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DR JOSEPH HUNG Clinical Assessment Matters in Heart Failure
DR PATRICK CRAWFORD Paraproteins – Their Significance
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DR ALISON 37 CREAGH Contraception and Weight
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Editorial By Dr Rob McEvoy Medical Editor
Things are happening quickly in general practice, exemplified by the ongoing proliferation and adaptation of online appointment systems. They offer a range of possibilities, many of which we outlined in our March edition. Some practices have welcomed the opportunity to fill limited appointments with online bookings, for small additional cost and hassle. Others are looking to find an integrated system that reflects what their practice is trying to achieve with their patients, but saves them time and money and offers add-ons they can easily use. General practices are reticent to spend. Asking health consumers to pay for an online booking is a barrier to participation. Third parties may want to reach health consumers or specialist services may want to reach GPs – both may be willing to pay for access. The medical ethics around the handling of patients is therefore crucial.
Proliferation of services Last month, our Case Report mentioned that HealthEngine was listing GPs in WA practices registered with them as potential sources of specialist referrals. This issue of easier specialist access is not new. In October 2012, we ran a story about two GPs providing referrals to specialists nationally, from their Perth practice. This was soon after national registration was introduced. Patients anywhere in Australia could send in their details, that of the specialist, their symptoms and current medications, allergies and previous medical/ surgical history, along with the $10 fee, and referral was more or less assured. The website (www.thewalkingp.com.au) no longer requests their usual GP’s details so the specialist’s report can be forwarded to them. Best Practice (BP) has just fully integrated the online referral service MEDrefer into its clinical software. MEDrefer has 8000 medical specialists and 15,000 allied health people listed from publicly available information – the GP can search within BP by specialty and keyword that might relate to sub-specialties, location, availability and things like gender or languages spoken. The GP can despatch a single encoded referral to a suitably linked specialist, or generate a list of up to five specialists for the patient to choose from, by using the GP’s favourites or the MEDrefer central database list. The patient is left to ring and book with a particular specialist. The specialist’s receptionist goes to the medicalforum
How Convenient Specialist Referrals?
ll o P e
DOCTOR POLLS A big contributor to difﬁculties in patient management is difﬁculties in communication between doctors. 64% agree vs. 22% disagree. GPs rely on patient feedback in judging specialists they have referred to. 77% agree vs. 6% disagree [These questions were prompted by discussions at a Doctors Drum breakfast, entitled “GPs and Specialists, Partners in What?”; n=233 GPs, specialists and DITs; Nov 2013]
Referral can come to you from f chance h encounter GPs or from the patient’s primary care GP. By your estimate, what percentage of your referred patients come from a primary care GP? Average 78% (range 40-95%) If the referring GP is not the primary care doctor, this could create an awkward situation for you as a specialist. In these circumstances do you think it is best practice to send a copy of your letter of response to the patient’s primary care GP? Yes 89% No 11% [n=155 specialists; Aug 1996]
corresponding website or uses a desktop tool to enter the referral certificate, which unlocks basic referral information, and then ‘accept’ the referral or not – the GP is notified then, and later if the patient attends. Specialists pay $100 for 24 referral tokens, with the service promoted as building patients for specialists starting up. If specialists are in the GP’s list of favourites but not the MEDrefer database, the GP can send an automated email to nonlisted specialists, inviting them to join.
Arguments for and against There are arguments for and against online promotion of specialist referrals. How you feel about this depends a lot on whether you think a particular system has a strong potential to interrupt continuity of care, a type of care both the RACGP and AMA have supported as good practice. Arguments for online promotion of consumer-driven referrals include: health consumers should not have to wait inconvenient periods for a referral; many medical matters are suited to referrals like this; when people are unhappy with the performance of the usual GP, or he/she refuses referral, easy access to alternative referral sources are appropriate; health consumers will return to their usual GP for any matter requiring detailed referral; consumers should be free to shop around for the cheapest referral offered; and the HIC determines the minimum standards for referral through its Medicare rebate.
at hand, in most circumstances that doctor should be consulted; rudimentary referrals that adhere to HIC requirements can still miss important history or test results, leading to unnecessary duplication or delays for the patient; doctors who deal with complex or chronic care patients deserve the added income from referrals; clinical software makes in-house referral easier and more detailed; doctors who refer to specialists rely on patient feedback to judge the specialist’s performance, so doctor shopping could counteract that; referrals dictated too much by health consumers will result in inappropriate and costly referrals to specialists; and patients embarrassed by a referral of convenience may ask the specialist to not cc their usual GP with any correspondence. O
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Arguments against consumer-driven referrals include: some waits are reasonable in the circumstances; many medical matters are not suited to referrals of this nature; if someone has a ‘usual GP’ for the problem 3
Scramble for the spoils Dear Editor, Dr McEvoyâ€™s editorial [March edition] speaks to my perspective on the chasm between the militant representation of doctorsâ€™ collective best (economic) interests and the wiser heads that know we are all in this human pond together. The health funding pie is not just contested in the community between disease groups and across the age spectrum. Health funding is hotly contested between doctors and between the strata of practitioners with differential power to access the funds that are there to be claimed. This is a more interesting truth that rarely, if ever, gets explored in the public domain. There seems to be a doctorsâ€™ vow of silence regarding competition in their own market place for the limited state and insurance funding pool, plus the personal funds consumers are prepared to spend. Challenging this code of silence is something that outsiders like Michael Moodie were put to the stake for when he opened a discussion on a tiny pocket of doctor funding privilege at PMH. It is unlikely to be an isolated case in an honour system of funding based on cultivated elitism and a deep sense of entitlement that exists within medicine. The extraordinary demands of medicine, the practice of medical care, the exquisite human challenges in being a doctor, must be rewarded. Society needs those exceptional skills, but why do we permit those with secret rights and privileges to access our health funds through honour systems and double and triple dipping into private and public purses, regardless of the worth and merit of their service offerings? Why should doctors who perform gratuitous services be rewarded to a greater degree than those who persevere at the coal face of the communityâ€™s health care need, for what sometimes looks like a fairly ordinary salary? Open the discussion wider to competition for research funds and the charity dollar that is directed at health care,
all there to be drawn upon, and the field of the contest widens. The problem for the community is that it is only insiders that can start to ask these questions and shine a light on the uglier revenue generation activities of their own that reflect clever wealth creation but poor use of public health funding. Ms Maxine Drake, Health Consumer Advocate
Value the GP More Dear Editor, I found Sean Stevenâ€™s comments on general practice very interesting [March edition]. There is, however, a disparity in working hours between the older and the younger GP. Older GPs also have families and at a time in their lives when scaling down would be an objective, they are working harder, often for less money as their clients age and expect to be bulk-billed. Their pathologies become more complicated and with all the will in the world, there is a limit to the number of care plans that can be done. Cherry picking the easier bits of general practice has left those remaining in full-time practice with the more vexing and exhausting areas of chronic disease management (CDM) and mental health (MH) as their core practice. GPs cover those areas extremely well, so GPs focusing on them should be well remunerated. What could make things easier for the GP? t *ODSFBTFUIF.FEJDBSF3FCBUFBDSPTT the board. Wouldnâ€™t that be wonderful? t &YUSBQBZNFOUTGPSZFBSTPGFYQFSJFODF t )JHIFSQBZNFOUGPSBIJHIFS$%. and MH practice load. t "MMPXBGUFSIPVSTXPSLUPBUUSBDUBO after-hours payment, including early morning starts. t 3FTLJMMJOH(1TBOESFUVSOJOHSFCBUFTPO joint injections and cryotherapy. t "IJHIFS.FEJDBSFGFFUPBMMTLJODBODFST
removed, instead of the special sites; melanoma on the trunk is valued differently to melanoma on the neck but both have the same propensity to kill. t .PSFNFEJDBMTDIPPMTDIVSOJOHPVUNPSF doctors? Probably not! t .PSFGJHIUBHBJOTUUIFJODVSTJPOTPG pharmacists and nurse practitioners who are trying to lay claim to what remains of general practice. t "VOJUFEGSPOUXIFOEJTDVTTJOHHFOFSBM practice with government â€“ none of whom really recognise the GP as the cornerstone of Primary Care? So why do I still get up in the morning and go to work? Well, I just love the job. Dr Frances Cadden, Coolibah Medical Centre
Dollars not necessarily sense Dear Editor, The latest Medical Forum e-Poll [March edition] highlights some interesting challenges facing health consumers and professionals alike. We like to think that health is different, and in at least one sense it is â€“ the market in which it operates is distorted, on at least two fronts. Firstly, the Medicare system subsidises the community service component. Ironically, this â€˜public goodâ€™ component is developed, evaluated and managed with little input by the community. Secondly, the various professional colleges control the capacity of the â€˜marketâ€™ to meet demand, potentially compromising effectiveness. The strong survey support for consumers to receive a price signal to manage demand is quite surprising. Many consumers would argue that there is also a need for a â€˜quality signalâ€™ for providers. Anyone who has had to wait half an hour to see a GP, or weeks to see a specialist, even with health cover, More letters P6
Addendum â€“ Online Booking Systems Last monthâ€™s article about online booking systems prompted one of the online providers to point out to us that the issue of vendor risk ought not to be overlooked. Dr Marcus Tan, Chief Executive Officer of HealthEngine.com. au, believes that the choice of a vendor that is trustworthy with patients â€“ many of whom he believes are poorly informed about navigating the health system â€“ is paramount. â€œSome providers have little understanding of the clinical environment they are catering to and are unable to offer the level of support most practices require and expect.â€? â€œHealthEngine was created by well-regarded doctorsâ€? and had become a â€œtrustworthy platform,â€? he said. 4
Last monthâ€™s article also raised the issue of privacy, drawing attention to the optâ€“in check box on the HealthEngine booking form and the apparent inconsistency between the opt-in check box and the booking terms and conditions. Dr Tan said that HealthEngine used its check box as an additional measure to confirm that â€œpromotionalâ€? material was being sent to only those who had opted in on the check box. He said that both convenience and cost were important to the health consumer, and â€œprogress and innovation requires us to do user acceptance testing of both patients and practitioners [and to] learn and adjust as requiredâ€?. O medicalforum
Clinical Assessment Matters in Heart Failure
Professor Joseph Hung Cardiologist
About the author Heart failure (HF) is a chronic, debilitating, and progressive disease associated with substantial mortality and morbidity. Despite sophisticated imaging techniques and chemical biomarkers that can provide the contemporary clinician with an abundance of diagnostic and prognostic information, a careful and thorough clinical assessment remains crucial.
Symptoms and signs of HF The hallmark symptoms and signs of HF reflect congestion, the manifestation of elevated intracardiac filling pressures. Orthopnoea is the most reliable symptom for elevated left-sided filling pressure, which should be considered due to cardiac congestion unless otherwise explained.
Given significant heterogeneity between patients regarding their perception of symptoms, elucidation of â€œbendopneaâ€? may increase detection of patients with HF and elevated filling pressures.
Functional assessment Despite some subjectivity, the New York Heart Association (NYHA) functional classification remains a very useful tool to assess treatment response and long-term outcome. This system relates symptoms to everyday activities and the patientâ€™s quality of life.
Conclusion In HF, a careful assessment for symptoms and signs remains highly relevant in providing important diagnostic, prognostic and therapeutic information above and beyond imaging and biomarker characterisation.
Haemodynamic monitoring has shown that intracardiac filling pressures are usually rising more than two weeks before symptoms precipitate hospitalisation; thus clinical detection of congestion provides an opportunity for early prevention. In patients with chronic HF, the persistence of congestive signs on physical examination (i.e. peripheral oedema, jugular venous distension, and pulmonary rales) is a powerful predictor of increased heart failure-related deaths and hospitalisation. Patients with continued signs of congestion and hypoperfusion (the â€œwetâ€? and â€œcoldâ€? profile) have a greatly increased risk of death or rehospitalisation compared to those with a â€œdryâ€? and â€œwarmâ€? profile.
Joseph Hung holds current appointments as Winthrop Professor of Cardiology, UWA, and Consultant Cardiologist at Sir Charles Gairdner Hospital. He did his advanced training in Cardiology at the Royal Prince Alfred Hospital, NSW, and then fellowships abroad at Stanford University Medical Centre (USA) and Montreal Heart Institute (Canada). He combines clinical and research interests in novel risk factors and in the prevention, diagnosis, investigation, and treatment of ischaemic heart disease, arrhythmias, valvular heart disease, and heart failure. He consults privately at Wembley and Joondalup.
Class I (Mild)
No limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, or shortness of breath.
Class II (Mild)
Slight limitation of physical activity. Comfortable at rest, but ordinary physical activity results in fatigue, palpitation, or shortness of breath.
Class III (Moderate)
Marked limitation of physical activity. Comfortable at rest, but less than ordinary activity causes fatigue, palpitation, or shortness of breath.
Class IV (Severe)
Symptoms of cardiac insufficiency at rest. Unable to carry out any physical activity without increased discomfort.
Bendopnea â€“ a new symptom? A new HF symptom was recently described: â€œbendopneaâ€? which is shortness of breath or uncomfortable head fullness within 30 seconds of bending forward while sitting, such as putting on shoes or stockings. It occurs in a substantial minority (about 30%) of HF patients and appears to be mediated by a further increase in filling pressures during bending when filling pressures are already high, particularly if cardiac output is reduced.
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Letters Continued from P4 would like to have the ability to ‘backcharge’ for poor service that you would not tolerate in a local café. Price is a crude and poor signal of demand and supply in health, as the existing gap complaints clearly demonstrate. What is needed is a clearer understanding of the responsibilities of consumers and providers to reduce unnecessary servicing, including where consumer behaviour has been a contributing factor. The Health Consumers’ Council would rather see incentives for quality of service, rather than increasing private health fees to the point where only the chronically ill stay members. Direct financial arrangements between funds and doctors can lead to further market distortions, consumer disadvantage and variable service outcomes. Mr Frank Prokop, Executive Director, Health Consumers Council WA
What’s there, not missing Dear Editor, Most people’s response to Dr Katharine Mallory’s story [February edition] would be “amazing”, “inspiring”, “remarkable” etc. My reaction, as a lawyer who is blind, and as Australia’s Disability Discrimination Commissioner is “what a great story about Katharine doing life.” Someone once asked me if I was scared travelling the world on my own. “Sure I am,” I replied. “Then why do you do it,” he said. My response: “Because the alternative – not doing it – is much scarier.”
One in five Australians has a disability. So if we want a community which includes everyone then it needs to be an accessible community. I congratulate Medical Forum WA for running this story, and Katharine for “doing life.” Mr Graeme Innes, Disability Discrimination Commissioner
Prescribing for elderly Dear Editor, Dr Potter’s article on the complex matter of medications and older people raises some very interesting points [March edition]. This is a minefield for clinical safety, patient wellbeing, and elderly people’s chance for continued independence. The elderly person living at home is likely to be taking several medications, and is unlikely to be taking them correctly. There are many reasons for this, from not hearing or understanding the doctor’s instructions, finding the bottles or packs too difficult to unscrew or tear open, confusing medications in the kitchen drawer, to forgetting, or simply finding it too much bother. Add a touch of nausea, or dizziness, and compliance vanishes. An occasional home visit by the GP is a very useful diagnostic technique – look in the kitchen drawer! Dr Potter makes the point that when a person enters residential care, compliance is restored. The safety and structured daily routines of residential care can restore confidence and improve function and
Whatever issues we face in life – marital or family problems, a lack of confidence in public speaking, disability etc – we still have a life to lead. You play the hand of cards you have been dealt, the best way you can. So I’m pleased, but not surprised by Katharine’s story. Because for me it’s not about what’s missing – it’s about what’s there. The biggest barrier that people with disabilities face in Australia is the attitude barrier – the way people limit us by assuming that there are things we cannot do. Of course I cannot drive a car, and Katharine can’t reach medical supplies down from a high shelf. But it doesn’t prevent me being a lawyer, nor her being a doctor. Medical practices should be accessible for patients, as should all other facilities in our communities. That’s why the Australian Human Rights Commission worked with the RACGP some years ago to have adjustable height couches mandatory in general practices. Not only do they achieve better outcomes for patients with mobility disabilities, they also mean that doctors and nurses protect their backs, so it’s a win-win. 6
wellbeing, once the emotional trauma and grief over the move from home have settled. The second factor in this interplay is the prescribing doctor, and I agree with all of Dr Potter’s comments. Rewriting scripts for the same list of medications, deserves more thought, review, and clinical acumen than is often given. Elderly people’s physiology places them in a highly vulnerable state to the effects of a single drug, let alone multiple drugs, with the almost inevitable side effects and interactions. We should take as much care with prescribing for the elderly as we would with an infant. Dr Penny Flett, CEO, Brightwater Care Group
Slow response to consumers Dear Editor, We write in response to Mitch Messer’s column [March edition]. We are a group of committed consumers and carers involved with health policy-making groups through Health Networks and through Community Advisory Councils, which advise hospitals and health services on local health needs, issues and developments from the perspectives of consumers and carers. Many of us have chronic conditions that require frequent interactions with a wide range of health professionals, hospitals and health services. We both agree and disagree with Mitch Messer’s point of view. When it comes to More letters P8
Joke A husband reads an article to his wife about how many words women use a day – 30,000 to a man’s 15,000. The wife replied, “The reason has to be because we have to repeat everything to men.” The husband turned to his wife and asked, “What?”
By the Book A man and his wife were having an argument about who should brew the coffee each morning. The wife said, “You should do it, because you get up first, and then we don’t have to
wait as long to get our coffee.” The husband said, “You’re are in charge of the kitchen, you should do it, I am happy to wait.” Wife replies, “No, you should do it, and besides, it is in the Bible that the man should do the coffee.” Husband replies, “I can’t believe that, show me.” So she fetched the Bible, and opened the New Testament and showed him at the top of several pages, that it indeed says...”HEBREWS”
By Dr Patrick Crawford Haematologist Clinipath Pathology & Mount Medical Centre
Paraproteins â€“ Their Significance A paraprotein is a monoclonal immunoglobulin secreted by an expanded single-cell clone of plasma cells or lymphoid cells and is usually an intact immunoglobulin but sometimes only light or heavy chains are produced. Any immunoglobulin produced by such a clone will be composed of only one class of heavy chain and/or one light chain type. The chemical uniformity is responsible for the migration as a discrete band on electrophoresis, which is generally how a paraprotein is detected and quantified.
Paraprotein disease states The major disease associations of paraprotein are myeloma and lymphoid malignancy such as chronic lymphocytic leukaemia and nonHodgkin lymphoma. A much rarer group of disorders is where small clones are thought to play a major role and these include AL amyloid, some cryoglobulinaemia, cold haemagglutin disease and neuropathy. However, the majority of patients have monoclonal gammopathy of unclear significance, or MGUS. Paraprotein is common (>95% of cases) in myeloma with about one fifth producing light chains only. Both serum and urine should be looked at for a paraprotein if myeloma is suspected. Only a very few cases are non-secretory. The lymphoid malignancies referred to above produce a paraprotein but less frequently, and usually at a lower concentration. Paraproteins are also seen rarely in non-malignant conditions such as autoimmune disease, certain skin disorders and hepatitis C.
Clinical significance In clinical practice the starting point often is the suspicion of a paraprotein and this is being recognised more frequently. A high globulin level, unexplained elevated ESR, increased immunoglobulin levels, hypogammaglobulinaemia, as well as a suspicion of myeloma or lymphoma are reasons to follow up with a serum and urine protein electrophoresis. In population screening the frequency of a paraprotein depends on the demographics. A Swedish survey found a paraprotein in almost 1% of a population over 25 years
while a large American survey found a paraprotein in 3.2% of a population over 50 years. The chance finding of a paraprotein is determined largely by age and thus most of those requiring investigation for this are older. One challenge is to plan investigation so as to minimise missing an asymptomatic myeloma, while not subjecting a large number of individuals to invasive investigation with a low probability of finding significant pathology (i.e. most older people will have MGUS).
Laboratory testing explained Once a paraprotein has been detected by electrophoresis, quantitation is generally possible, and the paraprotein can be characterised as light and heavy chains through immunofixation. The paraprotein concentration is an important guide to the initial diagnosis and perhaps to the long term outlook. Different studies have used different numbers. One major group takes 30g/l or less in an IgG paraprotein as indicative of probable MGUS, while a higher figure suggests asymptomatic myeloma; other investigators use lower values and make a distinction between paraprotein type - a value of 15g/L for IgG paraproteins is taken as the upper limit for a diagnosis of MGUS while 10g/L is used for IgA and IgM paraproteins.
Clinical course and monitoring The initial assessment should focus on pointers to myeloma such as bone pain, renal insufficiency, hypercalcaemia or anaemia and weight loss, night sweats or fevers; or perhaps lymphadenopathy and splenomegaly in lymphoma. The
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serum protein, serum light chains and urine protein electrophoresis should be completed. If the only abnormality is the finding of an IgG paraprotein at a concentration of <15g/L it is probably not necessary to investigate aggressively. MGUS is the likely diagnosis that should be followed clinically, haematologically and biochemically. More urgent and aggressive investigation such as marrow studies is indicated if there are pointers to myeloma-related organ or tissue damage such as anaemia, osteporosis, renal failure, hypercalcaemia or immunosuppression. The progression or otherwise of a patient with a paraprotein and MGUS is relevant. In some with apparent MGUS the true diagnosis is early myeloma, apparent with a rising paraprotein level or perhaps a change in the paraprotein type, such as the appearance of light chains. The conversion rate from MGUS to myeloma is about 1% per year. The elderly patient with a low concentration paraprotein, particularly IgG type, requires assessment and follow up but no invasive investigations. A young patient with a similar presentation merits more investigation as the patient will be at risk for longer. Stratification of risk has been suggested e.g. a patient with IgG paraprotein concentration <15g/L and normal free light chain ratio has a 5% chance of progression over 20 years, while a non-IgG paraprotein at a higher concentration and an abnormal free light chain ratio has a 58% of progression.
Letters Continued from P6 developing Models of Care for a range of conditions and population groups, there is much evidence of a true partnership approach with health care planners and providers. However we are unconvinced that there are widespread signs that our considerable time and effort has made a big difference in how and where services are delivered, where it counts. Members of many Health Network Advisory Groups have expressed concern about the slow rate of implementation of Models of Care, even within the public health system, let alone the private sector. Community Advisory Councils – closer to the service end of things – report that there are frequently long delays between when even simple issues are raised and when remedial action occurs, for example, ensuring that hospital and other health service records indicate clearly to staff that a carer is involved and should be included in discussions. Effective partnerships between consumers and carers, and health care providers are often hard to find. They often rest on the particular attitudes of a practitioner. Hunting for a “partnership-capable” GP or specialist then becomes the patient’s responsibility, rather than a normal part of medical practice. Health care is arguably a challenging area to bring about change, but we cannot wait. By all means change the paradigm. We look forward to more opportunities to “walk the walk” because we want to be part of making this difference. It will benefit everyone. Ms Jenni Ibrahim, Mr Tim Benson, Terry Cook, Mr Ben Hogan, Ms Petrina Lawrence, Ms Kerry Mace, Mr John Powdrill & Ms Janice Thair, Health Networks Consumers & Carers
Online appointments Dear Editor, Patients want access, continuity and a doctor ‘who listens’ (Online Appointments – Right for You? March edition). Timely access is a perennial problem for our patients and tests the very best organised general practice. Patients by and large drive the agenda: they are the ones with the illness that requires careful clinical appraisal. This is acute disease management – patientgenerated consults. As we all now recognise, chronic disease accounts for 50-75% of a GP’s working day: these patients may have an acute exacerbation or merely require monitoring. These are doctorgenerated consults. Various appointment strategies are described in the medical literature e.g. open access, book on the day, supersaturate, 8
carve out and advanced access systems. Whatever system is in use must be easy for our patients to access. As we all know, telephone lines get clogged, patients get exasperated and our reception staff are in a no-win situation! Is online booking part of the solution? There is a paucity of literature available to support this new key area of primary care, because the technology has moved so quickly. Intuition would suggest this is a positive direction. What about all the associated privacy issues? The RACGP has produced a handbook for the management of health information in general practice, which is a useful resource. The ‘tick boxes’ in the Medical Forum article around practice efficiency, patient handling, and patient convenience are an excellent starting point as well. However, online systems that suggest and support specific referral pathways would not be supported by the RACGP. My practice commenced online booking about nine months ago. The particular model we chose allows patients to book and cancel appointments without reception involvement: we started slowly and gradually involved all the practice GPs. Privacy is ensured. At present we have opted out of online scripts. Critically, in the system we chose, no alternative appointments are offered outside our practice. Some staff training was required. Monitoring the process once installed is vital. Currently about 15% of our appointments are made online, and could easily reach 25%. Our practice philosophy revolves around providing quality continuity of care for our cohort of patients: to date the online booking system has certainly enhanced access and patient feedback is positive. Dr Frank Jones, Principal of Murray Medical Group, Chair RACGP WA Faculty
The crook knee Dear Editor, Research fails to support any worth to arthroscopy in many arthritic knee patients, unless to address the mechanical symptoms mentioned [Arthroscopy of an Arthritic Knee, March edition], which may also present as a source of pain. While activity modification would be recommended in the case of subchondral bone changes as outlined, the arthritic treatments proposed fail to mention the evidence base for exercise rehabilitation as a valuable adjunct treatment in patients with arthritic lower limb joints. A comprehensive exercise program reduces knee pain, whilst
improving the muscular support and biomechanics of an arthritic knee joint, irrespective of the stage of degeneration. While severe pathological cases or those that fail conservative treatments are certainly cases for surgical intervention, referral to a physiotherapist or exercise physiologist should be considered for arthritic knee pain sufferers to improve knee pain and function. Inevitable knee replacement surgery may be delayed, or the patient better prepared physically and mentally for surgery and post-operative recovery/outcome improved. Dr Jay Ebert PhD, Assist Prof School of Sport Science, Exercise and Health, UWA
eRx on the move Dear Editor, I noticed a report on eRx Express [March edition] and was hoping to provide more information and correct one point. Firstly, thank you for the review and feedback. We will look into why the reviewer was directed to a NSW pharmacy – that shouldn’t have happened. eRx Express is a new service and so far there are 19 pharmacies in WA using it. We expect the WA number to grow steadily. eRx Express is a smartphone app that provides patients with secure access to the national network eRx Script Exchange. eRx has been running for five years and connects 20,000 doctors and 4300 pharmacies. eRx Express is owned and run by eRx Script Exchange, not the Malouf Group (they are users of eRx and eRx Express). As to the question of why the paper is still needed: paperless scripts are a future many of us are actively working on. For now, though, the paper copy is the only legal document permitted to authorise supply of PBS medicines in a community pharmacy. Legislative changes are required before a digitally signed electronic record can fulfil that role. Mr Roger Boot, eRx Express
Send in your letters, 300 words or less please, by April 10 to ed firstname.lastname@example.org You can lea leave a message on our website at www.medicalhub.com.au
The GP-Physio Marriage Are you conﬁdent treating musculoskeletal patients? Dr Andrew Thompson, both physiotherapist and GP, has some helfpful tips. It seems physiotherapists are the health professionals that GPs most commonly refer to. Yet GPs cite ‘location’, ‘convenience’ or ‘habit’ as reasons they refer to a physiotherapist. Is this really the best rationale for referring your patients... to anyone. Musculoskeletal conditions are the third most common reason for patient presentation, so how can we understand and improve on this? GP training does not teach us about what physiotherapists do to treat patients, their wealth of manual-therapy and exercisebased treatments, or the pervasive use of ‘nonsense’ treatments like ultrasound, laser or acupuncture. How can GPs work more effectively with physiotherapists? Let’s start with the basics…
Simple rules for choosing a physiotherapist No machines. If your physiotherapist uses ultrasound, TENS, interferential, acupuncture (not ‘dry-needling’ – this has some merit), laser, homeopathy, Reiki etc. then find another physiotherapist. These treatments have no purpose. They are the refuge of the desperate and the lazy. Find another physiotherapist. Read their letters. A physiotherapist graduates with an impressive knowledge in anatomy and orthopaedics, and a formidable appreciation of evidence-based medicine. If you read correspondence from a physiotherapist and it appears their grasp of the problem is no better than yours … find another physiotherapist. Talk to your local physios. Ask them about their professional interests, strengths and weaknesses. A good ‘knee physiotherapist’ is not necessarily the right person to treat your patient’s neck. Be wary of over-servicing. There are many “12-week physios” who treat workers’ compensation or MVA patients frequently for the first 12 weeks (with minimal correspondence) and then commence them on an exercise program at considerable expense to the insurer. Others exhaust all five annual EPC consultations before referring back to you. A good physiotherapist will know when manual or exercise-based treatments are not suitable and will refer back to you for alternative management. Time is of the essence. In 20 years I have never met a physiotherapist who can effectively assess and treat a patient in less 10
than 30 minutes – and that’s pushing it. If your patients are not receiving this level of ‘hands-on’ time with their physiotherapist, you know what to do. Be proactive. Regularly invite local physiotherapists to present to GPs at your clinic. Get their perspective on the management of a particular pathology. Ask them to show you how they assess patients and explain their treatments. Learn how to apply strapping tape – this alone will vastly improve your treatment outcomes. Ask to sit-in on physiotherapy consultations – manual therapy is fascinating, complex and beautiful to watch; no less awe-inspiring than a gifted surgeon.
Golden rules of musculoskeletal medicine Musculoskeletal medicine is detested by most GPs. Embrace it. Learn your trade. There is no excuse for not knowing how to assess and treat orthopaedic patients. Sure, it may be taught badly in every medical school on this planet but look at the reality – it is relatively formulaic, your diagnosis can often be confirmed by imaging, treatment options are numerous and fascinating (no more ‘rubber-stamping’ prescriptions from behind a desk) and your patient is relieved of pain. Start with the basics. If you understand six common pathologies that afflict each region of the body you can effectively manage 95% of your musculoskeletal patients. There are so many treatment options, you can never get bored. It’s just not possible. Using excuses like ‘my anatomy isn’t very good’ or ‘I don’t know how to inject’ is inexcusable. Too many GPs function as if their sole purpose is to prescribe analgesics or refer to other health professionals. Stop that immediately! Work with your physiotherapist. That means picking up the phone. Physiotherapists can be woeful communicators. Coordinate your treatments with theirs. A good physiotherapist will know when to recommend an injection, how best to follow up the treatment with manual or exercises-based therapy and when you are flogging a dead horse and surgery is
imminent. A good physiotherapist will make you shine. Learn the basics of injections. Trigger point injections (local anaesthetic) are fundamental. Ask your physiotherapist how to stretch the muscles you inject. Local anaesthetic injections can help dissect complex musculoskeletal presentations and determine what tissue structures are contributing to a patient’s presentation. Steroid injections. Learn how to strap after you have injected. This will improve your outcomes dramatically. Prolotherapy. If you don’t have the facilities to provide PRP (Platelet Rich Plasma) then use ABI (Autologous Blood Injections) – these require considerable knowledge in pathology and anatomy in order to time your injections and place them accurately. If you are not comfortable with injecting, then learn prolotherapy dry-needling (which is different from ‘trigger point dry needling’). Your physiotherapist can teach you both. Prescribe purposefully. Not all NSAID’s are created equal. Oral corticosteroids have their place. “Rest” can be a masterful prescription. Hit pain early and hit it hard – chronic pain is much harder to manage. Palpate…often and accurately. The skill of palpating and knowing the anatomy of what you are touching will add enormous scope to the accuracy of your diagnosis and treatment. And finally…if you get bored with musculoskeletal medicine, call me. O ED. The author is at Kingsley Medical, Tel 9408 1144 medicalforum
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Single Woman’s Survival Guide By Ms Wendy Wardell
Is bartering our gender skills the way of relationships in the future? If so, will a hot meal pay for pool maintenance?
ver since reading Douglas Adam’s So Long and Thanks for All the Fish, I’ve been acutely aware that the skills I possess would be of no use to mankind in either establishing an outpost on another planet or surviving on a post-apocalyptic Earth. When giant cockroaches are stalking the streets or you’re trying to figure out how to make your lungs run on methane, the person you need around isn’t someone who can create a good marketing pitch or put a well-turned phrase in a wedding ceremony.
Many women for instance need training in basic DIY. Money is often tight and with a new found spirit of independence, we set about jobs with way more enthusiasm than aptitude. These may even involve power tools. An early attempt to put up a curtain rail left my wall looking like it had been attacked by a myopic woodpecker tripping on LSD. I have also emerged victorious from a pile of flat-pack boxes with a clumsily constructed chest of drawers and flesh wounds.
I can’t build a generator out of old bean tins or sew even a rudimentary spacesuit. My practical survival skills are limited to cooking things that come vacuum-packed from Coles, making me roughly as useful to the future of humanity as mime artists.
In the absence of an alien invasion, the time that we become most keenly aware of our lack of skills is when we cease to be part of a couple.
This, I suspect is a major reason why people like to hang out in couples. Nature makes us attracted to people with complementary skill sets, so that when the bug-eyed monsters are bearing down on you, at least one person will be able to fashion a laser gun from their spectacle case and ensure the survival of the species. For me, unless there’s an app for that, I’m dead meat.
The Government is putting in money to persuade people to have pre-marriage relationship counselling, which is a good idea, but a tough sell. It seems a bit like inviting the funeral directors to your 50th birthday party just to save time later. Divorce Training Workshops would be more practical and save millions on Emergency Department admissions.
Les Conceicao (MBA MIR BA Grad Dip FP FFin AFP)
Senior Financial Adviser Authorised Representative 296710
08 6462 1999 | www.morgans.com.au/perth Level 20, 140 St Georges Tce Perth WA 6000
As a secondary benefit, Divorce Training Workshops would also provide a great forum for bartering your skills. It would be possible to trade a bathtub spider removal for a meal that didn’t taste like it had been stored for a month in a wrestler’s armpit. In the process, this would also save people from the risks of dating potential new partners just to get their domestic needs met. While they’ve yet to invent the set of shelves that would make dating Kyle Sandilands seem like a good idea, many an otherwise sensible girl’s head has been turned by notions of a re-planked verandah. Divorce Training Workshops will ensure the survival of the species – even for those who are really bad at relationships. It just needs someone to write the marketing pitch. O
GESB Award Winning Financial Adviser Les has over 14 years experience as a licensed ﬁnancial adviser with over 5 years as a Senior Financial Adviser with GESB Financial Advice and is a multiple award winner of the GESB Financial Adviser of the Year. Les has specialised knowledge to create tailored tax-effective strategies to maximise your beneﬁts from: GESB West State Super GESB Gold State Super
Additionally, Morgans offers the Wealth+SMSF Solution service which frees up your time by taking care of the establishment and complete administration of a SMSF. We also offer top class equities and securities research, enabling comprehensive management of your SMSF portfolio. To make an appointment or discuss your needs, please call Les on 08 6462 1960.
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Managing Injury to Stay in the Game For WA’s own tennis star Casey Dellacqua, it hasn’t always been blistering backhand winners down the line. After a dominant performance at this year’s Australian Open followed by a solid trouncing of Russia in the Federation Cup, Casey Dellacqua is on a roll. The girl who grew up in Woodvale and hit her first tennis ball on a suburban court in Kingsley is firmly back in the world’s top 100. “It’s pretty unusual for any elite athlete to perform at the top level all the time. You have to manage the physical side of it quite carefully and try to make sure you’re at peak performance for the most important events of the year, the Grand Slams.” The 2013 US Open wasn’t one of Casey’s finest moments. She was beaten in the first round and needed a complete reappraisal of her game to get back inside the winner’s circle. “I made a fresh start with my new coach, Shannon Nettle. It was important to make sure that my game keeps evolving and he’s helped to bring a new enthusiasm to my competitive tennis.” “We’ve put a lot of work into my singles game and the success I’ve been having in doubles has helped my self-belief. And I built up some confidence playing some of the less prestigious tournaments late last year.” The Women’s Tennis Association (WTA) circuit is relentless with constant travel across time-zones and young up-and-coming players eager to dislodge the old guard. Not that Casey, at the age of 28, could be described
as ‘old’ but there’s no doubt that the game takes a physical toll. “I had shoulder surgery in early 2009 followed by foot surgery in July 2010, so that was a tough couple of years. It’s so important to have a strong medical team with people you can trust. The Federation Cup doctor is Carolyn Broderick and I’ve been getting medical advice from her for most of my career.”
CASEY’S CAREER HIGHLIGHTS t t t t t
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“And, for me, it’s important to focus on injury prevention at this stage of my career.” Casey, a left-handed player, thanks her grandmother’s genes for her career as a tennis player. “My Nan introduced me to tennis, she’s the ‘lefty’ in the family and loves to take credit for my success! We’re a big, sporty family and it was a great way to grow up. We were encouraged to be active and have a healthy lifestyle.” In September 2013, Casey announced she was in a same-sex relationship and that she and her partner, Amanda Judd had a newborn son named Blake. Casey agrees that life experience and maturity, both as a person and a competitor, has given her tennis an added dimension. “Having the baby is a wonderful experience and having a family to focus on tends to put everything in perspective. Although tennis is my job and I love doing it, life isn’t just about tennis anymore.” “It’s too soon to tell what life holds for me after competitive sport. I’d like to give something back to the game and we’d love to have more children as well.” O
By Mr Peter McClelland
Have You Heard? for discharge summary information and the ageing TOPAS patient administration system still used in some hospitals is delaying the schedule. However, hospitals using the Notifications and Clinical Summaries (NaCS) system, through which they can view discharge summaries generated by systems such as Royal Perth Hospital’s TEDS, are understood to be the first to go live.
‘Decriminalising’ patient transport One of the contentious issues for mental health consumers and carers during the public comment stage of the Mental Health Bill, currently before State Parliament, was the issue of involuntary patient transport. The current Act requires a police escort for patients between hospitals – not popular with either patient or the police. Mental Health Minister Helen Morton has announced a two-year pilot transport service that would see specially trained WA Health personnel escort people between hospitals. Quite rightly, she said it would reduce the stigma associated with acute mental illness, while also relieving emergency departments of patients who require specialist mental health care. The trial will begin with 19 specially trained people who have been made ‘Special Constables’ to comply with the current Act.
WA nearer to PCEHR If the state health informatics weren’t in enough of a muddle, Pulse +IT reports that WA is close to connecting with the PCEHR but differing clinical software products used
Don’t overlook volunteers The Health Consumers Council WA has paramedics in its sights. The Executive Director Mr Frank Prokop says the council is liaising with paramedics as they seek to formalise and improve professional career structures. Frank says paramedics undertake an important role in first response care but he also wants to highlight the “important and valued work” of St John Ambulance volunteers at public events. Frank says better professional recognition for paramedics should be done without compromising the satisfaction and contribution of volunteers.
World stage for Virax In biotech news, Perth-based Virax Holdings has entered into a binding agreement to acquire Pathway Oncology, the holder of exclusive worldwide licence of anti-cancer technology developed at Yale University and the Moffitt Cancer Centre in Florida. Business News reports the deal would transform Virax into one of only a few ASX-listed biotech companies with potential for multiple clinical trials in the US. Virax will issue Pathway 60m shares on settlement, plus up to another 180m shares upon achievement of major value-creating milestones.
Research focus on women Premature birth and breastfeeding have been keeping local researchers busy. Work is under way at the Women and Infants Research Foundation (WIRF) where Dr Demleza Ireland (above) is investigating the link between early cases of preterm birth, and infection and inflammation in the uterus. Under the microscope is the reaction in the placenta
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Have You Heard? Rural serviced honoured The annual Rural Health West awards took on an extra shine this year as the organisation celebrated its 25th anniversary. Before the gala dinner last month, 21 doctors were acknowledged for their service to rural and remote WA communities. Ophthalmologist Dr Angus Turner, who was on the cover of the July 2013 edition of Medical Forum, Dr Rosemary Lee, who consults on Cocos Islands; and Dr Andrew Taylor, from Busselton, received Wesfarmers awards. WACHS awards went to Dr Peter Lines for his contribution to Narembeen and Dr Diane Mohen, for her rural obstetric work. Rosemary was unable to attend the ceremony. O
caused by cytokines and studying a new group of drugs that block them. At Curtin University, Dr Christine Pollard and her team have just had their research paper into population perceptions of breastfeeding published. The benefits were happy reading but nearly half the women surveyed cited work as a barrier to breastfeeding with soreness and milk supply were next. More alarming was that nearly a quarter of both men and women thought breastfeeding in public was not acceptable.
Naloxone project widens Curtin University has won a Drug and Alcohol Office contract for $28,500 to provide data collection services for a Naloxone project where researchers will
Q Dr AndrewTaylor Dr Diane Mohen Dr Angus Turner Dr Peter Lines and the Governor Mr Malcolm McCusker
interview participants after they have been dispensed with replacement doses of the opioid antagonist. It’s expected that up to 150 people will join the project over a two-year period. Part of the evaluation will be interviews with key informants such as ambulance officers, medical practitioners, Needle and Syringe Program (NSP) staff, and WASUA staff involved in the training.
False conduct findings Two Perth-based breast imaging providers have felt the hot breath of the Federal Court last month. Breast Check and its former owner [and former GP] Alexandra Boyd’s guilty findings of false and misleading conduct were well publicised. On March 19,
Ms Joanne Firth, who owned Safe Breast Imaging, was also found to have engaged in misleading or deceptive conduct and made false representations about its breast imaging services. Both companies were using a Multifrequency Electrical Impedance Mammograph device. The court also took SBI to task for promotional material which represented that named medical doctors had interpreted and written reports when they had not. In other instances, people named as doctors in the reports were not medical doctors. ACCC chairman Rod Sims said both cases sounded a clear warning to the medical services industry that claims about medical services must be accurate and supported by credible scientific evidence. O
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‘Doctors vs the Pace of Change’
124 GPs (56%), Specialists (36%) and Doctors in Training (7%) responded within the seven days. A small miracle again! Thanks to all those who took part. Many questions were fashioned from discussion at the Doctors Drum, where “The Pace of Change” Ch was centre stage.
Consumer expectations; Information explosion; Technology revolution; Rising costs; Limited resources; Time constraints. It sounds like a recipe for professional burnout and for some it is but for most doctors it’s reality. They also formed the basis of a lively discussion at the first Doctors Drum breakfast of 2014. The panel, comprising fertility expert Dr Jay Natawala, GP and RACGP stalwart
E comments in the ED polls reflect back on the breakfast’s lively discussion.
Given the ‘health information overload’ online, is it a good idea for doctors to offer expert advice on the usefulness of some of this information?
There is no overload
ED. Surveyed doctors and those at the breakfast agreed – patients are in information overload and only a few want us to agree with their Internet expert opinion, while most want guidance on where to get good information.
Will health professionals outside hospitals find time to adopt worthwhile technology if there is no financial incentive?
ED. For whatever reason, ‘money speaks’ in a large section of the profession. Are those doctors greedy, needy or just business minded? See responses to the next question…maybe we missed mentioning investing in better patient outcomes. 16
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Doctors Drum supported pp by:
Dr Mike Civil, occupational medicine specialist Dr Craig White, futurist Ms Elena Douglas; DIT Dr Lee Fairhead and lawyer Karina Hafford, all brought their unique perspectives to the table. We put these issues to the Medical Forum readership through our monthly e-Poll and came up with some interesting points of view.
Innovation and Cost
This requires deep thought! Does a litigious society make medical innovation safer by slowing the pace of change?
ll o P e
Who has the mostt power for bringing about innovative change in medicine [multiple choice]?
ED. The lawyer panellist at the breakfast disagreed with our surveyed doctors. The panellist said wariness fuels better learning and more cautious adoption of innovations, whereas market forces or money can speed things to the health consumers’ detriment.
What’s the most important driving force for innovation in medicine [choose one]?
Making money (market forces)
Better patient outcomes
Both the above
None of the above
Which of the following do you think will encourage medical innovation that has broader community interests in mind [multiple choice]?
ED. Interestingly the Doctors Drum breakfast talked little of money whereas surveyed doctors feel commercial interests, presumably other than doctors, were the biggest drivers of change. Certainly, there seems no shortage of people jostling for top spot in the technology stakes.
If you believe state or federal governments allocate some health funds inappropriately, what are the most important factors, in your view [multiple choice]?
Vested interests interfering with good decisions
Following poor advice
Lack of integration of changes
Greater transparency in costs/pricing
Not enough consideration for the end user
Online consumer forums
Inappropriate influence from doctor groups
Patients having say over a personalised health budget
I don’t believe govts allocate funds inappropriately
ED. Maybe people are tired of cost blowouts and surprises and treating taxpayer funds like they are a gift from a political party or suchlike? There is a sense that soon the honeymoon will be over.
ED. At the Doctors Drum, discussion centred more on the lack of integration of changes so maybe these respondents feel vested interests and political influence are the ‘baddies’ in this story? 17
Finding Your Niche and Living It The spirit of adventure and commitment to the remote communities of the Kimberleyy er to celebrate. and Pilbara GP obstetrician Dr Susan Downes a career Nearly 10 years ago, the then Health Minister Jim McGinty unwittingly set GP Dr Susan Downes on the ride of her professional life. Back then the offand-on again saga to close Woodside Maternity Hospital in East Fremantle finally came to an end when the historic hospital was closed in 2006 leaving the GPs who had been the backbone of the service with a much reduced role at the publicly acquired Kaleeya Hospital. For Susan, the closure of Woodside, where she had made her mark not only as a procedural obstetrician but also as an organiser and mentor, was initially a disappointment but after a couple of deep breaths, it opened up the vast expanses of the Western Australian Outback to her. Now, what was the part-time trip bush to the Kimberley and Cocos and Christmas islands, has become a permanent role which sees the 65-year-old spend 11 days every month doing procedural obstetrics, emergency medicine and medical registrar shifts at Derby Hospital and in remote
Aboriginal communities, where she says there is “incredible need for procedural GP obstetricians”. Derby Hospital’s catchment is vast. “Everything that doesn’t go to Broome or Kununurra, comes to Derby. I do emergency and elective caesarians, minor gynaecology and I also cover the ward. The gynaecologists are based in Broome and come to Derby once a month for a clinic, so we work pretty much alone.”
When Susan’s not in Derby, she’s conducting antenatal clinics at Fitzroy Crossing; or women’s business clinics in Looma, Yakanarra, One Arm Point and Lombardina. It’s here she sees the full gamut of women’s health – pregnancy, post-natal, contraception, menopausal, real cradle to grave medicine. Has she seen changes?
Impact of ultrasound and Implanon “I have really propelled myself into the use of ultrasound and encouraged the RFDS
Photo courtesy Whe atbelt D
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Taking care of Western Australian rural medical practitioners for 25 years Rural Health West offers a diverse range of programs so general practitioners can take care of their communities: Business and Practice Support Service z Locum Placement Service z Access to financial incentives
Contact us to find out how we can help you take care of others. W www.ruralhealthwest.com.au | T 08 6389 4500 | E email@example.com 18
and all small hospitals and even Aboriginal medical services to buy and use ultrasound. It is now pretty well universal. It is making a big difference, especially with early dating of pregnancies and reducing the need for women to travel which is often problematic.” “Our message now is prevention – we put a lot of work into education. Our number of deliveries has decreased because of Implanon. We’re not seeing very young girls having babies because Implanon is doing its job and it has given young women a better chance to mature and allow their bodies and minds to develop before falling pregnant.” “In the Western Desert, where I have been visiting continually for the past 12 years, there have been amazing changes. I haven’t been able to quantify them but, anecdotally, women now come to me and repeat back the things I’ve taught them through my oneon-one and group education sessions. They understand some reproductive physiology and anatomy and know what they need to look out for; they understand what makes a child sick and when to seek help.” “In the early days, I used to go out there and the women would all be out goanna hunting and I would have to go and find them. I’d end up doing the clinic at 9 o’clock at night. Now the nurses hardly need to put the sign up before the women are asking when I am coming.” “Back then, the nurses would give me a list, whether it was pap smears or Mirena or something to follow up, now they struggle to keep a list because women just come and tell me what they want. They want to talk about all sorts of things, so my practice with them has changed from crossing things off a list to real empowerment for them through education.”
Continuity the key
“That’s not to say that it’s easy. The work is bloody hard. The conditions are extraordinary, the places I stay, the pushing, shoving and lumping gear in and out of planes and trucks – it’s hot, dusty, and hell sometimes but there are just magic, magic times that make everything worthwhile.” The future is never far from Susan’s thoughts. While her love of the medicine is palpable, she is ever conscious of the need to help mentor young GPs just as much as championing remote procedural obstetrics. “There’s me and a couple of colleagues in our 60s then there’s a gap to doctors in their late 20s early 30s and no one in between, so we have to keep these people.” “I have mentored lots of young GPs doing their advanced diplomas of obstetrics and gynaecology and they have gone on to other rural areas – Kalgoorlie, Geraldton, Kununurra and Derby. Dr Anne Karczub at KEMH has done an incredible job pushing the advanced obstetrics/gynaecology diplomas for GPs, so I am just trying to be supportive of her.
Power of working alone
Susan’s secret is continuity and trust – “total and utter trust,” she said.
Susan says the attraction of remote obstetrics and gynaecology is its freedom and independence and a chance to use skills.
“It’s as simple as that. I’ve been overwhelmed by the women’s trust, to the point where some even bring their husbands with them to discuss things. Culturally, that act just crosses all boundaries. It’s amazing.”
“Doctors in the big hospitals can’t conceive of working without the team support around them so for young doctors who are going to work remotely by themselves, you have to gradually build their confidence
and be with them at all hours of the day and night and then gradually unleash them. They also know they can ring me anytime day or night and I’ll be there to talk them through it.” “We can’t afford to frighten them off, we just have to support them until they’re ready to work alone and that experience is not available to their city colleagues in the big hospitals who have 10 people above them.” Susan’s enthusiasm for her work and her deep affection for her patients and colleagues are both tangible, but she is less positive about the big picture of Aboriginal health and is reluctant to be drawn into the politics of it. “It’s a very difficult situation and I don’t pretend to know the answers. I can only do what I can do. If I start thinking about the big picture I get quite depressed so I just concentrate on my little patch. What I have seen working is education – more Aboriginal people are getting to colleges and they are going on to do courses such as Aboriginal health nursing. We’re getting these little chinks of light and there are some really clever people. The women are brilliant.” Obviously sensing that Susan would find it hard to walk away from this kind of commitment, WACHS has recently signed her up for another 4 ½ years. “I told them, you do know how old I’ll be then!” But there is the issue of her health, having had a single mastectomy and reconstruction 2½ years ago and a growing tribe of grandchildren and family who need her. “I’ve got these beautiful grandchildren who I love dearly, I look after my elderly mother and I do want to spend more time with them. But I’ve moved into this area of medicine. I’ve found my niche and I adore it. I just need to get the balance right.” O
By Ms Jan Hallam QPostnatal check in Derby
Emotional Investment in Making Babies There’s a truckload of emotion riding on fertility treatment. .FEJDBM'PSVN spoke to fertility counsellor Cailin Jordan about helping couples ride the rollercoaster. Psychologist Cailin Jordan sees couples at their most vulnerable – their hopes wrapped in fear and uncertainty, Q$BJMJO+PSEBO so how does she prepare them for the fertility treatment journey? “Assessing their expectations of their treatment from the outset is critical. Most couples nowadays know someone who has been through a treatment – one in six couples need some form of assistance – so they have an idea how easy or difficult the journey will be. We’re even seeing couples whose parents have needed some kind of fertility assistance.” However, being informed does not necessarily equate to realistic expectations. “On average people have been trying to conceive 2 ½ years themselves before they seek treatment, so they are usually quite emotionally exhausted by the time we see them. They start treatment hopeful it will work but it depends on a lot of factors.”
“Age is key – the younger the woman the better. Over 40 and success rates decline quite rapidly year on year. So I see a range of people – with older couples it is issues of egg donation, or if it is a male-female issue, embryo donation.”
Psychosocial issues of donation Gamete donation is a deeply emotive and legal issue, which Cailin helps couples navigate. Legislation may differ from state to state and individual practices may have their own guidelines, but whatever the framework, gamete donation carries with it quite charged psychosocial implications for all the parties involved. “At our practice, we only do known donations – where the parties meet one another first … be that for egg, sperm or embryo. There are psychosocial implications for the donor, for the recipient and for any child that may be born now and in the future. People frequently say, ‘I wondered why we had to do this counselling, but now I can see there are so many things we hadn’t considered for all of us’. It is complex but we do prepare patients the best we can.” Cailin said that in WA there was a threemonth legal cooling-off period for egg
Q: “How old is too old for IVF?”
I will respond to this very provocative statement as a practitioner, rather than a researcher in the IVF field. Most couples attending a fertility clinic will have tried to conceive for some years. So seeking IVF treatment is not a frivolous decision. Age is a factor in IVF for both men and women but for women, age is even more critical in that it determines the number of eggs available and subsequent embryo quality and pregnancy outcomes. The statistics are quite clear – beyond the age of 35 a woman’s ability to conceive will be limited by the quality and number of eggs she produces. IVF just for ‘women with fallopian tube disorders and severe male infertility’ may have been the immediate objective for some pioneers of IVF but the new process today 20
has a broader application that is obvious to every infertility researcher and practitioner. If we reserved IVF treatment for a very specific group of patients, how would the community respond? Not just infertile couples are involved in decisions about IVF; sometimes potential grandparents are. How would they respond to their adult children being excluded from treatment because they did not meet a specific clinical need? I do not have a simple answer to the question of age but IVF is not the only treatment patients can receive at a fertility clinic. A complete medical is taken, lifestyle issues explored and appropriate investigations undertaken. From this analysis come decisions about the nature of treatment.
and embryo donation and six months for sperm donation. “If everyone is happy at the end of that time, we go through the counselling again just to make sure everyone is certain, then they go ahead.” The issue of expectations is vital here too. “It tends to work best when people’s expectations about any ongoing relationships are compatible because once a child is born it’s really all about the relationships. However, it is true across the board of fertility treatment – realistic expectations help people adjust and cope with changes.”
What is success or failure? When it comes to expectations, Cailin says they can vary enormously but discussing them helps couples examine what they think success and failure is. “I always ask couples what success means to them. For some, it is generating embryos on their first attempt, for others, it’s that and being pregnant at their first attempt; or
Dr Simon Turner, Medical Director of Hollywood Fertility Centre responds. fundamental reason for infertility, which may be exacerbated by work or financial pressures. Being overweight, recreational drugs usage and alcohol consumption are also typical factors discussed ahead of any treatment plan. Singletons are now the norm in assisted reproduction. Improvements in infertility techniques and the associated science means that results are much more reliable and the implantation of more than one embryo is available only in limited circumstances on the express request of the patient. Whilst most practices have firm policies on age limits, it is highly unlikely a woman will deliver beyond their 50th birthday, with or without donor eggs. O
Sometimes lifestyle factors are the issue. Abstinence from sexual contact can be the medicalforum
couple has to undergo genetic screening of their embryo, they may come in the morning and see the genetic nurse, who will explain the screening process, then they will see the embryologist, who will explain scientifically what will be happening with their embryos, then they see me and we discuss their emotional preparedness for the process. Then they see the doctor.â€?
Talking helps relationships Cailin says there is a lot of satisfaction helping people through their fertility issues but she added that there was also grief and loss to work through, though her couples were generally tighter and happier than many in the wider population. conceiving within two years. Knowing this helps me assess what is realistic.â€? â€œAbout 40% of couples under the age of 38 will conceive on their first attempt, but that leaves 60% who donâ€™t. We discuss fertilisation rates, not just in treatment but in the wider population, and discuss what is â€˜normalâ€™ and it gives people an understanding of the bestcase scenarios and that it may take more than one attempt to get pregnant.â€? â€œSo some of that thinking is working out what is failure to them. It means different things to different people.â€?
Most of Cailinâ€™s counselling sessions are part of the cost of fertility treatments, except in the case of people doing donor cycles where there is legal mandatory counselling at the outset and three or six months later, which incur a cost. Fertility technology and treatment is changing all the time and the nature of the multi-disciplinary team means Cailin must keep abreast of professional developments.
â€œLong-term studies show that couples who have gone through treatment actually fare better than those who donâ€™tâ€™, mainly, I think, because the process forces them to have deliberate conversations. Thereâ€™s no â€˜oops, weâ€™re pregnantâ€™ itâ€™s more like â€˜how much do we want to be parents and how far are we prepared to go to achieve thatâ€™. They tend to understand what their values and goals for life are.â€? O
By Ms Jan Hallam
â€œThis is my seventh year at Hollywood Genea and it is a very holistic team. We all know whatâ€™s happening. For instance, if a
Changes from 1 July 2014
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News & Views
Violence in the Home Domestic violence may often occur behind closed doors, with drugs and alcohol often involved, but agencies are working together to help women and children. The statistics of domestic violence paint a sobering picture but it is an incomplete one. As numbers are drawn from many sources, there are the cases that never come to light. What we know is that WA police attended 48,000 family and domestic incidents last year and 16 domestic-related homicides. The recently published Personal Safety Survey reported that an estimated 62% of women (1,055,200 of the 1,716,300 women who had been physically assaulted by a male) had been assaulted in their home; 17% of all women aged 18 years and over (1,479,900 women) and 5.3% of all men aged 18 years and over (448,000 men) had experienced violence by a partner since the age of 15. Alcohol and drugs play a terrible role. The survey indicates that 53% of women (917,200) reported that alcohol or drugs had been involved in their most recent incident of physical assault by a male. This is no news to Holyoake’s Jen Lowe and Tegan O’Malley who see women and children caught up in this circle of violence
– some of the women have drug and alcohol issues, others dealing with the violence of a partner who does.
use, but in the process, and within a peer support setting, there is considerable discussion about domestic violence.”
“It’s a very common scenario,” Jen said. “Adult women in relation to their own drug and alcohol use often speak about their experience with violence in current and past relationships.”
Jen said that group therapy was powerful for women in these situations.
Holyoake runs programs for men, women, young adults and family of drug and alcohol users and sometimes as family groups with alcohol and drug use as its focus but with violence an ever-present shadow for many. “Female partners of users often report that violence is a big issue, not just for them but for their children, so we also run programs for children aged three to 17.” In the Safe at Home program, Tegan said, women who experience violence in the home are helped with life skills such as boundary setting, taking responsibility for themselves, communication and self-esteem.
“When women start to talk about their own experiences and start to understand that they are not the only ones, and other people have been through similar circumstances – and survived – they realise there are strategies that can help. People get a lot of strength from that.” When violence is brought to the attention of counsellors, a risk assessment is done and a referral is make to the relevant agency, be it police, the Department of Child Protection or a family member. “It is a planned and negotiated referral system. We are not a specific violence counselling service, so we might refer someone on but in a slow and steady way and when they are ready,” Jen said. O QSee Police Guest Column on P28.
“There are 12 different topics we focus on with an emphasis on drug and alcohol
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News & Views
Film Takes on Brutal Tradition After out 2011 story, .FEJDBM'PSVN can report that Perth neonatalist Dr Sanjay Patole’s ﬁlm on Indian female infanticide has been screened.
Female infanticide is rife on the subcontinent. Perth neonatal specialist, Dr Sanjay Patole, has taken a Bollywood approach with his film, RIWAYAT to draw attention to this barbaric practice. “The name of the film comes from an Urdu word meaning ‘tradition’ and dates back more than 1000 years to an epic battle between Mohammed and his enemies. I chose the title to highlight the fact that there is no written historical record anywhere stating that girls are inferior to boys.” “But somehow this ‘tradition’ exists, this hidden and unspoken belief that results in the death of millions of girls in the world’s poorest nations.” “The State of Rajasthan in Northern India is one of the worst areas for female infanticide. There are villages with no young girls at all and young men have to leave to find a wife. There have been eye-witness accounts of aborted female foetuses being thrown to dogs on the side of the road. No religion has ever condoned this sort of thing.” With support from people in Perth and faculty colleagues in India, the film was released in September 2013. As Sanjay points out, it was a long and winding road. medicalforum
“I took the film, which is a traditional Bollywood drama, to various film festivals around the world. When I attempted to get a national release in my own country I was met with rampant bureaucracy and corruption at every turn. The film would get stuck in different government departments for months. My 85-year-old father was getting on buses and trains taking it from one place to the next.” “I’ve approached a number of Art Film chains here in Australia but it’s got that Bollywood stamp and they’re not sure how to pitch it.” Sanjay has been in Perth since 1990 after working with Professor Ajay Rane in obstetrics and gynaecology in Queensland. The passion that drives Sanjay stems from the grotesque disparity he’s seen in the treatment of female babies. “As a clinician you put so much effort to try and save a baby. I’ve stayed beside a struggling baby for 48 hours and sometimes you just can’t save them no matter how hard you try. It’s such a sad moment when you can’t do anymorwe and you hand a dying infant back to their mother. The grief you see in her eyes stays with you forever. I remember every one of them.”
where full-term, healthy foetuses are destroyed on the basis of a perverted belief. If this film can convince just one person that it’s wrong, I’ll be pleased.” Sanjay is well aware of the popularity of cinema in India, particularly the formulaic and highly entertaining Bollywood genre. He’s also aware of its limitations. “The power of cinema is very strong in India. However, it’s obvious that a film can never change an entrenched belief such as this one. A film-maker can only show what’s happening, raise the issue and ask people to think more deeply about it. Whether an audience changes their opinion is up to them. My job is to present this material and urge them to try.” Sanjay won’t be stepping away from the camera anytime soon. His next project is closer to home and deals with a serious health issue. “My next film will focus on organ donation. We have an appalling record here in Australia so I’ll be getting out my begging bowl to try and raise around $1m to get that project off the ground.” O
By Mr Peter McClelland
“And then you see this situation in India 23
News & Views
Lego Gives a Leg Up A Perth GP tells how Lego and an autistic son has helped to make her a better doctor.
Sometimes life throws a curve-ball and changes your world in ways you could never imagine. Dr Cathy Parsons has her 24 year-old son, James, and thousands of brightly coloured pieces of plastic to thank for a richer and more reflective life. “We can all become complacent when things are going well. As doctors we live quite privileged lives, we’ve usually grown up in comfortable situations, attended good schools and worked hard to achieve scholastic success. We’ve had a lot of advantages.” “It can be a relatively new experience to be placed in a position where things don’t go smoothly. Having a son with a disability has opened my life up in so many ways. I don’t know whether it’s made me a better person but it has made me a better doctor.” “I look at the world in a different way now.” James’s autism meant that he had real difficulties engaging in social situations. It was something of a light-bulb moment when Cathy spotted an advertisement in The West Australian for PALS – the Perth Adult Lego Society. “James wasn’t getting out much, he didn’t have a driver’s licence and he was very anxious in other people’s homes. He had a fear of contamination so it was difficult for 24
him to interact with other people. It took me a while to convince him that Lego would be a good idea and we went together for the first time in 2012.” “And since then it’s been so much better.” “I would really say that the Lego Club has helped James get back into the real world from the dark place he’d got himself into. He enjoyed it from the first day, the people were welcoming, kind and non-judgemental. They’re often a little eccentric. I guess you’d have to say that Lego isn’t exactly a mainstream hobby for adults.” The bell-curve of family life, and particularly its more idealistic portrayal, has clearly identifiable social markers along the way. Cathy makes the point that caring for a disabled child puts a few kinks in the trajectory and that has an effect, both personally and professionally. “Dealing with a disabled adult has its own set of issues. It has a massive effect on family life but it has given me a greater empathy for people who have to make difficult choices.” “For a GP, part-time work is easy to negotiate and when your children are small it’s almost a necessity. But for most doctors there’s a career transition and many of my contemporaries are at a different stage now because they’ve gone back to longer hours. James is 24 and I sometimes feel that
Q Dr Cathy Parsons works on the Lego suspension bridge that has been a mission for she and her son.
people are thinking, ‘when are you coming back full-time?’ I’m not sure when that will happen or, indeed, if it ever will.” “It’s not just me in this situation. I know female doctors who’ve stopped work completely to support children going through a difficult adolescence.” “I’m very lucky that I’m able to structure my day around James’s needs. Some patients can get a bit grumpy if they can’t make an appointment whenever they like, but I’ve been well supported by my colleagues and I’m grateful for that.” Cathy draws a clear line between the medical profession and the general population when it comes to disability. “I think doctors deal with disability pretty well most of the time. It’s the rest of society that finds it more challenging.” “James goes to Tuart College and is aiming for university. I go to the gym twice a week with him which has evolved into him learning how to drive and that’s something I never thought he’d do. And Lego is something I never thought I’d do either!” “My involvement has come through James. If someone asked me if I had a hobby, I wouldn’t say it’s Lego.” O
By Mr Peter McClelland
Doctors in Love (with Work?) The melt-down of personal relationships is a constant risk inside the furnace of medicine. Are you holding the match? When the stress and strain of medicine gets too much it begins to affect personal relationships. Medical Forum spoke with two professionals with considerable experience in the field of doctor burnout and relationship breakdown to tease out some of the issues. Dr David Oldham has been the Convenor of the Doctorsâ€™ Health Advisory Service (DHAS) for the past seven years and a GP educator for Q%S%BWJE0MEIBN more than a decade. In the latter role, his interest was piqued by the stress placed on both GP registrars and their more senior mentors. David sees the DHAS as a triage service to help medical professionals deal with the consequences of such pressures. â€œIâ€™d have to say that we donâ€™t get a lot of calls from doctors worried specifically about the state of their marriage. Itâ€™s much more partners or friends and family who will get in touch with us. They are concerned about burnout, depression and the effect thatâ€™s having on family life.â€?
linked to their inherent personalities. They are high achievers and theyâ€™re often quite obsessive, but an integral part of the practice of medicine is the expectation that doctors will carry on in the face of adversity.â€?
Culture plays a part â€œIn hospitals Iâ€™ve worked in, itâ€™s often seen as a badge of honour not to take sick-leave. Some of that culture comes from hospital executives and, admittedly, there can be difficulties getting adequate leave coverage.â€? David sees changes in the shifting gender balance within medicine and reaffirms the direct effect of career transition on stress levels. â€œGenerally speaking, women are in tune with work-life balance and there are definitely more females in medicine now. Younger doctors, particularly in the 30-year age group, are also more lifestyle oriented. Research shows that when someone begins their specialty training thereâ€™s a tacit acceptance that theyâ€™ll be putting their heads down for five years.â€?
High risk groups â€œThere are two distinctly high-risk groups â€“ medical students and doctors undergoing their specialty training. Where the latter are concerned, and also mid-career doctors more generally, a female partner will often contact us asking for help. Relationship breakdown is usually not the main issue, itâ€™s just one component of an increasingly difficult home environment.â€? â€œWeâ€™ll suggest they talk about their concerns with their partner and usually theyâ€™ve already done that. Theyâ€™ll call us because they feel the situation is approaching a crisis point. Where the doctorâ€™s concerned, a good first step is to see their GP because there may well be medical issues. They might need medication and we donâ€™t want doctors self-medicating which some tend to do in those situations.â€? â€œWe also offer advice on issues that might overlap with the Medical Board but essentially we see ourselves as a safety net for doctors who arenâ€™t sure about taking the next step.â€? Doctors have the same flaws and failings as everyone else but itâ€™s worth remembering, says David, that they often work in an intensely demanding environment. â€œA Beyond Blue study in 2013 highlighted that many doctors are subject to high workplace stress. Some, but not all, of this is medicalforum
Psychologist Dr Aldo Gurgone has worked in the field of relationship counselling for many years and is a recommended DHAS clinician.
â€œI see quite a number of doctors, both GPs and Specialists. The main issues, irrespective of social status and career path, are essentially the same. However, within some professional groups certain scenarios are more likely than others.â€?
â€œThe end result is that theyâ€™re not easily available to meet the needs of their family and, from that point, itâ€™s easy for things to break down. There are parallels with similar professional sectors. Traditionally, although this is obviously changing, the woman dedicates herself to the children and her husband becomes increasingly â€˜marriedâ€™ to his career.â€?
Changing gender balance Aldo, like David Oldham, acknowledges a profound shift within medicine due to the changing gender balance. â€œThere are many more women in senior positions and itâ€™s absolutely vital that couples are aware of issues such as equity within a relationship. Anything that remotely resembles an antiquated sexist approach from a male partner isnâ€™t going to work.â€? Linked with the gender aspect is a scenario involving a perceived imbalance in professional status. For example, a female doctor married to a plumber. â€œProblems may arise from a relationship such as this, however the severity would depend less on differences in social class and more on the capacity of the each individual to complement the other. Having said that, once the love or lust phase begins to wane and, if then, the more qualified person begins to feel slightly embarrassed within her social or professional circle, there is potential for serious issues to develop.â€? â€œIf the going gets tough and one partner is emotionally distraught, itâ€™s important that thereâ€™s an awareness of the commitment to one another. Thereâ€™s every chance of a successful relationship if mutual support exists.â€? O
â€œTake the example of a well-respected medical specialist whoâ€™s lauded by his colleagues and patients but is emotionally absent at home. It may be doubly difficult for that person because theyâ€™re also not receiving the same sort of accolades they get within their professional careers.â€?
By Mr Peter McClelland
WORK AND GENDER t .BMFTPG(1TBOEPGTQFDJBMJTUTXPSLFEISTXFFL t 'FNBMFTPG(1TBOEPG4QFDJBMJTUTXPSLFEISTXFFL t -POHFTUIPVSTXPSLFEoNBMFPCTUFUSJDJBOT DBSEJPMPHJTUTBOETVSHFPOT t 'FNBMFEPDUPSTSFQPSUFEIJHIFSSBUFTUIBONBMFEPDUPSTPGDVSSFOU psychological distress (4.1% vs 2.8%) t 8PNFOSFQPSUFEHSFBUFSXPSLTUSFTT FHWTGPSDPOnJDU CFUXFFODBSFFSBOEGBNJMZQFSTPOBMSFTQPOTJCJMJUJFT
(Sources: 2011 Census; Beyond Blue Doctors Survey, 2013)
Sex Workers Want Decriminalisation Sex worker Rebecca Davies argues that the Swedish Model of industry regulation that criminalises clients will in effect criminalise sex workers.
s the saying goes, politics makes strange bedfellows, and that is certainly the case when it comes to those advocating for the â€˜Swedish Modelâ€™ of sex industry regulation. The Swedish Model puts a ban on the purchase of sexual services. The peculiar alliance pushing for these laws in Australia and abroad is radical feminists, church groups and conservative politicians for a variety of sometimes intersecting reasons. The Swedish Model is based on the belief that sex work is inherently victimising and sees no difference between consensual adult sex work and sexual trafficking. It is also based on the false and limiting belief that all workers are female and all clients are male, disregarding male workers and female clients and ignoring trans and gender diverse people altogether. Proponents of this model often tout that it is the client who is criminalised, not the sex worker, however criminalising any part of sex work also criminalises sex workers. When our clients face penalties, this has obvious flow-on effects to sex workersâ€™ occupational health, rights and safety. Many people might not care that criminalising clients has a negative effect on sex workersâ€™ income, but what about sex workers health and safety? If police can
X Dr Tony Robins has been appointed Executive Director Medical Services at the WA Country Health Service. Former Acting EDMS Dr Andrew Jamieson returns to his role as Midwest Regional Director of Medical Services. Dr Kelvin Billinghurst is the new Regional Director of Medical Services in the Goldfields. X Urologist Dr David Sofield has been appointed chair of Bethesda Hospitalâ€™s Medical Advisory Committee. Gynaecologist Prof Roger Hart is the new vice-chair. The appointments come after the retirement of plastic surgeon Dr Alister Turner who was chair for nearly 15 years. He will remain on the board. 26
use condoms as evidence against clients, it discourages both populations from using condoms. Sex workers voicesâ€™ need to be heard and we are saying that the Swedish laws are ridiculous and harmful. It is absurd to tell me that to â€˜protectâ€™ me you will cut off a large part of my income by criminalising my clients, and you will make the work I am left with more difficult. As long as people view sex workers as some kind of stereotyped victim, we wonâ€™t be heard and laws will be implemented that are not only ineffective in regulating the industry, but do real harm to sex workers and our clients. We cannot conduct vital peer and community education programs effectively if these programs run alongside criminalisation. When people are concerned about legal status, they will try to avoid any kind of intervention from health practitioners for fear of being reported. The optimal regulatory model for the sex industry is decriminalisation, recognised by both the World Health Organisation and UNAIDS. This is the model WA sex workers are calling for and one proven in practice in both NSW and New Zealand. Australian sex workers have excellent sexual health, with low rates of STIs, and this can
X The Rural Clinical School has opened at the Muresk Institute just out of Northam providing fifth year medical students a one-year placement where they will be placed at medical centres and hospitals in Northam, York and Toodyay. X Foyer Oxford, a new facility in Leederville has opened that will provide transitional accommodation and training for up to 98 homeless young people aged between 16 and 25. The federal government contributed $10.7m, the State Government, $9.1m and Lotterywest, $3.2m. X Perth barrister Ms Ros Fogliani has been appointed as WAâ€™s State Coroner â€“ the first woman to hold the position. X In the December issue, we reported that St Bartholomewâ€™s House was
be built on with decriminalisation and better resourcing of sex worker organisations and peer-education programs, which, through harm-reduction strategies, have helped avoid major public health risks. All of these positive outcomes can be maintained with decriminalisation, or undone with the Swedish Model. Personally Iâ€™d prefer decriminalisation, something that actually works. O References on request ED: Rebecca Davies has been a WA sex worker for over a decade, and is a campaigner for People for Sex Worker Rights in WA and is also on the Executive Committee of Scarlet Alliance.
DOCTORSâ€™ E-POLL -BTUZFBSOFBSMZPG(1TBOE specialists believed that decriminalisaUJPOPGUIFTFYJOEVTUSZXPVMEJNQSPWF IFBMUIPVUDPNFTGPSTFYXPSLFST And more than half [53%] also agreed UIBUDMJFOUTPGTFYXPSLFSTXPVMECF healthier if it were decriminalised. 22% were uncertain while 25% disagreed.
looking for a doctor to replace Dr Sheryl Whitford on the board. The search continues. In the meantime, Mr Michael Brown has replaced Mr Andrew Birch as chairman. X Mr Stephen Besci has resigned as CEO of WA-based aged-care provider Bethanie. The COO Mr Christopher How is acting CEO. X The Salvation Army has just opened its four-story, $23.3m 102-room crisis and transitional accommodation centre, Lentara, in Northbridge to accommodate homeless men. X The WA Government has announced a $19.3m package for providers of Home and Community Care services for the elderly and disabled living in rural, remote and outer metropolitan areas. medicalforum
Abortion Obstacles Remain Dr Kamala Emanuel, of the FPWA Sexual Health Service, says restricted access to affordable abortion is affecting marginalised women.
ince Australian women rallied for ‘free, safe, accessible abortion on demand’ 40 years ago, much has been achieved. Legal reform of some kind has taken place in most states and territories, there is Medicare funding for pregnancy termination, mifepristone is available on PBS script and women no longer suffer the complications of illegal “backyard” abortion.
Yet there are still obstacles for women to access affordable pregnancy termination services in a timely manner. Legal obstacles. The 1998 WA law reform, while decriminalising most abortion, imposed the obligation for an extra doctor’s visit – with counselling from a doctor uninvolved with the procedure. This gatekeeper role of GPs, including those personally opposed to abortion, means for some women, obstruction, delays, and extra expense and risk. Service capacity. Last year’s closure of one of Perth’s privately run women’s health clinics has put pressure on the remaining services. Public hospital service provision is patchy, depending on a coincidence of willing clinicians and acquiescent administrations. The lack of either, spells an end to public pregnancy termination provision. Full or part-privatisation (e.g. public-private
partnerships) also threatens provision, especially where the private provider objects to pregnancy termination.
to expense, making their needed abortions delayed or simply unattainable.
Cost. Privately, abortion is expensive and out-of-pocket expense can put the procedure out of reach for many women. Many GPs are unaware that the public hospitals that don’t provide abortion may be able to fund its private provision.
Law reform. The barriers to self-referral, including younger women and women with later gestation pregnancies, should be removed. Legal protection for clinicians to avoid involvement in abortion should not be used by institutions to decline abortion provision.
Abortion data for WA is available only up to 2012, so it is too early to know what impact the 2013 PBS listing of mifepristone and misoprostol (termination up to seven weeks’ gestation), is having on abortion accessibility. It certainly has the potential for improving access, especially for women in regional or remote areas. However, the need for the prescriber to undergo (admittedly straightforward) online training, to arrange a designated pharmacy to dispense the drugs, to ensure management pathways for the expected cases of ongoing pregnancy or complications, institutional resistance, and the assumption that abortion is something for someone else to provide, may all deter the uptake of prescriber status by medical practitioners. And then there are the difficulties for marginalised groups – those unable to access Medicare, young women, homeless women, Aboriginal women – with barriers additional
So, what needs to be done?
Access. The public should be able to expect public hospitals to provide the full range of essential surgical and medical procedures, and abortion should be no exception. Retaining public hospital services in public hands, with full accountability to the community’s expectations, would also help ensure the services are provided. Training. Creating a new generation of abortion providers, to remove the sense that it’s someone else’s responsibility, would help. Cost. Increase Medicare rebates to cover the actual cost. Despite remaining stigma, the ideal service is much like many sexual health services associated with public hospitals – co-located to manage complications, confidential and separate patient files, a dedicated staff that respect patients’ wellbeing, autonomy and privacy, publicly funded and with the option of self-referral. O
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X The General Manager Operations at Youth Focus, Ms Felicite Black, has been appointed as a Casual Board Director at Primary Care WA. X In DoH Tender news, Sharon Brown & Associates has been awarded a $3.5m tender to provide Progress Software Analyst/Programmer and Technical Services to support the department’s HCARe CMS application. X Fiona Stanley Hospital contracts include: $1,072,500, 12-month contract to Fujitsu Australia for project management services for the hospital’s ICT program; Journey One will provide change management and communication services for the ICT program for a cost of $1.12m; and Cordelta has been awarded a $600,000 contract for a Learning Management System. medicalforum
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Family Violence From Police Eyes Police response to family and domestic violence is as complex as the problem itself. Detective-Inspector Valdo Sorgiovanni says doctors are a crucial link.
he WA Police response to family and domestic violence (FDV) is not solely about arrests, charges and prosecutions. The primary role of police, in simple terms, is to help the victims and deal with the perpetrators. Achieving these two objectives is often complex and challenging, and it can’t be done by police alone. Firstly, the scale of the issue needs to be put into perspective. In 2013, almost 48,000 family and domestic violence incidents were reported to WA Police. WA Police also responded to 16 domestic-related homicides, compared to 29 the previous year. Sadly, these deaths included adults and children. The impact is always devastating, particularly as extended family, close friends and the broader community try to comprehend the tragedies.
medical professionals can play. Some victims may be reluctant to approach police for fear that their partner may go to jail, and they may instead confide in a medical professional providing their treatment.
remain in their homes when it is safe to do so, maintain their local support networks and continue with day-to-day education and employment. The co-location model was expanded in 2013 and has proven effective.
It’s right here, at this point, that we believe there is an opportunity to offer extra assistance to the patient. Where appropriate, the medical professional can explain that a police report triggers a response involving police, the Department for Child Protection and Family Support (DCPFS) and nongovernment organisations.
Police are obligated, by legislation, to issue violence restraining orders, police orders or to make a written record of why no action has been taken.
The groups work together under a model that involves co-location of resources, meaning staff from each group digest information on contemporary incidents and make decisions on how best to respond.
The raw figures are shocking but numbers alone don’t accurately describe the scale of the issue. We know many victims endure long periods of abuse before they seek help.
The response may involve the introduction of the Safe At Home program. That program involves early intervention to connect victims and perpetrators with support services for counselling, advocacy and assistance in an effort to prevent further incidents of FDV.
Police have a number of tools to tackle FDV and we want to highlight the role that
The program provides outreach to women and children and is designed to help them
Medical professionals may also have a role to play in court processes – ranging from violence restraining order applications through to prosecutions for domestic violence incidents that result in serious criminal offending. This court involvement may cause some concern for medical professionals but our message is simple – our combined efforts are all about trying to address an issue that can cause so much heartache, and our combined efforts may prevent another tragic death. O ED: DI Sorgiovanni is the Family Violence State Coordinator, Sex Crime Division, WA Police
WE’REEXPANDING Hollywood Private Hospital is proud to announce it has embarked on a $74.1 million expansion that will see it emerge as the largest private hospital in Western Australia. Our expansion includes: Six more operating theatres
Two new wards
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WE’RE BIG IN HEALTH AND GETTING BIGGER For more information on our exciting expansion visit hollywoodprivatehospital.com.au
Know What You’re Testing For? The CEO of Rise Community Support Network, Ms Justine Colyer, is a NFP boss who thinks poorly matched pre-employment medicals are a problem.
petite woman attends a routine pre-employment medical check at your practice; one of dozens over the year if you are the practice of choice for a nearby, large employer who is constantly recruiting new staff.
The woman may or may not come with a copy of her position description and list of duties. The employer may have provided you with it some time ago and it’s on file, somewhere, possibly out of date. How are you really going to know if she’s capable of doing the job required without risk? The social services sector predominantly employs women to carry out support work. It can be a very physical task, especially if they are supporting someone with physical disabilities and mobility issues. Double the difficulty if the person they support is significantly larger and stronger than them. Soft tissue and other injuries related to a woman performing these tasks are common and the financial, social and client impacts of someone being out of work, both for the
employer and employee are significant. Our experience is that the pre-employment physical assessments are pretty much the same regardless of whether someone is an office worker or a support worker. It might be enough for me to be able to demonstrate I can bend down to lift something off the floor or reach over my head. But then I’m not a 45kg woman pushing a 120kg client in a wheelchair up a steep hill littered with honky nuts. Nor am I that same person helping a man twice my size shower and toilet. In the same way, how do we get a better understanding of someone’s emotional and mental resilience to perform a job given that a good number of workers’ compensation claims are related to mental health and stress? Interviews and referee checks can only reveal so much and psychometric testing on a large scale is uneconomical. Jobs in this area often support people with challenging behaviours and/or those who have been through significant trauma which can be distressing to hear.
But should we be able to identify and manage/prevent potential issues with a more tailored medical assessment? What do we need to do to help you tailor your tests to meet the particular physical and mental requirements of that job? Some suggestions are: t 8FHJWFZPV FBDIUJNF OPUPOMZBMJTUPG duties of the position but also supplementary information around trends we have noticed to do with soft tissue injuries or emotional stress t ćFDIFDLMJTUUIFFNQMPZFFIBTDPNQMFUFE for us noting what pre-existing conditions they have so that should they identify something to you that is not on our form, you can look into why that might be and if we are harbouring a problem for future. t 1SBDUJDBMJOGPSNBUJPOTFTTJPOTTIPXJOH you exactly what is involved in lifting, supporting, moving people Feedback please! O
Rural Shires Take on GP Shortage
n 2010, the shires of Corrigin, Lake Grace, Kondinin and Kulin lost their GPs when the corporate medical service departed. It became clear that recruiting a solo general practitioner to each of their towns was unsustainable in the long term. So Rural Health West and the shires have contributed funding to design a new model of service, which will see the ‘back-room’ business systems and processes of general practices provided for. The local Shires will pay for the ongoing delivery of the Wheatbelt General Practice Business Support Service (WBGPBSS) in each town, while First Health has been contracted to provide the services, including management, recruitment, human resource management, accounting and bookkeeping, information technology support and maintenance, clinical leadership and service coordination. “This service will ensure that general practices across the region will be supported by one entity and offered greater business support, removing the burden from both medicalforum
local government and/or individual GPs,” Rural Health West’s Ms Kelli Porter said. Corrigin will kick the initiative off and others will follow when their current GP arrangements end. It is intended that GPs will operate their own practices, but with the added benefit of the WBGPBSS providing the backend management support to assist with the business aspect of the practice. Where the GP requires sponsorship (e.g. IMGs), First Health will employ the GP. The GPs are expected to provide full-time services in their local towns and surrounding communities. In the case of the Kondinin and Kulin shires, the GP will share time between the two towns and also service the nursing post at Hyden. The Lake Grace practice provides a satellite service at Newdegate and the Varley nursing post. Suitably credentialed GPs may also provide services at the local hospitals at Lake Grace, Corrigin, Narembeen and Kondinin, along with the Kondinin/Kulin Multi-Purpose Service Kulin. Doctors can also participate on the Southern Inland Health Initiative hospital rosters if they choose.
While the shires are contributing substantial funds, they hope that federal or state funding will support the initiative and also a locum service. “The Shires have shown great tenacity and leadership in not only starting this initiative, but continuing to work together to develop something that is truly innovative and sustainable for rural general practice and primary care services,” Kelli said. The WA Country Health Service (WACHS) will evaluate the project. O 29
News & Views
Staying at Home Chemotherapy is one of a raft of treatments that are literally being taken â€˜in-houseâ€™ and a vast majority of doctors in our latest e-poll see ďŹ‚ow-on beneďŹ ts. a more flexible service has positive spinoffs for specific patient groups.
Haematologist Prof Richard Herrmann and RN Ms Julie Wilkes both agree that the social and demographic landscape of cancer treatment is changing rapidly. They also share a common view that home-based services are flexible, individually focused and the patient emerges as the real winner. â€œI was doing both laboratory and clinical work relating to haematological cancers in the mid1990s and I firmly believed that we could treat people in their homes or as outpatients. We got some funding Q3/.T+VMJF8JMLFT Q1SPG3JDIBSE)FSUNBOO to do some bone-marrow transplants in the home and the outcome was quickly. Itâ€™s just a matter of changing that they did much better compared with a attitudes. Most importantly, the biggest hospital environment,â€? said Richard. winners from this service are the patients.â€? â€œItâ€™s certainly more labour intensive treating Julie Wilkes detects a shift in the political a person one-on-one and there are some wind. things that are more difficult such as â€œThereâ€™s a much improved armament in the frequent administering of drugs and 24-hour treatment of cancer compared with 20 years infusions. But it saves a lot of money not ago. Metastatic colorectal cases used to have having someone in hospital, thereâ€™s a reduced a life expectancy of around six months and risk of infection and most patients appreciate now itâ€™s over two years. We have a plethora being away from the regimentation of a ward. of treatment options and thatâ€™s exciting but The oldest person weâ€™ve treated in this way itâ€™s also the reason why a lot of services are was 82 and he sailed through it!â€? struggling.â€?
Richard says that the reaction from some clinicians has been sceptical at the outset but the positives of domiciliary chemotherapy could not be so easily dismissed. â€œThe vagaries of bureaucracy can be a problem and medical politics can always be interesting. Some in the profession can be quite suspicious of new developments. I think some doctors in private practice felt they might be cut out of the loop in terms of fee for service and a few even said â€˜you must be killing people doing these sorts of things at homeâ€™.â€? â€œOnce doctors see that these new developments work, they get onside pretty
DOMICILIARY CHEMOTHERAPY t 1SJWBUF)FBMUI'VOETSFJNCVSTFGPS the service. t 1VCMJD1BUJFOUTCJMMFEEJSFDUMZ t 4FSWJDFPQFSBUFTXJUIJOLN SBEJVT$#% t 1BUJFOUTOPUUSFBUFEZFBSTPGBHF t 'VMMJOUFHSBUJPOXJUIQBMMJBUJWFDBSF and enhanced pain management.
â€œThe baby-boomer generation is demanding more for their health dollar. It was heartening to see changes to some Private Health Insurance rules which show that the Federal Government is becoming increasingly supportive of a shift to domiciliary services.â€?
Pressure on hospital services By 2050 the number of people aged over 65 is projected to increase by more than 250% to around 7 million people. â€œThe number of people affected will be significant and no matter how many hospitals or day units are built it will be impossible to keep up with demand. Even with Fiona Stanley Hospital, the Childrenâ€™s Hospital and the new comprehensive cancer centre at SCGH, these numbers will put a strain on resources.â€? â€œTheyâ€™ve built in allowances for population growth but not for the increasing shift of cancer to a chronic disease and patients living longer. Itâ€™s a different model of care and patients are having multiple lines of chemotherapy. The options are so much better now.â€?
â€œFor a number of different reasons Aboriginal patients donâ€™t do well in some clinical settings. Itâ€™s culturally very different and they donâ€™t have the support of their extended families. Weâ€™ve treated a number of indigenous patients at home and, from a psychosocial point of view, they fare much better than in a hospital environment.â€? â€œThis extends to adolescents and young adults as well. Theyâ€™re often poor compliers with hospital-based therapies. At home they can carry on with their normal lives and health professional can get a better idea of the family dynamics making it easier to tailor appropriate support.â€? The domiciliary service doesnâ€™t cover all eventualities. â€œSome patients revert to hospital services for clinical reasons. There may be a change in regimen or the patient may require a hospital-based intervention. Occasionally, non-compliance results in patients returning to hospital although this is uncommon,â€? Julie said. â€œOncologists and haematologists are becoming increasingly supportive of this service. Weâ€™re moving into rheumatoid and neurology treatments using immune modulating drugs and clinicians treating MS patients are seeing the benefits too.â€? O
By Mr Peter McClelland
ll o P e
Do you think domiciliary chemotherapy should be seen, if it is needed, as a welcome opportunity to engage palliative care services in a more patient-friendly manner?
Spinoffs for patients As Julie points out, the shift from a treatment model with hospitals as fixed institutions to medicalforum
It’s Not Just About Money EDs are expensive places to practise medicine and Murdoch ED has a unique set of circumstances heading its way, as Medical Forum found out.
Q(The Murdoch ED staff, during one shift. The five doctors pictured are highlighted (l to r): Paul Bailey, Andrew Christophers, Guy Buters, Julie Dockerty and Ian Rogers
The Australian Government prices an ED consult at $115 (charged to non-Medicare attendees, plus $115 for each procedure). SJOG Murdoch ED charges a $290 flat rate and attendances were only down 4% last year. How things change when Fiona Stanley opens its doors is anyone’s guess. “For some people it’s a lot of money and for others it’s worth it. For us, the challenge is to provide a service that is worth it,” Murdoch QDr Paul Bailey ED director Dr Paul Bailey said, pointing to their 20,000 or so attendances each year and the 24% admission rate, which is pretty standard across peripheral EDs in Australia. What about their patient mix? “We are probably a little short on children, about 10-15% [whereas other EDs typically have 20%] but we see a reasonable mix of surgery, medicine, cardiology, oncology, and so on. What we don’t have is extremely unwell patients with high acuity and high complexity. Those patients are best cared for in a multimedicalforum
doctor team environment for which major trauma is the ‘poster child’ but also acute GI bleeding as another example. So we are trying to focus on those things we are good at and redirect patients appropriately,” he said. This probably explains why big public hospitals have admission rates of 40-50%. The ambulance drivers usually take care of things in transit so that serious cases and the uninsured go public. Future patients may not declare their private cover and opt for the new swanky Fiona Stanley Hospital instead. The Murdoch ED will be out to compete on service, which makes their recent award for short wait times more important if Fiona Stanley Hospital ends up with comparatively longer times. Paul said they have three stated aims: top clinical care; short wait times; and a good environment. “Our competitors are pretty close by already – Fremantle Hospital is just down the road – and I’m sure if we continue to provide great service we’ll be fine.” “It’s about gaining access to the ED area and staff as quickly as possible. Patients used to go through a full triage process and were registered out front before gaining access to the clinical ED area. Now, when we have
downstream capacity, we do our best to bring patients straight through to the ED after a brief triage; which means they are getting contact with our doctors more quickly.” Their ED nurse practitioner fast tracks certain patients, like minor injuries, and junior resident staff and medical students are absent. That leaves an interesting mix of doctors – about 25 in all (or 12 FTE), roughly one third each of FACEM registrars, emergency consultants and GPs. The vast majority of GPs are ex-rural. “We respect the skills that everyone brings. They are not necessarily identical but I have a lot of faith in our GP crew. This department has always been a broad church for different doctors. We have a really effective clinical team and have no issue with it at all,” Paul said. “There comes a time in your career where the letters after your name are less important than what you know how to do. Many of our registrars have recently done ICU anaesthetics and retrieval terms, so even though they are at the relatively junior end of the spectrum they bring a lot of positive stuff as well.” continued on P32 31
News & Views
Practice Trends in Online Bookings advantaging all patients, while others felt it was best confined to new patients (7%), or existing patients (37%)
Last October, the Australian Association of Practice Managers (AAPM), with the assistance of 1stAvailable.com.au, conducted an opt-in survey of its members that included questions around online appointment scheduling. A total of 235 respondents (13.4% of 1750 members emailed) completed the internet survey and although demographic data was not collected from respondents, we noted that a number of specialist practices and a few dental practices were involved. One big question is will online appointment scheduling be seen as marketing to patient convenience or a way of improving practice efficiency?.
Results of Interest t 7JSUVBMMZBMMQSBDUJDFT IBWF computerised appointment scheduling and 72% of respondents had their own website.
t *OPSEFSPGVTFGVMOFTTQSBDUJDFTQPJOUFEUP o Being able to book an appointment 24/7. o Frees up practice staff to do other jobs. o Improves patient satisfaction by providing more booking options. Usefulness was not rated highly when it came to increasing profitability by filling vacant appointments or booking appointments more accurately.
healthcare appointments would be made online.
t "UUIFUJNFPGUIFTVSWFZ BNJOPSJUZXFSF using online appointment booking (15%) but about half of the remainder (49%) were making plans or considering it.
t "MUIPVHIBCPVUJOSFTQPOEFOUT (29.3%) said that in the last year they had come to see the benefit of online bookings, a similar proportion (31.2%) still thought telephone bookings were best.
t +VTUPWFSIBMG BOUJDJQBUFEUIBU over the next 1-3 years a majority of all
t 0GUIPTFOPUDVSSFOUMZVTJOHBOPOMJOF appointment system, most (56%) saw it as
t Ä‡FNBKPSJUZ GFMUUIBUJODSFBTFE efficiency would only flow from online booking if it was integrated with their current booking software, while 22.3% said online bookings would not improve practice efficiency due to things like errors, lack of triage, and variable appointment lengths. O ED. 1st Available is an online appointment booking portal and mobile app integrated with practice management software.
Itâ€™s Not Just About the Money continued from P31 Dr Andrew Christophers is a FACEM specialist, WA-trained, and has been at Murdoch for 14 years. He said that a Q%S"OESFX$ISJTUPQIFST few ED physicians and experienced GPs picked up the baton when the ED started in 1994, and thatâ€™s how it has been since â€“ qualified doctors who could act and think independently. Most of the GPs have done a rural stint. â€œMost FACEM guys work elsewhere and know the pressures of the public system and are used to getting patients in and out. They also bring other things, other systems and people they can talk to by phone.â€? â€œItâ€™s enough to keep us interested because at one of the other hospitals you are more supervisory where here it is more hands on. There are no constraints of 4-hour rules so you can give the patient the care they need in the time necessary.â€? â€œItâ€™s a nice place to work. You have pretty experienced nursing staff. And there are no 32
blockages to patients getting out of the department.â€? What about when market forces of comparative wait times and cost come into play? â€œThe department has credibility. People know they are going to get good care. When you think of what $290 buys these days, itâ€™s not a massive amount for your own health. You are getting quality care in good time.â€? Dr Mike Butcher left rural general practice to work at Murdoch ED 14 years ago, where he now works full time. On busy days Q%S.JLF#VUDIFS he is rostered on with two or three other doctors and he still does occasional country locums. â€œED is an attractive place to work because you keep your skills. Murdoch will provide training courses and make sure you are upto-date with things like EMST,â€? Mike added, acknowledging that there are always gaps in knowledge.
What does he enjoy most? â€œThe staff is collegiate and friendly and there is variety of work and support. We donâ€™t do major trauma unless they come in our door, but we move them on. Itâ€™s busy, so we donâ€™t sit around twiddling our thumbs.â€? â€œThe relationship with the FACEM guys is excellent. We ask each other questions. Everyone has special interests, so quite a few of the ex-country GPs still do some country work, or obstetrics elsewhere, and quite a number of GPs work part time to accommodate those interests.â€? His personal opinion is that skilled GPs improve the ED and having a mix of GPs and specialists provides a broader cover of expertise. â€œWe are all doing the same work â€“ you have to have airway and emergency skills â€“ and most country GPs are comfortable with this.â€? The $290 ED fee doesnâ€™t faze him as a potential barrier, as it reflects the departmentâ€™s costs. O
By Dr Rob McEvoy
Antenatal inﬂuenza vaccine uptake increases Building on the 60% increase from 2012 to 2013 By Dr Donna Mak, Public Health Physician, Communicable Disease Control Directorate Although the World Health Organisation singles out pregnant women as the most important risk group for seasonal influenza vaccination and free influenza vaccine has been available to pregnant Australians since 2009, uptake has been poor.
care provider.1 By 2013, this proportion had increased to 59%. However, we need to improve this to 100% because three quarters (74%) of unvaccinated women reported that they would have influenza vaccine if their antenatal care provider recommended it.1 O
Fortunately, in WA the situation is improving. A recent telephone survey of 831 randomly selected women who were pregnant during the 2013 influenza vaccination season showed that influenza vaccination uptake in WA pregnant women jumped from 26% in 20121 to 41% in 2013 – a 60% increase. Nearly two-thirds (64%) of vaccinees were immunised in general practice.
Vaccine safety is an important consideration for pregnant mothers. Influenza vaccine uptake is higher among women who believe influenza vaccine is safe for themselves and their babies. A total of 3173 WA pregnant women (92.1%) who had agreed to postvaccination follow-up were contacted by SMS or telephone and asked whether they experienced any adverse events within the week following their vaccination. Eleven
1. Taksdal S, Mak D, Joyce S, Tomlin S, Carcione D, Armstrong P, et al. Predictors of uptake of influenza vaccination A survey of pregnant women in Western Australia. Australian Family Physician. 2013; 42: 582-6 2. Regan AK, Blyth CC, Effler PV. Using SMS technology to verify the safety of seasonal trivalent influenza vaccine for pregnant women in real time. Med J Aust. 2013; 199(11): 744-5.
percent of vaccinated pregnant women selfreported a reaction/s to the influenza vaccine in 2013 (swelling/pain at injection site [4%], headache [3%], cough/congestion [3%], fever [2%] and fatigue [2%]). No serious vaccinerelated events were reported.2 In 2012, only 36% of WA pregnant mothers reported having been recommended influenza vaccination by their antenatal
During the 2014 influenza vaccine season: t 3FDPNNFOEJOGMVFO[BWBDDJOFUPBMM pregnant mothers, and t 3FBTTVSFUIFNPGUIFWBDDJOFTFYDFMMFOU safety profile. #ZEPJOHUIJTXFTIPVMECFBCMFUPCPPTU BOUFOBUBMJOGMVFO[BWBDDJOBUJPOVQUBLFUP 74% this year.
Women’s Health Education for GPs again on offer for WA GPs
(Formerly Vocational Graduate Diploma of Women’s Health)
The KEMH invite you to enjoy built-in ﬂexibility, CPD rewards, and up-to-date content make the course value for money. Fine tune your knowledge and build useful clinical contacts. Participants can access the information in part or in whole. There are only 40 places – kept low to safeguard interactive learning – so enquire early. The course is designed by educational gurus at King Edward Memorial Hospital.
THE 2014 THEMES ARE:
Women’s Health Education for GPs
1. Antenatal Shared Care - 29 April – 24 June 2. Ofﬁce of Gynaecology and Reproductive Health - 29 July – 23 Sept Each theme is delivered over 8 evening sessions, with light refreshments beforehand. If you miss a session unexpectedly, you can watch via 'Moodle' webpage. We also provide 'Scopia' for those rural participants. Some GPs are keen to update on one theme only. They can, or they can attend selected evening sessions within a theme. Up-to-date information builds clinical conﬁdence in women’s health, and participants learn of relevant services at KEMH and across WA.
Theme: ANSC så 4HEå'0Så2OLE så "IRTHå/PTIONS så &ETALå!NOMALYå3CREENING så 4HEå&ETUSåATå2ISK så 5SEåOFå0RESCRIBEDå$RUGSå$URINGå0REGNANCYåANDå,ACTATION så 3MOKING å!LCOHOLåANDå)LLICITå$RUGå5SEåINå0REGNANCY så 0OSTNATALå#AREåOFå-OTHERåANDå"ABY
GP Paulien de Boer. “As a graduate from out of state, this course enabled me to gain an awareness of all the women’s health and information services in WA… and make some very useful contacts.”
så #OMMONå$ISEASESåINå0REGNANCY så #OMMONå)NFECTIONSåINå0REGNANCY
GP Liz Wysocki. “The lectures are of a very high quality, good notes and plenty of interaction and the obstetrics module is particularly useful to those of us attempting shared care.”
RTS A T S RIL AP 4 201
Tuesday evenings, 6.20-8.30pm. (Light refreshments 6pm). Agnes Walsh Lounge, KEMH. CPD points: 40 Category 1 per theme, 4 Category 2 per session (capped at 30 points) Cost: $685 (incl GST) per theme (8 sessions) or $90 per session. Contacts: email@example.com
A NEW INITIATIVE FOR PSORIASIS PATIENTS
LAUNCHING AUTUMN 2014 HELPING PSORIASIS PATIENTS STOP HIDING AND START LIVING Research published in JAMA in 2013 shows that a large proportion of patients with psoriasis are dissatisﬁed with their treatment (52.3%) or remain untreated.1 The Get Psorted program, a new initiative in Western Australia, aims to increase awareness of psoriasis, with a goal of improving outcomes for those patients who have psoriasis that is currently sub-optimally treated or untreated. The program is supported by funding from Janssen Australia and was compiled by an independent Steering Committee comprised of 4 Dermatologists. Associate Professor Kurt Gebauer, Chair of the program’s Steering Committee: “In my experience, I’ve seen a number of psoriasis patients present after having suffered in silence for years. The Get Psorted program is a great initiative to help patients suffering from psoriasis seek help about their condition, including obtaining educational material, assessment by an accredited dermatology nurse and referral back to their GP for further management, where warranted.”
GET PSORTED WORKS FOR YOUR PATIENTS: Patient becomes aware of Get Psorted program through GP or radio adverts
Patient contacts Get Psorted helpline nurse
Patient triaged to an accredited, independent dermatology nurse for free consultation, education and PASI* assessment
Nurse provides patient with educational materials and refers patient to GP**
HOW GET PSORTED MAY BENEFIT YOUR PATIENTS: Your patients may be pre-screened for psoriasis by an accredited dermatology nurse You may receive enquiries from patients who have undergone a screening PASI assessment and requested a referral letter
Should you wish to enrol your patients in or obtain more information about the Get Psorted program, call 1800 093 695
*The Psoriasis Area and Severity Index (PASI) is a formal system used to measure psoriasis symptoms and severity before and after treatment.**Patients in whom PASI screening suggests psoriasis. Reference: 1. Armstrong AW et al; Undertreatment, treatment trends, and treatment dissatisfaction among patients with psoriasis and psoriatic arthritis in the United States; JAMA Dermatol. 2013; 149(10): 1180–1185.
Get Psorted is supported by Janssen Cilag Pty Ltd, ABN 47 000 129 975. 1–5 Khartoum Road, North Ryde NSW 2113 Australia. Phone 1800 334 226. JANS0934/EMBC AU-STE0111 Date prepared: March 2014 medicalforum
Perspective: breast cancer inheritance risk When women with breast cancer ask, â€œWhy me ?â€? the usual answer is because you are a woman! One in eight women will develop breast cancer by age 85. Many women over estimate their inherited risk. Remaining breast aware and reporting new breast symptoms is important. All new breast symptoms require triple assessment with clinical, imaging and pathology, considered positive if ANY component is suspicious or malignant (for which referral is essential). Remember, breast cancer risk is increased by alcohol and post-menopausal obesity.
Inheritance in perspective The Angelina Jolie story has increased awareness of genetic testing in breast cancer but: t -FTTUIBOPGUIFQPQVMBUJPOBSFBU potentially high risk through inheritance, t 5IFNBKPSJUZPGXPNFOXJUIBGBNJMZ history of breast cancer do not fall into a high risk group and do not develop breast cancer t $BODFSTVTDFQUJCMFHFOFTBQQFBSEJSFDUMZ responsible for about 5% of all breast cancers. t (FOFUJDUFTUJOHJT/05PGGFSFEUPXPNFO on demand NOR is it recommended for the majority of women diagnosed with breast cancer. Who is potentially high risk through inheritance? Two or more first or second degree relatives on the same side of the family diagnosed with
breast or ovarian cancer (serous epithelial ovarian cancer) plus one of: t "EEJUJPOBMGJSTUPSTFDPOEEFHSFFSFMBUJWF with breast or ovarian cancer. t #SFBTUDBODFSEJBHOPTFECFGPSFZFBST of age. t #JMBUFSBMCSFBTUDBODFS t #SFBTUBOEPWBSJBODBODFSJOUIFTBNF woman. t "TILFOB[J+FXJTIBODFTUSZ (BRCA mutations). t #SFBTUDBODFSJOBNBMFSFMBUJWF Features particularly suspicious of gene mutation are young age of breast cancer (30s) and ovarian cancer (NB. important to confirm as often an unrelated gynaecological cancer).
What is the best online tool? Familial Risk Assessment- Breast and Ovarian Cancer (FRABOC) (see http:// canceraustralia.gov.au/clinical-best-practice/ gynaecological-cancers/familial-riskassessment-fra-boc). You can print out a patientâ€™s risk status.
Who should be considered for genetic testing? Genetic testing is offered to a living affected patient if the family history suggests a 10% chance of detecting a known gene mutation (usually multiple family members affected at a young age, or ovarian cancer). Results are given as either positive or inconclusive; no gene mutation found on testing does not mean that there is no definite gene mutation present.
By Dr Judy Galloway, Breast Physician. If a gene mutation is found then the rest of the family may be eligible for predictive genetic testing to see if they too have inherited the gene mutation known to be in their family. This result will be either positive or negative for the mutation with a 50/50 chance of either. Those patients who test negative can be reassured they are at population risk only. Only about 15% of people at potentially high risk who are tested actually return a positive result, the rest being inconclusive, meaning that the family remains at potentially high risk.
Who requires referral Assess the family history, using FRA-BOC to see if potentially high risk. Genetic services at KEMH can then assess and validate the family history, and liaise with genetic services within Australia and overseas. If they assess around a 10% chance of carrying a known mutation then genetic testing can be offered (many high risk women do not qualify for testing). High risk surveillance is then offered through RPH, SCGH and Perth Breast Clinic.
High risk surveillance This commences at 35 years of age, or five years younger than the youngest affected relative. An annual mammogram is complimented (until age 50) with an annual MRI (or for younger women an MRI alone is used). At age 50 most women can be assessed through BreastScreen WA. O Further reading: www.eviQ.org.au
Supporting Ophthalmic Research, Education and Overseas Projects
EYE SURGERY FOUNDATION Our Vision Is Improved Vision After 18 months of expansion, the Eye Surgery Foundation amalgamated two buildings and re-commenced surgical procedures in November. The new day hospital is twice the size â€“ four operating
theatres, a dedicated Laser room with a Femtosecond Laser, two recovery rooms, large reception, and a spacious staff room. The hospital is managed by Perth Eye Centre P/L.
Dr Ross Agnello Tel: 9448 9955 Dr Malcolm Burvill Tel: 9275 2522 Dr Ian Chan Tel: 9388 1828 Dr Steve Colley Tel: 9385 6665 Dr Dru Daniels Tel: 9381 3409 Dr Blasco Dâ€™Souza Tel: 9258 5999
Dr Brad Johnson Tel: 9301 0060 Dr Jane Khan Tel: 9385 6665 Dr Ross Littlewood Tel: 9374 0620 Dr Nigel Morlet Tel: 9385 6665 Dr Robert Patrick Tel: 9300 9600
Dr Graham Furness Tel: 9440 4033 Dr Kai Goh Tel: 9366 1744 Dr David Greer Tel: 9481 1916 Dr Boon Ham Tel: 9474 1411 Dr Philip House Tel: 9316 2156
Dr Rob Paul Tel: 9330 8463 Dr Jo Richards Tel: 9321 5996 Dr Stuart Ross Tel: 9250 7702 Dr Angus Turner Tel: 9381 0802 Dr Michael Wertheim Tel: 9312 6033
5FM&JOGP!FZFTVSHFSZGPVOEBUJPODPNBV42 ORD STREET WEST PERTH WA 6005 35
Perth Radiological Clinic supports Low Dose CT screening for lung cancer On December 31st 2013, the US Preventive Services Task Force (USPSTF) endorsed Annual Low Dose CT screening of high risk smoking patients for the HDUO\GHWHFWLRQRIOXQJFDQFHU1RZWKDWWKHUHLVVXIÂźFLHQWHYLGHQFH35&ZLOO provide this service: " Very low dose chest CT screening scans using the latest iterative reconstruction techniques at all 15 comprehensive practices across Perth " All screening chest CT scans for early detection of lung cancer will be reported by our team of specialist chest radiologists " Screening chest CT scans for pensioners and health care card holders will be bulk billed across all sites " Same day or next day appointments available at most sites
Leaders in Medical Imaging medicalforum
Contraception and weight T
here are three main issues to consider when thinking about contraception and overweight women:
1 = no restriction
t 8JMMDPOUSBDFQUJWFNFUIPETCFBTFÄŒFDUJWF t "SFUIFSFJODSFBTFESJTLT t %PFTIPSNPOBMDPOUSBDFQUJPODBVTF weight increase?
30-34 2 = benefits usually outweigh risks
Is contraception as effective for overweight women? A thorough Cochrane review looked at the effectiveness of combined pills, skin patches (not available in Australia), implants and injections, and the available evidence pointed to the same efficacy for overweight women as for those of normal weight with these methods.
3 = risks usually outweigh benefits
smoking or high blood pressure, the level of contraindication may increase further to 4 = unacceptable health risk.
Does contraception cause weight increase? Despite the common myth, there is little evidence for weight gain as a result of using contraceptive methods, with the possible exception of women using Depot injections who are already overweight.
There is now good evidence that the effectiveness of levonorgestrel emergency contraception is reduced in women who weigh over 75kg, and it is no better than placebo once the womanâ€™s weight is over 80kg.
For the combined pill, there is insufficient evidence to prove that there is no weight gain, but a number of reviews show that there is no evidence of weight gain when compared to placebo.
Does contraception pose increased risk for overweight women?
For the vaginal ring, the evidence suggests similarity with the combined pill.
Yes - for some methods. The main risk for overweight women is if they use combined hormonal methods - pills, rings and patches. This is due to the increase in risk of venous thrombo-embolism (VTE) for these women. For overweight women with extra risks for cardiovascular disease, such as diabetes,
Weight gain associated with Depot injections seems to be related to weight at baseline. Overweight women are reported to gain significantly more weight than normal weight women when using Depot, and obese Depot users gain more weight than obese combined pill or non-hormonal method users.
Cervical cancer screening C
ervical cancer is one of the few cancers where screening detects pre-cancerous lesions that can effectively be treated; usually squamous cell cancers that take more than 10 years to develop. A Pap smear every 2 years is the best protection against cervical cancer.
Women should start their Pap smears around 18-20 years or a year or two after first having sex, whichever is the later, and continue every two years until age 70 while they have a cervix. The NHMRC approved guidelines for managing asymptomatic Pap smear detected abnormalities, are based on epidemiological and scientific evidence, and an understanding of the role of HPV in cervical cancer. These guidelines are uniquely Australian and differ to guidelines used elsewhere.
Human Papilloma Virus This is responsible for up to 99.7% of cervical dysplasia and will infect 80% of women
at some stage of their lives. Genital HPV should be regarded as a normal part of being a sexually active person. In around 90% of women it clears up naturally in about 8-14 months. The HPV vaccine will prevent infection by HPV subtypes 16 and 18 in those patients vaccinated prior to exposure. Whilst the vaccine reduces the risk of cervical cancer it has not altered the need for screening. HPV is spread through genital skin contact during sexual activity; condoms only offer limited protection, as they do not cover all areas of genital skin. Testing for presence of HPV should be reserved for women who have been treated for high-grade abnormalities. Any symptomatic patient (unexpected bleeding, discharge or pain) or if any suspicion of cervical dysplasia is evident on examination, the patient should be referred for further evaluation irrespective of the Pap smear result.
By Dr Alison Creagh, Medical Educator, FPWA Sexual Health Services Progestogen only pills are not associated with weight gain. There is insufficient data comparing Implanon to non-hormonal options to know if weight gain is due to this method. IUDs are not associated with weight gain. Copper IUD users have the same changes in weight as hormonal IUD users. References available on request O
RECOMMENDATIONS t 3FDPSEIFJHIU XFJHIUBOE#.* for all women considering combined contraceptive methods.
t "WPJEDPNCJOFENFUIPETJG#.* over 35. t 3FBTTVSFQBUJFOUTUIBUUIFJSXFJHIUXJMM not affect the efficacy of their ongoing contraceptive method. t 1SPWJEFSFBTTVSBODFBCPVUUIFMBDL of evidence for weight gain with all DPOUSBDFQUJWFNFUIPETFYDFQUQFSIBQT %FQPUJOKFDUJPOT
Author declaration: FPWA receives funds from Bayer and from MSD to provide training workshops in the use of IUDs and Implanon.
By Dr Cliff Neppe, Obstetrician & Gynaecologist, Duncraig. 5FM
Colposcopy Examination of the lower genital tract under illumination and magnification reveals macroscopic malignant and pre malignant epithelial changes to the trained eye; pattern recognition allows biopsies from suspicious tissue. The triad of cytology via Pap smear, pattern recognition by colposcopy, and histology via biopsy, allows for a definitive management plan of the proven cervical dysplasia. Colposcopy is resource intensive and not cost effective as a screening tool.
Electronic screening techniques These are under development and large-scale clinical trials will be required to determine true performance. PolarTM probe and TruScanTM uses the principle that abnormal cervical tissue Continued on P38
Probiotics in pregnant women Dr Chris GrifďŹ n Consultant MFM and Obstetrician, KEMH. Tel 0450 851 152
robiotics can influence health in many organs by affecting immunological factors, mucosal permeability and bacterial translocation in the gut, and secreting various metabolites to modulate the immune response. In women, demonstrated benefits from probiotics have not been translated into clinical practice, despite overwhelming evidence of safety. Complete consideration of risk vs benefit ratio is recommended before prescribing, noting that the quantity and quality of the presumed bacteria in most over-thecounter preparations is not of high enough quality for clinical trials.
a probiotics dose-dependent reduction in early onset pre-eclampsia of up to 40%; twice the effect of prophylactic aspirin.
Obstetrics did not fully realise that the placenta was developing its own unique microbiome in the apparently sterile environment of the uterus. Using metagenomic techniques, fragments of bacterial DNA can be found throughout the placenta These fragments are influenced in number and diversity by antenatal infections.
Why is it that we are not trying more probiotics in pregnant women, given the data already available (and although watertight biological plausibility for benefit may be lacking)? The answer is complex but perhaps these observations are pertinent.
Some effects of probiotics in women Vaginal infection. Certain lactobacilli strains can safely colonise the vagina via â€˜displacementâ€™ or bactericidal activity against pathogenic organisms (e.g. Gardnerella vaginalis; E Coli and other enaerobes). Treatment with probiotics in pregnancy will decrease the rate of vaginal infections by 90% and probiotics given for the treatment of bacterial vaginosis is as effective as antibiotics (Cochrane reviews). Preterm birth. The vaginal microbiome is less diverse in women destined to deliver preterm, with a preponderance of anaerobic bacilli, which makes manipulation of the maternal microbiome an extremely attractive mechanism to reduce preterm birth. Offspring allergies. Maternal use of probiotics in the last month of pregnancy and continued infant ingestion of lactobacilli reduces the IgE mediated allergic diseases in infants born via Caesarean section. Pre-eclampsia. A Danish long term study involving over 30,000 women documented
Gestational Diabetes. GD increases the risk for type II diabetes in the offspring. Probiotic treatment showed a 60% reduction in rates of GD as well as reduction in plasma glucose and improved insulin sensitivity with a reduction in maternal truncal obesity post partum. Specific types of lactobacilli exhibit highly specialised functions e.g. cholesterol lowering effects, reduction of markers of inflammation (CRP).
The medico-political climate
The Cochrane database concluded that we needed better designed trials with larger sample sizes to test the effectiveness of promising drugs for treating bacterial vaginosis, despite the equivalent activity of lactobacilli in treating and more importantly preventing vaginal infections; only the promising drugs were mentioned. The Lancet recently published a short-term probiotic, randomised trial to reduce adult antibiotic related diarrhoea (PLACIDE study), yet the biological plausibility was completely absent. Lactobacillus treatment was over a short period of time and in a large number of patients, antibiotic treatment had commenced prior to â€˜rescue therapyâ€™ with lactobacillus. There is at stake, an annual $65billion probiotic market. Many probiotic symposiums at conferences are funded by food companies with a particular product line interest. The push to patent specific species for specific actions by global conglomerates makes economic sense but this will result in the loss of cheaper alternatives which are more applicable worldwide.
Western culture believes in the magic oneoff cures. In contrast, probiotic use is a way of life, requiring self-discipline. Any randomised controlled trials in pregnancy that also contain markers for poor selfdiscipline (e.g. 15% rates of smoking, morbid obesity), create doubt around stated compliance with probiotics and thus the potential for type II error.
Advice for patients Advice to patients is to keep it simple. I would recommend using the cheap natural yoghurt preparations with lactobacillus acidophilus present. However, probiotics use is not a quick fix, requiring long term use and dietary prebiotic support to reach full potential. My prediction is that over the next two years we will see an exponential increase in studies around probiotics and pregnancy. Currently, the largest randomised trial to date (SPRING study), is being conducted in Brisbane involving 540 women with a BMI > 25 with the primary outcome measure of a GD incidence reduction of 50%. Probiotic defn.: living microorganisms, which when given in adequate amounts, confer a health benefit on the host. Further reading: www.ncbi.nlm.nih.gov/pubmed/23180045 - overview of gestational diabetes www.ncbi.nlm.nih.gov/pubmed/23205866 - a systematic review www.biomedcentral.com/1471-2393/13/50 - the SPRING study O
Continued from P37 has characteristic electrical and optical properties that can detected by a probe on the cervix are then analysed algorithmically. Spectroscopy (using a fluorescent probe) relies on the principle of differential light emission by normal and abnormal tissue types. References available on request O
Declaration: No competing interests. 38
KEY POINTS 1. NHMRC guidelines refer to asymptomatic screen-detected abnormalities TFFXXXDBODFSTDSFFOJOHHPWBVJOUFSOFUTDSFFOJOHQVCMJTIJOHOTG$POUFOUHVJEF 2. Colposcopy remains the gold standard for diagnosing cervical intraepithelial neoplasia following abnormal cytology. 3. Testing for presence of HPV should be reserved for patients treated for high-grade abnormalities. 4. Electronic screening techniques appear very promising.
Herb use by menopausal women By Dr Nathan Francis, Integrative Medical Practitioner, Mount Pleasant. In 2012, speakers at the ANZCOG scientific meeting pointed to the problems with symptomatic menopausal women. Prof Henry Burger said best practice in women complaining of menopausal symptoms required the consideration of HRT. Prof John Eden said many menopausal women were suffering unnecessarily and were being prescribed anti-depressants instead of HRT. It is important to be aware of our patientsâ€™ use of over-the-counter formulations for various reasons, including a fear of HRT due to cancer risk, and this article discusses herbs patients may be buying to treat climacteric symptoms.
PIVET MEDICAL CENTRE Specialists in Reproductive Medicine & Gynaecological Services
by Medical Director Dr John Yovich
Quins & Quads at 25th Birthday â€Ś the pleasure and the pain
Black Cohosh This is the most common herbal extract consumed for menopausal symptoms. The extract is derived from Cimicifugae raceroot and is standardised to contain 2.5% triterpene glycosides. One study randomised 60 women under 40 years old, with climacteric symptoms (post hysterectomy with an intact ovary) into four groups. They were treated for six months with oestriol, conjugated oestrogens, oestrogenprogesterone sequential therapy or Black Cohosh. There were no significant differences in treatment success between the groups(1). Rachel Ruhlen, from the department of Surgery, University of Missouri, Columbia, found that 50 women taking Black Cohosh extracts experienced relief of menopausal symptoms with no effect on serum oestrogen markers and no effect on pS2 or cellular morphology in nipple aspirate fluid(2). Black cohosh is contraindicated in pregnancy and breast feeding. Side effects can include headaches, breast tenderness, rash, GI upsets and vaginal bleeding. There are reports of hepatotoxicity and it is contraindicated with hepato-toxic medications and certain chemotherapy treatments.
Traditional Chinese medicine Traditional Chinese medicine has a six ingredient herbal formula to treat climacteric symptoms. It contains Rehmannia glutinosa (rehmania) root, Cornus officinalis (Asian cornelian cherry) fruit, Dioscorea oppositifolia (Chinese yam) root, Paeonia suffrticisa (tree peony) root cortex, Poria cocos (poria) sclerotium and Alisma orientale (water plaintain) rhizome. Commercially, it is often combined with Ziziphus jujuba (ziziphus) seed and Anemarrhena asphodeloides (anemarrhena) rhizome for further benefits. In a randomised control trial, women with an average age of 50.6 years were allocated to receive the herbal formulae or placebo. The treatment group had relief of their menopausal symptoms with reduction of FSH and LH and significant (p<0.001) increase in oestradiol levels. Ziziphus has sedative and calming effects. Anemarrhena has been shown in animal models to have anti-depressant effects and has potential benefits in menopausal related depressant effects. The six herb combination is contraindicated in oestrogen sensitive cancers Use with caution in co-administration with hypogylcaemics, anticoagulants and phenytoin. In my view, the Rehmania mix, in combination with the two other herbs, is extremely useful is the early peri menopausal female with hot flushes and anxiety who is not keen on the combined OCP or an SRRI medication. References: 1. Lehmann-Willenbrock E,Riedel HH. Zentralbl Gynakol 1988; 110(10):611-618 2. RL Ruhlen et al. Nutrition and Cancer 2007,59(2), 269-277 O
Declaration: No author competing interests.
Nine healthy, happy children celebrating their 25th Birthday with Dr John Yovich who provided unique assistance to their two equally happy mothers.
The March 3 edition of the weekly magazine Womanâ€™s Day contains a very happy story of PIVETâ€™s quintuplets and quadruplets who were born at KEMH on the same day â€“ 18th January 1989. Those pregnancies were the result of novel techniques being applied during 1988 â€“ the quins arising from a laparoscopic PROST technique (pronuclear stage tubal transfer) and the quads from a trans-cervical TEST procedure (tubal embryo stage transfer). Although Western Australia was leading the world with the generation of numerous IVF children from 1982, pregnancy rates were relatively low at the time, being around 15%. A number of QHZWHFKQLTXHVWULDOOHGLQSURYHGEHQHĂ€FLDODQGZHZHUH taken by surprise with a dramatic 36% pregnancy rate for that year, but with â€œquite a fewâ€? twins, triplets and even higher-order pregnancies. However PIVET had special strategies for those pregnancies as well, including prolonged progesterone support during the entire antenatal period â€“ an idea only now being taken up widely around international high-risk obstetric centres to reduce preterm deliveries. The nine children from two mums are all healthy and have developed successful social and professional lives. The downside was a rush to legislation by the â€œauthoritiesâ€? resulting in the unnecessary, rather repressive, WA Reproductive Technology Act (1991). Nowadays, with the improved IVF technologies, PIVET applies a single embryo transfer policy meaning twins are rare, being mostly monozygotic, and higher order multiples are avoided entirely.
NOW AT 3 LOCATIONS LEEDERVILLE, JOONDALUP & BUNBURY
For ALL appts/queries: T:9422 5400 F: 9382 4576 E: firstname.lastname@example.org W: www.pivet.com.au
Treatment options for female urinary incontinence
By Dr Phil Daborn, Urogynaecologist, Subiaco. Tel 9382 2055
he involuntary leakage of urine affects up to 30% of women in their lifetime. The most common types are: Stress Urinary Incontinence (SUI) where a rise in intra-abdominal pressure leads to urinary leakage; Urge Incontinence (UI) where uninhibited detrusor contractions lead to the inability to defer voiding and leakage; and mixed incontinence.
Risk factors for incontinence include age, menopausal status, pregnancy and hereditary collagen factors. Stress incontinence may be due to either a defect in the valve mechanism or the urethral supporting structure. Urge incontinence is a symptom of many different pathophysiological mechanisms resulting in detrusor contractions.
Treatment options for stress incontinence t 1IZTJPUIFSBQZQFMWJDÄ˜PPSNVTDMF exercises (PFME). t "$POUJGPSNQFTTBSZNBZCFVTFGVMGPS women who only leak reproducibly in high impact situations such as exercise. A tampon is an alternative. t 4VSHJDBMPQUJPOT.JEVSFUISBMTMJOHT (MUS) are the surgical procedure of choice amongst gynaecologists for the treatment of SUI. Long-term data supports the use of the Tension-free vaginal tape (TVT), as efficacious as any other procedure but
with comparatively less morbidity than previous surgical options. Other slings have been developed using the â€œmid urethral placementâ€?, and are divided into three main groups: retro-pubic; transobturator; and single incision. None have been shown to be more effective than the TVT. t 0UIFSTVSHJDBMPQUJPOTGPSTFMFDUFEDBTFT Includes urethral bulking agents, fascial slings and urinary diversion.
Treatment options for urge incontinence t 1IZTJPUIFSBQZXJUICMBEEFSSFUSBJOJOH Tibial nerve transcutaneous electrical nerve stimulation. t "OUJDIPMJOFSHJDQIBSNBDPUIFSBQZ Solifenacin, oxybutynin patch, darifenacin and tolterodine generally have fewer side effects than the traditional option of oral oxybutynin. These medications all have similar efficacy. As a class of medication they have relatively poor long-term compliance, as side effects (dry mouth, constipation, blurred vision and lethargy) are common; having management strategies to deal with side effects helps compliance. Contraindications include narrow angle glaucoma and gastroparesis. If one anticholinergic is ineffective you can trial another. Patients with nocturia may benefit from low dose antidepressants such as imipramine at night time.
t *OUSBWFTJDBM#PUPYTM injections (into the detrusor muscle during cystoscopy) may be used in refractory detrusor overactivity. It has a relatively low morbidity rate and the clinical effect typically lasts 6-9 months. t 4BDSBM/FSWF.PEVMBUJPOXJUIUIF InterStimTM device has been licensed in Australia since 2010 for refractory detrusor overactivity, urge frequency and nonobstructive voiding disorder; 50% of patients will have a 90% improvement in their symptom scores and 80% will have a 50% improvement in their symptom scores. O
MANAGMENT IN GENERAL PRACTICE t 5SFBUQPUFOUJBMMZSFWFSTJCMFDBVTFTTVDI as constipation, UTIs and vaginal atrophy. t 7BHJOBMPFTUSPHFOUIFSBQZJO postmenopausal women. t 1IZTJPUIFSBQZ t "OUJDIPMJOFSHJDTGPSVSHFTZNQUPNT t 3FEVDFDBGGFJOFBOEBMDPIPM t 1BUJFOUTUPSFGFSFBSMZBSFUIPTFXJUI a history of voiding dysfunction, pain and haematuria, insensible loss, concomitant large vaginal prolapse or postoperative incontinence.
Author declaration: no competing interests.
Fair Work Moves on Bullying nti-bullying provisions of the Fair Work Act took effect on January 1, which allow some workers, for the first time, to be able to make a complaint directly to the Fair Work Commission (FWC) and the commission has the power to hear, arbitrate and issue determinations.
The FWC can issue an order to stop bullying if the worker establishes that â€˜repeated, unreasonable behaviour â€Ś creates a risk to health and safetyâ€™ has occurred and that the risk to health and safety is ongoing. Orders cannot be made where the worker is no longer connected with the workplace or for some other reason is no longer exposed to bullying by the individual or group at work. The new provisions are limited to â€˜constitutionally-covered businessesâ€™, which are: 40
t BCVTJOFTTUIBUJTBDPOTUJUVUJPOBM corporationâ€”e.g. a proprietary company (often indicated by â€œPty Ltdâ€? at the end of the organisationâ€™s name); a not-for-profit association incorporated under State or Territory incorporated associations legislation (usually indicated by â€œIncâ€? at the end of the organisationâ€™s name); a statutory authority incorporated under special legislation. t UIF$PNNPOXFBMUI t B$PNNPOXFBMUIBVUIPSJUZ The individuals and entities not covered by the new provisions are: t TPMFUSBEFSTPSQBSUOFSTIJQT
t TPNFMPDBMHPWFSONFOUT QSPWJEFEUIFZ are not trading or financial corporations t DPSQPSBUJPOTXJUIPVUTJHOJÄ•DBOUUSBEJOH or financial activities. Avant has a detailed â€˜FAQâ€™ concerning the new provisions on its website. The FWC must start to deal with the workerâ€™s application within 14 days of the application being made and goes through a six-step process that ends with a determination by the Panel Head. There is no â€œstandardâ€? procedure but some examples of how an application may proceed are mediation, conciliation or hearing. Websites: www.fwc.gov.au; www.Avant.org.au; www.cciwa.com O
t TPNFTUBUFHPWFSONFOUEFQBSUNFOUTBOE (non-corporate) state public sector agencies medicalforum
The PMS blues
By Dr Stephen Lee, Director Postgraduate Medical Education KEMH. Tel 9340 1388
remenstrual syndrome (PMS) is common and can cause significant distress to the patient and their loved ones. Treatment is relatively easy and can vastly improve the womanâ€™s quality of life, so screening for it may relieve previously unrecognised suffering in someone with intrusive symptoms that warrant a diagnosis of PMS While up to 85% of Australian women have menstrual cycle-related symptoms of some description, in the 3-30% of women diagnosed with PMS the following criteria must be met (Magos, 1984): t %JTUSFTTJOHQIZTJDBM CFIBWJPVSBMBOEQTZDIPMPHJDBMTZNQUPNT t "CTFODFPGVOEFSMZJOHPSHBOJDPSQTZDIJBUSJDEJTFBTF t 3FHVMBSSFDVSSFODFPGTZNQUPNTEVSJOHUIFMVUFBMQIBTFPGFBDI menstrual cycle; AND t %JTBQQFBSBODFPSTJHOJÄ•DBOUSFHSFTTJPOPGTZNQUPNTCZUIFFOEPG menstruation.
New understanding Unfortunately, some health professionals still believe PMS is a socially constructed illness and do not pay it the attention it deserves. The absence of PMS in puberty, pregnancy and menopause indicates that cyclical ovarian activity plays a major role. Although its precise aetiology is unknown, functional MRI and PET studies of the brain have found a reduction in serotonin receptor activity in the luteal phase compared to the follicular phase. The proposed evolutionary rationale behind PMS is interesting: PMS prompts females to reject infertile males, as females who manifest PMS are those who have not been impregnated; an infertile male/potentially fertile female partnership would tend to break down, which allows a new partnership to be formed.
CASE HISTORY Jane broke down and confessed that her horrible premenstrual mood swings had caused her husband and children to move out of the house for several days each month. â€œI am a total b----, during that time of the month,â€? she cried. Jane was originally referred by her GP because of heavy periods and her battle with PMS came up during routine screening when QSFTDSJCJOHUIFMFWPOPSHFTUSFMJOUSBVUFSJOFTZTUFN -/(*64 GPS IFBWZNFOTUSVBMCMFFEJOHo*IBWFTFFOBXPSTFOJOHPG1.4 XJUIUIFVTFPG-/(*64+BOFQPMJUFMZEFDMJOFEUIF-/(*64BOE revealed that her PMS was more problematic and no-one in her household would tolerate a worsening of her PMS. The consultation became focused on the management options for PMS and she DIPTF POUIFCBTJTPGDPTUBOEUBCMFUNJOJNJ[BUJPO MVUFBMQIBTF sertraline. She agreed to keep a symptom diary for both before and BGUFSTUBSUJOHUSFBUNFOU'PVSNPOUITMBUFS+BOFTBJEMVUFBMQIBTF sertraline had improved her premenstrual depressed mood and irritability significantly, but the best thing was that her family no longer had to move out for a few days every month!
Declaration: No author competing interests.
Documenting things accurately A more objective symptom diary can help demonstrate the recurring nature of symptoms, which can be divided into three groups: 1. Psychological e.g. mood swings, irritability, depression and feeling out of control;
Declaration: No author competing interests.
2. Physical e.g. breast tenderness, bloating and headaches; and 3. Behavioural e.g. reduced visual-spatial and cognitive ability, and an increase in accidents.
Treatment Advice regarding exercise, diet and stress reduction is beneficial as both overweight and a sedentary lifestyle are often linked to PMS. First-line treatments such as cognitive behavioural therapy, combined new generation pills such as Yasmin, and continuous or luteal phase (day 15-28) low-dose SSRI can be implemented â€“ all shown in randomised-controlled trials to be effective in the treatment of PMS. Second-line treatments, often by a gynaecologist, includes: t 0FTUSBEJPMQBUDIFTXJUIPSBMPSFOEPNFUSJBMQSPHFTUPHFOTUP protect the endometrium; t )JHIFSEPTF443*TFJUIFSDPOUJOVPVTMZPSEVSJOHUIFMVUFBMQIBTF t (POBEPUSPQJOSFMFBTJOHIPSNPOFBOBMPHVFT (O3)B XJUIBEE back hormone replacement therapy; t 5PUBMBCEPNJOBMIZTUFSFDUPNZBOECJMBUFSBMTBMQJOHP oophorectomy. This final measure, although effective in some cases, is fortunately rarely needed, and must not be employed as a management option until GnRHa has been trialled and proven to be effective. O
g n i h g i e e h t W up s e v i t i s Po Club rowing has become the focus for healthy choices for a doctor and a student who have both struggled with weight issues. Stepping gingerly into a rowing scull on the Swan River at ďŹ ve oâ€™clock on a winterâ€™s morning is not for the fainthearted. But thatâ€™s exactly the point. Quite apart from the cardiovascular workout, radiologist Dr Susanne Guy and elite sculler Amy Walters love the camaraderie of gliding across the water to the rhythm of ďŹ‚ashing oars. i5IFSFTBTUSPOHUSBEJUJPOPGSPXJOHJONZ family. My father and brother rowed and I did the same when I was young and also competitively at medical school in the UK.
Q Amy Walters
I had a 10-year hiatus during my physician and radiology training and became very unfit and overweight,â€? said Susanne. â€œI moved to Perth in 2004 and wanted to HFUCBDLJOUPBIFBMUIZMJGFTUZMF*KPJOFEUIF West Australian Rowing Club (WARC) and, combined with watching my food intake, ended up losing 42kg.â€? Susanne is very conscious of the impression that medical professionals make on UIFJS QBUJFOUT 4IFT B GJSN CFMJFWFS JO UIF EJDUVN A1IZTJDJBOIFBMUIZTFMG â€œI feel very strongly that doctors and OVSTFTTIPVMETFUBHPPEFYBNQMF)PX can anyone work in our field and preach about the merits of a healthy lifestyle XIF XIFO UIFZSF PCFTF UIFNTFMWFT :PV hav have to be able to look after yourself bef before you can begin to look after others ers.â€? i*W i*WF TFFN NFEJDBM TUBGG XIP BSF un unable to walk down a hospital corrid ridor without becoming breathless. *U *U SFGMFDUT XIBUT IBQQFOJOH JO UIF HF HFOFSBM QPQVMBUJPO BOE JUT TBE th that Australia now has the fastest in increase in obesity rates in the develo oped world.â€? i i5IBUT QSPCBCMZ QBSU PG UIF SFBTTPOXIZ*NBMJUUMFJOUPMFSBOUPGNZ o overweight colleagues. I reflected o on my professional appearance and NBJOUBJOFE NZ XFJHIU MPTT *N BO FYGBUUZBOEUIBUTQSPCBCMZBCJUMJLF CFJOHBOFYTNPLFSw
0OF PG 4VTBOOFT SPXJOH DMVCNBUFT "NZ Walters, knows the difficulty of an eating disorder, having struggled with it for the past seven years but the discipline and camaraderie of rowing has been a significant factor in her ongoing recovery. Amy, 25, is an elite rower competing on the national level and is studying nutritional medicine, She happily admits that rowing is a huge part of her life, both physically and emotionally. â€œI love the feeling of being out on the water BOE*NRVJUFDPNQFUJUJWF UPP*UTHPPEUP work towards a specific goal. The Swan 3JWFSTBCFBVUJGVMQMBDFUPCF FWFOBUGJWF in the morning with a bow light!â€? When Medical Forum caught up with Amy she was training for the national championships where she was competing in the single sculls, double and quads. Training was intense BOEUIBUTUIFUJNFTIFOFFETUIFGSJFOETIJQ and support of her clubmates most. â€œA few years ago I started losing weight when I increased my training levels. No one ever made any comments, negative or posiUJWF BCPVUNZBQQFBSBODFCVU*KVTUTUBSUFE cutting certain foods out so I could stay at a certain weight. There was a massive fight going on in my head because I knew what * XBT EPJOH XBT NBLJOH QFPQMF *N DMPTF UPWFSZVOIBQQZ"OEJUDFSUBJOMZEJEOUIFMQ when I was keeping it secret.â€? i8FWF QVU JO QMBDF B NVUVBM BHSFFNFOU between my doctors and my coach that *N OPU BMMPXFE UP SPX JG * ESPQ CFMPX B
E S I D A R A P IN
Q Dr Susanne Guy
Film-maker Clive Neeson, who bounces between Claremont, WA, and Taranaki in New Zealand, will unveil nearly 50 years of adventure onto the big screen when his life work, Last Paradise, opens next month in Perth. Clive, who completed two years of medical school before becoming a physicist, has a driving passion for the physical sciences and the TIFFSKPZPGUIFPVUEPPSMJGF
certain weight. I hated having to do it, but I knew it was necessary. I needed to put a system in place that would keep things in some sort of order.â€? i*WFCFFOTFFJOHBQTZDIPMPHJTUPODFBGPSUOJHIUGPSUIFMBTUUXPBOE BIBMGZFBSTBOE*WFCFFOHPJOHUPBEJFUJDJBOGPSBMPOHUJNF.Z(1 is wonderful and she understands my situation really well.â€? Susanne, approaching her mid-40s with two young children, freely BENJUTTIFDBOUTVTUBJOUIFUSBJOJOHSFHJNFSFRVJSFEGPSIJHIMZDPNQFUJUJWFSPXJOH/POFUIFMFTT UIFGMFYJCJMJUZPGCPUIBOFRVBMMZBDUJWF husband and her medical specialty sees Susanne out on the water two or three times a week. â€œI used to train really hard when I was competing at a high level, but that was before marriage and children. My husband, who works in hospital occupational health and safety, is a keen mountain-biker so we have to keep everything fair and balanced.â€? i*UT JOUFSFTUJOH UIBU NPTU PG NZ SBEJPMPHZ DPMMFBHVFT BSF FRVBMMZ DPNNJUUFEUPIFBMUIBOEGJUOFTT*UTBTQFDJBMUZUIBUMFOETJUTFMGUP a balanced lifestyle and you can structure your day quite easily. If ZPVSFBXBSECBTFEDMJOJDJBOJUDBOCFBMPUNPSFVOQSFEJDUBCMFw 4VTBOOF XBYFT MZSJDBM SFHBSEJOH UIF MPOHFWJUZ BOE QMFBTVSFT PG rowing. i*UTTPNFUIJOHZPVDBOEPVOUJMBSJQFPMEBHF*IBEBDPBDIJOIJTT IFTTUJMMSPXJOHBOE JOGBDU IFXBTCBDLJOBCPBUUXPXFFLTBGUFSB UPUBMIJQSFQMBDFNFOU*UTBCJUMJLFTXJNNJOH JUVTFTFWFSZNVTDMFJO your body. And the endorphin hit is wonderful!â€? O
By Mr Peter McClelland medicalforum
i*E BMXBZT XBOUFE UP NBLF B GJMN BOE TPNF PG UIJT GPPUBHF HPFT back nearly 50 years. All the people involved were friends from New ;FBMBOE 8F XFSF KVTU SFMJWJOH PVS ZPVUI BT B CVODI PG XJEFFZFE kids playing in the wilderness.â€? i*UT TP JNQPSUBOU UP SFUBJO UIBU DIJMEIPPE FYDJUFNFOU UP LFFQ UIBU grin on your face and a sense of wonder at the world around us. The action in Last ParadiseJTBNB[JOHCVUUIFTFDPOEBSZJOUFOUJPOJTUP make people think more deeply.â€? 8"XSJUFS 5JN8JOUPOoOPTUSBOHFSUPFOWJSPONFOUBMDBVTFToXJMM JOUSPEVDFUIFGJMNBUJUT1FSUITDSFFOJOH#PUI$MJWFBOE5JNBSFQBTsionate advocates of a closer relationship with the natural world. â€œThere have been some very damaging changes since the 1970s and T XIFO XF GJSTU CFHBO GJMNJOH /BUVSBM QMBZHSPVOET IBWF CFFO EFTUSPZFE XFSFMJWJOHJOBQFSQFUVBMDPNGPSU[POFBOEZPVOHQFPQMF have forgotten how to manage difficult situations.â€? i5IFZSFOPUFYFSDJTJOHUIFJSASJTLNVTDMFTBOZNPSFBOEXFSFHFUting too comfortable living in a nanny state.â€? $MJWFTCBDLHSPVOEJTBUFTUBNFOUUPUIFGSVJUGVMNBSSJBHFPGUIFUXP DVMUVSFToBSUBOETDJFODFoBOEJUTBCJMJUZUPIBSOFTTUIFQPXFSTPG imagination and innovation. â€œI helped to develop the first digital camera and climate monitoring system. The technology was utilised for robotic vision and morphed into a Skype variant used for remote surgery in the 1980s.â€? i*UTXFMMLOPXOUIBUGFXFSZPVOHQFPQMFBSFTUVEZJOHTDJFODFBOE XFOFFEUPDIBOHFUIBU*UTTPJNQPSUBOUUPSFUBJOUIBUTFOTFPGXPOder and I hope that comes through in the film.â€? -BTU1BSBEJTFTDSFFOTBU-VOB-FFEFSWJMMF .BZO
By Mr Peter McClelland 43
Myraâ€™s g Spirt n i t h Lives On f ig
Q Patricia Routledge and Piers Lanes
One womanâ€™s determination to heal the wounds of war with music echoes through the decades in a new stage show. It takes a remarkable story to draw the talents of remarkable people and Admission: One Shilling is just that remarkable story. Heading to His Majestyâ€™s Theatre next month, the show sees one of Australiaâ€™s most celebrated musicians, pianist Piers Lane, join forces with one of the Britainâ€™s most recogniseable actors, Patricia Routledge.
â€œHis double-take sowed a seed in my mind. In 2009, I commissioned Nigel Hess, .ZSBT HSFBU OFQIFX BOE B XFMMLOPXO DPNQPTFS UPXSJUFBTDSJQUCBTFEPO.ZSBT diaries and interviews. Then he and Patricia, EJSFDUPS $ISJT -VTDPNCF BOE * IBE TFWFSBM fabulous lunches, refining the script and the NVTJDBMJEFBToBOEUIFTIPXXBTCPSOw
5IF TUPSZ JT GJUUJOH UIF DBTU o QJBOP WJSUVPTP .ZSB )FTT XIP GPS TJY ZFBST EFGJFE -POEPOT CMBDLPVU CPNCJOH BOE MPDLEPXO to give the gift of music to hundreds of thousands of war battered civilians and service people in a series of lunchtime concerts at -POEPOT/BUJPOBM(BMMFSZ
â€œWe weave words and music together. I QMBZTIPSUQJFDFTGSPN4DBSMBUUJUP)FTTT own famous arrangement of Jesu, Joy of Manâ€™s Desiring (once, according to the late John Amis, infamously introduced on the SBEJPBT+FTTJF +PZPG.FOT%FTJSJOH w
)FTTTNVTJDIBTMPOHCFFOBQBSUPG1JFST musical life, describing her as â€œa musical grandmotherâ€?. â€œI studied with Yonty Solomon, one of her only long-term students, and grew up listening to her recordings,â€? he told Medical ForumGSPNIJTCBTFJO-POEPO
1JFST XIPIBTCFFOCBTFEJO-POEPOTJODF 1983, is perhaps one of the busiest men in UIFCVTJOFTToQMBZJOHTPMPSFDJUBMT PSDIFTtral concerts and collaborating with fellow artists in some of the great halls and venues in the world.
It was also where the idea of Admission: One Shilling coalesced.
His prodigious talent saw him leave his #SJTCBOFIPNFBUUIFBHFPGBOEIFIBT CFFOPOUIFSPBEFWFSTJODF)FTQMBZFEBU Carnegie Hall, the Proms at Albert Hall and DPODFSUT XJUI UIF MJLFT PG .BSUIB $MBSLFT /FX :PSL EBODF DPNQBOZ NF[[P TPQSBOP "OOF4PGJFWPO0UUFSBOEIJTDMPTFGSJFOET "VTUSBMJBO TJOHFST $IFSZM #BSLFS BOE 1FUFS Coleman-Wright on numerous occasions.
â€œAt the very first Day, Patricia Routledge XBTJOUIFBVEJFODFoTIFTBHSFBUDPODFSU goer. A friend of mine was startled to look up and see Myra Hess sitting in the hall (she died in 1965!) and then realised it was Patricia.â€?
And there is, of course, a hefty discography with a collection of his concert encores, Piers Lane Goes To Town KVTUSFMFBTFEPO the Hyperion label, which he described as BiRVJYPUJDNJYoCVUTPNFIPXSFQSFTFOUBtive of me.â€?
Since 2006, Piers has directed the annuBM .ZSB )FTT %BZ JO UIF #BSSZ 3PPNT BU the National Gallery, where the legendary series of weekday wartime concerts took QMBDFGSPN0DUPCFSVOUJM"QSJM
"T 1BUSJDJB OBSSBUFT )FTTT BNB[JOH TUPSZ 1JFST QMBZT QJFDFT GSPN )FTTT XJEF SFQertoire as photographs from the time are QSPKFDUFEPWFSIFBE
8IJMF UIF XPSME JT 1JFST TUBHF UIF QVMM PG home is strong. Apart from regular visits to play, he has also been musical director of UIF"VTUSBMJBO'FTUJWBMPG$IBNCFS.VTJDJO 5PXOTWJMMFTJODF#VUJUXBTOPUKVTUB fabulous musical gig that lured him. â€œMy mother and her parents were all born JO 5PXOTWJMMF *E TQFOU FWFSZ $ISJTUNBT holiday from the age of eight to 16 with my grandparents in Innisfail, a small cane town north of Townsville.â€? â€œThe North was in my blood and it seemed FYUSBPSEJOBSZ * XBT PGGFSFE UIBU QPTJUJPO JO Townsville soon after my mother and her mother had died, so taking it on felt like a sort of homage to them.â€? /FYU NPOUI UIF NVTJDBM IPNBHF UVSOT UP Myra Hess and Piers believes Australian BVEJFODFT XJMM EJTDPWFS BO FYUSBPSEJOBSZ woman of resilience, determination and talent. i5IF TIPX BMTP FYQSFTTFT UJNFMFTT USVUIT BCPVU NVTJD XBSUJNF BOE IVNBO FYQFSJFODF JO HFOFSBM 8FWF QFSGPSNFE JU UISPVHIPVU UIF 6, BOE JO #FMHJVN BOE BMXBZTBVEJFODFTTFFNUPCFNPWFECZJUo to the point of tears on occasion. I suspect Australian audiences will react similarly.â€? O
By Ms Jan Hallam
WIN Admission: One Shilling is at )JT.BKFTUZT5IFBUSF .BZ 'PSZPVDIBODFUPXJOUJDLFUT go to Competitions, P51.
Good Drops from the Hill
2012 Lakeview Sauvignon Blanc Semillon
By Dr Martin Buck
This is still a lively wine bursting with lime and grassy aromas. The palate has HPPEMFOHUIXJUIDSJTQBDJE MFNPO[FTUBOETIFSCFUGMBWPVST5IFSFJTTUJMMMJGF in this classic blend and will be good drinking for another year or so. A great choice with a local marron salad.
I have heard good things about Brown Hill Estate recently but I had not tried their wines. All was now about to be revealed with a selection of their latest-release red wines as well as a white and an older blend.
2012 Trafalgar Cabernet Merlot Though still young this classic blend, with 30% merlot, has visible intensity in the HMBTT"EFFQ CSPPEJOHXJOFXJUIQMVNBOEDJHBSCPYBSPNBT.BUVSBUJPOIBT CFFOJOBNJYPGOFXBOENBUVSFPBLXJUIBQMFBTBOUDPNQMFYJUZBOEGJOFUBOOJOT Age will bring the fruit to the fore and I would keep in the cellar for another year.
The vineyard is located in the more out of UIF XBZ 3PTB #SPPL BSFB BSPVOE NJOutes from the town of Margaret River. Soils and viticulture are harsh, more accurately unirrigated, to produce concentrated fruit and wines of great depth. My tasting was a great package of very well priced wines that are already on the radar of smart wine buyers. It is also reputed to have the friendliest cellar door in the South West.
2012 Chaffers Shiraz 5IJTXBTUIFSVOOFSVQJO3BZ+PSEBOT#FTU7BMVF8JOFPGUIF:FBSBOEJUJTB big wine. It has a deep crimson colour and a concentrated nose of plum, spice and DFEBS0ODFBHBJO JUTBHFEJO'SFODIPBLXJUIBSPVOEBRVBSUFSOFX-PXHSBQF yields give intensity to the palate, which will make this another wine with ageing potential. 2012 Ivanhoe Reserve Cabernet Sauvignon The finale of the young 2012 reds is the Ivanhoe, which is handpicked off vines XJUIUIFMPXFTUZJFMEJOHGSVJU&YUFOEFENBDFSBUJPOBOETLJODPOUBDUHJWFT NPSFCPEZBOEDPNQMFYJUZ5IFSFTMPBETPGGMBWPVSBOEMPOHQBMBUFPGCFSSJFT chocolate and well-balanced tannins. It was a sensational wine with my Scotch fillet and highly recommended. 2010 Bill Bailey Shiraz Cabernet -BUFQJDLFEGSVJUBOENPSFDPNQMFYXJOFNBLJOHDPNCJOFUPDSFBUFBCMPDLCVTUFS PGBSFEXJUINBTTJWFGSVJU TNPVMEFSJOH KBNNZ DIFSSZBOEDIPDPMBUFGMBWPVSTXJUI subtle integrated tannins. If you like your red with enough machismo to hold its own with your favourite aged beef, then this is your wine! Cellaring is optional and JNNFEJBUFFOKPZNFOUSFDPNNFOEFE
WIN a Doctor's Dozen! In what wine subregion is Brown Hill Estate situated? Answer:
ENTER HERE!... or you can enter online at www.MedicalHub.com.au! Competition Rules: One entry per person. Prize chosen at random. Competition open to all doctors or their practice staff on the mailing list for Medical Forum. Competition closes 5pm, April 30, 2014. To enter the draw to win this month's Doctors Dozen, return this completed coupon to 'Medical Forum's Doctors Dozen', 8 Hawker Ave, Warwick WA 6024 or fax to 9203 5333.
E-mail: ......................................................................................................... Contact Tel:
Please send more information on Brown Hillâ€™s offers for Medical Forum readers.
Q Yosemite Fawn
Into the Wild of Yosemite
The journey to the Yosemite National Park may throw up some challenges but the sights will take your breath away.
It would be fair to say that most visitors to America do not include Yosemite National Park in their itinerary. There must be myriad reasons for this, not the least of those being, driving on the opposite side of the road, the several hours it takes to drive to the valley and, the high cost of what I would call comfortable accommodation. Driving holidays are, however, my favourite kind of holiday so it seemed silly to be drivJOH GSPN 4BO 'SBODJTDP UP -BT 7FHBT BOE
not make the detour into Yosemite. Having said that, my husband and I had no real idea of the great natural wonder that awaited us and, we had to compromise our one rule of BDDPNNPEBUJPOoIBWJOHBOFOTVJUF Due to cost, and our propensity for â€˜livJOH PO UIF FEHF XF IBE DIPTFO UP TUBZ at Housekeeping Camp, a site with several IVOESFE AUFOUT NVDI MJLF UIPTF TFFO JO National Lampoonâ€™s Vacation. We had educated ourselves thanks to YouTube, on the risk bears posed to our rental car and looked forward with a little trepidation to the possibility of sighting said bears.
Q Yosemite Valley
in this region throughout most of August were still being brought under control and BO IPVST EFUPVS XBT SFRVJSFE UP FOUFS UIF QBSL 5IF FYDJUFNFOU CVJMU BT XF GPMMPXFE the winding roads through the mountains and stopped for petrol at the last place XIFSF ZPV XPVMEOU IBWF UP TFMM ZPVS DIJMdren to pay for it. 5IFHJBOU TNJMJOHGPSNPG4NPLZUIF#FBS made for an ominous greeting under the circumstances. With every turn of the road, gasps of wonderment filled the car but it XPVMEOU CF MPOH CFGPSF XF XFSF MBVHIJOH at ourselves for our misplaced use of a dicUJPOBSZTXPSUIPGTVQFSMBUJWFT
The bushfires which had wreaked havoc
Red All Over The WA Medical Students Society will be TFFJOH SFE OFYU NPOUI y CVU JU XJMM CF GPS BHPPEDBVTF8".44T3FE1BSUZXJMMCF IPTUJOHUIFGJSTU"VEJ3FE"XBSF(BMB#BMMUP SBJTFGVOETGPS)*7"*%4BGGFDUFEDPNNVOJties in South Africa and the wider medical DPNNVOJUZJTJOWJUFEUPFOKPZUIFFOUFSUBJOment, charity auction and a three-course EJOOFSEFTJHOFECZ'SBTFSTFYFDVUJWFDIFG Chris Taylor. 5IF HBMB JT UIF CSBJODIJME PG #JKJU .VOTIJ BOE "SKVO ,BVTIJL XIP XFSF MPPLJOH GPS new ways to raise valuable funds. Since 46
the launch of the Red Party the QSPKFDU IBT SBJTFE OFBSMZ XIJDI IBT CFFO EPOBUFE UP 0YGBN "VTUSBMJBT*OUFHSBUFE)*7BOE"*%4 Program in South Africa. 5IF "VEJ 3FE "XBSF (BMB #BMM XJMM UBLFQMBDFPO.BZBUUIF'SBTFST 4UBUF 3FDFQUJPO $FOUSF 'PS NPSF information about the event and tickFUEFUBJMTWJTJUSFEQBSUZPSHHBMBCBMM
QArjun Kaushik and Bijit Munshi from the Red Gala Ball committee.
Travel Q Housekeeping camp
Yosemite National Park The 3000sq km Yosemite National Park is in Central Eastern portion of California. Most travellers spend their time in the 18sq km Yosemite Valley. Almost 95% of the park is designated wilderness with BNB[JOHCJPBOEHFPEJWFSTJUZ
Car hire cost:.JESBOHF BXFFL
Accommodation:7BSJFToGSPNCBTJDUFOUT BUIPVTFLFFQJOHDBNQBUBOJHIU and depending on time of year, a hotel SPPNXJUIFOTVJUFGSPNBOJHIUBUUIF 8BXPOBUPBOJHIUBUUIF"XBIOFF
t *UTIBSEUPUIJOLPGBCFUUFSQMBDFUP TUBZUIBOJOUIFWBMMFZ*GZPVEMJLF to stay in a tent book a few months in advance because of high demand.
Getting there:#ZDBSo4BO'SBODJTDP UP:PTFNJUF GPVSIPVST-PT"OHFMFT UP:PTFNJUF TJYIPVST-BT7FHBTUP Yosemite, a complicated nine hours. There are a few airports 1-2 hours from :PTFNJUFTPZPVDPVMEGMZDMPTFSGSPN-" then a combination of rail and bus.
Websites:XXXOQTHPWZPTF OBUVSFTDJFODFCFBSTIUN www.nps.gov; www.yosemitepark.com; www.yosemitehikes.com (prices here are outdated)
When we reached the heart of Yosemite Valley with its winding, clear, pebbly river BOE NBKFTUJD GPSFTUT TXBUIFE JO HSFFO * looked up at the sheer, white granite that surrounded me and realised that I was in the PGGJDFPGOBUVSFTCFTUQTZDIJBUSJTU
rise and was able to stand on a lovely stone bridge and watch in awe as the great granite mountains imposed their reflection on to the still waters of the lake beneath me.
were seeing as I was and rather than the immense and seemingly endless white granite mountains making me feel insignificant, I felt an incredible sense of belonging.
'PSDJOHNZIVTCBOEPVUPGCFEBOEJOUPUIF car at such an early hour was also living on the edge but it gave us the opportunity to see large numbers of deer with their young feeding along the roads. A reasonably easy 40-minute walk through the forest was filled with squirrel sightings and the fascinating sound of woodpecker birds.
I could say I was lost for words but the truth JT GPS UIF GJSTU UJNF JO NZ MJGF * EJEOU XBOU to speak. The sheer face of the Half Dome stands immovable in time and space, pressing against your consciousness and telling you that living life on the edge might sometimes be terrifying, like turning a corner onto the wrong side of the road and being able to do nothing but scream as loud as you can CFDBVTFZPVSFOPUUIFESJWFS#VUMJGF VOMJLF :PTFNJUF JTGMFFUJOHBOEUIJTLJOEPGFYIJMBration is worth the risk. O
At Housekeeping Camp you can request a tent near the ablution facilities if available and basic but comfortable beds are provided with electrical outlets for doing your own cooking. I followed the rules strictly on placing food and toiletries in the bear locker, but it did come as a shock when I turned around to find a squirrel in our bags in search of food. 5IF SVMF IFSF JT ALFFQ XJMEMJGF XJME BOE ZPVMM IFMQ UP LFFQ UIFN BMJWF BOE JU XBT learning this that saved me from being disappointed that I did not see a bear. I was the lone visitor up both mornings before sun-
0O PVS TFDPOE EBZ XF NBEF UIF IPVS and-a-half drive along roads that felt like they might disappear over the edge at any moment, to a viewing location called Glacier Point. Sometimes being around crowds of PUIFSUPVSJTUTDBOTQPJMUIFFYQFSJFODFPGB natural location, but every person at Glacier 1PJOU XBT KVTU BT TQFFDIMFTT BU XIBU UIFZ
t &EVDBUFZPVSTFMGPOUIFCFBSSVMFTBOE follow them. t *GZPVQMBOUPIJLF QMBOJOBEWBODF t -PPLPVUTJEFUIFWBMMFZQSPQFSGPS day trips.
By Ms Nicola Bradbury
UNDISCOVERED ITALY Travel the back roads of Abruzzo - the undiscovered gem of central Italy. Take the road less travelled as you immerse yourself in true village Italy and live like a local. Experience northern and central Abruzzo with its towns and medieval hilltop villages, enjoy a private cooking class and taste fine local olive oils, wines and seasonal produce. Dine in sensational slow food restaurants in true Abruzzese style. Speak to one of our experienced consultants to plan your next Italian adventure today.
Shop C7, Currambine Central, 1244 Marmion Avenue, Currambine Freecall 1800 605 044 travel-associates.com.au/brice Flight Centre Travel Group Limited (ABN 25 003 377 188) trading as Travel Associates. Lic No. WA 9TA589. TAADV57204
Opening Perkins Institute tt, the Governor, Malcolm McCusker
e out er, Tony Abbo search world cam The Prime Minist e medical and re th ical of ed o M wh of o’s te tu wh Perkins Insti and 400 of the ry ar H w ne e th ening of ribbon, The PM cut the for the official op IMR) at SCGH. A W rectors ly di er t rm en es (fo pr Research and past and la Iff y rr ts. La r M lcomed the gues Perkins chairman ter Leedman we Pe of ins, Pr rk d Pe an r n M e ke mily. The lat Prof Peter Klin s bers of Perkins fa wa em R, m IM re A we W of em Among th d chairman an y tit en id s . te er tu esfarm the insti a well-known W tion of cash into first major injec e th r fo le sib on resp
QHarry Perkins institute
QE/Prof Alan Robson, Prof Peter Leedman and wife Dr Sarah Paton, and Mr Stephen Carney
QProf Peter Klinken
QSJG Murdoch CEO Mr John Fogarty, SKG founder Dr Paul Sprague and SJG Subiaco CEO Dr Lachlan Henderson
QPM Tony Abbott ofﬁcially opens the Perkins Institute
QNobel Laureate Prof Barry Marshall
SJGH Murdoch Open Day Hundreds of visitors visited St John of God Murdoch Hospital’s 20th anniversary open day on March 9 where they treated to tours of the hospital including the new Endoscopy Unit and the simulation wards in the Training and Education Centre. There was plenty of fun for the children outdoors with entertainers and a Teddy Bear Intensive Care Unit.
QHospital Area Manager Mr James Tilbury with Denver Nothling 48
QCaregivers (from left): Colin Keogh, Jody Williams, Alison Johnston, Marie Condon, Jo Nothling and Lizzie Thelwell.
Q Dr Sanjeeva Kariyawasam, Dr Krishna Epari, Dr Alan Thomas and the UpperGI West team.
st 2 5 Year e W h lt a e H l ra u R Dinner Dance la a G y a rs e iv n n A ealth West to s joined Rural H
QRural Health West Chairman Grant Woodhams and Gabrielle Woodhams, Prof D’Arcy Holman, CEO Ms Belinda Bailey and Dr Kim Hames and Stephanie Hames.
ce d health agenthcie Gala Dinner Dan Over 250 GPs an anniversar y at a 25 r fo n’s tio ed sa ay ni pl a ga hestr celebrate the or ian Doctors’ Orc Western Austral es launched a am H m Ki r last month. The D er ist in M lth ea H d the organisation over the gathering an evements of the hi ac e th on ok bo ile Rural Health commemorative da Bailey said wh lin Be s M O the needs of CE s. focus of meeting the last 25 year re co its e, bl ra immeasu West had grown ained the same. m re le op rural pe
QMs Angela McGlone and Dr David Gaskell
QMLA Dr Graham Jacobs and Kathryn Jacobs with Mr Gerry Gannon
QMr Kim Snowball, Dr Felicity Jefferies and Dr Willie Walker
QRural Health Workforce Australia Chairman Ian Taylor and Sandy Taylor with ACRRM President Prof Richard Murray
QMs Lesley Taylor and Dr Andrew Taylor
Students say thanks The University of Notre Dame’s Australia Rural and Remote Health Placement Program (RRHPP) celebrated its 10th anniversary with four simultaneous ‘Thank You’ dinners in the Wheatbelt towns of Cunderdin, Kellerberrin, Merredin and Narrogin. Notre Dame’s Head of Population and Preventive Health, Prof Donna Mak said the program, which earned a national teaching award last year, taught medical students the importance of service and the ethical and personal aspects of delivering health care – something which cannot be achieved by academics and course books alone.
QNotre Dame students and Prof Alan Wright (right) outside the Merredin District Hospital.
the end of the day she is shown to a nice room, and has a quiet meal on the balcony, looking out over the setting sun and the ocean. She marvels at the scenic beauty of heaven.
I want new curtains = and carpeting, and furniture, and wallpaper I heard a noise = I noticed you were almost asleep
QQThe Perfect Woman
Do you love me? *NHPJOHUPBTL GPSTPNFUIJOHFYQFOTJWF
Jesus was preaching to his GMPDLBCPVUTJOBOEKVEHJOH others. He put his hand on the shoulder of a prostitute and said, â€˜let whoever is without TJODBTUUIFGJSTUTUPOF
5IFOFYUNPSOJOH 4U1FUFS takes her to the fiery gates of hell and hands her off to Satan.
How much do you love me? = *EJETPNFUIJOHUPEBZZPVSF going to hate
A stone whistled through the air and hit the woman on the side of the head. He turned around and Mary was grinning at him. Jesus paused, seeking divine guidance. A4PNFUJNFTZPVSFBMMZQJTTNFPGG.VN
Satan takes her to a power breakfast given in her honour. She then has a game of tennis with her old boss, some co-workers, and previous business acquaintances and catches up on the gossip. Her old boss then takes her to a gourmet restaurant and TIFIBTBOFYDFMMFOU meal with vintage wine.
*MMCFSFBEZJOBNJOVUF,JDLPGG your shoes and find a good game on TV You have to learn to communicate = Just agree with me Are you listening to me!? = [Too late, ZPVSFEFBE>
After lunch he takes IFSUPBOFYDMVTJWFHPMGDPVSTF and they play 18 holes of golf and then he drops her at a spa where she is pampered with beauty and body treatments. A bit of shopping and a fabulous evening gown later, Satan himself takes her to a huge party with drinking, dancing, gourmet food, and famous people.
QQWork is Hell
Yes = No No = Yes Maybe = No *NTPSSZ:PVMMCFTPSSZ We need = I want *UTZPVSEFDJTJPO5IFDPSSFDUEFDJTJPO should be obvious by now %PXIBUZPVXBOU:PVMMQBZGPSUIJTMBUFS We need to talk = I need to complain 4VSFHPBIFBE*EPOUXBOUZPVUP *NOPUVQTFU0GDPVSTF*NVQTFU you moron! :PVSFTPNBOMZ:PVOFFEBTIBWFBOE you sweat a lot #FSPNBOUJD UVSOPVUUIFMJHIUT*IBWF flabby thighs This kitchen is so inconvenient = I want a new house
C I S S A CL S
"IBSEXPSLJOHGFNBMFFYFDVUJWFEJFTBOE meets St. Peter at the pearly gates and IFTBZT i:PVWFTIPXOBOPVUTUBOEJOH aptitude for making business decisions. Choose whether you will go to heaven or to hell.â€? i*EPOULOPXwTIFGMPVOEFST â€œTell you what,â€? St. Peter says, â€œYou can have 24 hours in heaven and 24 hours in hell. Then you have to decide where to spend eternity.â€?
5IFOFYUNPSOJOH TIFNFFUT4U1FUFSBU the pearly gates. â€œWell, have you made your decision?â€? He asks.
i0LBZUIFO wTIFTBZTi*MMTUBSUXJUI IFBWFOTJODF*NIFSFBMSFBEZw
i*WFEFDJEFEPOIFMM wTIFBOOPVODFT â€œSo be it.â€? St Peter waves goodbye and she reappears before the fiery gates of hell.
She goes in the pearly gates and makes some acquaintances. They have a nice walk among beautiful gardens. They have a nice quiet lunch. They have a nice stroll along a pristine, white, sandy beach looking out on a brilliant blue ocean. At
0ODFJOTJEFTIFJTUFBNFEVQXJUIIFS old boss again, only this time everyone is wearing rags. They are filthy, diseased, malnourished, and living in a barren desert. i8IBUIBQQFOFE w4IFFYDMBJNFE
In politics, if you want anything said, ask a man; if you want anything done, ask a woman.â€? â€“ Margaret Thatcher
â€œWell,â€? said her boss, â€œYesterday you were a recruit. Today you are staff.â€? O
From FFro ro om Dr Dr John John oohhhnn Qu Q Quintner uint iinntne nner err
From: The Health and Diseases of Women by RT Trall MD, 1872. DRUGGING DURING PREGNANCY. But if the woman escapes with dear life the ailments incident to puberty, other perils are before her. In the common order of events, the matrimonial relation is formed. Then come child-birth and nursing, with all their joys and sorrows. Lucky is the woman who can, on these occasions, escape the doctorâ€™s lancet and drugs. During pregnancy she usually suffers more or less of nausea, cramps, constipation, vertigo, etc., for which she is bled, physicked and narcotised, predisposing her to haemorrhage, milk-leg, broken breast, and other sequelae, and multiplying the occasions for taking more medicines. 50
Entering Medical Forum's COMPETITIONS is easy! Simply visit www.medicalhub.com.au and click on the 'COMPETITIONS' link (below the magazine cover on the left).
Musical Theatre: Admission One Shilling 5IFNPWJOHBOEJOTQJSJOHTUPSZPGWJSUVPTPQJBOJTU.ZSB)FTTT XBSUJNF DPODFSUT BU -POEPOT /BUJPOBM (BMMFSZ XIJDI IFMQFE MJGU UIF TQJSJUT PG NPSF UIBO #SJUJTI BOE BMMJFE USPPQT #SJUJTI 57 BDUSFTT 1BUSJDJB 3PVUMFEHF JOTUBOUMZ SFDPHOJTFBCMF GPS IFS SPMF BT )ZBDJOUI #VDLFU JO ,FFQJOH VQ "QQFBSBODFT BOEJOUFSOBUJPOBMDPODFSUQJBOJTU1JFST-BOFCSJOHUIJTXPOEFSful story to life. His Majestyâ€™s Theatre, May 29-31
Movie: Healing After 18 years in prison, as Viktor Khadem (Don Hany) nears the end of his sentence he is sent to a low-security prison farm where a Senior Case Worker (Hugo Weaving) has established a unique program to rehabilitate broken men through giving them UIFSFTQPOTJCJMJUZGPSUIFSFIBCJMJUBUJPOPGJOKVSFESBQUPST)FBMJOH is a powerful, moving story based on real events. In cinemas, May 8
Movie: Sunshine On Leith 3FUVSOJOHGSPNEVUZJO"GHIBOJTUBOUPUIFJSIPNFJO-FJUIKVTUPVUside Edinburgh, best pals Davy and Ally kindle romances old and OFX"MMZXJUI%BWZTTJTUFS-J[ BOE%BWZXJUI:WPOOF IJTMJUUMF TJTUFST CFTU GSJFOE &WFSZUIJOH HPFT TXJNNJOHMZ VOUJM B GBNJMZ secret past threatens to tear everyone apart. Adapated from the stage musical by Stephen Greenhorn, the film features the music of The Proclaimers. In Cinemas May 1
Movie: Spanish Film Festival 'PS TPNF i3FFM *OTQJSBDJĂ˜Ow EPOU NJTT UIF JNQSFTTJWF BOE FYDJUJOHBXBSEXJOOJOHBSSBZPGGJMNTBUUIJTZFBST4QBOJTI'JMN 'FTUJWBM 4UBSSJOH JO UIF GFTUJWBM BSF FNPUJPOBM SPBEUSJQT TQJSited comedies, swindle rom-coms, suspenseful thrillers, stylish dramas, and high-octane action rides, all topped off with some IFBSUZCBUUMFTPGUIFTFYFTBOEQMFOUZPGMBVHITBMPOHUIFXBZ Cinema Paradiso, May 6-21
Movie: Fading Gigolo -PWFST PG UIF $PFO #SPUIFST BOE TBTTZ /FX :PSL films will instantly pick the laidback irony of John Turturro, who not only stars in this film with Woody Allen, but also writes and directs. In a scheme to make money, a book store owner (Allen) convinces his middle-aged, nerdy friend (Turturro) that a fortune could be made by becoming a professional HJHPMP 0G DPVSTF UIF OFSEZ GSJFOE FYDFMT XJUI some of the most beautiful women around (cue SofĂa Vergara, Sharon Stone and Vanessa Paradis). In Cinemas, May 1
Doctors Dozen Winner Palmer a Welcome Addition 'SFNBOUMF &YFDVUJWF %JSFDUPS PG UIF JT B #MZ JE )PTQJUBM %S %BW sting a boa tor lec col e win keen Mann, k Jac 1 few bottles of 200 abelled unl as up ked pic he which n basement cleanskins at a bargai CJH GVMM FOET GSPN 3JFTMJOHT UP FYU BUF QBM JET %BW QSJDF PNJOH VQD T TPO B $BCFSOFUT BOE CPEJFE .BSHBSFU 3JWFS %PDUPST IF JOU FOU BMME BTN LF NB TUCJSUIEBZJTCPVOEUP %P[FO1BMNFS8JOFT
MEDICAL FORUM $ 10.50
WINNERS FROM THE FEBRUARY ISSUE Theatre â€“ A Streetcar Named Desire: Dr Shelley Davies Movie â€“ Tracks: %S)JMBSZ$MBZUPO %S.FMBOJF$IFO %S3BGBM'SBODJLJFXJD[ .T(MFOEB#VUUFST %S.BY5SBVC %S.PJSB8FTUNPSF %S3BZ#BSOFT %S4UBOMFZ,IPP %S4UFQIFO"EBNT %S4JNPO.BDIMJO Movie â€“ Le Week-End:%S"MJTPO1IJMMJQT %S$MZEF+VNFBVY %S:PIBOB,VSOJBXBO %S+PIO#FMM Dr Donald Reid, Dr Monica Keel, Dr Christina Wang, Dr Simon Weight, Dr Cathy Kan, Dr Stephen Edlin Movie â€“ Non-Stop:%S*BO8BMQPMF %S/JDLZ&OEBDPUU %S-BXSFODF$IJO %S3BDIFM1SJDF %S.JL1BSPMB %S+FOT#VFMPX %S)FMFO4MBUUFSZ %S#PFZ-FOH-PZ %S-JOEB8POH %S.JLF#SBZ Movie â€“ Cuban Fury: %S&TUIFS.PTFT %S"NJS5BWBTPMJ %S"EF,VTVNBXBSEIBOJ %S%BWJE#BLFS %S+BNFT1SPWBO %S$BUIZ1BSTPOT %S,FOKJ4P %S*PBOB7MBE %S1BVM,XFJ %S4V[FUUF'JODI
Are you Ready? t Reform:
Pace of Ch Rebates; ange; Leaders; Accreditati t Stroke Ma on nagement Resources t Clinical Trends Ac ross Discip lin es t Guest Co lumns; an d more t Christm as Social Photos
February 20 14 ww w.mforum.co
WEST LEEDERVILLE Great Lifestyle! 1BSUUJNF VQUPGVMMUJNF 73(1JOWJUFE to join long established West Leederville family practice. Computerised, accredited and nonDPSQPSBUFXJUIBOPQQPSUVOJUZUP private bill if desired. Lots of leave flexibility with six female and one male colleague. Email: email@example.com or call Jacky, Practice Manager on 9381 7111 FREMANTLE Fremantle Womenâ€™s Health CentreSFRVJSFTBGFNBMF(1 73
to provide medical services in the area PGXPNFOTIFBMUIPSEBZTQX*UJTB computerised, private and bulk billing practice, with nursing support, scope for spending more time with patients, and provides recently increased remuneration plus superannuation and generous salary packaging. FWHC is a not-for-profit, community facility providing medical and counselling services, health education and group activities in a relaxed friendly setting. Phone: 9431 0500 or Email: %JBOF4OPPLTEJSFDUPS!GXIDPSHBVPS %BXO/FFEIBN firstname.lastname@example.org FREMANTLE General Practice in Fremantle requires 73(1'5PS15GPSQSJWBUFMZPXOFE family practice. Accredited, computerised with full-time Nurse support. Phone: Practice Manager 9336 3665 JOONDALUP CANDLEWOOD MEDICAL CENTRE GP required to join our friendly team for After Hours work immediate start Weekdays 6 â€“ 9pm and Saturday 12 - 5pm Very Attractive remuneration Privately owned, AGPAL accredited general practice Fully computerised Contact Michelle 08 9300 0999
WOODLANDS Woodlands Family Practice (SFBUPQQPSUVOJUZGPS'51573EPDUPSJO a well-run, newly extended, inner metro, mixed billing, privately owned practice. $BMM%S.BSZ.D/VMUZPS %S%BWJE+BNFTPO or email email@example.com
NORTH PERTH View Street Medical requires a GP F/T or P/T. We are a small, privately owned practice with a well-established patient base, computerised & accredited with nurse support. 3JOH)FMFO BULL CREEK 15'573(1SFRVJSFEGPS"DDSFEJUFE Privately owned, Friendly Family Practice Please call â€“
MANDURAH GP required for established, accredited Practice. Large client base, newly renovated, private practice. Well-equipped medical centre staffed CZFYQFSJFODFE3FHJTUFSFE/VSTFT Generous remuneration. /P%84QMFBTF/PPODBMM $POUBDU3JB9535 4644 Email: firstname.lastname@example.org
MT HAWTHORN Mt Hawthorn Medical Centre requires a 15'573(1UPKPJOPVSQSJWBUFMZPXOFE practice with a well-established patient base, computerised & accredited with nurse support. A monetary incentive after 12 months service with us. 1IPOF3PTF9444 1644 NORTH BEACH Close to the beach! Opportunity for a P/T or F/T GP to join our privately-owned practice. Flexible hours and mixed billing. "OJOUFSFTUJOXPNFOTIFBMUI an advantage. On site pathology, psychologist and nurse support. 1MFBTFDPOUBDU)FMFOPS%BWJE to discuss or Email: reception.nbmc@ bigpond.com GIRRAWHEEN %PDUPSTSFRVJSFEGPS5IF/FX1BSL Medical Centre Girrawheen. Opening in February 2014 we are seeking '5BOE15(1TUPKPJOUIFUFBN &ORVJSFTUP%S,JSBOPO0401 815 587 Email: email@example.com SOUTHERN SUBURB (113"$5*$&73(1 '5PS15SFRVJSFE for a privately owned Group practice. Located in the southern suburb, BQQSPYJNBUFMZNJOTGSPNUIF$#% In a prime location, busy shopping centre, with good exposure and ample parking at the front and rear. Private billing, this is the perfect opportunity for an enthusiastic GP. Generous percentage offered and interest in ownership/ partnership considered. Administrative and nursing services will be provided, along with pathology collection on-site. Contact: email to :firstname.lastname@example.org BENTLEY 3PXFUIPSQF.FEJDBM$FOUSFJTBOPO profit, friendly practice seeking a part time GP to provide visits to our onsite residential aged care facilities. Practicebased consultations are also available. t 'VMMZDPNQVUFSJTFE t /FXMZSFOPWBUFEQSFNJTFT t .PEFSOFRVJQNFOU t 0OTJUFQBUIPMPHZ t )PVSTUPTVJUZPV For enquiries, please contact Jackie on 6363 6315 or 0413 595 676
WESTERN SUBURBS GP Wanted GP Opportunity Are you looking for an alternative to General Practice? GP required for a newly established Private 1SBDUJDFMPDBUFEXJUIJO4QFDJBMJTU3PPNT with special interest in: t %FSNBUPMPHZ4LJO$BODFS t .JOPS4VSHFSZGPSFYDJTJPO t 8PNFOT)FBMUI t .FOT)FBUI t $PTNFUJD.FEJDJOF t "OUJBHFJOHNFEJDJOF Must have appropriate Insurance and Provider Number. Please contact Practice Manager on 0419 957 779 or Email enquiries to email@example.com NEW PRACTICE - Inner Northern Suburb Located in an inner northern suburb, BQQSPYJNBUFMZNJOTGSPNUIF$#% In a prime location on a main road, with good exposure and ample parking at the front and rear. Also next door to a 7-day pharmacy. With recent retirements in the area, this is the perfect opportunity for an enthusiastic GP or group of GPs. Generous percentage offered and interest in ownership considered. Administrative and nursing services will be provided, along with pathology collection on-site. Opening April 2014. Call for details. KOONDOOLA 73(1SFRVJSFEGPSBXFMMFTUBCMJTIFE privately owned, purpose built practice with onsite pathology and pharmacy. %84TUBUVT Please email firstname.lastname@example.org BALGA Balga Plaza Medical Centre has now opened in the Balga Plaza shopping centre and is steadily growing. We are in the process of expanding, and looking for enthusiastic GPs to be part of this exciting process. Generous locum percentage offered and interest in ownership considered. Contact - email@example.com Phone: SORRENTO 73(1GPSBCVTZ.FEJDBM$FOUSF in Sorrento. 6QUPPGUIFCJMMJOH Contact: THORNLIE 73(1SFRVJSFEGPSBO"(1"-BDDSFEJUFE computerised, non-corporate practice. Full time nursing support. No after- hours. Friendly support staff. 3BQJEMZHSPXJOHQBUJFOUCBTF Outer Metro Visa 457 sponsors. Excellent renumeration and conditions. Contact: / 0403 009 838 Email: firstname.lastname@example.org
VR GP3FRVJSFEGPSNEW PRACTICE MPDBUFEJOBO"4($3location east of Perth. This brand new practice is the perfect opportunity for a GP to work in the inner regional area of Perth located BQQSPYJNBUFMZNJOTGSPNUIF$#% This large community with no current TFSWJDJOH(1TJTMPDBUFEOFYUEPPSUPB busy pharmacy and can accommodate 2 GVMMUJNF(1T Admin and nursing services will be provided along with pathology onsite. 3FMPDBUJPOJODFOUJWFNBZBQQMZUP this location. For more information please call or email@example.com
PALMYRA Palin Street Family Practice requires a GVMMPSQBSUUJNF73(1 We, at this privately owned fully serviced computerised practice enjoy a relaxed environment with space and gardens. &BSOPGNJYFECJMMJOHT For further information call Lyn on 9319 1577 or %S1BVM#BCJDIPO.
NEDLANDS 'VMMUJNFPSTFTTJPOTBWBJMBCMFGPS73(1JO non-corporate family practice. Predominantly private billing, weekends optional. Close to UWA in shopping centre, in the process of being accredited. Full time practice nurse, care-plans, immunisation, ECG/Spiro. Please contact Suzanne at 9389 8964 or Email: firstname.lastname@example.org
DUNCRAIG DUNCRAIG MEDICAL CENTRE requires a female GP FYJTUJOHQBUJFOUCBTFBT-BEZ%SNPWJOH to Albany) Flexible hours, excellent remuneration. Modern, predominantly private billing practice with full time Practice Nurse. Fully computerised. Please contact Michael on &NBJM%S%JBOOF1SJPS email@example.com PERTH CBD 'VMMBOEQBSUUJNF73(14UPKPJOPVSCVTZ inner city practice located in the Hay Street Mall. Non corporate, mainly private billing, accredited, fully computerised with full admin and nursing support and on-site pathology. Flexible hours and high earning potential for suitable candidates. 1MFBTFDPOUBDU%FCSBPO 0408 665 531 to discuss or Email: firstname.lastname@example.org
MAY 2014 - next deadline 12md Tuesday 15th April - Tel 9203 5222 or email@example.com
Looking for a sea change? We may have the job for you. If you have ﬁnished your GP training or looking for a subsequent term placement or an experienced GP looking for a change for the better, phone Jill on 08 97521133 or email firstname.lastname@example.org. Busselton is located on the pristine shore of Geographe Bay in the Margaret River Wine Growing region, just a short 2 hour drive from Perth.
MEDICAL SUITE – For Lease South Terrace, South Perth
Purpose built medical suite vacant and available now. Reception / waiting / 2 consulting rooms (14.2sqm and 15.6sqm). More information and inspection contact: Marcia Everett CEO/Director of Nursing South Perth Hospital 9367 0275
OPENING MID 2014
OPPORTUNITIES NOW AVAILABLE Leases for suites and sessional rooms are currently available for a range of specialist services including:
The Cockburn Integrated Health and Community Facility, which incorporates the Cockburn GP Super Clinic, is situated within approximately 10km of Fiona Stanley and St John of God Murdoch Hospitals and will be providing services to a growing population in the Cockburn and central south metropolitan areas. This is a unique service hub with a broad range of primary health care and related services under the one roof. With opportunities to develop integrated service models with other health care providers at the site and potential linkages with the University sector, the Cockburn Integrated Health and Community Facility is set to become a unique multi-disciplinary service hub in Western Australia. Enquiries, please contact Clory Carrello, Chief Executive Ofﬁcer, Cockburn GP Super Clinic at email@example.com or phone 0447 060 442.
MAY 2014 - next deadline 12md Tuesday 15th April - Tel 9203 5222 or firstname.lastname@example.org
85% take home,
enjoy ﬂexible hours, less paperwork, & interesting variety...
Equipment Provided - WADMS is a Doctors’ cooperative Essential qualifications: s General medical registration. s Minimum of two years post-graduate experience. s Accident and Emergency, Paediatrics & some GP experience. så så så så
Fee for service (low commission).så Non VR access to VR rebates. 8-9hr shifts, day or night. så Bonus incentives paid. 24hr Home visiting services. så Interesting work environment. Access to Provider numbers.
Supplement your income: Are you working towards the RACGP? – we have access to provider number for After Hours work. Are you an Overseas Trained Doctor with permanent residency and working toward RACGP? - we have access to provider number for After Hours work.
Specialists – opportunity for easy private practice in Fremantle! Ellen Health (Ellen Street Family Practice) will be moving from 59 Ellen Street Fremantle, to the beautiful old Beacon Theatre - 69 Wray Avenue (corner Hampton Road), Fremantle, co-located with pharmacy, pathology and allied health. Doctor-owned and managed, Ellen Health is a multi-disciplinary team, providing excellence in health care. We invite specialists to join the team, offering an instant referral base with our established general practice, and with the ease and comfort of fully serviced new rooms.
Contact Trudy Mailey at WADMS
We are recruiting specialists and VR-GPs now.
F: (08) 9481 0943 E: email@example.com www.wadms.org.au
Enquiries to Dr Catherine Douglass 0421 520 767 www.ellenhealth.com.au
(08) 9321 9133
WADMS is AGPAL registered (accredited ID.6155)
Are you wanting to sell your medical practice?
We are committed to maintaining confidentiality.
Looking for dedicated GP’s and Specialists who love the South West and want to stay – move across to our state of art practice – we have oodles of space. You can have your own room. Excellent working conditions with limited after hours needed through Bunbury After Hours GP Clinic.
You will enjoy the benefit of our negotiating skills.
Contact Dr Brenda Murrison for more details!
As WA’s only specialised medical business broker we have sold many medical practices to qualified buyers on our books. Your business will be packaged and marketed to ensure you achieve the maximum price possible.
To find out what your practice is worth , call:
Brad Potter on 0411 185 006
We’ll take care of all the paper work to ensure a smooth transition.
9791 8133 or 0418 921 073 GPs Wanted - South Metro Multicultural Health Clinic
Suite 27, 782 - 784 Canning Highway Applecross WA 6153
Ph: 9315 2599 www.thehealthlinc.com.au
FOR SALE HOLLYWOOD SPECIALIST CENTRE
Specialist Consulting Suite Ŕ TRN1SJNFTU'MPPS1PTJUJPO
(Belmont, 39 Belvidere Street )
Ŕ "MMPDBUFEVOEFSDPWFSQBSLJOHCBZ BEEJUJPOBMGSFFQBSLJOHGPSTUBŢ
GPs Wanted - GP After Hours Clinics in Belmont, Armadale and Rockingham
Ŕ 'VMMZţUUFEPVU Ŕ -FBTFEVOUJM
METWAY REAL ESTATE 9228 2255 Tom Waddle Eric Rogers
Mob 0419 916 243 Mob 0412 228 555
*HQHURXVKRXUO\UDWHV )OH[LEOHZRUNLQJKRXUV &OLQLFDODQGQXUVLQJVWDIIVXSSRUW 0RGHUQZHOOHTXLSSHGIDFLOLWLHV )XOO\FRPSXWHULVHG
*HQHURXVKRXUO\UDWHV 0RGHUQZHOOHTXLSSHGIDFLOLWLHV )XOO\FRPSXWHUL]HGDQGDFFUHGLWHGFOLQLFV 3ULYDWHDQG%XON%LOOLQJRSWLRQV &OHULFDODQGQXUVLQJVWDIIVXSSRUW For more information contact Liz Williams at 08 6253 2100 or firstname.lastname@example.org
MAY 2014 - next deadline 12md Tuesday 15th April - Tel 9203 5222 or email@example.com