patients must have undergone treatment and failure of response to three of the four disease modifying agents and phototherapy. A new phosphodiesterase 4 (PDE4) inhibitor called apremilast (OtezlaTM) is approved for use in chronic plaque psoriasis and psoriatic arthritis in the US, Europe and Australia, though it is not listed on the PBS here. It down regulates the inďŹ‚ammatory response by modulating other cytokines such as tumour necrosis factor and interleukin-1. Not an immunosuppressive medication, its efďŹ ciency seems similar to methotrexate. It reduces the severity of moderate to diffuse psoriasis involving the scalp, palmar-plantar and nail manifestations in adults and can improve psoriatic arthritis. It has been shown to give a 75% reduction in psoriasis severity in about 30% of patients. The most common adverse events in trials included faecal frequency, nausea and headache. Apremilast does not appear to be associated with increased risk of infections and malignancies and rarely is associated with laboratory abnormalities, thus not requiring regular blood test monitoring.
Our current MSc student Sarah Firns recently SUHVHQWHGVRPHRIWKH PIVET studies at an RTCVSRQVRUHGSRVWJUDG PHHWLQJKHOGDWWKH 8:$&OXE)RFXVVLQJRQ VPRNLQJWKHSUHYDOHQFH DPRQJ3,9(7SDWLHQWVLQ ZDVRIZRPHQ DQGRIPHQDIIHFWLQJ ERWKDGYHUVHO\LQGLIIHUHQW ZD\V
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Author competing interests â€“ no relevant disclosures. Questions? Contact the author on 9380 9690
For ALL appts/queries: T:9422 5400 F: 9382 4576 E: firstname.lastname@example.org W: www.pivet.com.au
DECEMBER 2015 | 45
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Oral Cancer By Prof Camile Farah Prof of Oral Oncology Head of School of Dentistry UWA Oral cancer makes up 3% of all cancers in Australia (but up to 40% of cancers diagnosed in India, associated with betel nut/quid long term use). About 95% are squamous cell carcinoma (SCC). In Western populations, oral SCC is mostly seen on the lateral borders of the posterior oral tongue and ďŹ‚oor of mouth, usually in older males with a history of smoking and alcohol consumption. Trends show oropharyngeal SCC is increasingly related to infection with HPV (typically 16, 18, 31, 33), especially in younger adults.
Fig 3. Non-homogenous white lesion (leukoplakia) on the lateral tongue. Note the mixed erythematous pattern in the background, and textural changes of white areas. Final histopathology, squamous cell carcinoma.
Early diagnosis is paramount Early diagnosis is the greatest challenge amongst doctors and dentists. Recent evidence states that medical practitioners are concerned they lack the skill and expertise to identify oral cancers properly.
Fig 2. Mixed red and white lesion on the ďŹ‚oor of mouth in an elderly patient - note the non-homogeneous pattern in a lesion persistent for more than two weeks. Clinically erythroleukoplakia; ďŹ nal histopathology, squamous cell carcinoma.
More worrisome, is the lack of training in identifying precursor lesions (or pre-cancers) in the mouth. We know that early identiďŹ cation results in better outcomes, made more important by the fact that many more patients consult their doctor rather than their dentist about a lesion in the oral cavity.
â€˜Red ďŹ‚agâ€™ signs and symptoms:
Precursor lesions â€“ what are they?
Detecting precursor lesions brings treatment outcomes better than 95% survival in ďŹ ve years. Misdiagnosis is unfortunately commonplace. Many chronic non-healing ulcers are mistreated with various topical agents or antibiotics. Any lesion that does not resolve in two weeks should be considered sinister pathology until proven otherwise, and requires assessment and biopsy by an oral medicine specialist.
sĂĽ #HRONICĂĽNON HEALINGĂĽULCERSĂĽINĂĽTHEĂĽMOUTH sĂĽ ,UMPSĂĽINĂĽMOUTHĂĽORĂĽNECK sĂĽ /LDERĂĽPATIENTĂĽWITHĂĽHISTORYĂĽOFĂĽSMOKINGĂĽANDĂĽ alcohol consumption.
The continual review of non-resolving oral lesions without a conďŹ rmed diagnosis may introduce diagnostic delay that worsens outcomes for patients.
Guiding Principles sĂĽ 0EOPLEĂĽWITHĂĽORALĂĽLESIONSĂĽOFTENĂĽCONSULTĂĽ their doctor before their dentist. sĂĽ 7ITHĂĽEARLYĂĽDETECTIONĂĽOFĂĽORALĂĽCANCERĂĽ you can save lives. sĂĽ 2ECOGNITIONĂĽOFĂĽPRECANCEROUSĂĽLESIONSĂĽ is paramount. sĂĽ 2EFERĂĽANYTHINGĂĽTHATĂĽDOESĂĽNOTĂĽHEALĂĽ within two weeks, for biopsy.
Failure to diagnose can be devastating Late stage diagnosis has 50% ďŹ ve year survival rates at best, dropping to 35% on the posterior lateral tongue and ďŹ‚oor of mouth, following surgery.
Author competing interests: No relevant disclosures. Questions? Contact the author on email@example.com
Precursor lesions are mostly white or red patches. Irregular, non-homogenous white patches (leukoplakia) are more likely to display epithelial dysplasia; the single most common predictor of malignant transformation.
27/146 Mounts Bay Rd, Perth WA 6000 8/100 Murdoch Drive, Murdoch WA 6150 Respiratory Diving Medicals r Osmotic Bronchial Provocation Test r Detailed Pulmonary Function Test for gas trapping r Clinical assessment r 48 hour turnaround Additional Tests Available â€“ Cardiopulmonary Exercise, Bronchial Provocation, Oxygen Assessment, Nasal Resistance and Allergen Skin testing Fig1. Chronic non-healing ulcer on the lateral tongue. Note the central area of necrotic ulceration. The lesion feels ďŹ xed and indurated on palpation. Final histopathology, squamous cell carcinoma.
FOR ALL APPOINTMENTS Tel 08 94812244 Fax 08 94812255 Email firstname.lastname@example.org com.au u
DECEMBER 2015 | 47
Fertility, Gynaecology and Endometriosis Treatment Clinic
When your patient’s family plan isn’t going to plan... Fertility North can help. zCycle Tracking z Timed Intercourse z Artiﬁcial Insemination zOvulation Induction zIn-vitro Fertilisation (IVF) zIntra-cytoplasmic Sperm Injection (ICSO) (ICSI) zPregnancy Monitoring zDonor Services zSperm / Egg Freezing zOncology Fertility Preservation zEgg Freezing for Social Reasons zSemen Analysis
Dr Vince Chapple
Dr Jay Natalwala
Dr Santanu Baruah
Dr Gian Urbani
Dr Megan Byrnes
Fertility Specialist Qualiﬁcations
MB, BS (London) FRANZCOG MRepMed
MB, BCh (UK) DRCOG FRANZCOG MRepMed
MBBS, MRCOG (UK) CCT (UK), CGES FRANZCOG
MBCHB, MMEd(O&G) FRANZCOG MRepMed
BMedSci, MBBS FRANZCOG MRepMed
MBBS, DRACOG FRACGP
Dr Jane Chapple
Suite 30, Level 2, Joondalup Private Hospital, 60 Shenton Avenue, Joondalup WA 6027 Phone: (08) 9301 1075 Fax: (08) 9400 9962 Email: email@example.com
Fertility, Gynaecology and Endometriosis Treatment Clinic 48 | DECEMBER 2015
Meningitis vaccination in travellers Meningococcal disease in travellers deserves our attention. A nineteen year old WA university student died of this in London in 2013 within days of arriving, and after an illness of just a few hours. The responsible strain was W135, which we generally think of as belonging in subSaharan Africa. Air travel has changed all that – Heathrow handles 200,000 people every day from every corner of the planet and 10% (about 20,000) will carry the meningococcus in their nasopharynx. Amongst the 13 pathogenic strains of meningococcus, A, B, C, W135, and Y are most common. In Australia, 85% of disease is caused by strain B. Strain C is declining due to childhood vaccination. Tropical Africa, especially in the drier months of December to June, is the highest risk destination.
By Dr Peter Burke Travel Medicine Nedlands
Table: Meningococcal vaccines Type of Meningococcal Vaccine
Strains Duration* Comments
Conjugated Type C
May be the one required by US and European Universities etc., but consider four strains instead.
A C W Y 5 years
Preferred vaccine in most travellers
A C W Y 2-3 years
B Strain monovalent
Inferior immunogenicity in children B
High fever common in infants. Give alone. Paracetamol.
Different strains and vaccines This has become complicated. The table summarises the meningitis vaccines registered for use in Australia (excluding the various childhood vaccines). The decision regarding strain B vaccination is more relevant to those staying at home. Cost and side-effect proﬁle have limited its use in general practice. For travellers, I would say the choice is easy. Conjugated vaccines are more immunogenic, last longer, and boost better. You want to cover all four strains, not just C. Use a conjugated quadrivalent vaccine in at-risk travellers unless contra-indicated. For each of the three conjugated ACWY vaccines the manufacturer gives differing ages above which vaccination has not been approved. The Australian Technical Advisory
* Commonly used estimates for duration of protection. Group on Immunisation says anyone from age two upwards can be vaccinated.
certiﬁcate required), and doctors (sick people gravitate to our profession).
A very high risk traveller may need prophylactic antibiotics (e.g. asplenic traveller to West Africa).
There is a case for vaccinating all travellers using conjugated quadrivalent ACWY vaccine every ﬁve years. Routine repeat B strain vaccine can be argued for those residing in the developed world. Higher risk groups include: those aged <5 or 15-25, smokers, splenectomised, functional asplenia or other immune compromise, group accommodation (e.g. university accommodation), longer term travellers, expats, travellers to tropical Africa (the “meningitis belt”), travellers exposed to crowds (e.g. backpackers catching local buses or aid workers), Hajj and Umra Pilgrims (vaccination
Risk is relative. No location, job, or traveller can be said to have no risk of exposure to this awful, often fatal, illness. Consider meningococcal vaccination in your travellers, your ‘stay-at-home’ people at risk, and yourselves. References available on request. Author competing interests - no relevant disclosures. Questions? Contact the author firstname.lastname@example.org
Anaphylaxis – Stings, Foods & Other Things Some interesting points came out of the recent talk by Dr Richard Loh on anaphylaxis, some worthy of recall here… så 9OUåCANåGETåANåANAPHYLAXISåALLERGICåREACTIONå without a skin response i.e. hypotension – typical examples are the pale ﬂoppy infant or the adult with persistent dizziness – and this applies to 1 in 6 fatal food reactions.
så )FåSOMEONEåREACTSåTOåAåCOMBINEDåMEAL å best to keep (freeze) the ingredients for a later whole food screening skin test.
så &EARåANDåANXIETYåAROUNDåANOTHERåPOSSIBLEå hypotensive episode becomes a secondary problem for children or adults (who often describe their episode as a ‘near death’ experience).
så 4HEåQUALITYåOFåLIFEåIMPACTSåONåSOMEONEå with bee allergy or food allergy have been estimated to be more than with diabetes.
så 4HEREåAREåSOåMANYåINCONSISTENCESåAROUNDå testing for food allergies and the likelihood of a reaction if eaten that a controlled challenge in a safe environment is needed if the person really wants to know. så åOFåPEOPLEåWILLåHAVEåHADåAåMILDåORå moderate food allergic reaction before their fatal reaction.
så 4HEREåISåNOåTESTåTHATåACCURATELYåPREDICTSåTHEå severity of an allergic reaction.
så åINFANTSåHAVEåhFOODåALLERGYv åDECREASEDå to 4-6% at 4 years and 3% of adults, with a lessening tendency for people to grow out of it (although this varies with the food). så #OOKINGåPRAWNSåANDåROASTINGåPEANUTSå increases their allergic potential.
15-20 minutes max (but takes 45 mins to absorb if injected into subcutaneous fat). så 5PåTOååOFåTHOSEåTREATINGåANAPHYLAXISå require two autoinjector doses. så !LWAYSåSENDåSOMEONEåWHOåHASåHADå anaphylaxis home with adrenaline because of the risk of a rebound 4-6 hours after initial treatment – observation for 4 hours after a reaction is necessary. så 'ETåAåGRANDPARENTåORåPARENTåTOå demonstrate the use of an adrenaline autoinjector – it increases their proﬁciency in use ﬁve-fold.
så !NTIHISTAMINESåHAVEåNOåROLEåINåTHEåTREATMENTå of anaphylaxis. IM Adrenaline lasts about
DECEMBER 2015 | 49
Sacral Nerve Stimulation for Severe Faecal Incontinence
Background Severe faecal incontinence (FI) affects up to 1.5% of the Australian population across all age groups costing the community an estimated $1.6 billion annually. Most patients with mild to moderate symptoms of FI can be successfully managed with diet modiﬁcation, biofeedback/pelvic ﬂoor retraining and anti-diarrhoea medications. Having failed conservative therapy, the surgical options are limited. Past surgical therapies such as artiﬁcial bowel sphincter, injectable bulking agents, and dynamic graciloplasty have been trialled but their complication rates are high with poor long-term outcomes. Current available surgical modalities to manage severe FI having failed non-surgical management include anal sphincter repair, colostomy, and sacral nerve stimulation (SNS). Each of these modalities has its limitations. However, SNS seems to have the lowest morbidity, complications and long-term studies have reported good outcomes. Sacral nerve stimulation Sacral nerve stimulation was ﬁrst introduced to manage urinary incontinence. It has since been adapted for the management of severe FI. The aim of SNS is to provide continuous or cyclical stimulation to one of the unilateral S3 nerve roots (Figure 1). This is achieved using a permanent tined lead with an implantable pulse generator. SNS implantation is divided into 2 stages. Stage 1 involves insertion of a tined lead into the foramen of S3, which is connected to an external battery pack. Optimal lead placement results in anal sphincter contraction and foot plantar ﬂexion. The patient then undergoes a 4-week trial period with them keeping a continence diary. Patients demonstrating at least 50% improvement in their incontinence symptoms and incontinence scores will proceed to Stage 2, where a permanent battery pack is implanted subcutaneously in the lumbar area.
Dr Zee Hame Wong, MBBS, Mr Patrick Tan, MBBS FRACS.
Mechanism of action The mechanism of action of SNS has not been fully understood. Multiple hypotheses have been proposed including: modulation of somatovisceral reﬂex with inhibition of propulsive colonic activity; modulation of perception leading to reduced reﬂex defecation; improved perception of the need to defecate; and direct enhancement of external anal sphincter activity. At present, there is no conclusive evidence deﬁning the mechanism of action. Table 1 shows the current indications for SNS. Table 1: Clinical indications and patient selection Refractory to conservative management. Not for patients with uncorrected anatomical abnormality (e.g. rectal prolapse, ﬁstula). Not for patients with uncorrected evacuation disorder. Not for patients with chronic constipation and overﬂow incontinence. Contraindicated in patients with complete spinal cord impairment. Contraindicated in patients who require MRI Clinical outcomes Early short to medium-term outcomes have been promising with success rate reported at up to 87% and total continence achieved in up to 47% of patients. Currently, at St John of God Subiaco, 39 patients with mean follow-up of 3 years underwent Stage 1 trial. 30 patients went on to Stage 2, with implantation of the battery pack. Satisfactory outcome was reported in 51% of patients with signiﬁcant improvement in Wexner Continence Scores. Total continence was reported in 13% of patients as deﬁned by complete absence of incontinent episodes from the time of SNS insertion. Due to the cost of SNS, careful selection of patients is essential to ensure optimal cost effectiveness of the procedure. Patients with severe FI but with no signiﬁcant history of evacuation difficulties and/or chronic constipation have the best outcomes (Table 1). 5-year follow-up has shown that up to 48% of patients continue to experience good continence status and 19% have total continence. Complications The most commonly reported complications were local discomfort, lead displacement, infection, and seroma. Overall, the complication rate was reported in up to 15% of patients with 3% requiring explanation. Conclusion SNS has an advantage over current surgical options for management of severe FI as it carries relatively low morbidity with relatively good long-term outcomes. Furthermore, SNS has the advantage of a trial stage to select patients who will likely have a positive outcome from the intervention prior to implantation of a permanent system. References on Request
Figure 1: Optimal placement of permanent tined lead.
50 | DECEMBER 2015
News & Views
Art in Practice Art has healing properties and when it comes to artworks by patients, it also has an enormous community beneﬁt. A general practice waiting-room is a perfect place to display the creative talents of patients, according to Dr Pradeep Jayasuriya. Works of art in different styles and mediums line the walls of his Belgravia Surgery in Cloverdale with plenty of positive spin-offs for both patients and staff. “We redesigned the entire space and it looks much more like an art gallery than a place where people come to see their doctor. Patients walk around, look at the art and talk with each other. People have got their heads up rather than staring down at a magazine and they’re more engaged.”
“Sometimes I’d be given a work of art, it’d be sitting there and a patient would comment how wonderful it was. So I thought it’d be rather nice if the artists had the opportunity to hear it for themselves.” “We created the gallery as a way of celebrating our patients’ talents in a caring environment. It’s had a great response on a wider level because, naturally enough, the artists are known to many of their fellow patients. In many cases it’s only one or two degrees of separation between the artist and the viewer.” The gallery began in March and a second exhibition is launching soon.
“I’ve noticed a big difference when a patient walks in for their consultation. The art is a talking point and often our ﬁrst conversation is about a painting rather than how terrible they feel. Our entire workplace has a different feel and it’s much more uplifting for everyone.”
“We plan to rotate the paintings every three months and many of the artworks are for sale. In our ﬁrst exhibition we sold about 90% of the paintings. When we hang a picture, we ask the artist to write a little story and that gives an added personal touch.”
Pradeep has had longstanding relationships with many patients in a practice spanning two decades, so it wasn’t entirely surprising that he uncovered hidden creative talents.
“From a health point of view it’s something we, as health professionals, should be tapping into and promoting. Health needs to be seen in a wider context. I’m sure the art gallery
Dr Pradeep Jayasuriya admires artworks in his waiting room. Picture: Courtesy Community Newspapers Group
has had a positive impact and it’s been an important way to build relationships within our community. As GPs we need to step outside our boundaries and it can be so satisfying when we do.”
By Mr Peter McClelland
Dr Sanjay Nadkarni MBBS, FRANZCR,FRCR,FCP,MRCP, DA 221 Stirling Highway, Claremont 6010 T: (08) 92842900 F: (08) 93845725 M: 0410407044 To see a full list of services provided: www.endovascularwa.com.au | www.newlifeclinic.com.au
Dr Sanjay Nadkarni is one of Perth’s most experienced specialists in the minimally invasive outpatient management of varicose veins. The full gamut of cutting edge endovenous techniques including Endovenous Laser (EVLA) , Ambulatory phlebectomy, Ultrasound guided foam sclerotherapy and Microsclerotherapy are performed in our “walk in–walk out” purpose built Claremont clinic.
PRE & POST LASER
PRE & POST PHLEBECTOMY
Endovascular WA is your “one stop shop” for the diagnosis (Doppler Venous incompetence studies) and management (Treatment, clinical and ultrasound follow up) of varicose veins. Call our friendly reception staff on (08) 9284 2900 to book your consultation. PRE & POST SCLEROTHERAPY
DECEMBER 2015 | 51
HeartsWest is pleased to announce some important new developments. DR PETER DIAS MBBS, MRCP, FRACP Consultant Cardiologist Specialist in Advanced Heart Failure and Cardiac Transplantation Specialist in Echocardiography Peter graduated with honours from Leeds University Medical School in 2004, also receiving a 1st class honours in Human Anatomy. He moved to Perth in 2008 and completed his general cardiology training and Advanced Heart Failure and Cardiac Transplant Fellowship through Royal Perth Hospital. *iÌiÀÃ >À` iÀÌwi` V V>À`}À>« ÞLÞÌ iƂiÀV>-ViÌÞv V V>À`}À>« Þ and a member of the Royal College of Physicians and a Fellow of the Royal Australasian College of Physicians. Peter is currently employed at Fiona Stanley Hospital as a consultant cardiologist in the state Advanced Heart Failure and Cardiac Transplant service. *iÌiÀ½Ãwi`ÃvÃ«iV>ÌÞVÕ`ii>ÀÌ>ÕÀi] >À`>V/À>Ã«>Ì>`iV >V>-Õ««ÀÌ] Echocardiography and general cardiology. Peter consults from our Armadale and Rockingham rooms.
DR WEN-LOONG YEOW MBBS, FRACP Consultant Cardiologist Coronary Interventionist Adult Structural and Valvular Interventionist Wen-Loong (or Wen) graduated from the University of Western Australia, he completed his cardiology training and two-year coronary interventional fellowship at Royal Perth Hospital in 2011. He then completed a two-year fellowship in adult structural and valvular interventions, with clinical and basic science research at Cedars-Sinai Medical Centre and the David Geffen School of Medicine at UCLA in Los Angeles. His research has been published in peer reviewed journals. He returned to Perth in 2014 and has joined Hearts West. He also has a locum appointment at Sir Charles Gairdner Hospital. In addition to interventional cardiology, he provides general cardiology support to the practice. Wen-Loong consults from our Armadale and West Leederville rooms.
Echocardiography. We are upgrading our echocardiography machines with Speckle Tracking Strain imaging, a new modality that allows detection of ventricular dysfunction before any reduction in function is detected by conventional means. It is particularly Useful for those with hypertrophic conditions and those who have had cardiotoxic pharmacotherapy. Stress echocardiography Service. Expansion of this service should allow a minimal wait for stress echo appointments for patients. Smartphone monitoring. We have access to AlivCor home monitoring that allows patients to make ECG recordings on a Smartphone during symptoms, sending them electronically to HeartsWest for review. Smartphone lease or purchase of a device that attaches to their Smartphone is available. This system is designed to diagnose infrequent arrhythmias not detected on Holter monitoring, without the need for implanting a monitoring device
Telephone 9391 1234 Fax 9391 1179 Email email@example.com www.heartswest.com.au 52 | DECEMBER 2015
Scarring alopecia in women Alopecia (hair loss) is a common and distressing complaint, necessitating identifying and treating the cause, plus being aware of the potential psychological, social and cultural consequences for the patient. Clinicians play a key role in providing women with a thorough evaluation, a speciﬁc diagnosis, evidencebased treatment options, and counselling.
By Dr Kate Borchard Dermatologist Mt Hawthorn
Figure 3. Scarring alopecia algorithm based on examination ﬁndings.
Consider infection, folliculitis decalvans, dissecting cellulitis, acne necrotica, acne keloidalis nuchae
Consider tumour, lichen planus, discoid lupus erythematosus, alopecia mucinosa.
Consider trauma, burnt out lichen planus or discoid lupus erythematosus, scleroderma, pseudopelade of Brocq
Causes of alopecia in women The mechanisms of alopecia include decreased hair growth, increased shedding, loss of hair follicles and hair breakage. Those of dermatological aetiology present with pruritus, pustules, scale or scarring, whereas systemic causes present with increased shedding and thinning in a patterned or diffuse manner. Common causes of alopecia in women are androgenic alopecia, nutritional deﬁciency, autoimmune disease, hair care practices and trichotillomania. The most helpful approach is to think of alopecia as scarring or nonscarring. Scarring is permanent, so early diagnosis and prompt treatment has the best potential to limit the extent.
Frontal ﬁbrosing alopecia
Scarring alopecia Clinical approach
Trauma, infection and skin disease may injure the hair follicle, resulting in localised areas of scarring and bald patches in which there are no visible follicles. In the acute or active phase, there may be pustules, follicular erythema or scale. In burnt out lesions, the affected scalp is smooth and atrophic, and the surrounding follicles may become trapped or tufted (multiple hairs in a single follicle). Once the follicles are lost, there is no potential for regrowth, and the alopecia will be permanent. In the infective causes, especially kerion and Staphylococcus, alopecia may be preventable with early diagnosis and prompt treatment. Skin diseases include folliculitis decalvans, dissecting cellulitis, acne keloidalis nuchae, cutaneous lupus erythematosus and lichen planus. Lichen planus and its variants are more common in women than in men. Lichen planopilaris, though rare, is one of the common causes of scarring alopecia. It may
develop in association with lichen planus affecting the skin, mucosa and/or nails. Symptoms are often absent, but may include pruritus or pain/tenderness/burning. The clinical appearance is of multifocal scarring alopecia often with an atrophic centre, and surrounding follicular erythema and scale. These areas may merge into larger irregular areas, and may uncommonly cause diffuse scarring alopecia.
TABLE. CAUSES OF SCARRING ALOPECIA Trauma
Injury, burn, surgery, pressure, radiotherapy or traction (from tying or braiding the hair too tightly)
Staphylococcal folliculitis or tinea capitis (esp kerion). Herpes zoster, tuberculosis less common.
Shaving hair too close to the scalp (more common in men), when severe, can scar.
Folliculitis decalvans, dissecting cellulitis, lichen planus such as lichen planopilaris and frontal ﬁbrosing alopecia, alopecia mucinosa, acne necrotica, acne keloidalis nuchae, discoid lupus erythematosus and scleroderma.
In the history, ask about onset (sudden or gradual), amount of hair loss, areas of involvement, presence of local (itching, pain, discharge) and systemic symptoms. If suspicious of kerion, ask about animal contacts. Examination includes identiﬁcation of the pattern and extent of hair loss, signs of active disease (erythema, scale, pustules, positive hair pull test) or burnt-out disease (atrophic or keloidal scarring, tufting). To perform a hair pull test, gently but ﬁrmly pull approximately 60 hairs and if more than 6 are obtained the test is positive. In the case of cutaneous lupus erythematosus and lichen planus, look for other areas of involvement. Investigations will depend on clinical ﬁndings, but may include swabs and biopsy. Treatment depends on the cause and is aimed at symptom control and limitation of severity and extent. Realistic expectations are important. Scarring alopecia is permanent, so treatment for extensive disease becomes cosmetic camouﬂage and psychological support. Local causes may be treated with topical or intralesional steroids, calcineurin inhibitors, antibiotics, antifungals, immunosuppressants, immunotherapy or retinoids.
Author competing interests - no relevant disclosures. Questions? Contact the author firstname.lastname@example.org
DECEMBER 2015 | 53
t s u B r o a i l o Mong Four West Australian health professionals break down some cultural barriers during their trip of a lifetime.
Three medicos and a dentist in a couple of Toyotas through some of the toughest terrain in the world. Dr Jeff Veling and his colleagues kicked the tyres in Cinqantenaire Park in Brussels in mid-July 2015 and ﬁnished in Ulan Bator seven weeks and 16,000km later. No breakdowns, no punctures and they were still talking to each when they switched off the engines for the last time. “The rally is run by a charity in the UK called Go Help”, Jeff said. “It raises funds for children’s education in Mongolia, you have to raise a minimum amount and you also have the opportunity to donate the cars at the end of it.” “Andrew Bochenek and I, under the banner of Team Khanonaussie, were in a Toyota Hilux 4WD and Peter Le Soeuf and Mark Edwards – Team Quokkastan – had a Toyota Troop Carrier, which they named the Quokkavan. All the vehicles were required to be commercial models less than eight years old and the variety of vehicles was amazing. There were ambulances and ﬁre trucks!” Preparation is everything “Our cars were prepared in Perth, shipped to London and provisioned with food, water, fuel and camping equipment. The preparations took a lot of work because we knew we’d be striking temperatures ranging from below zero to 45C. Visas and letters of introduction needed to be arranged as well.”
54 | DECEMBER 2015
Once the cars rolled out of Brussels they were on their own and Khanonaussie and Quokkastan wouldn’t meet again until Istanbul. They had some very different destinations in mind! “Andrew and I were keen to see Vlad Castle in Romania and Plovdiv in Bulgaria whereas Peter and Mark were keen to visit the Black Sea and the Munich beer halls. We travelled through Turkey, staying at Trabazon and the Sumela Monastery, which is built into the side of a cliff. In one guest house we gained an insight into the plight of the Kurdish people.”
A16 Highway Mongolia
“The owner told us it would be a good idea to leave soon because ﬁghting was due to start in two days’ time. He was right!” “It became even more chaotic at the Iranian border. The guards had no idea how to process travel papers from Australia, despite the help of our local guide. Entry charges and fuel taxes were open to negotiation, but diesel was cheap att around 25 cents a litre.” Finding the common thread “Once we got inside the country it was safe, enjoyable and culturally fascinating. One of the highlights was talking about some prettyy controversial topics with a Muslim cleric. p Turkmenistan, with its repressive dictatorship much like North Korea was pretty interesting, g,
capital Ashga bat
Welcome from Cleric Husseni Holy City
of Qom, Iran
too. Its capital, Ashgabat, with its massive white buildings and town squares full of fountains, had policemen every 50m and a night curfew.” If anyone is planning to follow in the tracks of Jeff and his fellow adventurers, sitting behind the wheel of a 4WD might be a good idea. “The roads were severely pot-holed in Uzbekistan but its three Silk Road cities of Khiva, Bukhara and Samarkand were amazing to see! Then it was off to Tajikistan and the city of Dushanbe where the Socceroos recently played a match. We followed the Afghanistan border for nearly 1000km and then into the Palmir Mountains at 4680m where our cars and, to a lesser extent, our lungs were a little oxygen deprived.”
speak any Russian and couldn’t even read a menu. It took us eight hours to get across the border – six of those getting our papers stamped!”
“The scenery was stunning, the roads and ravines treacherous but we never felt in any real danger.”
“The Gobi Desert was hot, ﬂat and dry. Finding suitable places to camp and tracks to drive on required a great deal of faith in our GPS.”
If you do decide to set a course for Mongolia, a Cyrillic language App may prove useful.
“A highly recommended trip and, for anyone who is interested, we have useful contacts and planning information that may prove helpful.”
Finish Line Ulaan Bataar
Challenges of border crossings “Our knowledge of local dialects was improving slowly but it wasn’t much help at the harrowing two-to-six-hour border crossings. Kazakhstan was the only place where serious bribes were demanded and we managed to fob them off with some dolls and toys.”
Ashgabat capital of Turkmenistan
By Mr Peter McClelland ED: There are more pictures and information at the teams’ website -- www.khanonaussie.com and Facebook, Quokkastan.
“We had to cross into Russia before entering Mongolia and were amazed at the friendliness of the locals. That helped a lot because we didn’t
DECEMBER 2015 | 55
Direct Me TO The Body Shop By Wendy Wardell
As Gumtree seems to be the go-to place now for pretty much anything, I'm assuming they've got a section for people willing to part with those bits of their bodies they haven't used much, so they can save up for a jet ski or maybe stop the wife complaining about clutter. With 90% of people who've bought a treadmill never having used it for anything other than making amusing cat videos to upload to YouTube, that must equate to a lot of knees that have barely been run in. If all people are going to do with them is the occasional bend to get the ice cream out the bottom of the freezer, knees are, quite honestly, a luxury they could do without. It's like ﬁring up a Lear Jet to go to Rottnest. It's been on my mind because I'm in the market for replacement parts. I've been rocking up to my GP with monotonous regularity this year, each time sporting a different aching joint as a result of having tried to move it a few times in the name of exercise. It appears that I'm now too old to safely do anything more active than knitting. I don’t think that’ll work either though, as knitting needles are probably already deemed
offensive weapons, even before they’ve been responsible for a Christmas-themed jumper. Despite the fact that my body has reached a point where it's likely to lose its organic certiﬁcation due to the amount of cortisone it contains, various joints are still creaking like a stuck sound effect on The Little House of Horrors. So what I want is a solution that enables me to execute amazing feats of middle-aged athleticism like changing gears while driving without throwing out a shoulder. Luckily, I've reached that happy place of falling into the Medicare safety net for the year. This gives me just a couple of months to organise the rapid replacement of any of my more marginally viable body parts before the gravy train pulls into the terminus at year's end. It's hard though, to pick favourites when you're talking body parts. The ovaries have earned their right to rest their follicles at the home for Retired Reproductive Organs, but I still intend to get a bit more mileage out of the liver, so that has to be a candidate, along with any moving parts.
PUT THAT IN THE PIPE … A pipe burst in a doctor's house. He called a plumber. The plumber arrived, unpacked his tools, did some mysterious plumber-type things for a while, and handed the doctor a bill for $600. The doctor exclaimed, "This is ridiculous, I don't even make this much money!" The plumber replied, "Neither did I when I was a doctor".
FAST AND FURIOUS How do you test the gender of an ant? Throw it in water. If it sinks, it’s girl ant. If it ﬂoats, it’s buoyant. Why does it take 1 million sperm to fertilise one egg? Because like all men, they won't stop to ask directions. What did the elephant say to the naked man? How do you breathe through something so small?
56 | DECEMBER 2015
In a Podiatrist's ofﬁce: "Time wounds all heels." On a Septic Tank Truck: Yesterday's Meals on Wheels At an Optometrist's Ofﬁce: "If you don't see what you're looking for, you've come to the right place." On a Plumber's truck: "We repair what your husband ﬁxed." On an Electrician's truck: "Let us remove your shorts." In a Non-smoking Area: "If we see smoke, we will assume you are on ﬁre and take appropriate action." At a Car Dealership: "The best way to get back on your feet - miss a car payment." Outside a Mufﬂer Shop: "No appointment necessary. We hear you coming." In a Veterinarian's waiting room: "Be back in 5 minutes. Sit! Stay!" In a Restaurant window: "Don't stand there and be hungry; come on in and get fed up." In the front yard of a Funeral Home: "Drive carefully. We'll wait."
Surely the day can't be too far off when our signiﬁcant birthdays are no longer marked by letters from the Government containing dire warnings that bits of our body are about to go rogue, trash the place and invite in gatecrashers. Instead we just get a big box of replacement parts, a set of surgical Allen keys and a large sheet of mostly incomprehensible explanatory diagrams. It's obviously possible to get these things done already. AFL players constantly get injuries that would have mere mortals clogging up the waiting rooms of orthopaedic surgeons for a couple of years. Somehow though, just a couple of weeks later, these boys are able to run away from even the ﬁttest arresting ofﬁcers with impressive alacrity. Maybe they just have access to special joints.
SHAGGY DOG You are on a horse, galloping at a constant speed. On your right side is a sharp drop, and on your left side is an elephant travelling at the same speed as you. Directly in front of you is another galloping horse but your horse is unable to overtake it. Behind you is a lion running at the same speed as you and the horse in front of you. What must you do to safely get out of this highly dangerous situation? Get your drunk bum off the merry-go-round!
IT’S LOOKING LIKE CHRISTMAS Three men hailed a taxi after a long ofﬁce Christmas party. The taxi driver knew that they were drunk so he started the engine and turned it off again then told the men: "We have reached your destination". The ﬁrst man gave him money, the second said “Thank you" while the third man slapped the driver. The driver was shocked: "What was that for?". The third man replied: "Control your speed next time, you nearly killed us!"
Sparkling at any time A mixed bag of sparkling wines arrived at my ofﬁce this month hailing from Spain and the Loire Valley to Tasmania, Adelaide Hills, King Valley, Victoria, and McLaren Vale. All different grape varieties and varying styles from light zesty aperitifs through to bolder food-friendly styles and one delicious red sparkler made from the obscure Chambourcin variety. Sales of bubbly are forever trending upwards especially in the warmer months in Australia. With quality at levels not seen a decade ago the consumer can conﬁdently venture outside the classic Champagne district of France for a decent festive wine. All the wines presented ﬁnish dry and are of good quality only varying in style, showing that bubbles can be enjoyed not only for starters but also throughout the meal. By Dr Louis Papaelias
Pizzini Prosecco 2014 From the King Valley in Victoria, this is a lovely fresh aperitif made in the Italian Prosecco style. It has aromas of apples, ﬂowers and citrus. Clean and crisp with a dry ﬁnish, it really won’t disappoint. Cava Julia & Navines Brut From Catalonia and made from three Spanish varieties – Macabeu, Xarel-lo and Parellada – they have been skilfully blended and crafted. This wine has a steady bead and reﬁned autolysis aromas. Shows some class and elegance and a long, dry ﬁnish. Vouvray De Chanceny Brut Excellence 2011 Pale gold in colour and with a ﬁne bubble, this has some development and depth of ﬂavour. This sparkling chenin blanc is full, crisp and dry, showing ripe fruit characters and some nuttiness leading to a clean, lingering ﬁnish. Its fuller style lends itself to accompanying food but also sits very well as a starter. 42 Degrees South Made by Frogmore Creek Wines in Tasmania’s Coal River Valley, this area has a reputation for top quality Chardonnay and Pinot Noir. This wine shows the cool climate character of those two classical varieties that go into the making of high quality sparkling wine. The preponderance of chardonnay (90%) gives the wine a creamy character with hints of ﬂower and brioche. It ﬁnishes clean with persistence of ﬂavour. ‘Spark‘ Adelaide Hills Sparkling Pinot Noir 2014 Made by Lambrook Wines from 100% pinot noir grown at Lenswood and Oakbank in the Adelaide Hills, it has a lovely soft pale salmon colour in the rose style. There are strawberry aromas of young pinot and a heady vinosity. Soft and round in the mouth it shows generosity and balance. Would accompany foods of a delicate nature. D’Arenberg The Peppermint Paddock NV (100% Chambourcin) Chambourcin is a complex hybrid red variety bred in 1945. It has high natural acidity which makes it suitable for sparkling wine. This wine is deep purple in colour with lashings of grape berry and sweet spice aromas. Full and fresh in the mouth, its crisp acidity is evident as are plenty of ﬂavour and a clean ﬁnish. This is the wine to accompany the Christmas turkey and ham. Perfect red for a hot summer’s day and could easily handle a beef curry for that matter. All of the above wines retail at somewhere between $20 and $30 a bottle and in my opinion are very good value indeed.
ED: These wines have been made available for this review and for this month’s Doctors Dozen from The Wine Thief, 69 McCourt St, West Leederville, phone 0414 836 439
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DECEMBER 2015 | 57
Viva le Passport! TThe h world ld awaits i – andd there’s h ’ a lot l off world ld to see. Here are just a few ideas from some of our readers. Getting away from it all is wonderful and four distinctly different destinations evoke some of the delights to be found at the end of a 22-hour plane journey. Listening to a scintillating conference paper or two is a small price to pay for a stunning change of scenery.
warned – in the height of summer you won’t be the only visitor in town.” “On the south side of the ridge you can’t go past Lourmarin, Ansuis and Cucuron. Lourmarin gets its share of tourists but the latter two are smaller and quieter. Cucuron has a unique feature in the middle of town giving it a distinctive feel – a raised, rectangular pond, or étang.” “This shaded oasis on a hot Luberon summer’s day with its arching plane tree canopy is a welcome sanctuary for a glass of Provençal rosé. The fact that this is Peter Mayle country is an added attraction. Indeed, ﬁlm buffs will recognise the étang from Ridley Scott’s ﬁlm adaptation of Mayle’s book, A Good Year, recommended viewing for those planning to visit this beautiful part of southeastern France.”
Dr Simon Moss Southern France
Italy’s Northern Lakes Dr Ross Agnello paints a vivid picture of the Northern Lakes of Italy with its stunning scenery and homes of the rich and famous.
The beauty of the Provence region is well known. Dr Simon Moss zooms in on the Luberon and waxes lyrical about its many virtues.
58 | DECEMBER 2015
“Along the shores of Lake Como there are many magniﬁcent summer villas. One of the most exquisite is the Villa del Balbianello, located on the tip of a wooded promontory on the western bank of the lake. It sits on the site of a 13th century Franciscan monastery and was originally built in 1787 as the summer residence for a Catholic Cardinal.” “For a real sense of occasion try arriving by water taxi or, even more spectacularly, on a Riva speedboat!” “It was bequeathed to the Italian National Estate in 1988 by its last owner, the famous explorer Guido Manzini. The splendid interior of the villa is only accessible on a guided tour and secret passages abound. The rooms are ﬁlled with priceless artefacts acquired by Manzini on his numerous adventures. Highly recommended!” “The terraced grounds are sublime with its central point a magniﬁcent open loggia with trained ancient vines on the porticoes and panoramic views across the lake. Allow yourself plenty of time for quiet contemplation sitting alongside the classical statues on the stone balustrade terraces.” “The village of Lenno is close by and relaxing at one of its waterfront bars will make a perfect end to your visit.”
“Stretching across western Provence is a piece of elevated geology called the Lubéron Massif. The ridgeline runs east-west from Mansoque to Cavaillon and deﬁnes the Parc Naturel Régional du Lubéron, an area known as the Luberon.” “There’s a ‘golden triangle’ of high, perched villages to the north of the mountain range with names such as Menerbes, Bonnieux and Gordes. They’re all lovely places to visit and linger for the obligatory two-hour lunch, but be
Dr Simon Moss’s travels took him to Cucuron in Provence with its unique water feature in the centre of town
Africa Studying medicine at Notre Dame hasn’t stopped Lindsay Green from accumulating lots of exotic stamps in his passport.
lo Dr Ross Agnel
“We left Nairobi in a truck packed with camping equipment, cameras and lots of eager faces keen to see what Africa had to offer. It was a great moment in the Serengeti to catch a glimpse of a leopard leaping between
cen centuries decimated the local population. Mo More recently, the D Day landings of Op Operation Overlord on the 6th June 19 1944 ﬁred the ﬁrst salvos in the Battle of N Normandy and resulted in the liberation of Pa Paris.
e pontoon which was The remains of a concret our built for the D-Day pa rt of the artificial ha rb landings at Arromanche. trees! And not far behind that were the lion cubs in the Ngorongoro crater with their protective family sitting nearby.” “There were smiling children everywhere and in Malawi they were particularly keen to have their picture taken and giggled when they saw it on the display screen. Zimbabwe is stunningly beautiful. In the small town of Victoria Falls I swam with three large Nile crocodiles and as one of them slid across our protective cage I gave him one of the most unusual high-ﬁves of my life!” “Africa gets under your skin and keeps you going back for more – it’s a must-see continent!” Normandy and Arromanche, Northern France For those who love to combine history and pleasure, the Normandy region of France is both poignant and full of delights. The carnage wrought by a succession of wars between the French and English in the 12th and 13th
T Thankfully, it’s not all cannon-ﬁre and death a as you head north along the picturesque A A13 to the beaches of Normandy. It’s well w worth having a look at La Roche Guyon, a an 11th century castle with stunning vviews across the valley with the Seine m meandering peacefully through the countryside.
The delights of the national estate Villa Balbianello on the shores of Lake Com del o were soaked up by Dr Ross Agnello.
At Arromanche, the village which overlooks the sea-batted remnants of the artiﬁ artiﬁcial harbour built in just a few short weeks by the British for Operation Overlord, is a delight to wander. Alongside the fascinating museums are quaint shops and, of course, the local produce is on ample display at the Brasserie d’en Face on the Arromanche seafront. Moules with Frites or Andouillete (a superb rustic pate) followed by a zingy Calvados Sorbet with a bottle of Cidre Fermier makes for a long lunch that will wash away any thoughts of returning to work. A visit to the American Cemetery at Collevillesur-Mer is a reﬂective way of ending your visit and a reminder of the sacriﬁce of nearly 9500 young Americans. Most were killed storming ashore at Omaha Beach on the ﬁrst day of the landing. Allow plenty of time if you plan on driving back to Paris. The French farmers have the quaint habit of going on strike and blocking the highway with a load of potatoes.”
By Mr Peter McClelland
Fremantle Suite 4, 1 High Street • Floor Area 129M2 • Suit Medical use/Ofﬁce • Quality Fitout – Move straight in Cameron Porter (08) 9470 9700 www.portercommercial.com.au
DECEMBER 2015 | 59
Christmas Music Sally-Anne Russell is one of Australia’s best-loved and busiest mezzo sopranos but for a couple of tricky knees we could be having this conversation with a premier Australian dancer. The Adelaide-born singer as a youngster was all ﬁred up to be a dancer and a musical theatre star – one out of two ain’t bad!
e two years and somewhere in the second year I auditioned for the Victorian State Opera hoping to get into the chorus after Phantom had ﬁnished. To my surprise I was accepted into the young artist program instead.”
“I started dancing at the age of three and in the process sang and danced in pantomime and kids’ theatre. There was a big kids’ theatre scene in Adelaide when I was growing up. I joined South Australia Opera’s youth opera at 10 and so many of us who were in involved in that are still in involved in the arts now,” she told Medical Forum.
With theatre and music running through her S ll A veins, it’s little surprise that when Sally-Anne comes out on stage the audience senses that it’s not just going to hear a great singer but also witness a great performer.
“That’s a really interesting stat … if you are exposed to the arts when you’re young it becomes normal; it’s not elitist or anything, it’s just a part of your life.” The tricky knees were a turning point for SallyAnne when at the age of 14 she injured herself at ballet and took a year off school. The only thing left to do was to keep singing and by the age of 18 she was just one of two paid singers in the Opera Chorus. “I’m eternally grateful for the bad knees because if I had become a dancer I would be retired by now – as a singer, I’m in my prime.” After graduating from university in 1990, her career kicked off with a two-year contract in the original Australian production of Phantom of the Opera alongside Anthony Warlow and Marina Prior in Melbourne. “I was 21 and in the biggest show in Australia – it was a wonderful time. The show ran for
60 | DECEMBER 2015
Sally Anne Russell with the Perth Symphonic Chorus.
“I grew up on stage and feel very at home there but not everyone has been as lucky as me. It doesn’t worry me to stand on a stage. Performing is like osmosis; when you are surrounded by other people you learn things even when you don’t realise it. I draw from people around me.” Her talent and innate stage craft has also kept her in steady demand for a variety of work, be it recital, recording, concert or opera all over the world. “The whole gamut of music interests me and having diverse characters to explore is fun and exciting. I’ve just done my 66th role and it’s really interesting what you can bring to a character and what a director can get out of you. I have recently been doing a lot of the Rossini and Bizet repertoire – composers who often cast mezzos as their leading ladies.” “And the supporting mezzo roles are also hugely satisfying. Those roles add so much to the drama and to the protagonists’ character – they’re not a sideline, they are crucial.”
This month, Sally-Anne will be in Perth for the Perth Symphonic Chorus’s Messiah at the Perth Concert Hall on December 19, alongside her longtime friend and colleague, soprano Sara Macliver, tenor Richard Butler, bass James Clayton and all under the direction of Dr Margaret Pride. Sally-Anne says she’s lost exact count of how many Messiahs she’s sung in but said she and renowned conductor and musicologist Graham Abbott have an ongoing rivalry as to who has performed it more. At this stage, Sally-Anne has about 130 under her belt, Graham is slightly ahead. “But I never get tired of Messiah. Every time you perform it is different – each conductor, orchestra and choir brings so many different colours to the piece that you can never get bored.” “I could sing Handel and Bach all day, every day.”
By Ms Jan Hallam
From Sea to Cliffs Over 80 GPs travelled from all over WA for the Rural Health West Skills by the Sea Conference at Fremantle for a range of clinical workshops including procedural dermatology, palliative care, obstetrics ultrasound, surgical and practical medicine, paediatric and ENT updates and cardiac emergencies.
1 Dr Gareth Taverner and Dr Vinod Pushpalingam receiving training on plastering techniques at the Fremantle Skills by the Sea conference.
Rural Health West
2 Two doctors study an ultrasound during a live scanning on a third trimester pregnancy.
Wilderness Medicine Conference Another 34 GPs road-tested Rural Health West’s newly developed Adventure Weekend – Emergency Simulation of Medical Encounters (AWESoME) Wilderness Medicine Conference at Margaret River region. Delegates hit the trails, hiking, abseiling, canoeing and caving as well as completing their Advanced Life Support (ALS) One accreditation. 1 Participants conducting CPR. 2 Dr Matt Archer abseils down a cliff face during a rescue scenario.
3 Dr Sue Phillips, Senior Medical Ofﬁcer at Broome Health Campus, gets treated for a broken arm during a scenario. 4 Dr Simon Hemsley in action
DECEMBER 2015 | 61
Entering Medical Forumâ€™s competitions is easy!
Simply visit XXXNFEJDBMIVCDPNBV and click on the â€˜Competitionsâ€™ link (below the magazine cover on the left).
COMP Movie: The Revenant Leonardo DiCaprio and Tom Hardy star in this epic survival movie based on the life of 18th century American woodsman and explorer Hugh Glass (DiCaprio). When he is attacked by a bear, Glass is left for dead by his own hunting team and betrayed by his friend and conďŹ dant. In cinemas January 14
Movie: Spotlight Movie: Carol Based on the novella by Patricia Highsmith (The Talented Mr Ripley fame), Carol is the story of a young woman (Rooney Mara) unhappily working in a Manhattan department store in the 1950s who is dreaming of becoming a photographer. She meets the elegant but unhappily married Carol (Cate Blanchett) and sparks ďŹ‚y. Mara won the best actress award at Cannes this year for her work.
The Boston Globeâ€™s â€˜Spotlightâ€? team is a renowned investigative team which won a Pulitzer Prize in 2003 for its work to uncover the sex abuse scandal inside the Catholic Church in Massachusetts. Spotlight, starring Mark Ruffalo, Rachel McAdams and Michael Keaton is the smart, thrilling depiction of that investigation. In cinemas January 28
In cinemas, January 14
Doctors Dozen Winner Itâ€™s always a cause for celebration when a young member of the family ďŹ nishes Year 12 and that moment has arrived for Dr Clare Hanavan and her daughter. Theyâ€™re heading off to Melbourne together to see Taylor Swift in concert and thereâ€™s sure to be a bottle of Palmer Wines opened to share among the adults for the occasion.
Two old friends, Fred and Mick (Michael Caine and Harvey Keitel), are on vacation together in an elegant hotel in Switzerland where they watch their own lives and careers fade into the shadows as the ambitious youngsters begin nipping at their heels. In cinemas, December 26
Movie: The Belier Family Hereâ€™s a perfect Christmas ďŹ‚ick with heart and intelligence. Everyone in the Belier family is deaf except 16-year-old Paula who is the familyâ€™s interpreter of the world of sound. Itâ€™s a big commitment being the lynchpin of the family business â€“ a French dairy farm â€“ and itâ€™s challenged by the arrival of a handsome young boy at Paulaâ€™s school. In cinemas, December 26
8JOOFST from the October issue Movie â€“ Mistress America: Dr May Ann Ho, Dr Bill Thong, Dr Jen Buelow, Dr Rachel Price, Dr Angeline Teo, Dr Helen Slattery, Dr Diana Fakes, Dr Ian Walpole, Ms Kellie Ashman, Dr Helen Mead
Time to Speak Up
Movie â€“ He Called Me Malala: Dr Indrani Saharay, Dr Sarat Rangaiah, Dr Paul Kwei, Dr Michael Armstrong, Dr Max Traub, Dr Linda Wong, Dr Rafal Francikiewicz, Dr Simon Machlin, Dr Norman Juengling, Dr Elena Monaco Movie â€“ Bridge of Spies: Dr Katherine Shelley, Dr Twain Russell, Dr Colin Stewart, Dr Stuart SalďŹ nger, Dr John Masarei, Dr Peter Melvill-Smith, Dr Paul Oâ€™Hara, Dr Gavin Leong, Dr Braad Sowman, Dr Clyde Jumeaux
t Taking on the Pollies t NDIS â€“ Dollar Dazzlers t Help for Nepal t Clinicals: Simulation, Cannabis, JIA, PTSD, Cough & moreâ€Ś
OCTOBER 2015 www.mforum.com.au
Movie â€“ The Program: Dr Jane Gibson, Dr Robert McWilliam, Dr Jo Keaney, Dr Andre Chong, Dr Kamlesh Bhatt, Dr Rimi Roper, Dr John Williams, Dr Katherine Creeper Rock Musical â€“ Next To Normal: Dr Colin Hughes Opera â€“ Faust: Dr Philomena Fitzgerald
62 | DECEMBER 2015
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GP WANTED â€“ BELMONT CITY MEDICAL CENTRE Ĺ” Busy non corporate practice requires Full Time/ Part Time VR GP Ĺ” On site Chemist, Pathology, Physiotherapy, Dentist and Gym Ĺ” 6km from Perth CBD (opposite Belmont Forum Shopping Centre) Ĺ” 65% - 70% of receipted billings Ĺ” Excellent nursing support Ĺ” Accredited and fully computerised Ĺ” Guaranteed hourly income for initial 3 months. Ĺ” DWS doctors can apply for after hours and weekend sessions Ĺ” Flexible sessions available
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ARE YOU WANTING TO SELL A MEDICAL PRACTICE? As WA’s only specialised medical business broker we have sold many medical practices to qualiﬁed buyers on our books. Your business will be packaged and marketed to ensure you achieve the maximum price possible. We are committed to maintaining conﬁdentiality. You will enjoy the beneﬁt of our negotiating skills. We’ll take care of all the paper work to ensure a smooth transition.
Leaders in cardiology
To ﬁnd out what your practice is worth, call:
Brad Potter on 0411 185 006 Suite 27, 782 - 784 Canning Highway, Applecross WA 6153 Ph: 9315 2599 www.thehealthlinc.com.au
STRESS TEST SUPERVISING PHYSICIAN CASUAL / PART TIME
GENERAL PRACTITIONERS REQUIRED Belvidere Health Centre (39 Belvidere Street, Belmont) Looking for something different? Are you seeking a ﬂexible working environment? Our clinic offers the following opportunities to GPs’ wanting to contract their services: Ŕ Ŕ Ŕ Ŕ Ŕ Ŕ
Generous rates Flexible working hours Clinical nursing support Fully computerised systems Varied client base On site Iron Infusion therapy
Days currently available: Mondays, Thursdays and Fridays. For further information please contact Rod Redmond at (08) 9458 0505 or firstname.lastname@example.org
Perth Cardiovascular Institute is one of the fastest growing private cardiac services in Australia, with a focus on providing outstanding patient care with an ethical, thoughtful and sustainable approach. Perth Cardio has invested in the best medical technology, high skilled staff and we value culture, teamwork and innovation and we are currently seeking an enthusiastic individual to join our team.
In the role you will: •
The ideal candidate will: •
HOW TO APPLY: Send an application with a cover letter, resume and referee details to email@example.com
Supervise patients undergoing Exercise Stress Tests and Stress Echocardiograms Be supported by a strong team of cardiac technicians, sonographers and cardiologists Be responsible for taking a lead in patient care in emergency situations Be able to undertake training to further your skills and knowledge in diagnostic testing Receive a salary that is negotiable and experience based
Have current advanced life support skills or be willing to undertake training Have interest in cardiology Be able to clearly explain procedures to obtain consent and reduce patient anxiety Have strong communication skills to document findings and interact with cardiologists
FEBRUARY 2016 - next deadline 12md Thursday 14th January 2016 – Tel 9203 5222 or firstname.lastname@example.org
OPPOSITE NEW MIDLAND - ST JOHN OF GOD HOSPITAL Vocationally Registered General Practitioner / Senior Medical Practitioner
Outstanding Exposure & Business Address
Next Step Drug and Alcohol Services Web Search No: 00011387 Level/Salary: SMP Year 1-5 $268,156 - $301,719 p.a. pro rata (inclusive of base salary, professional development allowance & private practice income allowance).
Now Leasing the First Floor 2640sqm plus Lift Able to be Subdivided
Synergies with Existing Tenants Flexible as to Use 300m to Bus & Train Station
Corina Johnson (08) 9274 7522 0418 911 135
The Mental Health Commission is seeking suitable applications for a Vocationally Registered General Practitioner / Senior Medical Practitioner to join Next Step Drug and Alcohol Services. The position provides medical care as part of a multidisciplinary team treating people with drug and alcohol problems. Training and supervision is provided for practitioners new to the alcohol and other drugs sector. To Access Detailed Information: jobs.wa.gov.au and key in the Web Search No. to access detailed information or Ph. 08 6444 5815 to be mailed an information pack. For Speciﬁc Inquiries: Please contact Dr Allan Quigley on 9219 1847
Medical Specialist Acquired Brain Injury Location: East Victoria Park Part Time
56 Almadine Drive, Carine p 08 9448 7799 m 0401 815 587
Brightwater Oats Street is looking for a part time Medical Specialist to join it’s interdisciplinary Rehabilitation team. Oats Street is a state of the art purpose built rehabilitation facility for people 18 – 65 years who have experienced a moderate to severe brain injury. Whilst supporting individuals across the full brain injury spectrum, the program has a strong focus on cognitive rehabilitation.
VR GPs wanted to join a friendly team
The team is comprised of allied health professionals, nurses and disability support workers with the sessional medical specialist (2 sessions per week) required to ensure medical governance of the 48 clients. The role also provides, as required, medical oversight of a transitional program for 12 people with complex disability at Marangaroo. As a medical specialist you may have a background in rehabilitation, geriatrics or neurology and have had extensive experience within the acute hospital setting.
Okely Woodlake Village Newpark Medical Centre Medical Centre Medical Centre CARINE
New Gumnut Medical Centre WANNEROO
contact Dr Kiran Puttappa 0401 815 587
Remuneration will be in line with AMA guidelines and working days and hours are negotiable. For further information please contact Tim Lo on 0438991375
ality WKH e y client DOXHIRU
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With a reputation built on quality of service, Optima Press has the resources, the people and the commitment to provide every client with the finest printing and value for money. 9 Carbon Court, Osborne Park 6017 } Tel 9445 8380
FEBRUARY 2016 - next deadline 12md Thursday 14th January 2016 – Tel 9203 5222 or firstname.lastname@example.org