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Rethinking Realities Pain Clinicals Mental Health Looking Ahead

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March 2018

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EDITORIAL Jan Hallam, Managing Editor

Yes, We Can So, here we are in March and the world is back at work. Forward planning has been locked into the ‘things we must do’ diary and we’re all praying for fair weather so that by the time we get to Christmas and that’s only 299 days away - the doing will be done.

And that brings us squarely to a dilemma.

Roadblocks (and what a lot of them there are!) some real, some perceived, but all impeding progress.

Today’s lesson is, My Health Record.

Towards the end of January, a call came through from the Assistant Minister for Health’s media adviser. There was an event he thought was right up our alley at one of the metropolitan Aboriginal Health Services where Minister Ken Wyatt would be urging consumers to get connected, initiate a record and begin the journey towards improved integrated health.

The event was to take place at 5.30pm in the Eastern Suburbs.

What message does that send? Come and get connected, if you can get here!

If we shove that to one side, the good news is that the tertiary sector is well on the sharing-the-care path. We know WA Health is on a mission because we have seen the Information and Communication Technology (ICT) tenders roll out in their millions and in our interview with the retiring SJGHC CEO Dr Michael Stanford (P12) we see that his group is committing $200m to do exactly the same.

What needs to be shouted out in large capitals is WILL THEY BE TALKING TO EACH OTHER?

PUBLISHERS Ms Jenny Heyden - Director Dr Rob McEvoy - Director Advertising Marketing Manager Kirsty Fitzpatrick (0403 282 510) advertising@mforum.com.au

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

One would hope so. That’s one advantage of Public Private Partnerships – they can’t be avoided even if you wanted to.

The potential for cost savings in this sector is enormous, just the eradication of duplication alone will save millions.

But where to Primary Care?

The shared care model of Health Care Homes (one of the topics needing serious exploration in 2018) necessitates a common, accessible record. Bridges need to be built to connect the sectors. And yes, that will also necessitate hospitals to write coherent, respectful information on management of the shared patient for their Primary Care colleagues.

Establishing a dialogue between the parties that includes the consumer is the key. No one is asking for War and Peace but if you can text, tweet or titter, you can communicate. The means are literally at our fingertips and it is at the heart of the job, not an optional extra.

ICT is a struggle for some and a way of life for others. In the media industry it is our core business. Providing a platform for others to communicate is what we do here at Medical Forum, so perhaps our sensitivities are geared more highly than most.

This month, Medical Forum is launching its new website to make it easier for readers to get connected. It has taken many hours of sweat and toil, but it’s been worth it and it was necessary.

On March 29 our Doctors Drum breakfast will be streamed live for the first time to connect all our readers, especially those beyond the city limits, to the important issues that affect their core business. That also took many hours in the planning but it’s a step we needed to take.

Communicating, and doing it well, is crucial.

Administration Jasmine Heyden (0425 124 576) jasmine@mforum.com.au Clinical Services Directory Editor Ms Jenny Heyden (0403 350 810) jen@mforum.com.au

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

MARCH 2018 | 1

CONTENTS MARCH 2018

INSIDE 12

15

16 23

Close-Up: Dr Michael Stanford Haka for Life: Men’s Mental Health WA Surgical Audit Cross-Cultural Cricket

16

15

NEWS & VIEWS Editorial: Yes, We Can – Ms Jan Hallam 1 4 Letters to the Editor

12

23 Major PARTNER 2 | MARCH 2018

4 6 7 18 21 29 37

Trans Youth in Crisis – A/Prof Sam Winter Ruah Runs South Service – Ms Learne Durrington ART Legislative Review – WA Health Curious Conversation – Dr Andrew Kirke Have You Heard?

Beneath the Drapes Codeine Rescheduling Police and Mental Health Mortuary CT Scanner Joint Replacement Report

FeATURES 38 Tall Tales and True: James Valentine 40 Funny Side 40 Wine Winner: Dr Mark Somerville 41 Wine Review: Brash Wines – Dr Louis Papaelias 42 WASO Celebrates 90 Years 44 Competitions

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CONTENTS MARCH 2018 clinicals

28

31

Trans-vaginal Mesh – What Now?

Technology & Type 1 Diabetes

Dr Jessica Yin

Dr Mary Abraham

33 Prediabetes – Clock Starts?

Dr Tim Welborn

36 Paediatric Eosinophilic Esophagitis

Dr Ajay Sharma

Future Medicine

35 Spinal Procedures: Who & When?

Prof Eric Visser

37 Chronic Post-Surgical Pain Dr Brian Lee

38 Opioids in Non-Cancer Pain Dr David Holthouse

GUEST COLUMNS

Playing the Change Game?

Join the conversation with panellists: Mr Roger Cook MLA - Minister for Health Dr David (Russ) Russell-Weisz - DG of Health Dr Rohan Gay - principal at Bayswater GP Practice Dr Mark Hands - principal at Western Cardiology Dr Rebecca Wood - Service Registrar (FSH)

Virtual attendance for rural doctors.

To attend or register for live steaming go to: www.doctorsdrum.com.au

11 The Future of Pain Dr Max Majedi

25 Broome Time Dr Jonathan Blundell

Thursday March 29

7:15 - 8:50am for a Free Breakfast Royal Perth Yacht Club Proudly supported by

27 Cost of Youth Violence Dr Steven Monterosso

27 Healthy Conversations Mr Nick Maisey

INDEPENDENT ADVISORY PANEL for Medical Forum John Alvarez (Cardiothoracic Surgeon), Peter Bray (Vascular Surgeon), Chris Etherton-Beer (Geriatrician & Clinical Pharmacologist), Joe Cardaci (Nuclear & General Medicine), Alistair Vickery (General Practitioner: Academic), Philip Green (General Practitioner: Rural), Mark Hands (Cardiologist), Pip Brennan (Consumer Advocate), Olga Ward (General Practitioner: Procedural), Piers Yates (Orthopaedic Surgeon), Stephan Millett (Ethicist), Kenji So (Gastroenterologist) Astrid Arellano (Infectious Disease Physician)

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MARCH 2018 | 3

LETTERS To THE EDITOR Trans Youth in Crisis Dear Editor, In Time for Talking is Over (February, 2018), Chris Harris of Youth Focus draws attention to the mental health crisis facing our youth today.

He emphasises the particular challenges facing, among other groups, LGBTI youth.

National Transpathways research recently spotlighted the alarming situation faced by transgender youth in Australia where three out of four participants had been diagnosed with depression; that almost as many had been diagnosed with anxiety and four out of every five had self-harmed.

Nearly half had attempted suicide.

Laws across Australia (with the exception of ACT and SA) currently force any married trans person wishing to change the sex marker on their birth certificate to first divorce from their spouse. (See P6) This divorce requirement, always a harsh one for the people involved, makes no sense now that equal marriage is a reality.

Across the nation the relevant authorities are reviewing their respective legislations. Trans advocates see a window of opportunity to press for a broader examination of these laws; a chance to advocate for removal of other unreasonable barriers preventing trans people, including trans youth, from having their gender identity legally recognised.

Some of those unreasonable barriers are medical in nature; involving requirements for diagnosis, hormones or surgery.

Requirements for surgery are especially problematic for trans youth.

Chris Harris is right to stress the importance of involving schools, improving training for health providers on mental health issues, and generally enhancing mental services as ways of tackling the youth mental health crisis.

The World Professional Association for Transgender Health (WPATH) is the peak global professional body focused on transgender health. It recently revised its Identity Recognition Statement to clarify its position on legal gender recognition for transgender people.

Beyond these and other broad initiatives, we need to take action on a very particular issue facing transgender youth (and trans people generally). It is the matter of legal gender recognition.

The statement urges governments worldwide to “eliminate barriers to gender recognition and to institute transparent, affordable and otherwise accessible administrative procedures affirming self-

determination”. It stresses the importance of legal gender recognition for all trans people, including trans youth and those who identify outside the gender binary.

It advocates for removal of requirements involving diagnosis, hormones and surgery.

The World Health Organisation and the World Medical Association have issued similar (albeit narrower) statements about surgery.

Many trans people have a genuine need for gender-related healthcare. But healthcare should not be a legal precondition for gender recognition. When that happens, medicine ends up being used for social control, and the capacity of patients to give full and free consent is undermined.

Leading health organisations are speaking out against that. State and Territory governments need to listen.

The Transpathways report is at www. telethonkids.org.au/globalassets/media/ documents/brain--behaviour/transpathwayreport-web.pdf The full WPATH Identity Recognition Statement is available at https:// s3.amazonaws.com/amo_hub_content/ Association140/files/wpath-identityrecognition-statement-11_15_17.pdf A/Prof Sam Winter, School of Public Health, Curtin University

continued on Page 8

CURIOUS CONVERSATIONS Dr Andrew Kirke looks back to a memorable patient and forward to the next generation of rural doctors.

Medicine remains an honourable profession because… at its simplest it’s all about alleviating distress and making sense of the craziness of life. Technology has delivered a lot but the human element remains at the core of our work.

I would love to have more time to… mess about on my block.

I have an ambitious project to build an interesting letterbox out of local limestone but I can’t seem to get started!

This will be an interesting year for me because… the Fremantle Dockers are looking good for the AFL finals. I’m feeling optimistic! I have also taken on a new job as Director of the Rural Clinical School. Educating the next generation of rural doctors is a cause very close to my heart.

SYNDICATION AND REPRODUCTION Contributors should be aware the publishers assert the right to syndicate material appearing in Medical Forum on the MedicalHub.com.au website. Contributors who wish to reproduce any material as it appears in Medical Forum must contact the publishers for copyright permission.

DISCLAIMER Medical Forum is published by HealthBooks as an independent publication for the medical profession in Western Australia.

4 | MARCH 2018

One patient I will always remember… was a charming gentleman who lived well past 100. He lived independently, swam daily and greeted life with gentle grace and dignity. He eventually passed away peacefully from progressive myelodysplasia and I was struck by his wonderful outlook on life.

One of my happiest moments is… having all our kids back together – it always warms my heart. That happened in July last year on a three-week Kimberley camping trip up the Gibb River Rd with family and friends. We crammed into two cars and were pretty feral by the end of it all. It was amazing!

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HAVE YOU HEARD? Sirtex boxes on

With all the talk last month on the Federal Government’s flu strategy for 2018 centring around a super vaccine for those over the age of 65, researchers have just released results of a study into why flu vaccines work better in some people which could lead to a better targeting of vaccines in vulnerable populations. Researchers at the Doherty Institute in Melbourne report that best-case vaccine effectiveness was only 60%. Last year it was much lower. But all admit the flu vaccine is a blunt instrument. They identified in best responders to the flu vaccine three types of white blood cells – T follicular helper cells, antibody-secreting cells and memory B cells that helped fight off the virus. They are hoping that with further work, it may be possible to make a vaccine that recruits or strengthens the response of these specific cells, improving protection for those vaccinated. It may also help predict how well individuals will respond to a particular flu vaccine. The government has been batting away criticism that its flu vaccines are ‘budget lite’ on effectiveness.

Perhaps they should enlist a few white cells.

The New Year has dawned brighter for Australian biotech company Sirtex Medical, developers of efficacious selective internal radiation therapy (SIRT) for liver cancer. It announced it had entered into a binding Scheme Implementation Deed with Varian Medical Systems by which Varian will acquire 100% of Sirtex, offering $28 a share.

Before going to press, we noted the markets liked the idea, with Sirtex stocks trading $27+. But there are clouds on the horizon.

Just 16 months ago, Sirtex shares were bumping down to $15 and the then CEO Gilman Wong controversially departing after offloading nearly $2m in shares before a company announcement. This has sparked a class action with Maurice Blackburn lawyers filing papers in the Federal Court.

Sirtex, with new CEO Andrew McLean, says it will vigorously defend the action.

In the meantime, the numbers game puts the offer price as representing in a fully diluted market capitalisation for Sirtex at $1.58b and an enterprise value of about $1.49b. Little wonder the board unanimously recommends the proposal to its shareholders, who have the opportunity to vote on the scheme at a meeting to be held in May 2018. The offer is subjected to the usual regulatory approvals.

Mental health relief At last, some movement in the rural mental health space. A new step-up, step-down mental health facility will open at the old Albany Hospice later this year. The Mental Health Commission and WA Country Health Service announced they would establish a six-bed facility for people in the Great Southern region so they can find treatment options closer to their support networks. The service will provide residential support and individualised care on a short-term basis for people who are discharged from hospital or for those who may avoid hospitalisation with an earlier intervention. Similar facilities are being established in Karratha, Bunbury, Broome and Kalgoorlie.

New docs hit the ground On February 1, 318 new interns entered the WA public hospital system – 273 (86%) of whom were trained in WA, including six Aboriginal graduates. FSH has received 118; Royal Perth Hospital 87; SCGH 103; and WACHS – Albany and Bunbury hospitals 10.

Ramsay Health Care campuses, under an agreement with the Australian Government, have received 18 interns, including 14 international medical graduates.

New era for PathWest PathWest has had its challenges over the 18 months with two separate Public Service Commission inquiries into breaches of procedure and privacy. But by July 1 this year, a new era dawns with its transformation into an independent health service provider reporting directly to the Director-General of Health. Currently its work is overseen by the NMHS board.

As a statutory body it will have its own chief executive and be subject to the same governance, performance and accountability requirements as other health service providers. Planning began well before the PSC reviews and has involved current Executive Director Silvano Palladino and Chief Pathologist Dr Dominic Mallon who have been working closely with Dr Glen Power, who has been employed to help with the transition. Glen was former CEO of SJG Midland Public and Private Hospitals. PathWest has 25 laboratories and 50 specimen collection centres throughout the State and provides clinical and other diagnostic services to other public

sector agencies as well as private facilities, including diagnostic, coronial and forensic testing, drug, food and water testing along with industrial health screening. The Health Minister said PathWest’s move to an independent identity would deliver greater transparency and oversight in its clinical, support and financial performance and enhance its public and private services.

WA Health clicking on The WA Health website is stepping up its real-time engagement. Doctors and consumers alike have found the ED activity snapshots useful, as well as bed availability in both metropolitan and regional hospitals.

The minister announced late last year that upgrades will continue during 2018. To be included in the upgrade is information on outpatient specialist waiting lists and elective surgery waitlist times. There is also improved transparency with performance reports, which while not absent on the website have been difficult to find. They will now be more easily found in the Our Performance tab at http://ww2.health.wa.gov.au

SSM ripple effect The legislation on same sex marriage is having a ripple effect for health legislation.

In the letters page, the review of the Human Reproductive Technology Act 1991 (HRT Act) which governs reproductive technology and surrogacy is calling for submissions.

Meanwhile, the Attorney General is moving to update gender reassignment legislation.

The AG has ordered a review into WA’s laws. However, his key focus is to abolish a legal anomaly requiring people to be single if they want to formally change their gender identity. This may happen sooner than later. Apparently the AG will not wait for the Commission's report before closing this legal loophole. The Commission is expected to release its terms of reference for public comment later this year.

Vale Dr Peter Graham Tireless worker to save the sight of the world’s disadvantaged is ophthalmologist Peter Graham’s legacy. Peter died on December 7 aged 90. His work overseas saw him and his family take residence all over Indonesia, Malaysia and more briefly Tanzania. His awards were numerous, his impact enormous.

Free range eggsactly Excuse the indulgence, but as chicken owners – and we know there are a few of you who are too – the ACCC is getting heavy on enforcing the new National Information Standard on free range eggs, which comes into effect on 26 April 2018. Under the new standard, egg producers cannot use the words ‘free range’ on their egg cartons unless the eggs were laid by hens that had meaningful and regular access to an outdoor range during the daylight hours of the laying cycle; were able to roam and forage on the outdoor range; and were subject to a stocking density of 10,000 hens or less per hectare, and that outdoor stocking density is prominently displayed on the packaging or signage. In the past 18 months, the ACCC has issued hefty fines (one producer was penalised $750,000) but it still hasn’t deterred some unscrupulous egg farmers. At the very least, consumers paying a premium price should have the confidence that they are buying a premium product. But anyone who has lived with a chook will be pretty keen to see these changes enforced on humane grounds. #FreeRangeAntonia

6 | MARCH 2018

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BACK TO CONTENTS

Flu’s white knights

drapes beneath the

BACK TO CONTENTS

Telethon Kids Institute and Curtin University have entered into a research affiliation agreement. It allows Telethon Kids Institute researchers to hold adjunct appointments at Curtin University and the university’s researchers to take up honorary appointments at Telethon Kids Institute.

It’s complicated In this issue we explore the work of the WA Audit of Surgical Mortality to offer transparency and the opportunity for meaningful improvement in WA hospitals.

Dr Stephen Duckett from the Grattan Institute is pumping for similar visibility in the area of hospital complications.

In his and Dr Christine Jorm’s report published recently, they say one in nine patients who go into hospital in Australia suffer a complication. If they stay overnight that increases to one in four. Complications vary depending on the hospital with worst-performing hospitals up to four times higher than at the best performers. The pair reckons if the safety performance is lifted to the level of the best 10% of Australian hospitals, 250,000 extra patients will leave hospital each year complication free.

The figures are pretty sobering and equally controversial is the secrecy surrounding which hospitals and which clinicians have higher rates of patient complications, and which are safety leaders.

“Hospital safety statistics are collected, but they are kept secret, not just from patients but from doctors and hospitals,” Dr Duckett said.

That seems far from an ideal approach, which doesn’t offer much hope of meaningful improvement.

Dr Duckett wants patients and their GPs to have access to the information on complication rates in different hospitals and for different procedures, so they can make better-informed decisions.

On the flip side, it would help doctors and hospitals to have this information so they can compare performances.

“At present, official hospital safety policies focus on only a small subset of serious complications classified by government as being ‘preventable’,” Dr Duckett said.

“Policy should instead aim to reduce the incidence of all complications to the best rate achievable. This requires building up a comprehensive picture of the whole gamut of hospital safety performance, from catastrophic but rare errors to less harmful but prevalent complications. The data should highlight the areas where there is a big gap between the best and the worstperforming hospitals, and it should enable patients – and taxpayers – to see which hospitals are improving and which are not.”

He added that private health insurers have a responsibility to release the information they gather on private hospitals, because reducing complication rates would mean quicker recoveries and lower premiums for their members.

Australia Day Honours in 2018 were awarded to opthamologists Dr Ross Littlewood (AM) and Dr Philip House (AM) for their work in Timor-Leste and his contribution to the Royal Australian and New Zealand College of Ophthalmologists.

Dr Michael Stanford (AM), group CEO of St John of God Health Care, for his services to the health sector; Mr Geoffrey Churack (AM) was recognised for his philanthropic support for medical research; gynaecological oncologist Prof Ian Hammond (AM); Mr John Schaffer (AM) for his philanthropy and board work in health: Goldfields Aboriginal health worker Ms Annette Stokes (AM); Mr Winston Jones (AM) for work with the John Fawcett Foundation; Dr James Savundra (AM) for his work in plastic and reconstructive surgery; GP Dr Chin Tan (AM) for his service to the Chinese community of WA; Mr Ross Whiteman (AM) for service to people with Motor Neurone Disease.

The new health service boards had a turnover last year. Prof Diane Twigg and Dr Daniel Morrison have joined CAHS; Dr Denise Glennon, East Metropolitan; Prof Rhonda Marriott, North Metropolitan; and Dr Amanda Boudville, South Metropolitan. Prof Simon Towler (NMHS) and Andrew Thompson (CAHS) have departed while Dr Hannah Seymour (EMHS) and Prof Julie Quinlivan (SMHS) left their respective boards earlier last year.

Bethesda Health Care in Claremont is the first hospital in WA to have been awarded a WorkSafe Platinum status for the third time.

Art access Lotterywest will fund the Sculpture by the Sea Access and Inclusion Program for the next three years which will allow people with a range of disabilities to enjoy the annual arts program.

Some of the programs include Tactile Tours, Disadvantaged Community Tours, Beach Access Days, Auslan-interpreted Artist Talks and tours for seniors and visitors with dementia and disabilities. The funding will also allow for the provision of wheelchair track mats and specialised toilet and wheelchair accessible ramps at Cottesloe Beach to ensure easy access for visitors with limited mobility. The event runs from March 2-19 and on March 14 and 15, Beach Access Days will be staffed with trained assistants from 10am-7pm. Special tours are free but require booking. http://sculpturebythesea.com/cottesloe/access-program

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UWA and Telethon Kids Institute diabetes researcher Dr Vinutha Shetty is the 2017 recipient of the Type 1 Diabetes Clinical Research Network’s Mentored Clinician Researcher Fellowship Award.

Medical Director of the Statewide Obstetric Support Unit Dr Diane Mohen and retired Fremantle Hospital consultant Dr Dan O'Donnell were joint recipients of the Minister for Health's Award. They were recognised particularly for their work championing rural and remote health and disadvantaged patients.

MARCH 2018 | 7

LETTERS To THE EDITOR The service will be based in Cockburn, but will be available for youth throughout the region via outreach.

continued from Page 4

Ruah to run south service Dear Editor, Ruah Community Services (Ruah) will be delivering an Early Psychosis Youth Service – Functional Recovery (EPYS) in the Perth South region for young people aged 12 to 25 years.

The EPYS will provide personalised recovery support, recognising that young peoples’ self-determination is a vital part of successful treatment and recovery.

Ruah will be working closely with other local service providers, including headspace centres, to complement existing youth mental health services and enable the delivery of seamless, coordinated care to those experiencing psychosis.

Funding of $2.5 million was awarded by WA Primary Health Alliance (WAPHA) to Ruah Community Services, which have begun preparations to launch the service, expected to be available from May this year.

The service will be developed using the Early Psychosis Prevention and Intervention Centre (EPPIC) standards and principles, relating to non-Government service delivery in a shared care environment with state mental health services.

For more information regarding the service, contact Emma Jarvis, Ruah Executive Manager of Operations 9485 3939 or emma.jarvis@ruah.org.au Ms Learne Durrington, CEO WAPHA

ART legislative review Public submissions are sought for an independent review, led by A/Professor Sonia Allan, into Western Australia’s reproductive technology and surrogacy legislation.

The Human Reproductive Technology Act 1991 (HRT Act) provides for the functions of the Reproductive Technology Council, and includes regulations for the practice, procedure and ethics governing the use of human reproductive technology.

The Surrogacy Act 2008 provides for the regulation of surrogacy arrangements in Western Australia, including the prohibition of surrogacy for financial gain.

It has been almost 20 years since the last comprehensive review of the HRT Act, and with advances in technology and trends, along with shifting societal expectations; there is considerable public interest in ensuring that the legislation remain abreast of current trends and fit for purpose.

Current figures show about one in six couples have difficulty in conceiving a baby and about four per cent of births in Australia are a consequence of using assisted reproductive technology.

Uses for this rapidly evolving genetic technology remain on the not-too-distant horizon such as mitochondrial donation.

The opportunities to improve patient health outcomes are numerous, as are the research opportunities.

The review will also explore where the science is heading and the effectiveness of the current licensing regime, and what improvements could be made to provide greater clarity in the legislation to allow the science to progress and develop.

The closing date for written submissions is 5pm Friday 16 March 2018. There will be a consultation period following the written submissions between 9-20 April 2018.

For further information visit ww2.health.wa.gov.au/Review

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MEDICAL FORUM

INCISIONS BACK TO CONTENTS

The future of pain: Suffering versus resilience

Anaesthetist and Pain Specialist Dr Max Majedi sees medicine as part of the problem as well as part of the solution.

In recent times we have been bombarded by numerous ethical and sociological issues such as global warming, over population, nuclear threats, sexual harassment, bullying, obesity, terrorism, gender inequality and many more. Imbedded in these issues are the inevitable growing concerns of our health.

We’ve witnessed health flourish to a multi-billion-dollar industry with enormous resources allocated in the Western world.

However, despite all the good intentions, the overall health of the population does not reflect the advances made in medicine and the money spent.

The obesity rate is rising every year, our mental health is waning and the rate of iatrogenic complications are increasing rapidly, including an increase in mortality from prescription drugs, namely opioids.

Despite all this, we are encouraged to ‘cure’ pain with further interventions that include other chemicals such as medicinal cannabis. One only has to look at the history of the human love affair with chemicals and its associated industry to realise that perhaps we are making the same mistakes, all over again, at a point in our global history where the expanding population is bursting at the seams and has major issues around resource distribution and sustainability.

Perhaps it’s time that we change directions to give the next generation and the planet a better chance for the future.

Perhaps, instead of politicians and the industry swaying our minds and action we need to be guided by sound and non-commercially conflicted science, intellectuals, philosophers and those who practise science and not entrepreneurship.

As far as pain medicine is concerned, the path is quite clear if you look beyond ‘curing pain’ to tackling suffering instead.

The essence of what we do, as medical practitioners, is not about fixing isolated problems but creating the opportunities for rehabilitation and return to function with emphasis on quality of life and purpose.

We need to be mindful that being passive and relying on chemicals and invasive interventions to solve our problems is not the way forward and has not been since the Industrial Revolution. There is a call for more thought into this and an approach with sustainability at the forefront. I like to think that I am more than an extension to a prescription pad or a hand on an invasive instrument and I can guide patients away from suffering rather than ‘cure‘ their pain.

It may sound far-fetched, however, I fear we only have a small window of opportunity to turn things around before demand outstrip resources, which will lead to a prolonged winter of suffering.

Please consider these reading lists and podcasts: Behave by Robert Sapolsky The Brain That Changes Itself and The Brain That Heals Itself by Norman Doidge Sapiens. A Brief History of Humankind by Yuval Noah Harari The Genetics of Health by Dr Sharad P. Paul Waking up with Sam Harris (Podcast) Jordan Peterson (Podcast)

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MEDICAL FORUM

10/01/2018 11:20:53 AM

MARCH 2018 | 11

CLOSE-UP

When to arrive and when to leave ... it is an art form. For retiring group CEO of SJGHC, the right time is now when corners have been turned and fresh fields await.

S

ixteen years is a long time to sit in a hot seat but Dr Michael Stanford, on the surface at least, appears to be one calm, cool and collected customer.

Late in January he publicly announced he was stepping down from the Group CEO’s position at St John of God Health Care for a quieter, non-executive life as a boardmember, firstly of the Melbourne-based Healthscope, with prospects of several others over the next few months.

In corporate terms, 16 years is a marathon for a group CEO. He told Medical Forum last month that he was a SJG record holder after four years. He’s pretty pleased by that.

“I came to the job when I was 42. Sally and two of our three children headed west with me while our then teen boarded for a couple of years in Melbourne so as to not disrupt his secondary schooling. We’d moved around a fair bit – I’m originally from Sydney and Sally from Geelong, but I was looking for a quality group that had good organisation and good culture.”

“I was fortunate to have had opportunities early in my career, running two public hospital networks in Victoria and then deciding to move into the private hospital sector to run an ASX listed hospital company. When I arrived at St Vincent’s in Melbourne in the early 90s, which was run by the Sisters of Charity, I saw what a difference great culture and deep knowledge can have on an organisation.”

“When the SJGHC position came up in 2001 it ticked the boxes. After 18 months,

12 | MARCH 2018

Sally and I were sure we wanted to stay and keep going.”

As the group has grown, so too has its management style.

A growing concern

Ears to the ground

If one word was to sum up Michael’s tenure, growth would have to be it. He has overseen the growth of the group from 1300 beds to 3300; revenue has increased 500% from $350m to $1.8b; the workforce has more than tripled from 4000 to 14,000.

“When I started 16 years ago, we only had three hospitals in Victoria and I travelled a lot in those early days. We always strive for local accountability with the local community, and you can’t manage well from afar. So for the past 10 years, I have had State Directors reporting to me.”

The group has built and manages the Midland Public and Private Hospitals – the first public-private partnership (PPP) for the group in the WA market –acquired Mt Lawley, doubled the size of the Subiaco and Murdoch hospitals, and doubled the capacity at Bunbury.

It has taken the number of hospitals in the eastern states (primarily Victoria though it has a presence in NSW) from three to 11 and its Outreach division has moved strongly into the counselling, homeless youth and disability services sectors.

On the other side of the ledger, SJG Pathology was sold in 2016 to Clinical Laboratories because, as the Group CEO put it, “we couldn’t do that as well as we would have liked. You have to be big to get pathology right”.

The national scope of SJGHC is not often visible to those on the home turf of WA. When we spoke to Michael, the group had just opened its 18th hospital in Berwick, a fast-growing region 40km southeast of Melbourne, not dissimilar in demographics to Joondalup and Perth’s eastern suburbs.

It has relocated what was a 70-bed hospital into a nearby 190-bed modern facility.

SJGHC has become a large business.

For the medical community in WA, the most recent mining boom saw an unprecedented phase of constructing medical infrastructure both in the public and private sectors. There was money and there was fast-paced population growth.

While the money tap may have been turned to winter settings, population continues to grow which has been driving health investment planning.

While the Midland PPP was conceived, negotiated and constructed in more robust financial times it remains one of the group’s boldest local moves, but entirely logical from Michael’s perspective.

“It was a bit weird that as a Catholic-owned entity we weren’t in public hospitals.

It’s been an integral part of this group’s history and of other Catholic health groups before Medicare came along. We made a conscious decision that we wanted to be in the mainstream of hospital care. We didn’t go to Midland to run a private hospital we went to Midland to run a big and growing public hospital,” he said.

MEDICAL FORUM

BACK TO CONTENTS

To boldly go...

CLOSE-UP “In this age, doctors go where there’s work.

We have been able to recruit the Midland medical workforce well, partly because of the new facilities – in our cases with both the public and private hospitals – and because of its growth potential.”

Potential of the east “Doctors recognise there is a huge population growth in the eastern corridor. Babies are being born and a lot of people want to use our services – that’s a good sign.”

So has the demand for Midland’s public services surprised him?

“Yes and no. Something I’ve learnt, and it’s partly related to Midland and Fiona Stanley Hospital as well, if you build a new facility, you will get more work coming through than you thought you’d get”.

“During the design and commissioning phases we sent our executives to visit every hospital in Australia that had opened in the past five years to learn from them. They all said, you will get more people through ED than you expect, and you’ll do more obstetric deliveries.”

“I’m sure there is an element of voyeurism that people want to take a look at a new facility, and new public facilities across Australia are unbelievably good. But nowadays, cost concerns for consumers are a serious reality.”

“We are delivering more babies at Midland but we have started losing deliveries at our private hospitals because of the out-ofpocket component, which is becoming a particularly big thing in obstetrics.”

While babies are welcome at Midland, it has created problems in the great chain of hospital activity.

“State governments have fixed budgets and buy what they estimate, but if we are faced with more people needing to be treated, the chances of more money from the government are very slim. More obstetric patients have an immediate impact on elective surgery because it is about the only thing that’s flexible in a public setting.”

Dr Michael Stanford at the sod turning ceremony of the new Midland hospital in 2012.

With him are the then Federal Health Minister Tanya Plibersek, Chris Palandri from Multiplex and the then WA Health Minister Dr Kim Hames.

Don’t abandon Reid The Midland experience has also reactivated Michael’s call (as published in our December magazine) for the government to return to the spirit of the Reid Report with its driving thrust being to treat people locally.

A lot of Midland’s patients are coming from well outside of the zone, the Wheatbelt included, and it has been a challenge for the Midland budget.

“Midland was premised on the idea of selfsufficiency for people living in its catchment – that’s logical. The hope and expectation was that 75% of people in the catchment would be able to be treated locally, instead of the previous 35%.”

“As part of our bid we had to show how we could go from 307 public beds to 460 beds in five years – in 2020. We are already nudging upwards and the government should be looking to not only fund us more but with a vision to build into the budget those extra beds.”

“We took the creative approach to build 60 private beds with our own money and told the government that with three years notice we will move those beds off-site, so we have those beds ready to go public. We have bought a separate block of land from the MRA nearby and we are likely to build 150bed private hospital to serve the expected 1.5% per annum population growth.”

“We will have our annual activity notice at the end of February and I’m sure we will be asked to treat more patients again because they have to be treated somewhere. It’s cheaper for the state to treat them at our place because it was part of the commercial bid that we had to offer a discount to the benchmark hospital bed cost. We are all set up for that, and we want to do that and grow.”

Dr Michael Stanford and wife Sally

MEDICAL FORUM

Midland will get bigger Michael has great expectations of

Midland and thinks the siting of the Curtin Clinical School there will have benefits for everyone.

“Curtin will need Midland to succeed and Midland will need Curtin to succeed. It will become a teaching hospital and people in the eastern suburbs will end up with a 460 bed public hospital, a 150+ bed private hospital and lots of doctors working in a thriving academic program. It will be fantastic for people there. We all have to grab the nettle to make that work because I think it will be something special.”

Cost was an ever-present companion in the conversation, and how value of health care was now driving decision making, from consumer level to group executive level. How and what health will be funded was a hot topic.

With population growth and an ageing population over the next 30 years, demand will not wane and Michael said governments needed to plan for the 2.5% more beds per annum or get smarter at what we’re doing.

Not surprisingly, he thought the combined public-private service offered in Australia was a good model which gave people choice and allowed services to do what they do best – acute and chronic in the public sphere; obstetrics, surgery, chemotherapy and rehabilitation in some circumstances in the private.

“What WA needs is to understand the maths of our future and its inevitability, plan for it and build capacity and capability ahead of time. How we do that within the current budget is the trick.”

It’s certainly not the time to ditch the private health insurance rebate, he said, and it is certainly a time for collegiality.

“We will all be better off when our systems are all interoperable and information can be shared. It’s not rocket science. There’s

MARCH 2018 | 13

CLOSE-UP

In his time at the St John of God Health Care, Dr Michael Stanford has been a champion of the arts and a champion of the healing power of creativity.

He has encouraged patient participation programs at the SJG hospitals and set free the corporate art collection for the enjoyment of staff and patients.

These pictures were taken late in 2016 when SJG partnered the Black Swan Portrait Prize and Michael agreed to sit for his portrait in the foyer of one of the metropolitan hospitals. On the wall hung around him were some of that’s year’s finalists.

no money to waste and it will improve productivity and efficiency and be much better for the consumer.”

work together, there will be major changes in the offing because health care will simply be unaffordable.”

Data linkage move

A competitive environment may also make a difference.

To that end, SJGHC is in the throes of committing $200m over five years to digitise its computing and communication systems. “As a state we are behind the others, and within WA, the public system is moving ahead of the private system in this area. We are finishing off our investment planning this year and expect to have an agreement around our Electronic Medical Record implementation next year.”

“It is a significant investment but we believe we won’t be able to attract the workforce or convince the health funders unless we have evidence. Our doctors are already working ahead of us with health technology and we have to catch up with them.”

When it comes to growing gaps being faced by consumers for specialist treatment, Michael is diplomatic.

“It’s a specialist’s business. They can assess the market and work out what is reasonable. But if every person acts in isolation, we could end up with a problem.

If the number of people insuring continues to decline, and if doctors went nuts and charged outrageously, ultimately the system will bite back because there isn’t enough money.”

“We are subject to market forces except that health care is an imperfect market.

Consumers don’t have full knowledge but that is changing with the rise and rise of consumer feedback portals. Consumer views on doctors and hospitals are already out there.”

“Currently there is little transparency about fees, and patients find it very hard to ask how much a treatment will cost. In that sense it is in everyone’s interest to have a sustainable portal for the doctor, fund and consumer. If the doctors and funds don’t

14 | MARCH 2018

Don’t fear competition “The past two or three years since the end of the boom, people are thinking about how to win the work for want of a better term. It’s one of the impacts of having more medicos around. The doctors may not like it much but it is good for the consumer,” he said.

“I am also acutely aware that having to compete against a very good free public system or another good private operator, it makes you try harder, and it makes you think about investing in facilities and equipment and intellectual capital that improve services for the patient.

Competition is good in the long run but painful in the short term.”

However, part of that imperfect market is the concept of best practice and Michael sees doctors committing to many hours of training on new equipment, studying new evidence, in order to deliver the best outcome for the patient.

“While there is a competitive element for doctors to learn these new skills, it is mostly driven by the commitment to deliver the best outcomes for patients,” he said.

“And when something new takes a while to diffuse, you must let it because doctors are very cautious and that’s a good thing.”

Michael’s 16-year journey with SJGHC ends on March 21 with his board’s deep regret but best wishes. His move to the Healthscope board was upfront and with a view that any potential conflict of interest could be managed.

“I raised this question with the Trustees and the Board and they preferred I stay six months rather than three! Of course I have confidentiality clauses written into

my contract and I am not now involved in any forward planning at SJGHC. My contribution to Healthscope will obviously include my knowledge of the healthcare market. The Mount is the only hospital Healthscope runs in Perth, though it has 46 across the country.”

Complex and rewarding “Health is a complex industry and a career within it gives you enormous experience.

It has lots of stakeholders – patients, doctors, workforce, funders both public and private, regulatory requirements, multibillion capital investment, construction, commissioning. It’s an evolving, hugely challenging market. That’s what I bring to my new life as a board member.”

“To succeed in this job you need to enjoy working with people – 14,000 of them.

Crucially, you need to be able to work with doctors, because they are our partners and between us, we want patients to get better.

Both sides need to understand the other.”

“I’ve had great executive teams, which I’ve loved developing. Seeing people such as Dr Shane Kelly and Dr Lachlan Henderson become group CEOs over east is a fantastic endorsement of SJGHC culture.

And I have worked with wonderful people.

But there is a lot involved and it’s a 24/7 operation. So I’m also looking forward to fresh non-executive challenges and I think it will be good for SJG to have someone come in with fresh eyes.”

“It will great to spend more time with Sally and the family; play more golf and tennis, and I’ve promised myself to learn Italian and French, but I’m starting with Latin because I want to get the grammar right.”

“I also want to read for pleasure after 23 years of reading reports. I want to be able to finish a Spectator magazine!”

By Jan Hallam

MEDICAL FORUM

FEATURE BACK TO CONTENTS

Haka for Life and Health Men’s mental health is being addressed in a vibrant and distinctive way.

For Leon Ruri, a Haka for Life sends a vital message to end the code of silence.

C

limbing the Sydney Harbour Bridge is one thing but when a group of men stand at the top of the span doing the Haka it’s bound to get tongues wagging. And that’s perfectly fine with Leon Ruri, the founder of Haka for Life. More men sharing their stories, plenty of community engagement and a reduction in the suicide rate.

“The Bridge Climb was pretty special and made for terrific YouTube footage. We received lots of ‘views’ and ‘shares’! That sort of thing had never been done before and it followed hard on the heels of the Haka we did at the Anzac Day Service in King’s Park last year,” Leon said.

“We’re consulting with the RSL for this year’s event and we’re also speaking with Noongar elders to see if they would like to perform a Corrobboree as part of the ceremony. The Department of Veterans’ Affairs is always looking for new initiatives to address the terrible legacy of PTSD and this will be a wonderful opportunity to celebrate the fact that men are finally finding their voices and raise awareness of these issues.”

Leon is committed to encouraging men to ‘open up’ and express themselves in a strong and passionate way.

“The Haka is a perfect vehicle for addressing the awful silences surrounding mental illness and suicide. It’s a full bodily expression of open and honest communication using the voice, body, muscles – everything!”

“We all know about the stigma attached to mental illness but surely we’ve gone beyond the point of it being acceptable that so many men are still dying in silence?

The destructive internal conversations that drive men to take their own lives need to be replaced by open, healthy engagement with supportive communities.

And it’s also crucial that men start to see that the services set up to help them are non-threatening, non-judgemental and passionate about helping them to live better lives.”

Leon, by his own admission, led a troubled and self-destructive life before he decided that enough was enough and changes were needed.

“I’m quite comfortable saying, ‘did I have a problem with drugs and alcohol?’ ‘Yes, I did.’ ‘Did I have a gambling problem?’

‘Yes, I did.’ They were coping mechanisms but they weren’t making me a particularly admirable person or a very good father. My marriage broke down, I was a recreational user of ice and I was starting to get into trouble with the police so it wasn’t entirely surprising that I drifted into depression and suicidal thoughts.”

“When I started exploring these issues in my own life I began to understand how I was put together and that it was possible to turn things around. I acknowledged my past behaviour but I refused to let it define me or shape the rest of my life.”

“In the end I felt compelled to reflect on my own behaviour and ask for help. There are so many stories of men struggling with life

and I was one of them. It’s a big problem in my own Maori culture but it encompasses all men. And women too, of course.”

“We need to do something urgently when six men and two women every day in Australia feel the only option is to take their own life.”

The entire Haka for Life enterprise is a oneman band with Leon providing the funding and managing the website.

“I work as a union organiser in the transport sector, which is a good thing because it puts me in touch with a lot of men, and I’m a single father with four teenage children.

I’m trying to set up funding to keep the momentum going but at the moment it’s very much a labour of love.”

“The website is being revamped and we’re going to have everything from quick and easy menus presented by a chef to videos of exercise programs and contact details for ongoing emotional support.”

For Leon Ruri and Haka for Life it’s all about fostering healthy conversations about mental illness with as many people as possible.

“What I’m doing with Haka for Life is encouraging men to take action and stand up for living a good life that empowers them and nurtures the people they care about.”

“It’s important to bring doctors into this conversation. We need to support them because they really are on the frontline of so many serious social issues.” www.hakaforlife.org

Leon Ruri and the Haka for Life team on the top of Sydney Harbour Bridge.

MEDICAL FORUM

MARCH 2018 | 15

FEATURE BACK TO CONTENTS

Surgeon, Examine Thyself Transparency and accountability of the College of Surgeons amidst sexual harassment and bullying claims has led to other performance appraisals.

T

he statement from the Australasian College of Surgeons late last year created curiosity. It said the 2017 report of the Western Australian Audit of Surgical Mortality showed a further small decline in mortality in patients under a WA surgeon. The audit, performed by peers external to the hospital where the surgeon works, is funded by the WA Department of Health and is aimed at the ongoing improvement of surgical care. What did we know of the audit?

But how independent are the case reviews?

WA Surgical Mortality Audit

Is it fear of speaking up, we asked. After all, our straw poll of GPs and Specialists in July last year showed that nearly all felt that not enough was done to protect whistleblowers.

It was a transplant of the Scottish system (now no more) by Perth general surgeon Mr James Aitken in 2001 when he moved from Edinburgh to Perth. Despite the protection afforded to participants by legal privilege, participation rates were low until it was mandated as a condition of CPD points (participation is now 99.2%). In about 2010 the audit became national. Total deaths in WA are low – 22.1 per 100,000 population in 2016.

We spoke to Mr James Aitken, current chairman of the committee that reported.

“We are now able to access high quality information and data which was non-existent before this process begun. This provides us with an honest appraisal of where we are at as a profession and guides us in any education and training activities that may be required.”

“Although an important driver to compliance has been the College, making participation a compulsory component of CPD, surgeons acknowledge it changes their personal practice. Surveys done in WA, Queensland and Victoria all show this. The single most useful feedback is the Case Note Reviews and especially the Case Note Review booklets that group 10-15 cases.”

16 | MARCH 2018

“An airline cannot investigate serious accidents any more than a construction or mining company can – by statute they have to call in Worksafe or an equivalent.

Yet a hospital can undertake an RCA with no external input and investigate itself, often finding ‘no fault’ when WAASM has notified the hospital because the external peer reviewer felt there was fault. A simple, easy and relatively cheap initiative in WA hospitals would be that all RCAs or SCA 1 (Severity Assessment Code 1) include the involvement of a person from outside the hospital.”

“WAASM operates under Qualified Privilege and this protection permits surgeons to provide very detailed and honest reports and this includes acknowledging where care could have been different.

Personally, I have never felt threatened when approaching either hospitals or the Department of Health with related issues.”

Emergency Laparotomies audit In a separate but related project, James led a prospective WA audit looking at outcomes-related Emergency Laparotomies.

“Outcomes following Emergency Laparotomy have been known to be poor for many years with an overall mortality of 15%, and in those over 80 years, between 25% and 40%. Between 2010 and 2012, prospective overseas studies drew attention to just how bad the outcomes were and that compliance with evidence-based care standards was poor, even very poor.”

“This prompted the UK government to set up the National Emergency Laparotomy Audit (NELA) in England and Wales. which has just published its third report.

Education and Quality Improvement have been key components and outcome and care standards are improving.”

“In the absence of any Australian data, the WA General Surgeons undertook the Perth Emergency Laparotomy Audit (PELA) in

the second half of 2016. It showed a low mortality compared with overseas but poor compliance with evidence-based care standards.”

“PELA results were presented nationally in May and June 2017 and have caught the imagination.” This was partly because Australia had no fast-track pathway for patients presenting with an acute abdomen, according to ‘Perspective’ in the MJA last November.

“The RACS and ANZCA are in the advanced stages of planning the Australian and NZ Emergency Laparotomy Audit - Quality Improvement (ANZELA-QI). It should start mid-2018. So like WAASM, an audit that started in WA is going to become (hopefully) bi-national. The Quality Improvement is an important advance” “The only missing ingredient is seed funding to establish ‘proof of concept’. We estimate the set up costs and three years of funding will be AU$1m and each day of reduced length of stay is worth about AU$34m per year (the NELA reduced hospital length of stay by 2.6 days). So the return on investment or ROI is massive” James has been involved with the surgical audit for over 20 years – what has it taught him about human nature and the personalities you deal with? He points to a number of issues.

“Most clinicians have little knowledge of what they do or their results and no knowledge as to how that compares with others. Even the return of simple objective outcomes (death, unplanned re-admission, returns to theatre or ICU) has been shown to influence change.”

He feels that in this regard Australia is over 10 years behind the UK, this being because of a lack of political interest in audit and a failure of hospitals to tackle issues that are often well known.

“The reality is most ‘problems’ are well known (think Bundaberg) and the reason they persisted was because nobody did anything. We do not want 'a Bristol' to change this.”

In this respect he thinks the community has failed itself.

MEDICAL FORUM

FEATURE

“There is overwhelming evidence that the public and patients want better data but politicians and hospitals fail to provide it.

So vote in politicians and go to hospitals which will provide it!”

He turns to the UK Minister of Health and his comment that ‘For data on surgical outcomes to be published, of course, they need to be robust, rigorous and risk adjusted’.

stewardship has assumed greater importance both in this problem and in preventing adverse drug reactions.

The report says we need to improve the quality of surgical antimicrobial prophylaxis prescribing and points to overuse, especially minor procedures, and the use of ‘rarely indicated yet frequently prescribed’ topical antimicrobials.

Surgical antimicrobial prophylaxis

The report says the Therapeutic Guidelines: Antibiotics is a key reference yet 40% of prescriptions were found to be inappropriate in the 2015 National Antimicrobial Prescribing Survey (22,021 prescriptions analysed from 281 hospitals).

As if to flag the new transparency and accountability of Australian surgeons, an examination of surgical antimicrobial prophylaxis arrived from the Australian Prescriber about a month later.

Antimicrobial stewardship since 2011 has been one of the compulsory criteria for hospital accreditation and hospitals have been required to monitor antimicrobial use and resistance since 2014.

With surgical antimicrobial prophylaxis the most common indication for antimicrobial use in Australian hospitals, surgeons have a big role to play in how appropriate that use is. With antibiotic resistance closing whole hospital wards, antibiotic

“The 2016 Surgical National Antimicrobial Prescribing Survey solely focuses on surgical prophylaxis prescribing. Its results highlight ongoing concerns regarding inappropriate prescribing (about 45%) in Australian hospitals. Where they were

“The UK has done this and outcomes for named hospitals and surgeons have been available on many websites for over 10 years. There is none in Australia.”

MEDICAL FORUM

available, 41% of procedural and 62% of post-procedural prophylaxis was nonconcordant with clinical guidelines…and antimicrobial prophylaxis was prescribed but not indicated in 40% of post procedural prophylaxis.”

The report says that appropriate surgical antimicrobial prophylaxis prescribing has these key elements: correct indication (not in clean non-prosthetic procedures), right antimicrobial chosen (look at microflora expected and patient-specific risk factors), drug dose (usually a single dose best), route (non-topical, usually parenteral), timing of administration and duration (usually within 60 minutes of incision).

The 2016 Prescribing Survey found that incorrect duration was the most common factor in inappropriate post-procedural antimicrobial prescribing (73.7%).

Prophylaxis should not extend beyond 24 hours, regardless of the surgical procedure.

Intravenous and oral antibiotic prophylaxis offered no benefit beyond this period.

By Dr Rob McEvoy

MARCH 2018 | 17

FEATURE

Pain of Codeine Restrictions Anxious patients, patient GPs and infuriated pharmacists make up the volatile landscape in a OTC codeine-free world.

C

odeine-containing products went under the counter of pharmacies as of February 1 and there have been varying reports as to its impact on consumers.

Medical Forum spoke to Mandurah GP and former RACGP president Dr Frank Jones and President of the Rural Doctors Association WA and head of the Rural Clinical School in Bunbury, Dr Andrew Kirke, and both doctors unreservedly welcomed the decision to make codeine a prescription-only drug.

“People have been buying low-dose codeine for a very long time, which hasn’t come to their GPs’ attention.

And it’s not a great drug for pain. The literature says that it’s not much better than paracetamol and NSAIDs,” Frank said.

“I think that’s a really good way forward, helping our patients understand there are better options,” he said.

Andrew said it was early days but he was keen to dispel the Pharmacy Guild concern that rural and remote patients were in danger of being denied medications.

“The rural-remote issue was a flag flown by the Pharmacy Guild, not by rural doctors, as an argument that people won’t have access to medications because they can’t get to the doctors and therefore they need to get them over the counter,” he said.

Frank said he has opened these conversations by informing the patient that understanding of drugs and medical conditions were changing all the time.

18 | MARCH 2018

Andrew says the real problem facing rural and remote patients and their doctors is not OTC codeine.

Health care access “The problem everyone knows about is the difficulty in accessing appropriate healthcare. Some places are more challenging than others and a box of OTC codeine is not an answer to anything.”

Frank said the codeine ban was an opportunity for pharmacists to be reinforcing the message that this drug was not a great painkiller.

On the announcement that the Health Minister Greg Hunt would be giving $20m to the pharmacy sector to monitor consumers’ pain medications, Frank issued a note of caution.

We spoke to Frank on week one of the changes and he said he had seen three people seeking a prescription for codeine.

“From my viewpoint as a GP, patients turning up for codeine is a fantastic opportunity to reassess what their pain is all about asking those doctors questions all good doctors should be asking their patients. We can explore what’s been going on in context and provide a different pain plan for them.”

“There are a lot of options for pain now and opioids are seen as a very poor first step in terms of pain management.”

“We’re in the same game looking after patients so we should be on the same page,” he said.

“The rest of the world has taken codeine off the counter, so we are simply falling in line with the guidelines.”

“The 8mg dose is not a lot but if you are taking eight of those a day, that’s not an insubstantial amount. Yes, they were anxious about the situation. They feel that this particular medication has given them some relief. They may not notice side effects of dry mouth, constipation and blurred vision, nor, importantly, a tendency to take it all the time, which can lead to dependency.”

“The most recent research (from 2005 to 2015) shows a massive increase in related deaths from opioids of all sorts and this is the first significant step as a health care service to make a difference to that.”

“I accept that pharmacists know a lot about pharmacology but they are not always good at the therapeutic benefits and I mean that with all due respect. They can’t understand the context of the whole patient. How can they? They don’t have the full story like their GP.” “The RDAWA has made it quite clear that this was raised as a red herring and was not about good pain management. Like our urban colleagues, we think the OTC ban gives rural GPs a chance to discuss appropriate pain management with patients rather than people self-prescribing.”

“Issues of codeine are simple really. The doses over the counter are actually not that effective and don’t make that much difference to pain control. Studies have shown that. However, OTC does mean that people can have access to as much as they like and they run the risk of harming themselves.”

“Pharmacists need to be on the alert and encourage people to see their GP.”

Rural Response The National Rural Health Alliance has produced a range of educational materials for consumers available at www.ruralhealth.org.au/codeine It will help people living in rural and remote areas with options and it contains a number of advice lines and health service contact details.

MEDICAL FORUM

FEATURE

Codeine Makes Headlines Since the OTC codeine ban took effect on February 1, the pharmacy organisations have gone on the offensive. The Medical Republic reported that pharmacists have reported two doctors to AHPRA for inappropriately prescribing codeine. One example cited was a Queensland pharmacy that received a prescription for 20 boxes of Mersyndol Forte with five repeats (or 2400 tablets). Another was in Victoria where a pharmacist referred a codeine-dependent patient to a GP only to have the patient return with a prescription for both codeine and benzodiazepines and a refusal to see the patient again.

Have you ever considered working in the Kimberley?

The report quoted Jarrod McMaugh, vice-president of the Pharmaceutical Society of Australia’s Victorian branch. He stressed the majority of prescribers were acting appropriately, and that around the country only about 20 prescriptions had been flagged with him as particularly excessive or inappropriate.

“So it is low volumes, but for those particular individuals, it’s a highrisk,” he said.

AMA Vice President Dr Tony Bartone was quoted as saying that during the transition period there were likely to be “unfortunate” incidents, but he stressed that taking an educative approach rather than a punitive one was key to the ultimate goal of reducing levels of codeine in the community.

TGA denies report Another story, the source of which is something of mystery, suggested that the TGA was considering removing GPs’ rights to prescribe highdose opioids. The TGA issued this statement in reply: “The story today that suggests GPs may not be able to prescribe high dose opioids under a review being done by the TGA is totally incorrect.

The medicines’ regulator is not proposing and will not be stopping GPs from prescribing high dose opioids. As part of the discussion paper the TGA has issued on the use and misuse of opioids, there is an option about the level of training for potentially dangerous drugs which is being discussed in consultation with the AMA, the RACGP and other appropriate bodies.”

When supply falls short Then there was a story from the CEO of national pharmacy chain Advantage Pharmacy which claimed the ban had created an imbalance in demand and supply.

Steven Kastrinakis said amid the stories of “illegal sales of codeine, stockpiling, price rises, and a spike in prescriptions being written for codeine pain killers” both GSK and Bayer had discontinued all of their product lines of paracetamol and low-dose codeine.

The drug giants flagged this in March last year when the TGA announced the upscheduling of codeine.

In a statement then, GSK said the company had undertaken a thorough assessment of the strong pain environment” and decided that Australians already have access to a wide range of high quality codeine-containing analgesics via prescription.

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“Based on this we have taken the decision not to move our codeinecontaining analgesics (Panafen Plus, Panadeine, Panadeine Rapid Soluble and Panadeine Extras) from S3 OTC to S4 prescription only medicines. This means that they will no longer be available in the Australian market.”

Bayer also confirmed it would pull its codeine-containing OTC products including Demazin PE Cold & Flu Relief, Demazin Cold & Flu Day & Night Relief and Demazin Day & Night Cold & Flu tablets. It said it had no plans to replace the products with new codeine-free formulations.

Into this landscape, which has been flagged for 11 months, Steven Kastrinakis said pharmacies would have to rely on other manufacturers to fill the gap with their product equivalents enclosed in a new ‘prescription only medicine’ packaging.”

“The surge in demand for these product equivalents is not met with the supply component of the equation. Pharmacies have not been able to order any stock from wholesalers of the newly packaged product-equivalents, despite seeing the need from patients presenting with prescriptions,” he said.

MEDICAL FORUM

The Kimberley. Put yourself in the picture.

MARCH 2018 | 19

Dr Paul Yoong

Vale Dr Paul Yoong, Radiologist January 5th 2018 brought sad news to the Perth Radiological Clinic family and the whole radiology community in Western Australia.

Dr Paul Yoong, an elder statesman in radiology in this state, passed away quietly, surrounded by his family, after a short illness.

Paul was the dynamo who created much of the momentum of what is Perth Radiological Clinic today. He will be sadly missed by all who knew him.

Paul was born March 22nd 1944 in Kuala Lumpur, Malaysia. His parents instilled strong family values of loyalty, integrity, hard work and academic excellence. These were all values and attributes Paul held and modelled throughout his personal and professional life.

Paul was schooled in Malaysia and Singapore and completed his undergraduate medical education at Adelaide University from 1963-1967. He returned to Penang to complete his internship and commenced training in radiology at the University Hospital in KL. Paul undertook further radiology training in London (1971-1974) at the Northwick Park Hospital.

In 1975, Paul packed up the family, wife Gek and sons Colin and Terry, taking up a post of consultant radiologist at Royal Perth Hospital. In the 1970s, RPH was a beacon for sourcing some of the most talented radiologists worldwide. Here, Paul met and built lifelong professional relationships, meeting like-minded colleagues. Professionally he laid the foundations as a pre-eminent gastro-radiologist in WA.

Dr Paul Yoong, wife Gek, grandchildren Hannah, Lachy and Isabella.

In the late 1980s, Paul was sad to leave RPH, recognising PRC needed his services more. He assiduously kept abreast of world best practice as the benchmark guide for the Australian industry in the future.

He developed lifelong peer relationships with local and interstate colleagues, sharing experiences and ideas. He wasn’t afraid to ask how to do something better. He had a passion for learning. For twenty years in the 1980s and ’90s, Paul held the position of Chairman or Managing Partner at PRC. Always a fierce advocate for radiology, Paul gave up many hours of his time committing to RANZCR business by sitting on various committees, including the Diagnostic Imaging Economic Standing Committee where he tried to shape and improve the profession as a whole.

In his private life, Paul lived a quiet and unassuming life. He was a devoted, proud and loving father always commenting on how blessed he was to be part of a close family that valued him all his life. Paul was never happier than when telling tales of his precious grandchildren, Hannah, Lachy and Isabella.

Most of those at PRC join because of the people and the culture. Paul, along with many others, was instrumental in shaping this. But Paul, with 40 years of deep involvement in PRC’s 70-year history, has made an indelible mark on PRC as an organisation and many of those in it.

He was contributing right up to his untimely death. He will always be remembered and sorely missed. We have been lucky to have had Paul as a colleague and guide.

Investing in our future

1977 saw the beginning of Paul’s long association with PRC, which was making the bold move to purchase the first whole body CT in the state.

Joining as a partner, Paul went back to Northwick Park Hospital for four months to master the new technology.

Dr Stephen Davis, Past Chairman Lenka Psar-McCabe, CEO

Geraldine Ormonde, Marketing Doctors Manager Perth Radiological Clinic is delighted toSenior welcome Rahul Lakshmanan, Sam Cherian, Liesl Celliers, Stephen Tiang, William Tee and Aran Sritharan to the Practice.

Paul was tireless in his commitment to excellence. He loved teaching, but also was always open to what he could learn from others. These were two of the things he valued most from his time at RPH. He was known for his academic excellence, technical prowess and characteristic efficient and no-nonsense approach. Paul was well respected as an expert in Abdominal Radiology. He was technically skilled in many procedural areas, but especially angiography and Barium studies. He produced beautiful images and could impart this knowledge to others, getting to the point with minimum fuss. He was energetic and highly respected, in what was an excellent department of colleagues.

Our success in attracting these talented radiologists lies in the calibre of our existing team, our www.perthradclinic.com.au uncompromising commitment to excellence and the reassurance of independent ownership.

20 | MARCH 2018

www.perthradclinic.com.au

MEDICAL FORUM

news & views

When Two Systems Combine…

Police and Health are working together to help people manage mental health crises close to home.

WA Police has concluded a two-year trial of the Mental Health Co-Response (MHCR) unit which is seeing more welfare-realated call-outs treated at the scene. The trial was sparked by the increasing number of such callouts and the long delays at Emergency Departments.

Superintendent Kim Travers and Inspector Stuart Mearns explained how the program, which involves mental health practitioners working alongside police, have been responsible for reducing the number of police transports of mentally unwell people to metropolitan EDs by 75%.

“Prior to the trial, police officers were transporting people suspected of having a mental illness in the back of a police vehicle to an ED and the wait could be 3-4 hours.

Back in 2007, we were looking at 4700 calls of this nature now there are 30,000 calls a year,” Kim said.

“Within the restricted trial parameters a total of 2907 confirmed mental health incidents were attended, 737 (25%) required transportation, 717 (25%) received a referral to other services and 1453 required other action such as advising existing case officer or no action needed.

The 1453 did not require transport an ED were able to remain in their homes.”

With no after-hours community crisis mental health services in WA, police, being the only 24/7 agency across the state, is often the first to get calls for help from people experiencing mental health crises, or from their family.

“Very few of these people are committing offences. It is almost always a medical issue, not a criminal issue. However, the reality is, people call police.” Stuart said.

The MHCR trial has three components.

An authorised mental health practitioner is based at the Police Operations Centre to assess the call for assistance and provide attending police with any available physical risk-related history.

The mobile teams, based in the North

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West and South East metropolitan districts, include two specially trained police officers (from a pool of 10 in each district) and a mental health practitioner, who is drawn from a community mental health team.

“The mobile teams are in effect bringing clinical services to the scene where the clinician is able to triage and deal with the incident there and then rather than police having to apprehend the person and transport them to an ED,” Stuart said.

Mental health watch “The third component is at the Watch House where, in this situation, people have come into contact with the criminal justice system. The health professional provides a risk assessment and offers management strategies for Watch House staff so they can deal with people who are suffering from some mental health crisis while in custody.”

According to Kim, very few of these cases are solely drug related.

“Certainly drugs and alcohol can be co-occurring factors but our evaluation of the trial has shown that far and away most people’s issues are psychosocial – homelessness, financial pressures, medical issues, family issues – a range of pressures which can trigger a mental health crisis,” she said.

“It’s not uncommon for police to attend a scene these days where drugs are involved and it’s not to say that they are not involved in these cases but they are not the primary factor. A lot of these drugs are in fact prescription drugs, not necessarily illicit drugs.”

Medical Forum was first alerted to the trial through the organisation Mental Health Matters 2 – a support group of families and carers convened by Margaret Doherty, a long-time advocate for mental health awareness. A police representative spoke at a recent seminar run by the group.

De-escalating crises “It’s important for us to speak to these groups about what we do because the coresponse delivers a diversionary approach

where police and health attend the scene as a team which is such a contrast from what they and their loved ones have experienced in the past. They are certainly strong advocates of the method being rolled out,” Stuart said.

“In that regard it’s important we tell the story to the police workforce as well.”

“We encourage family and friends to get the best advice from health services but the reality is, if someone experiences a mental health episode for the first time, neither they nor their family knows what to do and so the police are called. This trial is about working out better ways of responding to those incidences.”

Kim and Stuart say for police the trial has clarified some important issues. Firstly, most of these call-outs are medical issues and most can be dealt with clinically at the scene, which results in better outcomes for the person, their families, the police and the health system as a whole.

“The other thing we have learnt is that the mental health system is bursting at the seams. Placement in community based programs is at near capacity and families tell us that if people are unable to access those early intervention services, they will roll into a crisis more often,” Kim said.

“Our partners in health are equally passionate about reducing the number of people coming into an ED. Their workload is just phenomenal and this trial has shown how two departments with different cultures can work together to build efficiencies for both parties if we focus on a single method of service delivery. And most importantly, it has far better outcomes for the consumer, their family and carers.”

ECU’s evaluation of the trial is expected to be delivered in March and while the trial finished in January, its parameters will continue until the middle of the year when a review will establish if the program will be permanent.

By Jan Hallam

MARCH 2018 | 21

Dr Narelle Hadlow MBBS, MAACB, FRCPA, GAICD, AFCHSM

22 | MARCH 2018

MEDICAL FORUM

FEATURE BACK TO CONTENTS

Transcultural Cricket A cricket pitch, a red six-stitcher and a couple of bats have made a big difference to the lives of a group of asylum seekers.

“

This is a beautiful story,” says Tharanga de Silva from the Association for Services to Torture and Trauma Survivors (AseTTs). A group of young Sri Lankan asylum seekers awaiting visa approval and struggling to integrate with the wider Perth community formed their own cricket team – captained by a young man called Kapil Dev – and lifted the winner’s trophy in their first tournament.

“Every young Sri Lankan man knows how to play cricket and loves the game.

If you go into the countryside you’ll see villagers playing cricket on the roads,” says Tharanga, ASeTTS Community Development Coordinator.

“The team’s captain, Kapil Dev, was named by his father after the great Indian cricket captain – so you could say cricket’s in his blood.”

“Kapil founded the team and obtained sponsorship from ASeTTS for their first year in competition as ASeTTS Cricket Club.”

It’s no secret that asylum seekers have a difficult time settling into a new country, and the young Sri Lankans hitting cricket balls

on ovals around Perth had a few hoops to jump through, both on and off the field.

And, as a Sinhalese woman from Sri Lanka, Tharanga understands those challenges. Although the Sri Lanka civil war (a 26-year conflict born from ethnic tensions between Sinhalese and Tamils) ended in 2009, she had to build a level of trust with this group of young men.

“Most of them arrived by boat as asylum seekers, and, despite Perth having a wellestablished Tamil community, they weren’t welcomed in a particularly warm manner.

The social structure of the Sri Lankan community is complex and many groups don’t mix well.”

“Local Tamil groups were invited to attend the weekend matches, but were reluctant.

So some ASeTTS staff attended on Sundays to cheer on the team. The players have no family here, of course, so we filled that support role in many ways.”

“But when the team made the finals, cricket-loving Sri Lankans got right behind them. For the grand final, there was a crowd of supporters banging drums and making a lot of noise. And they won – it was a wonderful day!”

Buoyed by their success on the field, the team was able to source its own corporate sponsorship.

“The Commonwealth Bank funded some equipment and as the individual players obtained work, they were able to contribute their earnings towards maintaining the team. The players take their cricket quite seriously and look the part in their full cricket uniform. They were puzzled initially when their opponents showed up in T-shirts and shorts.”

“The young Aussies see the game as a social activity but for these Sri Lankan asylum seekers it means absolutely everything.”

“It can be difficult to give refugees and asylum seekers a feeling of hope. But for these young men, cricket has been a means to improve their wellbeing and foster important cross-cultural connections.”

“Most of them have obtained Temporary Protection Visas and are mixing more easily with the wider Australian community.

Now their sporting endeavours are quite independent of ASeTTS. They’ve even travelled to Brisbane for a tournament.”

By Peter McClelland

The winning ASeTTS team, left, and getting some tips from Australian cricket captain Steve Smith.

MEDICAL FORUM

MARCH 2018 | 23

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www.sjog.org.au/midland/private 24 | MARCH 2018

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guest column BACK TO CONTENTS

Living in Broome Time Dr Jonathan Blundell featured in February Curious Conversation as a new arrival from the UK. Broome’s had some wild weather in the past weeks including record rainfall so we wanted to know how the Blundell family pulled up. Jonathan’s wife Yvette and Violet (two) and Isobel (nine months) make up the team of intrepid adventurers.

What an introduction to Western Australia! Stifling heat, cyclones and floods – surely nothing could have prepared you for this?

“We’d spent a year in rural South Africa so we had some preparation for the heat and humidity. And it rained all summer in England before we left but nothing compared with the extremes of Broome.

The cyclones have been quite something!

So yes, it really has been quite an introduction.”

What were your first thoughts stepping off the plane in Broome?

“Thank goodness we made it! Coming here has been a long time in the planning,” said Jonathan. (J) “It brought back memories of The Castle.

We could’ve walked from the airport to our house!” said Yvette. (Y) Any thoughts of… ‘get me out of here!’

“Trash television is loved all around the world!” J “From snakes in the nursing sisters’ garden, the beach closed because of a crocodile and mosquitos by the ton, it’s a far cry from England’s most dangerous animal, the badger. Y Counting the sleeps until winter?

“Yes” says Jonathan. Yvette nods, “Absolutely!” and adds, “I’m working 24 hours a day looking after the kids while my

husband goes off to chat with grown-up people.” Y Things you miss most?

“The BBC, despite the fact that it’s unable to refrain from political bias and external influence, I really do miss that polished programming on both television and radio.” J “The rolling hills of Devon because Broome is absolutely super-flat.” Y Is Broome a friendly place, are you making lots of friends?

“We think it’s pretty friendly and relaxed here. We've been made very welcome by our local church and within a short period of time we’ve made some great friends.

And work is great fun and full of lots of lovely, funny and friendly people. It’s a pleasure to work with the Broome Regional Aboriginal Medical Service.” J Would you describe Broome as a ‘good’ place to live?

“Yes and no. We enjoy a great work and family life balance that’s far better than we had in the UK. But there’s not much to do in summer because it’s just too hot to even go for an afternoon walk. And we are really very isolated. We’ve been reliably informed that the ‘Dry’ is amazing and we sincerely hope that’s the case! The rental prices are ridiculously high here and we can’t believe that people haven’t made noises about that. Having said that, it’s a great place to live because we’re all together as a family

and there are loads of kids here! J The question of indigenous health and ‘Closing the Gap’ – a ‘hot potato’ and a long way to go?

“It’s definitely a ‘hot-potato’ question! I’m a bit uncertain about how much anything free is truly valued because the NHS is abused time and again in the UK. Here in Broome, the level of non-compliance and DNA is frustrating and I think the answer lies in education and ‘closing the gap’ from well before ‘day-minus-9 months’. If some mums can change their behaviour so that their children begin life on an equal footing, the gap will go a long way towards closing.” J What do you do in your leisure time?

“Leisure time… what leisure time? If we did have some we’d run, swim, cycle, tennis, play cricket, walk, read and drink coffee.” Y&J

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MARCH 2018 | 25

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guest column BACK TO CONTENTS

Getting Smarter Tackling Violence The social and financial costs of youth violence are high and as a society we need to address these issues at the community level, writes lawyer Dr Steven Monterosso.

Violence involving juveniles crosses racial, gender and geographical boundaries. Australia, and more particularly Perth, is not immune from these concerns. The end results such as injury, disability and death have a severe impact on individuals, families and communities with devastating flow-on effects within the medical and social welfare sectors.

If we just think about basic assault, the actual cost to the Australian community is estimated by the Australian Institute of Criminology to be over $1.4b annually. And this figure not only excludes insurance and legal costs but doesn’t even begin to cover intangibles such as pain, suffering and wider community anxiety.

It’s obvious that the ramifications of juvenile violence have significant physical, emotional and social consequences.

A disturbing trend that has emerged in Western Australia indigenous communities recently concerns domestic violence against girls as young as 12 by abusive men. It has been reported that exposure to this type of behaviour effectively normalises domestic violence and it’s now seen by some as a routine aspect of a relationship.

More than one million Australian children are reported to have been effected by domestic violence. Medical practitioners are often required to deal with family violence directed against juveniles and have an important role to play in the prevention, identification and responses to episodic violence of this nature.

This includes the detection of risk factors and early warning signs of violence in addition to the management of juvenile illness and mortality.

The physical and emotional trauma following an episode of juvenile violence is a major concern and extends to behavioural issues such as a perpetuation of physical aggression, diminished selfesteem, depression, poor socialisation and increased reliance on drugs and alcohol.

Clearly, the effect of violent events on juveniles is all-pervasive and extends to personal and family relationships.

There’s a financial cost, too. These can be punitive, everything from hospital payments

to mental health, rehabilitation services and, in the worst case scenario, coroner’s and funeral fees.

The social costs associated with juvenile detention are of particular concern in WA given the over-representation of indigenous juveniles in short- or long-term detention.

The disproportionate number remains at chronic levels and has rightly been described as a national shame.

It’s been well established that juvenile justice policy and WA policing methods have been identified as contributing factors to the high rates of indigenous incarceration. At the extreme end of juvenile violence, the incarceration of a juvenile following a homicide results in severe societal financial costs.

Juvenile violence is, sadly, a serious social reality in contemporary Australian society and it needs to be addressed in a more sophisticated manner. More research is required in order to ameliorate multifaceted and problematic violent juvenile behaviour and minimise the continuation of criminal behaviour.

ED: Dr Monterosso is a legal academic at Curtin University.

guest column

Healthy Conversations A healthy dose of social connection is the best medicine of all, says Be Friends CEO, Nick Maisey.

I trained as an Occupational Therapist and I now run a community-building organisation that has a strong focus on fostering friendship. And I’m often asked, ‘when did you stop being an OT?’ I usually respond by saying, ‘I haven’t really stopped’ because relationships – be they personal or professional – have a huge bearing on health and wellbeing. I work hard to tackle isolation and loneliness because scientific evidence, personal experience and common sense all point to one deep truth regarding social relationships.

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Human connection is crucially important for physical and mental health, happiness and lifelong fulfilment. I’d go further and say that the biggest threat to the overall health and resilience of our community is social isolation.

The journey started for me back in 2009 when a young man named Tim contacted the OT school where I was studying. He wasn’t seeking therapy or support. What Tim desperately wanted and needed was friends because making friends didn’t come easily to him. He explained how challenging it was for others to see beyond his cerebral palsy.

All of us can relate to the feeling of rejection, of being left out, of being the last one invited to a party or to join a team. And, for most of us, it begins at primary school.

But when that experience permeates every waking hour our internal sense of self-worth and belonging is eroded away. I’ll be honest, I saw something of myself in Tim and it wasn’t too difficult to see many others who are struggling to be, and feel, included.

To be human is to belong.

continued on Page 28

MARCH 2018 | 27

CLINICAL OPinion

By Dr Jessica Yin Urological Surgeon, Hollywood Private Hospital, KEMH.

Recently there has been a great deal of interest in this area with multiple media reports highlighting the complications of these devices.

Patients are understandably concerned and GP colleagues are requesting information/guidance in this controversial space.

Where are we now?

The withdrawal of trans vaginal mesh (TVM) for prolapse and the reduction of available slings provides a challenge to Gynaecological and Urology specialists in their management of patients with incontinence and prolapse. In many senses we have gone back to historical operations, with the limitations of native tissue repairs and (potentially) more morbidity.

However attention focused on TVM has highlighted the need for proper assessment of surgical devices before they are introduced into the market. www.tga.gov.au/media-release/strengtheningassessment-medical-devices-and-informationconsumers

A number of initiatives have commenced: 1. The Senate enquiry has looked at the scope of the problem and received input from: • patients who have had complications as a result of trans vaginal mesh • clinicians who operate to insert and those who manage mesh complications • representatives of government bodies including regional WA health representatives and the TGA • Local experts who have submitted, including Drs Nic Tsokos, Michelle Atherton and Jessica Yin 2. Australian Commission on Safety and Quality in Health Care (ACSQHC) have formed a working group to help guide and make recommendations with respect to the management of female Stress Urinary Incontinence (SUI) and POP. The working group includes urologists, urogynaecologists, colorectal surgeons, a physio, a RACGP rep and 2 TGA reps. It is anticipated

The consumer backlash against mesh implants in incontinence surgery has left gynaecologists, urological surgeons and GPs in 'no man's land'. Navigating the politics is not easy.

Here's an update. that within 6 months final documents including patient information brochures, suggested clinical pathways and GP info will be created. In addition, credentialing criteria, ongoing skill maintenance and a possible TV mesh registry will be addressed.

3. A Mesh Information phone line and dedicated mesh complication clinic has been established at KEMH. While the Urogynaecology Department has always handled complex mesh patients, a help line and extra resources have been allotted to deal with an increasing number of potential patients. (See below for further information).

Whilst these initiatives are laudable, the recommendations may not be available for some time. At the coalface GPs are today

continued from Page 27

I sense their pain and detachment, and I see how communities are weakened by devaluing, segregating and excluding people.

The research linking social connection with physical and mental health is overwhelming. Human contact affects us at a cellular level, releasing a cascade of neuro-transmitters that reduce stress, decrease pain and lift our mood. It’s self-evident that people who are well-connected to a broad social network live longer, happier lives, experience less emotional distress and recover from life’s inevitable setbacks in a positive way.

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Psychologist Susan Pinker puts this beautifully, ‘friendships create a biological force-field against disease and decline.

It’s a biological imperative to know that we belong.’

With one in four people reporting an absence of close relationships, a lack of connection is, quite literally, killing us. We’re investing a lot of time and money on some of the symptoms of disconnection such as depression, substance abuse and mental illness but it be more logical to invest in building inclusive and well-connected communities.

Tim wasn’t looking for a pill to mask his disconnection, nor did he want a referral to a service provider. He wanted friends and we need to start valuing conversation to break down social isolation.

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BACK TO CONTENTS

Trans-vaginal mesh – what now?

CLINICAL OPinion being inundated with patients requesting information, investigations and referrals that may be outside their scope of expertise.

Additional changes in the industry The TGA has now removed all TV prolapse mesh and single incision slings (“Minislings”) from the Australian Register of Therapeutic Goods (ARTG). Essentially this means that TV mesh prolapse repair is no longer a surgical option (unless confined to a clinical trial where it would require approval by the TGA through a special access scheme). Minislings have also been cancelled from the registry. This leaves retropubic and obturator mesh midurethral slings as an option to treat stress incontinence.

(see above TGA recall). Abdominal mesh sacroplexy is still offered as a surgical option without, it seems, the same rate of longterm complications.

Mesh midurethral slings (MUS) are still regarded as the gold standard operative management of stress urinary incontinence. It is recognised, though, that very significant complications can occur with these slings particularly if they

to imaging and interventional radiology, Pelvic Pain Specialists and Colorectal services are available. It is a public service and many of the clinicians do offer similar assistance through their private rooms.

One of the challenges faced is determining exactly what operation has been done and what device has been implanted. To assist, ANY information regarding the operation, surgeon, hospital location etc should be

www.tga.gov.au/alert/tga-actions-afterreview-urogynaecological-surgicalmesh-implants#actions www.tga.gov.au/alert/tga-actions-afterreview-urogynaecological-surgicalmesh-implants Johnson & Johnson have ceased supply of all TV mesh slings in Australia (Jan 2018).

This includes TVT (ironically the best studied MUS), TVT-exact, TVT-Abbrevo and TVT-O. Boston Scientific and Coloplast have agreed to comply with the recent TGA requirement to update the wording in their product IFUs, so these 2 companies will continue sales of their sling products.

Important points for our GP colleagues Transvaginal Prolapse Mesh. Whilst initially promising a more durable result in comparison to native tissue repairs, TV prolapse mesh has, over time, declared itself as problematic with complications being evident many years after insertion.

By and large TV prolapse mesh has been abandoned except in very specific recurrent prolapse and usually after assessment of the patient by a multidisciplinary team

Sling mesh eroding posterior vagina

Complications from mesh surgery for incontinence in women. are over tightened, placed in patients with suboptimal tissues or intraoperative bladder perforation goes unrecognised.

Fascial slings are an alternative choice for patients who have already experienced a complication with a mesh MUS or who are reluctant to undergo a mesh sling.

Full discussion of the pros and cons of each operation should be mandatory and patients should be encouraged to get a 2nd opinion if they are at all concerned.

included with a referral. Original operative notes may help identify the location (or, sometimes, the absence) of mesh.

Referral: is it a mesh problem?

In WA the centre with the most experience in dealing with recurrent prolapse and mesh complications is that of the Urogynaecology unit at KEMH. This unit is staffed by Urogynaecologists, Urologists, Pelvic floor physiotherapists, with access

Imaging should limited to patients who have had a proper specialist assessment such that appropriate clinical information can be requested from the radiologist. Recently one of the private imaging services has ceased doing 4D ultrasounds because of the number of inappropriate referrals.

4D ultrasound imaging may be helpful in locating mesh but currently we are seeing a situation where patients are pressuring their GPs for 4D US without any specialist assessment beforehand. In some cases patients have requested this imaging despite the fact that they do not have a mesh sling.

Introducing

CT for Mortuary The State Mortuary will take possession of a $1.1m scanner to improve forensic imaging thus eliminating the need for invasive post-mortem examinations to identify cause of death.

Practice Assist is a new easy-to-use support service available free of charge to all general practices in WA. Our goal is to enhance your practice’s viability and sustainability, freeing you up to do what you do best – care for your patients.

The Attorney General said the scanner would help speed up the processes of the Coroner's Court which would ultimately benefit grieving families.

"Not only will the new equipment allow cases to be resolved more quickly, it will also benefit other grieving families who have lost loved ones whose cases are part of the coronial backlog and have yet to be dealt with,” he said.

"It is hoped that use of the new scanner means that fewer Western Australians will need an invasive post-mortem examination, which is often resisted by families and also goes against some cultural beliefs.”

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Access online, telephone and faceto-face support, comprehensive resources, professional development, webinars and more.

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MARCH 2018 | 29

30 | MARCH 2018

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CLINICAL UPDATE BACK TO CONTENTS

Technology in the management of Type 1 Diabetes

By Dr Mary Abraham, Paediatric Endocrinologist, Princess Margaret Hospital Insulin pumps have come a long way since their introduction with almost 45% of our paediatric patients in WA currently on this therapy.

Pumps deliver short-acting insulin continuously through a subcutaneous cannula that is re-sited every third day. The basal insulin delivery is set to mimic endogenous insulin production. Prandial and correction boluses are administered via the pump under user control.

Further advancements are directed towards glucose monitoring and improved pump algorithms to reduce hypoglycaemia. Table 1 lists devices currently available in WA.

hypoglycaemia, especially with impaired hypoglycaemia awareness.

However, until recently prohibitive costs have limited CGM uptake. The Australian Government has now made available through the National Diabetes Service Scheme, subsidised CGM products to children and young people with type 1 diabetes (below age 21).

Technological advances have dictated advances in T1DM management particularly user friendly insulin pumps for younger patients.

The current CGM systems are more Continuous glucose monitoring (CGM) accurate and systems precise, reasonably unobtrusive and CGM systems empower patients to small. Some improve their diabetes management. A Medtronic 640 G Pump. Basal insulin suspended before low. Sensor glucose devices share the subcutaneous glucose sensor, re-sited displayed on the pump. sensor glucose every 6-7 days, measures interstitial glucose and compact, does not require calibration readings with every five minutes. The sensor is attached to by the user, and has a two-week period family or friends (Dexcom G5, Medtronic a transmitter which sends these readings to of use with good accuracy. This approach Guardian Connect). either an insulin pump or a receiver (patients provides glucose levels intermittently when on insulin injections), providing real-time The systems reduce the number of finger scanned by the user using a receiver or an continuous display of glucose readings. pricks, provide real-time information on Android smartphone, but currently cannot Calibration for optimal functioning uses glucose, provide trend arrows and alerts, provide alarms or control insulin infusion capillary blood glucose measurements to and enable the user to treat actual or rates. transform the sensor signals from interstitial impending hypo- and hyperglycaemia. fluid into glucose values.

Sensor-augmented pump therapy Some systems are also approved for use in Regular CGM use is associated with insulin dosing decisions (Dexcom G5).

Algorithms incorporated into sensorimproved glycaemic control and with augmented pump therapy focus mainly Flash glucose monitoring system reduction in severe hypoglycaemia and on reducing hypoglycaemia. The Low A flash glucose monitoring (FGM) system overall health costs. CGM is beneficial for Glucose Suspension (Suspend on Low) (Libre, Abbott), recently introduced, is small patients with frequent, severe, or nocturnal suspends basal insulin when sensor detects hypoglycaemia and reduces time in hypoglycaemia. Predictive Low Table 1: CGM Technology in the management of Type 1 Diabetes Glucose Suspension (Suspend before Low) suspends basal insulin with the prediction of Device Dexcom G4 Dexcom G5 Guardian Connect Libre* MiniLink Guardian Link 2 hypoglycaemia and prevents it occurring.

Pairs with

Receiver/Animas pump

Receiver/smart phone

Receiver/smart phone

No

Medtronic Veo pump

Medtronic 640G pump

Approved for insulin dosing

These systems are available in the Medtronic MiniMed 640G pump when used in conjunction with the Enlite sensor.

No

Yes

No

Yes

No

No

Where are we heading?

Alert functions

Yes

Yes

Yes

No

Yes

Yes

Share data with followers

No

Yes

Yes

No

No

No

Suspends insulin delivery

No

No

No

No

Suspend on Low

Suspend on Low / Suspend before Low

Product Life

7 days

7 days

6 days

2 weeks

6 days

6 days

Calibration required

Every 12 hrs

Every 12 hrs

Every 12 hrs

No

3 to 4 times a day

3 to 4 times a day

*not approved under NDSS

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The ultimate aim is to have a fullyautomated closed loop system that uses a control algorithm that autonomously and continually increases and decreases the insulin delivery in response to real-time sensor glucose levels.

Closed-loop artificial pancreas systems have been under development for several years with numerous algorithms, and are

continued on Page 33

MARCH 2018 | 31

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CLINICAL OPINION BACK TO CONTENTS

Prediabetes – when does the clock start ticking?

By Dr Timothy Welborn, Endocrinologist Practitioners can miss the patient who has prediabetes. Diabetes is epidemic, and the numbers keep rising. The prevention of Type 2 Diabetes (DM2) is a health priority, as important as vaccination policies.

Diabetologists recognise that when DM2 is diagnosed, ‘the clock starts ticking’ – it is a progressive condition where insulin resistance and declining insulin secretion often necessitates regular escalation of treatment, to achieve glycaemic control, and to prevent long-term complications.

How to recognise the prediabetic?

Most have features of the metabolic syndrome, including abdominal obesity, hypertension, and a specific dyslipidaemia (high triglycerides, low HDL-cholesterol).

Many have a clear family history of DM2.

Some show previous laboratory tests highly suspicious of diabetes but these are often dismissed as “borderline” or “mild”.

The occasional high blood sugar reading is overlooked as “incidental”. Particularly high-risk females are those with a past history of gestational diabetes (or big

Interventions at general practice level could delay when the ‘clock starts ticking’ on Type 2 diabetes if pre-diabetes is in our thinking.

babies), and those with PCOS. These patients must have a structured follow-up.

If the laboratory reports “impaired fasting glucose” (IFG is a plasma glucose of > 6.1 mmol/L), or “impaired glucose tolerance” (IGT is a 2-hour GTT plasma glucose of 7.9–11.0 mmol/L), or an intermediate glycated haemoglobin (HbA1c in the range 6.1%–6.4%), the clock is ticking. HbA1c levels of >6.5% are considered to indicate diabetes.

Prediabetes responds to vigorous clinical interventions, predominantly supervised change in lifestyle including dietary intervention to achieve weight loss (restrict total calories, saturated fat and alcohol, and refined carbohydrate), plus disciplined exercise (30 to 60 minutes daily).

In populations where progression from prediabetes (IFG and/or IGT) was about 10% annually, controlled clinical trials of diet and exercise over 3 to 6 years achieved risk reductions of 42% (China), 58% (Finland), and 58% (USA).

Drug therapy will provide additional risk reduction (metformin 25%, acarbose 25%, orlistat 25%). There appears to be a huge potential for the use of the new

GLP-1 agonists (ByettaTM, BydureonTM, or SaxendaTM by injection) to improve the impaired glucose metabolism and the overweight of prediabetic subjects, but no clinical trial data is available yet.

Ideally the prevention of diabetes should be a public health responsibility, with education, health promotion, and support for healthy lifestyle programs. At present, the burden of effective intervention is in general practice.

References: Welborn TA. Diagnostic and screening tests for diabetes and its precursors. Medicographia 2004: 26; 29-34 Barry Eleanor et al. Efficacy and effectiveness of screen and treat policies in prevention of type 2 diabetes: Systematic review and meta- analysis of screening tests and interventions. BMJ 2017: 356; i 6538 Author competing interests: nil relevant.

Questions? Contact the author on officetimwelborn@iinet.net.au

Technology and Type 1 Diabetes, continued from Page 31 being tested in, camps, supervised outpatient settings and free living conditions.

A hybrid closed loop system using the Medtronic 670G pump (FDA approved in USA) is under trial in Australia – it delivers insulin based on sensor glucose levels but needs the user to bolus for meals.

Ultimately, treatments should always be individualised and health care providers focused on achieving glycaemic targets by whatever means best suitable to the patient.

Challenges The systems require ongoing user involvement as well as experienced and informed diabetes teams for successful adoption.

The ‘patient-medical device interface’ is a complex paradigm, and central to success is the adherence, understanding, and engagement by the patient with the technology. The need to wear an additional device, troubleshooting sensor problems, and coping with alarms and alerts are potential barriers to uptake.

Flash Glucose Monitor (Libre). Scan the sensor and sensor glucose display on the reader.

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Dexcom G5 Sensor glucose display on phone.

MARCH 2018 | 33

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clinical update BACK TO CONTENTS

Spinal pain procedures: who and when?

Prof Eric Visser, Churack Chair in Pain Medicine UNDA & Pain Science Joondalup Chronic spinal (neck and back) pain affects up to 20% of the population and is associated with significant suffering, disability and economic loss. Management can be difficult.

As part of a contemporary multimodal approach, spinal pain management procedures (SPMPs) are usually not a permanent ‘pain cure’ (analgesia lasts weeksto-months) but in selected patients, they provide a ‘therapeutic window’ of pain relief to facilitate physical and psychological rehabilitation, reduced pain neuro-sensitisation (wind-up) and decreased analgesic use (particularly opioids).

imaging is not routinely required. If an initial FJI is ineffective (<50% pain reduction) reconsider the need for further injections. If FJI is effective but lasts <3M, then RF may prolong the analgesic effect. For unilateral buttock and thigh pain, consider a CNB (treats entrapment of cluneal nerves over the iliac crest), or a SIJI. TFESI is only indicated for subacute (<6M) radicular leg pain where multimodal treatment is ineffective or there is significant disability. A spinal MRI or CT scan is required prior to injection to confirm a targetable nerve root lesion. Do not order a cervical TFESI for radicular arm pain without specialist advice. These blocks are poorly-effective and associated with rare but catastrophic neurovascular events such as stroke, due to inadvertent intraarterial injection of particulate steroids.

Adverse outcomes of SPMPs include lack of efficacy (particularly in patients exposed to psychosocial stressors), worsening pain, tissue damage, neuro-trauma, infection, bleeding, drug reactions, radiation exposure and, rarely, paralysis or death.

About 20-40% of chronic neck and low back pain (LBP) is associated with facet joint arthropathy; 20% of LBP is due to sacroiliac joint arthropathy or cluneal nerve entrapment over the iliac crest and 10% of leg or arm pain is ‘radicular’ due to a spinal nerve root lesion (e.g. disc protrusion).

The most commonly performed SPMPs are: facet joint steroid injection (FJI), medial branch (nerves innervating facet joints) radiofrequency treatments (RF), transforaminal epidural steroid injection (TFESI), sacroiliac joint steroid injection (SIJI) and cluneal nerve block (CNB). RF treatments include pulsed RF (temporary electromagnetic inhibition of nerve function) and thermal RF neurotomy (nerve ‘cautery’ at 90°C).

Evidence for effective analgesia with FJI and RF in the spinal pain population is limited. However, there are individual responders. It is reasonable to consider FJI or RF in patients with chronic spinal pain who are over 60 years of age, or for neck pain following whiplash.

FJI or RF should be ordered based on clinical presentation (table 1); spinal

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Indications and patient selection for SPMPs are listed in table 1.

References available on request. The author acknowledges the assistance of Dr Luke Wheeler.

Author competing interests; nil relevant disclosures. Questions? Contact the author at eric.visser@nd.edu.au

Table 1. Spinal Pain Management Procedures (SPMPs) Procedure

Pain indication

Patient group

Follow-up RF treatment

C2/3 FJI

Upper neck pain with cervicogenic headache

Over 60 or

Pulsed RF or thermal RF neurotomy

C5/6 FJI

Mid-level neck pain radiating to shoulders

Over 60 or

L4/5 plus L5/S1 FJIs

Low back pain +/- referred buttock/leg pain

Over 60

Pulsed RF or thermal RF neurotomy

Sacroiliac joint steroid injection (SIJI)

Unilateral low back and/or buttock pain

More effective in inflammatory arthropathy

Thermal RF neurotomy of lateral branches to SIJ

Cluneal nerve block (CNB)

Unilateral buttock/thigh pain; tender iliac crest;

post-whiplash post-whiplash

Pulsed RF of cluneal nerves over iliac crest

altered sensation buttock

Lumbosacral transforaminal epidural steroid injection (TFSI)

Radicular leg pain <6M; no response to multimodal treatment

Pulsed RF or thermal RF neurotomy

MRI/CT to confirm nerve root lesion

FJI=facet joint steroid injection; RF=radiofrequency treatment of medial nerve branch of spinal dorsal ramus; SIJ(I)=sacroiliac joint (injection).

MARCH 2018 | 35

CLINICAL UPDATE

Dr Ajay Sharma, Paediatric Gastroenterologist and Hepatologist, Perth Eosinophilic esophagitis (EoE)is "a chronic, immune/ antigen-mediated, esophageal disease characterised by symptoms related to esophageal dysfunction and histologically by eosinophil-predominant inflammation”.

EoE has emerged as a commonly identified cause of esophageal symptoms in children and adults.

Pathophysiology and clinical features The increasing incidence of EoE may be due in part to increased recognition of the disorder, with a strong association with allergic conditions such as food allergies, environmental allergies, asthma, and atopic dermatitis.

The pathogenesis of EoE is thought to start when a food antigen activates the immune system of a genetically susceptible individual causing naïve CD 4 T cells to differentiate into T helper cells (Th2) that secretes Th2 cytokines like IL5, IL4 and IL 13. This causes symptoms of esophageal dysfunction, damage and remodelling.

Presentation varies with age. Younger children may often have problems that include feeding difficulties/dysfunction, and abdominal pain or even fussy eating habits. Dysphagia to solid foods is the most common symptoms in teenagers and adults.

Diagnosis from multiple clues The diagnosis of EoE is usually based upon endoscopic appearance which includes circular rings, strictures, linear furrows, whitish papules and a small caliber esophagus with biopsies showing >15 eosinophils per hpf.

Recent studies have shown that the clinical, endoscopic, histological and esophageal gene expression features of PPI-REE (Proton Pump Inhibitor Responsive Esophageal Eosinophilia) and EoE are virtually identical and one could contribute to the other.

The interaction with our environment can spark many problems, particularly in atopic children. This is one of them, and what we do about it depends on where you are coming from.

There are no diagnostic serum markers for EoE but 50-60% of patients may have elevated serum IgE levels. Other tests include endoscopic ultrasound, impedance planimetry, esophageal manometry, endoscopic confocal laser microscopy and esophageal string test but all are experimental at this stage.

Treatment presents quandaries The three main modes of treatment for EoE is drugs, diet and dilation.

Pharmacologic therapy includes topical glucocorticoids, and PPI. Dietary elimination has been shown to result in resolution of symptoms and improvement in histology. Allergen avoidance with elimination and elemental diets poses a risk of nutritional deprivation, can be difficult for patients and families and can lead to psychological problems, including unnecessary food aversion.

Topical swallowed fluticasone or budesonide are now becoming the first-line pharmacologic therapy for treatment of EoE. Patients without symptomatic and histologic improvement after topical steroids might benefit from a longer course of topical steroids, systemic steroids, elimination diet, or esophageal dilation. Use of mast cell stabilizers or leukotriene inhibitors, and biologic therapies remain experimental at this time.

Patients should be counselled about the high likelihood of symptom recurrence after discontinuing treatment.

Maintenance therapy with topical steroids and/or dietary restriction should be considered particularly in those with severe dysphagia or food impaction, high-grade esophageal stricture and rapid symptomatic/histologic relapse following initial therapy.

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According to a report co-authored by Prof Andrew Briggs from St Vincent’s Hospital, Melbourne, joint replacement surgery was growing at an unsustainable rate, and as many as one in four of these operations were not required for people with osteoarthritis (OA).

In 2016, nearly 100,000 Australians received joint replacements to treat OA of the hip or knee – at an estimated cost of over $2b. Between 1994 and2014, Victoria had a 175% increase in hip replacements and 285% increase in knee replacements, with no sign of demand slowing.

The report may challenge many of the existing OA practices. It recommends OA can be diagnosed without x-rays; successfully treated in a majority of cases without surgery, which should only be a treatment of last resort and pain management can be improved.

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BACK TO CONTENTS

Update: Paediatric Eosinophilic Esophagitis

clinical update BACK TO CONTENTS

Chronic postsurgical pain

By Dr Brian Lee, Fellow, Statewide Pain Service

The widely accepted definition of chronic postsurgical pain (CPSP) is: Pain developing after a surgical procedure, of at least two months duration, where other causes of pain have been excluded and there is no pre-existing pain continuing from a previous pain problem.

While not well understood, pathophysiology of CPSP is thought to involve central sensitisation and chronic pain changes in the nervous system. It commonly presents with pain of neuropathic nature (sharp shooting pain associated with allodynia and dysaesthesia).

Preoperative pain in the affected area is a risk factor as are psychosocial factors. Patients with depression, anxiety, catastrophising traits and hypervigilance are at particular risk. Females are at an increased risk of chronic pain conditions including CPSP.

the best starting point. Gabapentinoids, TCA and SNRI agents may be useful.

Opioids have little role in CPSP management but a trial of tramadol or tapentadol for its non mu-receptor activity could be considered.

Allied health treatments. Physical rehabilitation and improvement in function, rather than pain reduction, is the main focus. Physiotherapy and occupational therapy are appropriate especially with therapists skilled in this area. Psychological factors play a significant role in chronic pain development and psychology input is often invaluable.

Patient education. Patients should be encouraged to learn about their condition

With up to 100,000 patients affected each year chronic postsurgical pain (a common and serious surgical complication) its correct management will prevent a real burden on society. to help them be in control. Factsheets such as the one produced by the International Association for the Study of Pain (www.iasp-pain.org) is useful.

References available on request.

Author competing interests: nil relevant disclosures. Questions? Contact the author at briansunlee@gmail.com

Inguinal hernia repair is one of the commonest causes of CPSP with recorded incidences of up to 63%. Hip arthroplasty, cholecystectomy, caesarean section, amputation, mastectomy and thoracotomy also carry a high risk of CPSP as do long duration, open approach, and repeat procedures. Adequate postoperative pain control is essential as the severity of postoperative pain is a strong predictor of development of CPSP. Prevention and management The most important preventative method for CPSP is judicious consideration of indications and risks when contemplating surgery. Use of minimally invasive surgical techniques and incorporation of preventative regional anaesthetic techniques have some benefit. Despite common usage, evidence for perioperative antineuropathic agents is inconclusive.

Recognising patients with signs of CRPS is important, as urgent referral to Chronic Pain services and institution of treatment for the former condition may make a difference in outcome. Features of CRPS to look out for include pain disproportionate to the inciting event, hypersensitivity, colour or temperature change in the limb, oedema, and changes in sweating and nail/hair growth.

Principles of managing CPSP are in line with other chronic pain conditions, and include: Pharmacotherapy. Multimodal analgesia with paracetamol and NSAID is

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MARCH 2018 | 37

CLINICAL UPDATE

By Dr David Holthouse, Pain Neurosurgeon, Perth

Opioid medication has potential benefits for patients in pain but there are significant risks of narcotic side effects especially with high doses.

Furthermore, not all narcotics are created equal and some have a markedly higher propensity to cause problems, such as addiction etc..

Opioid addicted patients represent a high risk group for complaints careful documentation is imperative and an opioid contract desirable.

Chronic opioid therapy in non-cancer pain has been addressed extensively by the American Pain Society, with guidelines developed. One conclusion made was there is no evidence for long-term treatment with opioids - studies have not addressed endpoints for treatment, with no firm evidence supporting opioid medication in patients with chronic non-cancer pain.

Evidence is emerging of the costs of being on narcotics, particularly increased unexplained deaths in patients on opioids (especially higher doses).

Addiction and drug related behaviour No studies adequately address the cost effectiveness of opioids for non-cancer pain. The American Pain Society focuses on minimising doses and avoidance of high-dose opioids. Similarly, guidelines of the Australian College of Anaesthetists (Pain Section) reflect ongoing concern with opioids.

It is very common to find relatively functional patients with significant physical and psychological dependency on medications.

Some opioids are a higher risk than others.

Oxycodone and fentanyl constitute opioids with a higher potential for dependence, addiction and ultimately abuse. Diversion is a problem with addicts extracting opioid out of the fentanyl patches, either for injection or simply chewing or eating the patch. Oxycodone, even though reformulation has reduced the chances of injection, is still regularly injected and there is controversy about how much is diverted.

My view is these medications should be reserved for acute pain and not

Choosing pain killers wisely is no easy task when weighing up efficacy, patient demands, and medicolegal consequences.

These notes help. extrapolated to chronic pain. Targin SR in very small doses may be appropriate in the elderly with crush fractures who are predisposed to constipation etc. but mostly, oxycodone should be taken out of the arena for chronic pain (as happens with fentanyl patches). There have been a number of deaths examined by the Coroner of WA over fentanyl patch use.

Ideally, people on these medications (fentanyl and oxycodone) should be referred to a pain management specialist or a pain clinic where steps can be taken to change them onto some other medication.

Morphine also presents concerns for chronic use, with morphine elixir noted to increase abuse. In my view, morphine elixir should not be used for chronic pain. In the past, patients commenced because “they couldn’t tolerate tablets” but better options now mean this is no longer a valid reason for prescribing morphine elixir in chronic pain.

Choosing wisely Better narcotics e.g. Palexia in a SR preparation, means that opioids are now available with significantly less risk of addiction. In recognition of the lower propensity for addiction with patients on tapentadol (Palexia) the Health Department will allow use by GPs as a sole opioid in most dose ranges, without Specialist approval.

Tramadol presents another option, although many patients experience significant nausea. Buprenorphine, as patches, has a low propensity to addiction and should be favoured over other more addictive opioids.

Physeptone is another option and has less addictive potential for those not easily controlled by weaker opioids. Failing this hydromorphone SR could be used.

Some practitioners have had legal action against them by individuals “addicted” to opioids. The prevailing evidence is against using strong opioids for chronic non-cancer pain. I envisage it will become indefensible for a general practitioner to commence patients on stronger narcotics without an extensive trial of tramadol, tapentadol or buprenorphine first. Wherever possible oxycodone, fentanyl and morphine should be avoided.

38 | MARCH 2018

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BACK TO CONTENTS

Opioids in chronic non-cancer pain?

COMEDY

Tall Tales and True ABC radio jock James Valentine jumps out of the studio and into the theatre for a stand-up gig that will take the audience to some interesting places.

Even the show has a funny name! It’s called, Afternoons Tonight and it takes the bizarrely hilarious from James Valentine’s ABC talk-back radio gig and morphs it onto the stage in front of a live audience. And it’s coming to Perth as part of the Perth Comedy Festival kicking off in April!

primary school! But it did mean that when I started getting a few radio jobs I knew how to use my voice.”

“Our radio show has a mid-afternoon time slot in Sydney so by that time I reckon everyone’s heard more than enough on aeroplane crashes and State politics. I look for something that’s lighter and different so I ask myself, ‘what’s out there that’s interesting and funny?’.”

“I don’t think my parents were too shattered when I didn’t go down the law/ medicine pathway. Anyway, I was the youngest so by the time my parents got to me they were exhausted. My brother did law and hated it!”

“And the answer to that has just got to be people!”

James didn’t start immediately in the broadcast sector. After leaving school he went to Melbourne University and studied music with the saxophone as his instrument of choice.

“My first love was jazz, lots of Miles Davis and John Coltrane. I was a classically trained saxophonist, did all the exams and

probably ended up as a bit of a jazz snob.

But I soon realised that all the best paid gigs were in rock’n’roll so I teamed up with some great bands like Jo Jo Zep and was earning $1500 a week!”

Rock’n’roll lifestyle “Then I joined a band called The Models and we’d be on tour for months at a time. It was a lot of fun but the drugs and alcohol can be destructive. It can become a normalised lifestyle quite quickly and that’s not a good thing at all. The Rolling Stones do all this in private jets and French chateaus but we were doing it in Flag Motor Inns. It was crushingly dull! I did have a period of excess for a while and emerged intact but, sadly, some others were unable to rein in their consumption.”

“There’s nothing stranger than the human race. Some of the radio conversations we have are truly bizarre. You’ll never believe the way some people live their lives! What I’ve done for the theatre show is play about a dozen of the greatest callers we’ve ever had and we have a conversation with the audience about what we’ve just been listening to. There’s some pretty weird stuff out there and no shortage of people who are keen to talk about it.”

There’s a little less music and a lot more conversation in James Valentine’s working life and he loves every minute of it!

“What happens next is that the radio conversations spark people in the theatre to tell their own stories. And they’re often even more bizarre!”

“Afternoons Tonight goes in some highly unpredictable directions. We’ll open up a discussion on something such as, is it okay to snoop on your kid’s phone?

‘As often as you can and don’t let them know!’ said one audience member.”

“It’s the individuals with the strangest stories who are just busting to tell everyone else!”

Speaking proper James, it seems, was born to speak on radio. His polished articulation is in the genes and reinforced at an early age.

“My mother taught elocution lessons in Ballarat, a small regional town in NSW, and she spoke very precisely. In fact, she was able to enunciate the ‘h’ in ‘what’. Back in those days they actually had public speaking competitions with more lovely, rounded vowels than you could poke a stick at.”

“Needless to say, I didn’t speak like that in

“Both the radio show and its theatre spin-off have got a lot of life left in them. Bringing the show to Perth will be interesting because this will be the first time I’m playing in a place where I’m totally unknown as a broadcaster.”

“Trust me, it’ll be great!”

“Sometimes I’ll come out on stage with a dishwasher.

Apparently there are one hundred different ways to stack one and some people feel very strongly about the best way to do it! There’s also a story that I’ve dubbed, ‘Eric the Breast Feeder’ and I’m not going to say any more about that.”

“You’ll have to come along to the show to hear how it turns out.”

By Peter McClelland

How to Translate Work Emails I have a question = I have 18 questions.

I’ll look into it = I’ve already forgotten about it.

I tried my best = I did the bare minimum.

Happy to discuss further = Don’t ask me about this again.

No worries = You really messed up this time.

Take care = This is the last you’ll ever hear from me.

Cheers! = I have no respect for you or myself!

ED: These are not the views of this publication!!

E-mail Addresses It Would Be Annoying To Give Out Loud MikeUnderscore2004@yahoo.com MikeAtYahooDotCom@hotmail.com Mike_WardAllOneWord@yahoo.com AAAAAAThatsSixAs@yahoo.com 1OneTheFirstJustTheNumberTheSec ondSpelledOut@hotmail.com Still can’t read minds The guy who invented predictive text died last night.

His funfair is next monkey.

Never text Dad for help

“Now I know how a Muppet feels!”

Daughter: Dad there’s a moth on the outside of the bathroom door. Can you get rid of it?

“Could you write a note for my wife saying that my head is not up there?”

Daughter: Please hurry because I’m going to cry.

Zen and the Art of Breakfast

Daughter: Dad… Daughter: Dad…

There’s no menu—you get what you deserve.

Why You Should Make Love Once A Year

Portable Primping

A therapist has a theory that couples who make love once a day are the happiest.

So he tests it at a seminar by asking those assembled, “How many people here make love once a day?” Half the people raise their hands, each of them grinning widely.

“Once a week?” A third of the audience members raise their hands, their grins a bit less vibrant. “Once a month?” A few hands tepidly go up. Then he asks, “OK, how about once a year?”

People always ask me how long it takes to do my hair. I don’t know. I’m never there.

Recording on an Australian tax help line No Bedside Manner

The man yells, “Today’s the day!”

I’d never had surgery, and I was nervous.

“This is a very simple, non-invasive procedure,” the anaesthetist reassured me.

I felt better, until … “Truly,” he continued, “you have a better chance of dying from the anesthesia than the surgery itself.”

Colonoscopy Small Talk

If you understand English, press 1. If you do not understand English, press 2.

Hear about the new restaurant called Karma?

Dad: Dad is dead. You’re next. Love, Moth

One man in the back jumps up and down, jubilantly waving his hands. The therapist is shocked—this disproves his theory. “If you make love only once a year,” he asks, “why are you so happy?”

Repeat That, Mate?

“Any sign of the trapped miners, chief?”

Colonoscopies are important medical procedures that have saved lives. And yet they’re as popular as, a colonoscopy. Here are comments purportedly made by patients to physicians during their procedures.

- Dolly Parton

It is even harder for the aver age ape to believe that he has descended from man.

- H. L. Mencken

Wine winner

40 | MARCH 2018

The winner of the Zonte’s Footsteps popped a screw-cap on Valentines’ Day and no prizes for guessing the name on the label. Last year on a trip to Singapore Dr Mark Somerville and his wife, Jo, stumbled on a merchant selling a gorgeous Spanish Rioja at a reasonable price. “Jo went a few times and then sent me because she didn’t want to look like an alcoholic. He handed me a couple and said, ‘these are the last two. Your wife bought all the rest.’ Busted!”

MEDICAL FORUM

WINE review

Brash is Beautiful For over 50 years now, the Margaret River region has been slowly expanding with no seeming end to the amount of land available for quality wine. Every year a new vineyard or winery appears that captures the attention of the wine show system; gaining respectability in the ever-competitive wine market that now reaches beyond the borders of Western Australia to the rest of the world. One such newcomer is Brash vineyard. Established in 2000,

By Dr Louis Papaelias it sold wine originally under the Woodside label. The main focus was grape growing with most of the crop being sold to other wineries. About 10% of the crop is currently used to make wines under the Brash label which equates to 250 cases, of each of the four wines offered, for sale. That’s a small quantity indeed.

The vines are planted in the Yallingup sub-region, which extends from Abbey’s Farm Road northwards to Dunsborough. According to Dr John Gladstones, a unique feature of this sub-region is that northerly and north easterly winds in summer must come across from Geographe Bay, which result in cooler days and warmer nights with higher relative humidities than in the more land-dominated areas.

All of these factors are favourable for the quality wine production

Winemaker Bruce Dukes

1

2

3

1. Brash 2017 Sauvignon Blanc

Wines produced under the Brash label are Sauvignon Blanc, Chardonnay, Shiraz and Cabernet Sauvignon. The wines are expertly made by Bruce Dukes at Naturaliste Vintners. All are of silver or gold medal quality and represent the essence of Margaret River wine.

Fresh captivating aromas of fresh grass, citrus with fruity and floral overtones. Appealing in the mouth with lots of zing and minerality. Lovely to drink on its own but equally suitable to accompany seafood and spicy foods.

www.brashvineyard.com.au

2. Brash 2016 Chardonnay Lovely peach and grapefruit mingled with a sprinkle of fine oak barrel. This shows good balance, neither oaky nor overly fruity. Crisp and clean, medium-bodied with a long soft finish No rough edges here.

3. Brash 2015 Shiraz Spice and black fruit aromas prominent on the bouquet.

Supple fruit with a subtle background of oak make for a very approachable full-flavoured wine. Can easily be enjoyed now but will also keep for five plus years. This is definitely in the first division of Margaret River Shiraz

Brash 2015 Cabernet Sauvignon Last but best of all in the tasting, this wine shows why Margaret River is a world class wine region. Cassis and plum give way to a hint of violets on the nose.

Lovely balance of fine tannin and classy fruit. Whistle-clean with long satisfying finish. Attractive as it is now and it should be marvellous at 10 years of age.

MEDICAL FORUM

WIN!

A Doctor’s Dozen

ENTER ONLINE! www.medicalhub.com.au

MARCH 2018 | 41

MUSIC

Match Made in Heaven

Principal Conductor Asher Fisch In 2018, The West Australian Symphony Orchestra celebrates its 90th anniversary and it has much to shout about. From its humble beginnings in 1928 as a collection of unemployed musicians with the advent of the ‘talkies’, it has become one of the most respected and successful orchestras in the country.

Medical Forum caught up with principal piccolo Michael Waye, who as a veteran of 30 years is the joint longest-serving current musician in the orchestra and WASO’s CEO Craig Whitehead to talk about where they’ve been and where the year’s celebrations will take them.

Michael is a Sydney native who after graduating from the Sydney Conservatorium headed west in 1987 to take up his first symphonic job and he’s been here ever since.

“I never wanted to be a soloist, which is a bit weird. I wanted to play in an orchestra and be a part of team. There’s nothing like the mass sound of an orchestra,” he said. “Being principal piccolo you are quite prominent in the texture of the orchestra, so the nerves have been a bit frayed on occasion but it’s been a good time.”

Michael arrived in Perth when WASO was still a part of the ABC and a big chunk of the orchestra’s time was not in the concert hall but in the ABC studios in Adelaide Tce playing straight to air.

Radio days “It was a really nice time because we were still a part of the larger picture of the ABC, sharing the canteen with all the radio and TV people. I think I am still carrying the weight from those days. There was a pastry chef there who made these really delicious cream tarts and I couldn’t resist them. I had to have one at every break.”

Michael Waye

42 | MARCH 2018

“But we worked hard. We’d have a quick rehearsal, the green light would go on and, boom, we were broadcasting live or recorded for future airing. If we finished our allotted list early, the orchestra manager would scurry to the library to get another piece to record. No rehearsal, straight to tape. It could never happen now with all the industrial agreements in place.”

The transition from ABC to independent entity in the 1990s was a volatile and financially precarious time for the orchestra. Cast adrift, it had to establish its own funders and its own artistic direction. The steady hand of the then CEO Catherine Ferrari was credited as keeping the orchestra viable and establishing a businesslike administration, while her successor businessman Keith Venning knew how to chase down the dollars.

For Michael, longtime WASO chair Janet Holmes a Court has been a lynch pin.

“The evolution of WASO to the orchestra it is now has taken many musical directors and conductors and external influences.

Janet Holmes a Court has been a great stalwart of the orchestra. We say some people collect football teams, well she collects orchestras. She has stuck with us all the way through as chair and has been largely responsible for who is appointed CEO, head of artistic planning and chief conductors – all the pivotal people who have shaped the orchestra.”

Settling the ship With stability, comes development and that brings its own success and rewards.

“It’s nice to see the evolution from essentially a regional orchestra to one of the best in the country. The players and the style of players and style of conductors have changed enormously and the pulling power of the orchestra to get world-class soloists has gone up enormously,” Michael said.

MEDICAL FORUM

MUSIC That, he said, had so much to do with the current principal conductor, world renowned Asher Fisch, who landed in Perth three years ago and has had the city and its orchestra at his feet.

“Asher is a megastar on an international conducting stage, yet if we’re not playing as well as we should he’s humble to say it has something to do with him. That’s a huge difference from the autocratic conductors of the past. Now we have this collaborative relationship. It’s such a lovely thing.”

“I want to make Asher smile. That’s my mission.”

Under Fisch, WASO has embarked on ambitious annual concert packages which began with the Beethoven cycle in 2015 and continues this year with the highly anticipated Tristan & Isolde concert staging.

When he was as he described “tapped on the shoulder” by chair Janet Holmes a Court to take on the CEO’s role, the GFC had just hit. The interceding years have been notoriously bumpy financially but he and his chair and mentor have drawn strong corporate support to the company.

Michael said the reputation of his principal conductor has brought the likes of Laurence Jackson to the concert master’s role.

A star drops in The personal breathtaking moment for Michael Waye was back in November 2007 when Vladimir Ashkenazy stopped off for an all-Russian concert on his way to take up the baton for the Sydney Symphony.

“We were playing the fourth symphony of Tchaikovsky with this powerhouse of a conductor. It is terrifying for a piccolo. I had to sit there for 45 minutes then pull out a massive solo. When we were done, this megastar of the universe came up to me and said he loved what I was doing. That gave me so much confidence.”

“I’m looking forward to doing Tristan and Isolde in August with Asher for the same reason. It’s really wonderful music and directed by a spectacular conductor and a dream Wagnerian cast.”

MEDICAL FORUM

“That’s an enormous undertaking by the company but it’s an important investment because we strive to be as relevant to the community we serve as we can be.”

Craig has helped steer the orchestra into a financial position the envy of orchestras around the country. But it’s taken a lot of effort and a lot of commitment.

“I’m not retiring while Asher is around.

I want to be there until his tenure finishes in 2023 and a lot of my colleagues feel the same way.”

“Laurence should be a soloist, he is so spectacular. But he loves playing in an orchestra and playing alongside him every concert lifts the standards of everyone.”

“WASO is most engaged orchestra in the country. Last year we presented 435 individual community activities to 50,000 people across WA and that’s not taking into account the performances on stage.”

Craig Whitehead For the WASO CEO Craig Whitehead, who has been in the chair for nine years, it is the ultimate statement in just how successful the orchestra has become artistically and as a cultural institution.

“From an artistic point of view we are at a high point in the history of the orchestra.

This is the view of our orchestra members, our board and importantly our audiences.

We have the right principal conductor, at the right time, who has brought out the excellence of our musicians,” he said.

Engaging and relevant Craig is also enormously proud of WASO’s education and community engagement programs which sees the orchestra when not in concert visiting hospitals and schools, bringing the power of music to the ears of the young, the old, the vulnerable and the disadvantaged.

“We have had a strong financial outcome in difficult economic times. Perth is currently operating in the worst economic conditions of the past 27 years and we are performing strongly. But our financials and the artistic and community programs are all interconnected. We’re succeeding because we have become more relevant and have an important role in the wider community.”

For Craig, telling WASO’s extraordinary story to the world is exciting and hugely satisfying.

He has one of the world’s best conductors inspiring his 83 orchestral members to artistic heights and a city loving what they do.

“It certainly makes life easier for me.”

By Jan Hallam

MARCH 2018 | 43

Competitions

Entering Medical Forum's competitions is easy!

Simply visit www.medicalhub.com.au and click on the ‘Competitions’ link to enter.

Movie: The Guernsey Literary and Potato Peel Pie Society In 1946, writer Juliet discovers a mysterious literary club which started in Nazi-occupied Guernsey during the war so she visits the island to discover just what the islanders had to endure in those dark days.

In cinemas, April 19

Music: WASO Three Concert Package To celebrate WASO’s 90th anniversary, the orchestra and Medical Forum are giving readers the chance to win a three-concert package for this special season.

The first of the three concerts is Ingrid Fliter Plays Mendelssohn on April 6. Fliter is an Argentinian pianist with dazzling fingers necessary to dance as Mendelssohn demands! The symphony is the powerful Tchaikovsky No. 4. Then Spanish cellist Pablo Ferrandez pulls out the stops in the exquisite Dvorak concerto July 13. Finally the Frenchmen have it in spades with pianist Jean Yves Thibaudet joining conductor Ludovic Morlot and cellist Gautier Capucon for a program of Debussy, Dubugnon and Rachmaninov (Symphonic Dances) on October 12.

A special year, and some very special music-making ahead.

2018 Alliance Française French Film Festival The 29th annual celebration of French cinema kicks off in March and runs into April with a selection of 46 features, two documentaries and a cheeky Parisian TV series showcasing the diversity of contemporary French cinema.

Various cinemas, March 14-April 4

Movie: The Death of Stalin

M E DIC AL FO RU M $12 .50

Armando Vannucci (Veep, In the Loop) sets his satirical sights on Russian politics and focuses on the moment Joseph Stalin dies and the vultures circle. Talents of Jeffrey Tambor, Steve Buscemi and Simon Russell Beale are on display. But who’s running the government?

In cinemas, March 29

Movie – Breathe: Dr Diana Fakes, Dr Maria O’Shea, Dr Andrew Toffoli, Dr Suzette Finch, Dr Rimi Roper, Dr Astrid Valentine, Dr John Van Bockxmeer, Dr Sarah Chisholm, Dr Jeff La Valette, Dr Fiona Sluchniak

Movie: Peter Rabbit DECEM BE R 2017

Winners from December December 2017 Major Sponsor

Movie – Call Me By My Name: Dr Bibiana Tie, Dr Sally Price, Dr Kylie Seow, Dr Glenda Khoo, Dr Michael Leung, Dr William Thong, Dr Andrew Christophers, Dr Rob Hendry Movie – Jumanji: Welcome to the Jungle: Dr Mik Parola, Mr Ray Barnes, Dr Stephanie Bracknell, Dr David Storer, Dr Eric Khong, Dr Lynette Spooner, Dr Melanie Chen, Dr Simon Machlin

www.mforum.com.au

Take a Beatrix Potter legend, turn him into a screen idol with attitude and you have an irreverent, hilarious contemporary take on Peter Rabbit complete with the ongoing feud with long-suffering farmer Mr McGregor. Voice talents of James Corden and Margot Robbie among others.

In cinemas, March 22

Movie – Paddington 2: Dr Lindsay Livingstone, Dr Max Kamien

Comedy: Afternoons Tonight!

Movie – The Post: Dr John Thompson, Dr Ian Walpole, Dr Sarah Kurian, Dr Colin Stewart, Dr Yohana Kurniawan, Dr Suzanne McEvoy, Dr Lee Jackson, Dr Kym Connor, Dr Mandy Croft, Dr Simon Turner

ABC broadcaster and all-round funny guy James Valentine is one of the headline acts at this year’s Perth Comedy Festival, which is growing exponentially as the city’s premier comedy event.

For a full list of acts see perthcomedyfestival.com

Musical Theatre – The Rocky Horror Show: Dr Nuala Kelly, Dr Kevin Kwan

44 | MARCH 2018

State Theatre Centre, April 29, 5pm

MEDICAL FORUM

Stop heavy periods.

Period.

Did you know 1-in-5 women suffers from heavy menstrual bleeding?1 The NovaSure® endometrial ablation procedure is a minimally-invasive treatment option to discuss with these patients – especially those who prefer to avoid hormones or a hysterectomy.

Premenopausal women who have completed their childbearing may be candidates.2 5 minute procedure*

No hormones

Effective in 9-in-10 patients3

97% avoid hysterectomy at 5 years4

Find a NovaSure specialist

novasuredoctorfinder.com.au

Proven outcomes. Extensive data.

Over 2 million women treated worldwide.

novasure.com

* The NovaSure® procedure is performed by a gynaecologist. The average treatment time is 90 seconds, and the entire procedure typically takes less than 5 minutes to complete. 2 References: 1. National Women’s Health Resource Center (United States). Survey of women who experience heavy menstrual bleeding. Data on file, 2005. Based on women aged 30-50 years.

2. NovaSure® Instructions for Use. Bedford, MA: Hologic, Inc. 3. Cooper J, et al. A randomized multicenter trial of safety and efficacy of the NovaSure system in the treatment of menorrhagia.

J Am Gynecol Laparosc. 2002;9:418-428. 4. Gallinat A. An Impedance-Controlled System for Endometrial Ablation: Five-Year Follow-up of 107 Patients. J Reprod Med. 2007;52(6):467-472.

ADS-01814-AUS-EN REV.001. © 2017 Hologic, Inc. All rights reserved. Hologic, NovaSure and associated logos are trademarks and/or registered trademarks of Hologic, Inc. and/or its subsidiaries in the United States and/or other countries. This information is not intended as a product solicitation or promotion where such activities are prohibited. Because Hologic materials are distributed through websites, eBroadcasts and tradeshows, it is not always possible to control where such materials appear.

Hologic (Australia) Pty Ltd, Level 4, 2-4 Lyon Park Rd, Macquarie Park NSW 2113. Tel. +61 2 9888 8000. ABN 95 079 821 275.