Medical Forum WA 4/13

• The Tattoo Craze • Religion at Midland Hospital • Women Switch to Medicine • Profile: Ruth Tarvydas • E-Poll: Sex Assault, Euthanasia, Eating Disorders and more

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April 2013

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CONTENTS FEATURES

CLINICAL FOCUS

6 Ruth Tarvydas:

3 Non-invasive Test

Passion for Fashion

for Down Syndrome 1SPG 4ZEOFZ 4BDLT

18 WA Ink: The Tattoo

7 Radiofrequency

Craze 22 Eating Disorders –

System Overload 24 Right Turn Into

Medicine

NEWS & VIEWS 2 Letters:

6

Catheter Ablation for AF %S 5JN (BUUPSOB

39 Postnatal Depression %S #FBUF )BSSJTPO

43 Flu Vaccination in

Pregnancy %S %POOB .BL

t 1SPGFTTJPO JT #FJOH )JKBDLFE CZ %S .FSWZO )JSTDI

45 Removing Tattoos

t 3FWBMJEBUJPO +VTU 0OF .PSF )PPQ CZ %S "OHVT 8IJUGJFME

47 Over-diagnosis

t -FU T 5BML UP &BDI 0UIFS CZ %S -J[ 5PNQLJOT

t 1MFB UP (1T CZ .T $BSPMF 3VUUFS

t 3VSBM 7PJDF /FFEFE JO $BOCFSSB CZ %S .JLF &BUPO

t 4IPVMEFSJOH UIF #MBNF CZ %S 1FUFS )POFZ

8 Have You Heard?

10 Pass the Parcel at

%S %BWJE .BJO

in Breast Cancer Screening %S -J[ 8ZMJF

49 Support Group: Ishar

18

Midland Hospital

Multicultural Women’s Health Centre

LIFESTYLE 50 Antarctica – Andrew’s

Last Frontier 52 Culture: Bell’s Henry 4

12 Sexual Assault

53 Wine Review:

Resource Centre

Lavina Wines

35 AMA Desktop Toolkit

%S $SBJH %SVNNPOE .8

37 Beneath the Drapes

54 Satire: Midlife Crisis

Party

37 Practice Tip:

Empowering Staff 41 Aged Care Views 43 Immunisation Booklet 47 Raphael Centre Freo 49 Women in High Heels #Z %S /JDPMF -FFLT

.T 8FOEZ 8BSEFMM

22

22 Diagnosing Eating

.T 1JQ #SFOOBO

Disorders

20 Inspiration from

27 Euthanasia; Postnatal

Tragedy

.T 3FCFDDB %BWJFT

31 Showing ‘Love and

Fairness’ .S "OUPJOF #MPFNFO

16 Doctors Drum

E-Polls:

Silent Epidemic

Sex Work is a Health Issue

E-POLL & EVENTS 3FQPSU BOE TPDJBM QJDUVSFT

14 Sexual Assault – the

28 Decriminalisation of

56 The Funny Side

Breakfast

GUEST COLUMNS

.T .BSZ %PF

55 Competitions

24

Depression; Sexual Assault; Tattoos 28 Decriminalisation of

the Sex Industry 43 Flu Vax in Pregnancy 51 Perfect Gift for a

Woman

33 Working the System .S ,JN 4OPXCBMM

medicalforum

1

PUBLISHERS Ms Jenny Heyden - Director Dr Rob McEvoy - Director

MEDICAL FORUM MAGAZINE 8 Hawker Ave, Warwick WA 6024 Telephone (08) 9203 5222 Facsimile (08) 9203 5333 Email editor@mforum.com.au www.mforum.com.au

ISSN: 1837–2783 ADVERTISING Mr Glenn Bradbury advertising@mforum.com.au (0403 282 510) EDITORIAL TEAM Managing Editor Ms Jan Hallam editor@mforum.com.au (0430 322 066) Medical Editor Dr Rob McEvoy (0411 380 937) rob@mforum.com.au Clinical Services Directory Editor Ms Jenny Heyden (0403 350 810) jen@mforum.com.au Journalist Mr Peter McClelland journalist@mforum.com.au EDITORIAL ADVISORY PANEL Dr John Alvarez Dr Scott Blackwell Ms Michele Kosky Dr Joe Kosterich Dr Alistair Vickery Dr Olga Ward SYNDICATION AND REPRODUCTION Contributors should be aware the publishers assert the right to syndicate material appearing in Medical Forum on the MedicalHub.com.au website.

Contributors who wish to reproduce any material as it appears in Medical Forum must contact the publishers for copyright permission.

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

The support of all advertisers, sponsors and contributors is welcome.

Neither the publisher nor any of its servants will have any liability for the information or advice contained in Medical Forum . The statements or opinions expressed in the magazine reect the views of the authors.

Readers should independently verify information or advice. Publication of an advertisement or clinical column does not imply endorsement by the publisher or its contributors for the promoted product, service or treatment.

Advertisers are responsible for ensuring that advertisements comply with Commonwealth, State and Territory laws. It is the responsibility of the advertiser to ensure that advertisements comply with the Trades Practices Act 1974 as amended.

All advertisements are accepted for publication on condition that the advertiser indemniďŹ es the publisher and its servants against all actions, suits, claims, loss and or damages resulting from anything published on behalf of the advertiser.

EDITORIAL POLICY This publication protects and maintains its editorial independence from all sponsors or advertisers.

GRAPHIC DESIGN 2 Thinking Hats

Letters to the Editor

Profession is being hijacked

Parent details necessary for paediatricians

Dear Editor, In response to Dr Joanna Flynn, Chair of the Medical Board of Australia (Letters, February 2013) I graduated in 1964, became a GP in 1968 and retired in 2007. In that time I had no adverse contact with the Medical Board.

I saw my role as seeing patients, and took little interest in medical politics. This was my mistake because while I wasn't looking my profession was hijacked by bureaucrats and lawyers.

I am now informed: t * BN 3FTQFDUFE GPS NZ IJHIMZ EFEJDBUFE TFSWJDF t * BN OPU DPNQFUFOU UP XSJUF B TDSJQU PS SFGFSSBM for a patient who can't get an appointment with an overloaded GP. I also can't write repeats for a disabled friend who can't find a GP willing to provide home visits. t * NBZ OPU SFRVJSF SFHJTUSBUJPO UP UFBDI PS UBLF PO advisory roles! As George Orwell has left us I XPOEFS JG BOZPOF DBO USBOTMBUF UIJT 5SJQMFTQFBL Perhaps there is a clue in Dr Flynn's CV. * DPVME OPU CSJOH NZTFMG UP XSJUF B DIFRVF UP TVQQPSU such stupidity. I will donate the money to charity and walk off into the sunset, sadder but wiser.

Dear Editor, 'VSUIFS UP .T "MJTPO (PVMEhT SFRVFTU -FUUFST .BSDI NBZ * QMFBTF BEE NZ SFRVFTU UP HFOFSBM practitioners? I work in paediatrics and process many incoming referrals which lack the necessary information to facilitate easy contact with the parents of our prospective patients.

We are not always given the contact telephone numbers, and we are almost never provided with the parents' names, which makes it difficult to offer an appointment. It is especially important to know if the relevant contact person is not the parent.

At present, I waste a lot of time phoning GP practices to obtain this information and occasionally I strike a pedantic medical receptionist XIP XPOhU QSPWJEF JU EVF UP QSJWBDZ MBXT :PVS inclusion of this information in the referral would be greatly appreciated.

Dr Mervyn Hirsch, Dianella

Revalidation: Just one more hoop Dear Editor, I read with interest Dr Will Thornton’s piece on How Valid is Revalidation (March, 2013).

Those of us at the coal-face of General Practice in the 6, LOPX UIBU 3FWBMJEBUJPO JT CFJOH ESJWFO CZ PVS political masters, just as Appraisal was. How it will identify poor-performing doctors remains to be seen.

5IF 6,hT 3PZBM $PMMFHF PG (FOFSBM 1SBDUJUJPOFST DBO be commended for being proactive about engaging with our masters on exactly what is needed to revalidate, but at the end of the day this is just one more hoop for us to jump through.

Dr Angus Whitfield, via Medical Forum website

Let’s talk to each other Dear Editor, In Medical Forum (Letters, March 2013) a TQFDJBMJTU T SFDFQUJPOJTU SFRVFTUFE UIBU (1T JOGPSN the specialist when a mutual patient dies. Fair enough. In my experience many patients die in hospital. The usual way I find out one of my patients has passed away is when I read it in the local paper.

Our regional hospital does not inform local GPs of a patient’s demise because, as a previous medical director informed me, “it breaches patient confidentiality�. Luckily Albany is small and word gets around otherwise we, like the specialists, would be in the dark about our patients.

Ms Carole Rutter, Medical Secretary

Shouldering the blame Dear Editor, 3& Surgery for traumatic shoulder instability (March edition). Arthroscopic rotator cuff repair is relatively new and there has been no published data to suggest it is better or worse than standard open or arthroscopically assisted surgery.

As technical skills improve, surgeons will switch CFUXFFO UIF WBSJPVT UFDIOJRVFT BOE UIF DMJOJDBM results should also improve.

I am more concerned about the medical understanding of rotator cuff tear pathology. It mainly affects older people, and in most cases results from gradual wear and tear over time; deterioration or improvement is gradual, allowing the trial of prolonged conservative treatment before deciding on surgery.

However, there is a subset of patients for whom prolonged conservative treatment has a detrimental effect. Older athletes who have an acute, significant cuff tear as a result of a traumatic event, with significant immediate functional loss should have the injury assessed early.

A very large rotator cuff tear (two tendons or more) DBO SFUSBDU RVJUF B MPOH XBZ BOE UIF JOWPMWFE muscles can undergo fatty degeneration within months. If these big tears are not repaired early, the results of surgical treatment are poor.

I have seen many patients who were referred too MBUF BOE IBWF SFRVJSFE SFWFSTF TIPVMEFS KPJOU replacement for what initially would have been a very repairable tear.

Dr Peter Honey, Orthopaedic Surgeon, West Perth

Continued on P4

Dr Liz Tompkins, GP Obstetrician, Albany

medicalforum

Superior Non-invasive Test for Down Syndrome Until recently, routine pregnancy screening for Downs (and some other chromosomal aneuploidies) relied on both maternal blood and foetal ultrasound data, that is, the First Trimester Screen (FTS). Positive FTS tests are referred for invasive chorionic villus sampling (CVS) for definitive diagnosis.

The high false positive rate of FTS (5%) results in significant maternal anxiety and morbidity from unnecessary CVS, and there are also false negatives.

Analysis of cell-free DNA in maternal blood is a recent advance that allows foetal DNA to be accurately and non-invasively assessed. Clinipath Pathology now offers a new pre-natal screening test that has near diagnostic accuracy.

Basis of testing 5IF OFX UFTU WFSJGJÂĽ SFRVJSFT POMZ B TJNQMF blood test so it is non-invasive and can be performed from 10 weeks gestation on. The analysis is performed by Verinata, a CLIA certified specialist laboratory in the USA. During pregnancy, the maternal blood contains a mixture of maternal and foetal cell-free DNA. The verifiÂŽ test analyses the cell-free DNA and can detect trisomies in chromosome 21 (Down syndrome), &EXBSET TZOESPNF BOE 1BUBV syndrome). Additional testing for the most common foetal sex aneuploidies including Turner syndrome (Monosomy X), Triple X (XXX), Klinefelter syndrome 99: BOE +BDPCT TZOESPNF 9:: JT BMTP available at no extra charge if specifically SFRVFTUFE 5PHFUIFS UIFTF DISPNPTPNBM abnormalities make up ~80% of all prenatal chromosomal abnormalities.

Intended Use The test is designed for patients at 10+ week’s gestation with singleton pregnancies, considered at high risk due to any of the following:

medicalforum

By Dr Sydney Sacks, Chemical Pathologist (in conjunction with other Sonic Healthcare Pathologists)

verifiÂŽ test performance Unlike FTS, verifiÂŽ is not influenced by maternal age, maternal weight, ethnicity or gestational age. Test performance, markedly superior to FTS, is shown here: (see table) Chr

N

Sensitivity

95% CI

Specificity

95% CI

21

500

>99.9% (90/90)

96.0 – 100.00

99.8% (409/410)

98.7 – 100.00

18

501

97.4% (37/38)

86.2 – 99.9

99.6% (461/463)

98.5 – 100.00

13

501

87.5% (14/16)

61.7 – 98.5

>99.9% (485/485)

99.2 – 100.00

X

508

95.0% (19/20)

75.1 - 99.9

99.0% (483/488)

97.6 - 99.7

The verifi™ test has an option for information on common sex aneuploidies, previously known only through invasive results.

Chr N

Sensitivity

95% CI

Specificity

95% CI

Accuracy 95% CI

XX

508 97.6% (243/249) 94.8 – 99.1 99.2% (257/259) 97.2–99.9 98.4%

96.9 – 99.3

XY

508 99.1% (227/229)

97.7 – 99.7

96.9 – 99.9 98.9% (276/279) 96.9–99.8 99.0%

XXX, XXY, XYY Limited data of these more rare aneuploidies preclude performance calculations.

Sex chromosome mosaicism cannot be distinguished by this method (occurrence <0.3%). *Test performance data on file. t "EWBODFE NBUFSOBM BHF t 1PTJUJWF '54 TDSFFO SFTVMUT t 1SFTFODF PG VMUSBTPVOE BCOPSNBMJUJFT t 1SFWJPVT BGGFDUFE QSFHOBODZ GPS GPFUBM aneuploidy As verifiÂŽ test performance is significantly superior to FTS, the risks from false positive and false negative results are minimised, and a decision as to whether to proceed to CVS can be made accordingly.

Test ordering and reporting verifiâ&#x201E;˘ pre-natal test is available only at specific Clinipath Pathology collection centres and must be pre-booked on 5FTU SFRVFTUT JOJUJBMMZ POMZ BWBJMBCMF UP PCTUFUSJDJBOT SFRVJSF B TQFDJBM SFRVFTU GPSN

chromosomes option is selected, results for .POPTPNZ 9 999 99: BOE 9:: XJMM also be performed at no additional cost. (If no aneuploidies are detected, foetal sex will be reported.)

Test Cost WFSJGJÂ&#x2122; QSF OBUBM UFTU EPFT OPU RVBMJGZ GPS a Medicare rebate. Out-of-pocket cost to the patient totals $1250*, payable on credit card at the time of testing. The referrer has the assurance that testing is performed by a CLIA certified, state-of-the-art USA laboratory. *Correct as of February 2013, but subject to change without notice.

The test report contains results for chromosomes 21, 18 and 13. If the sex

3

Letters to the Editor

Rural Voice Needed in Canberra Dear Editor, I read with interest your report on GP groups in WA (February, 2013) and would like to remind your readers about the functions of Rural Doctors Association (WA). RDAWA is solely dedicated to representing your rural interests in the world of politics and negotiation.

Many of the benefits that doctors enjoy as VMO, DMO, visiting specialists etc are the result of RDAWA's continuing negotiation.

Without RDAA and RDAWA there would be no GP retention payments nor Locum Relief under ROALS. We are currently lobbying all parliamentary jurisdictions to have the appalling ASGC -RA rural classification system revoked or altered to reflect the realities of rural and remote medical services delivery. There is strong acknowledgement from some MPs now that the system is unfair and out of touch with rural medicine.

RDAWA as part of RDA is putting pressure on the federal government to ensure that the extra money granted to Medicare Locals (MLs) is distributed to those doing the work, not swallowed up in increased administration.

Current indications are that unless we

unite and force the issue, there will be no guaranteed increase in your payments despite the increased federal spending. Figures of $180,000 in increased admin costs have been quoted for some MLs around Australia.

The MLs out of eight have replied to RDA’s request for information on how they intend to support their after-hours doctors. RDAWA will continue to follow up the responses of our MLs regarding the funding allocations. We advise all doctors who are delivering afterhours care to make contact with your ML and make sure they are reflecting your needs and transferring the extra funding to you.

Although we are working on behalf of all rural doctors, only a fraction of the 741 GPs working in rural WA [including RFDS, GP Registrars, WACHS DMOs – excluding Peel, Bunbury, Geraldton, Kalgoorlie, and regular FIFO doctors] and the 145 rural resident specialists [including all specialists living rurally, not visiting from Perth] are actively supporting our work through their membership.

We need your support to continue to have the rural voice heard in Canberra and strongly urge you to join either online at www.rdaa. com.au/membership/how-to-join/ruraldoctors-association-of-western-australia or by mail.

CLARIFICATION The Hip Prosthesis Story on page 35 (March edition) was written by Dr Rob McEvoy and not Prof Piers Yates who wrote MoM hip replacements. What are the issues? alongside. Medical Forum apologises for any confusion.

We want to hear what you think.

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

Dr Mike Eaton, RDA(WA) president, Dardanup

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4 MEDIFIT_MFWA_HP_Ad_Jan2013.indd 1

medicalforum 7/02/2013 11:04:59 AM

medicalforum

5

Spotlight

The Passion for Fashion Sheâ&#x20AC;&#x2122;s famous for designing the sexiest red carpet gowns but for Ruth Tarvydas, standing out in a crowd has come naturally for more than three decades.

Ruth Tarvydas is a hard woman to catch.

The WA fashion designer squeezed in a chat with Medical Forum last month in between packing off a consignment to Harrods and putting the finishing touches to her first resort range, putting paid to last yearâ&#x20AC;&#x2122;s premature headlines of her business demise. Despite the hard economic times, which saw her close her signature shop in King St but reopen in Claremont with the help of businessman John Bond, Ruthâ&#x20AC;&#x2122;s international wholesale business has continued to fire.

Thatâ&#x20AC;&#x2122;s down to her own determination and passion for what sheâ&#x20AC;&#x2122;s be doing since she was a teenager. â&#x20AC;&#x153;Iâ&#x20AC;&#x2122;ve seen recessions and you have to ride them and make the necessary decisions for your business. Itâ&#x20AC;&#x2122;s not something that frightens or worries me too much, though reading last yearâ&#x20AC;&#x2122;s headlines were tough.â&#x20AC;? i3FBEJOH A5BSWZEBT DPMMBQTFT ZPV BMNPTU believe it, but then you pull yourself up and TBZ AIBOH PO ZPV WF HPU UP NBLF B EFMJWFSZ UP Harrods, youâ&#x20AC;&#x2122;ve got to do a new collection, youâ&#x20AC;&#x2122;ve got a showing in Paris. Come on, move your arse and get on with itâ&#x20AC;&#x2122;.â&#x20AC;?

As a child growing up with a sister seven ZFBST PMEFS 3VUI XBT USBOTGJYFE CZ IFS sisterâ&#x20AC;&#x2122;s weekend transformations from awkward teenager to exotic princess. â&#x20AC;&#x153;I could not believe it. The prettier the dress the prettier she looked.â&#x20AC;? But while she yearned for the pretty dresses, she was in no rush to join the date race. â&#x20AC;&#x153;I saw my sister getting so stressed about whether she would have a date on a Saturday night â&#x20AC;&#x201C; as if being dateless meant she was JOBEFRVBUF TPNFIPX * UIPVHIU UIFSF XBT no way I was ever going to be like that. So I decided as a young teenager that I was never going to get married or stress out over a man. And I held that line. I held on to my independence.â&#x20AC;?

8IFO 3VUI HPU IFS DIBODF UP UBLF UP UIF social stage, the era had changed. She had begun making her own clothes which had the same show-stopping effect as her designs do today. â&#x20AC;&#x153;All my friends wanted to borrow my dresses, especially the party clothes. I did lend them to girlfriends and they ended up not with just my dresses but with my boyfriends as well. The boys just followed the dress! How funny was that! When I opened my shop, one of those girls walked in, and * UIPVHIU ASJHIU ZPV DBO QBZ GPS UIF HPXOT now! I got my revenge.â&#x20AC;?

6

Q Ruth Tarvydas with celebrity client Ashley Roberts from the Pussy Cat Dolls. Inset: Ruth modelling her crochet bikinis in the 1970s

3VUI PQFOFE IFS GJSTU TIPQ JO XJUI UIF help of her brother Harvey, who was at the time in first year medicine at UWA. i.Z QBSFOUT XFOU UP &VSPQF GPS B TJY NPOUI holiday and Harvey and I had the house to ourselves and we thought what a perfect time to open a shop because Mum and Dad were not here to worry about us. We occupied the back room of a pharmacy in Hay St, near London Court, but the pharmacist gave us the front window, so we had these amazing dresses on show. Crochet bikinis wrapped with chain belts, minis and hot-pants and see-through tops, whatever was exciting in that era. â&#x20AC;&#x153;Crowds would gather in front of the window â&#x20AC;&#x201C; we even had TV stations filming the crowd of girls that would flock to the shop. The shop was so full that the pharmacist allowed the girls to change behind his shelves. The Sixties and Seventies were something else.â&#x20AC;?

The House of Tarvydas was born.

4VDDFTT DBNF RVJDLMZ GPS 3VUI BOE UIF pressure of being in the limelight began to take its toll. â&#x20AC;&#x153;The problem was that the Press kept using me as a model, and Iâ&#x20AC;&#x2122;m not a model, Iâ&#x20AC;&#x2122;m not a model size. So you change your appetite, you think you slim your legs by not drinking water, you do this and you do that BOE PCWJPVTMZ JU T OPU IFBMUIZ :PV POMZ EP

it because you want the next photo to look better. Suddenly I realised what I was doing and luckily for me I could stop.â&#x20AC;? â&#x20AC;&#x153;But you can see how some girls are taken in CZ JU *G ZPV TFF B QIPUP UIBU T OPU RVJUF SJHIU and youâ&#x20AC;&#x2122;re the only person who can fix it, a young teenager takes charge in any way she can. Models today certainly feel the pressure and itâ&#x20AC;&#x2122;s totally unrealistic, especially when there is so much Photoshopping about â&#x20AC;Ś but they still tell them they have to lose weight.â&#x20AC;?

Up until his death from an aneurysm in "VHVTU )BSWFZ IBE CFFO POF PG 3VUI T greatest supporters. He was deregistered JO 8" JO CVU 3VUI TBZT TIF IBT CFFO inundated with stories from patients who attribute their survival and good health to his ministrations when others had abandoned them. i)BSWFZ XPSLFE PVUTJEF UIF TRVBSF BOE XBT ahead of the pack so it breaks my heart that he hasnâ&#x20AC;&#x2122;t been recognized. His last words to NF XFSF A-FBSO UP CFMJFWF 3VUIJF -FBSO UP believeâ&#x20AC;&#x2122;. I reflect on those powerful words every day. It keeps me going and inspires me to take his work forward.â&#x20AC;? O

By Ms Jan Hallam medicalforum

3BEJPGSFRVFODZ DBUIFUFS ablation to prevent AF Management of AF (atrial fibrillation) principally aims to control symptoms and prevent stroke. Although antiarrhythmic drug therapies (ADT) such as amiodarone, flecainide or sotalol are generally first-line in the management of symptomatic AF patients, they have limitations including: limited efficacy (approaching 50% at 6-12 months); frequent side effects; and adverse events. This had led to the evolution of radiofrequency catheter ablation (RFA), which is an effective rhythm control strategy in appropriately selected symptomatic patients.

Indication for catheter ablation Symptoms are the primary driver.

Current guidelines recommend RFA in paroxysmal AF patients with symptomatic recurrences who have failed or are intolerant to ADT (class I), and in symptomatic persistent AF patients who have failed or are intolerant to ADT (class IIA). For patients with highly symptomatic paroxysmal AF with a low risk profile for catheter ablation, RFA should be considered firstly. There is also evidence that the same strategy may benefit patients with AF-related co-morbidity, such as heart failure or reduced left ventricular function.

The desire to cease oral anticoagulant therapy is not a sole indication for this procedure due to the risk of late recurrences, many of which may be clinically ‘silent’. The long term decision to anticoagulate is based on thromboembolic risk (using a scheme like the CHA2DS2VASc score)2.

Procedure Over a decade ago, finger-like extensions of atrial tissue into the pulmonary veins were found to be critical in initiating and “triggering” AF (Haissaguerre et al1) and led to catheter ablation techniques. Circumferential ablation to the antral aspect of the pulmonary veins (pulmonary vein isolation) is applied via a point-by-point approach with an irrigated ablation catheter.

Radiofrequency energy heats the tissue

medicalforum

and creates a scar that targets the “trigger” for the majority of AF episodes and aims to prevent arrhythmia initiation (see figure 1). Access to the left atrium is gained via a percutaneous femoral venous approach and double transeptal puncture from the right atrium.

Dr Tim Gattorna MBBS (Syd) FRACP Tim Gattorna is a cardiologist and electrophysiologist, whose areas of interest include cardiac arrhythmias (including catheter ablation), along with the implantation and management of cardiac devices. He has a clinical appointment at Royal Perth Hospital and Western Cardiology.

Success and complication rates Recent studies comparing RFA and ADT have demonstrated significantly improved efficacy, quality of life (QOL) and symptoms with RFA. The success of maintaining sinus rhythm is about 70% but varies between patients and may require multiple procedures to achieve success owing to recovered conduction from the pulmonary veins. Newer technologies, including contact force catheters, offer greater procedural success and reduced complications.

The procedure carries a 2-3% risk of major complications including stroke (0.6%), cardiac tamponade (1%) and peripheral vascular complications (1%).

The estimated mortality rate is 0.1%.

Procedural success – the importance of timing AF itself induces structural and electrophysiological changes that can further perpetuate the arrhythmia.

These pathophysiological considerations suggest that rhythm control therapy is best performed early after diagnosis when these changes are potentially reversible. There may be a “window of opportunity” for effective therapy before irreversible atrial remodelling occurs. AF requires a substrate for its maintenance and further ablation within the atria, in addition to the targeting of pulmonary vein triggers, is required in patients with persistent AF or with evidence of structural heart disease. This is termed “substrate modification” and efficacy in such patients is less favourable, with a higher rate of repeat procedures.

Q Figure 1: 3D Electroanatomical map of the left atrium and pulmonary veins demonstrating circumferential ablation (pulmonary vein isolation). Posterior view. Red dots = ablation sites, Yellow =right upper pulmonary vein, Light blue = right inferior pulmonary vein, Dark blue = left upper pulmonary vein, Purple= left inferior pulmonary vein, Red = left atrial appendage, Grey = left atrial body

FAVOURABLE FACTORS IN REFERRAL FOR RFA t 'BJMFE USJBM PG "%5 t :PVOHFS BHF MFTT UIBO ZFBST

t (SFBUFS TZNQUPNT t 1BSPYZTNBM MPOF "' t /P PS NJOJNBM TUSVDUVSBM IFBSU EJTFBTF or left atrial enlargement t "DDFQUBODF PG SJTL CFOFGJU SBUJP PG 3'" t 6OEFSTUBOEJOH PG BOUJDPBHVMBUJPO OFFE CBTFE PO $)" %4 7"4D TDPSF

t 5SFBUNFOU PQUJNJTBUJPO PG co-morbidities (incl. sleep apnoea, obesity or hypertension)

References: 1. Haissaguerre M et al. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. NEJM 1998; 339: 659-666 2. Friberg L et al. Evaluation of risk stratification schemes for ischaemic stroke and bleeding in 182 678 patients with atrial fibrillation: the Swedish Atrial Fibrillation cohort study. Eur Heart J. 2012;33(12):1500

7

Have You Heard?

Jail and the mentally ill

Inquiry slams AHPRA ")13" IBT CFFO HFUUJOH B QBTUJOH JO UIF 7JDUPSJBO -FHJTMBUJWF $PVODJM *ORVJSZ into its performance. The Australian Society of Ophthalmologists has wading JO DMBJNJOH ")13" IBT OPU TVDDFTTGVMMZ implemented a national scheme to eliminate waste and duplication, certainly not low-cost and low-impact. It claims no enhanced service delivery, patient safety or national administrative efficiency. It says resolution of state-based issues have become exceedingly difficult and doctors BSF TVGGPDBUJOH JO SFE UBQF ")13" JT bureaucratically bloated â&#x20AC;&#x201C; offices in every capital city and 700 staff (costing $53m) to manage input from 475 board members; reports to nine health ministers across the nation so the buck stops nowhere; received $122m and overspent this by $6m.

ASO wants a return to previous state and territory boards.

All about procedures The Federal Court fined Cotton-On Kids Pty Ltd $1 million after it supplied unsafe childrenâ&#x20AC;&#x2122;s nightdresses and pyjamas (breached mandatory standards for flammability). The ACCC took civil proceedings under the Competition and Consumer Act 2010. At the time of the CSFBDI $PUUPO 0O EJE OPU IBWF BEFRVBUF RVBMJUZ BTTVSBODF BOE DPOUSPM QSPDFEVSFT to ensure compliance. Medical device manufacturers are having to counter consumer discontent after the breast implant, cardiac catheter, and hip prosthesis QSPCMFNT 5IF &6 BJNT UP UJHIUFO JUT regulatory process from 2014 to keep pace with technological and scientific progress.

The extra tracking and testing may delay QSPEVDU MBVODIFT CZ ZFBST BT UIF &6 IBT been an easier nut to crack than the FDA in the USA.

Marlon Noble walked out of Greenough 3FHJPOBM 1SJTPO MBTU ZFBS BGUFS ZFBST without conviction, having been accused of sexually assaulting two children in Carnarvon in 2001 and deemed unfit for trial due to an intellectual disability. Intense public interest set him free. He is not alone.

Margaret Doherty, in our March edition (see www.medicalhub.com.au) says the Mentally Impaired Accused Act 1996 can incarcerate someone indefinitely, without appropriate treatment (45% in prison, 60% "CPSJHJOBM BOE XJUI JOGSFRVFOU SFWJFX UIBU lacks transparency. Mental health advocates claim more than 30 mentally impaired people across WA are in this boat.

Whatâ&#x20AC;&#x2122;s in a press release National Health Peformance Authority figures on GP access came out for the first time recently. Health consumers were saying they waited too long for GP appointments (13% nationally). Health Minister Tanya Plibersek said Medicare Locals were important because they gathered the info.

The AMA said it illustrated why we need more GPs. And NHPA got to report on the performance of one aspect of healthcare for the Council of Australian Governments.

Fortunately, in 2010â&#x20AC;&#x201C;11, between 86% to 96% of health consumers felt their GP always or often showed respect for what they had to say, and between 80% to 94% felt their GP always or often spent enough time with them.

See www.nhpa.gov.au for more.

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8

medicalforum

Common sense prevails

Still helping docs Doctors Health Advisory Service (DHAS WA), previously Colleague of First Contact, has a 24/7 confidential phone service (9321 3098) to access GP advice. Itâ&#x20AC;&#x2122;s for all doctors and medical students who need help with personal or health problems.

Doctors, a concerned family member, friend, colleague or staff member can phone anonymously about issues ranging from depression, substance abuse, grief or illness, even concerns about impaired performance.

Calls are exempt from the mandatory SFQPSUJOH SFRVJSFNFOUT PG UIF .FEJDBM Board of Australia. DHAS WA dovetails in with the GPs for Doctors program run

by Medicare Locals. Teaching hospital TUBGG DBO BMTP VTF UIF &NQMPZFF "TTJTUBODF Programme â&#x20AC;&#x201C; free professional counselling

by Converge International 24/7 on 1800 337 068. And junior hospital doctors can get help at www.jmohealth.org.au

6OUJM JU MBQTFE JO NJE UIF 3"$(1 ACCC deal allowed GPs in the same practice to agree on fees. After a little hooha, the federal AMA took up the cause for all GPs (not just its GP members) and has struck another similar deal with the ACCC. It started in March and runs five years.

GPs in the same practice can also negotiate collectively with hospitals and Medicare Locals on fees (e.g. after-hours services).

The ACCC says public benefits will flow from their approval.

Broker breakdown As we went to press, paediatrician Flemming Nielsen and his ex-Citigroup CSPLFS 3PC $BUFOB JO B KPJOU USJBM XFSF fighting insider trading charges laid by ASIC in April 2011, for share transactions back in 2006. Of particular interest to doctors with self-managed superannuation funds was evidence by Bell Potter JOWFTUNFOU BEWJTFS 3PDDP 5BTTPOF reported in The West Australian. He said brokers might not be thinking what you are thinking when they use â&#x20AC;&#x153;rumoursâ&#x20AC;? and â&#x20AC;&#x153;sourcesâ&#x20AC;? to convince their clients to buy and sell, and thereby generate a brokerage fee. Both Mr Catena and another ex-Citigroup broker Mr Hebbard, also facing insider trader charges, were banned in February 2009 by ASIC from providing financial services for five years.

GP Representation Fremantle GP Hilary Fine was elected to the board of Fremantle Local recently, from candidates amongst whom pharmacy was strongly represented. She said GPs are grappling with more complexity and medicolegal concerns while chasing worklife balance. Add decreasing profits and compliance with changes and she is not surprised involvement in GP representative groups is dwindling or is left to die-hards.

Pharmacists, on the other hand, jump at the opportunity to be part of the future and of primary care turf. She said Medicare Locals offer an opportunity to develop local health care that fragmented general QSBDUJDF TIPVME HSBTQ .FBOXIJMF IFS &BTU Fremantle Medical Centre, which recently achieved Super Clinic status, threw an event at Fremantle warehouse PS Art Space, is supporting Warlukurlangu Aboriginal artists whose designs are incorporated into fashion. O

Lifeâ&#x20AC;&#x2122;s challenges are our specialty.

At The Hollywood Clinic, we understand everyone needs a little help along the way when lifeâ&#x20AC;&#x2122;s challenges get too big. Thatâ&#x20AC;&#x2122;s where our experienced specialists are on hand to help your patients get back to business.

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If you would like more information on a speciďŹ c program our Program Coordinators would be happy to chat with you.

GPs can refer patients directly to The Hollywood Clinic by calling Clinical Nurse Manager, Caroline Dinnie, on 9346 6805.

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9

News & Views

Pass The Parcel – Midland Health Campus While everyone is talking generalities, Midland doctors are asking specifics on how the Catholic ethos of St John of God (SJOG), managers of Midland Health Campus (MHC), will impact on local patient services. Medical Forum compiled a list of relevant scenarios with the help of GPs and specialists who wanted answers (see below), and put them to Health Minister Dr Kim Hames. He handballed it to SJOG Health Care for a response.

Their response returns us to where we started, more generalities (see right). With no explanation from the Health Minister or SJOG on how scenarios depicted will be dealt with, we ask is it safe to assume the outcomes given are largely accurate? SJOG says it has “well established processes for RVJDLMZ BTTFTTJOH UIF BQQSPQSJBUF SFTQPOTF to each individual case” but prefers not to debate them in public. Public or not, doctors are entitled to direct answers.

Having not seen the doctor employment or hospital management contracts for Midland

Public Hospital, all we can do is echo the main concerns expressed amongst doctors on behalf of their health consumers: t 1VCMJD QBUJFOUT XJMM OPU CF PGGFSFE contraceptive and termination of pregnancy (TOP) advice, when needed, at the point of care. This could generate added physical risk for patients and medicolegal risk for doctors. t %PDUPST FNQMPZFE CZ .JEMBOE )FBMUI Campus could be prevented from advising public or private patients on matters relating to contraception and pregnancy termination (other than the Catholic stance on these matters). t (1T BOE QFSIBQT TQFDJBMJTUT XJMM CF asked by the Health Minister to provide services that MHC management decline to provide, when these services have not yet been defined (what, where, when and how). And will they only be available off-site?

Doctors we speak to have genuine concern for the relatively large number of patients in

the Midland area who are “disadvantaged”, and rely on the public hospital system. This concern is outside the philosophical angst amongst some that a management contract that forces West Australians to comply with the views of a minority community group in a secular, taxpayer-funded public hospital, is wrong.

Many services will be provided by MHC beyond the scenarios listed here. The Government has clearly decided the cost-benefit analysis of these makes it a worthwhile overall outcome for the community, despite limitations. Services at the public hospital will include “a significantly expanded emergency department […] general surgery (including day surgery) [… and] obstetric services, including antenatal and postnatal care”, the latter including outpatient services.

SJOGHC will build its 60-bed private hospital alongside, to open at the same time. O

By Dr Rob McEvoy

Contentious Clinical Scenarios This is a sample of the clinical scenarios, said by those who know to be relatively common, that were presented to the Health Minister. For obvious reasons, we have stuck with scenarios in which the Catholic ethos as Hospital Policy might be seen to disadvantage patients, put them at increased risk, or make the treating doctor medicolegally vulnerable.

While public patients from disadvantaged backgrounds (social unrest, drug and alcohol problems, mobility difficulties) are a big consideration, situations apply to any patient, mostly women, private or public.

O LOT at Caesarian not used. Due for her fourth child by repeat elective caesarean, all unplanned pregnancies. Both parents prior to caesarean request tubal ligation at LSCS, for contraceptive reasons.

Obstetrician does not have obstetrical reasons to want tubal ligation. OUTCOME: Contraception cannot be discussed (Hospital Policy) during antenatal or postnatal visits to the hospital, or after

10

delivery on the birthing ward. Woman delivers and leaves the hospital at risk of another unwanted pregnancy in the postnatal period and waits to be put on list for tubal ligation under GA (with its additional risk).

implant. IUD inserted at D&C is the preferred option. OUTCOME: Needs referral to outside the hospital (Hospital Policy) and runs risk for unwanted pregnancy meanwhile, due to wait times for appropriately skilled doctor.

O Vasectomy opportunity forgone. Six

O Contraceptive use blocks other uses.

week post natal follow-up. FlFO father of child attends unexpectedly with mother and baby asking for referral for vasectomy so they can arrange this for his next return home visit (leaving for up North tomorrow). Referral is declined (Hospital Policy). OUTCOME: Woman risks unwanted pregnancy because partner, who is hard to get to commit, is now disinclined. All her three previous children were born due to “contraceptive failures” and mother is not sure if she can afford tubal ligation privately.

Fertile woman with Polycystic Ovary Syndrome or heavy periods consults in outpatients and also seeks some way to prevent pregnancy. OUTCOME Progestogen impregnated IUD and other forms of oral contraceptive pill cannot be offered to control periods due to dual purpose of contraception (Hospital Policy).

O IUD opportunity missed. Urgent D&C for incomplete miscarriage in younger woman with an unplanned pregnancy.

Instances of failed oral contraception in the past and is intolerant for progestogen

O Unwanted pregnancy puts mother and child at risk. Woman with one young child with Foetal Alcohol Spectrum Disorder and drinking problem is admitted following an overdose, for mental health risk assessment. She asks for a progestogen implant to prevent unwanted future pregnancy. Neither her social worker or treating doctor can think of contraindications. OUTCOME. Her request

medicalforum

News & Views

Questions Still Remain Dr Marcus Rumpus is a recently retired obstetrician and gynaecologist who treated public patients at the Swan Districts Hospital.

Medical Forum spoke to Dr Rumpus who told us his concerns about the terms of some gynaecological procedures at Midland. â&#x20AC;&#x153;When the contract was offered to SJOG o OPU UP 3BNTBZT BT BOUJDJQBUFE o * SBJTFE UIF RVFTUJPO PG XIBU XPVME CF UIF FUIPT behind non-Catholic activities at a meeting of the Swan District MAC. There had been no contemplation of Catholic impact on medical freedom prior to that at the MAC. â&#x20AC;&#x153; â&#x20AC;&#x153;I was advised that contemplation of ways around the problem would be addressed and be available on campus. The then medical superintendent [December 2011] SFTQPOEFE UP B RVFTUJPO BT UP IPX UIF OFX public hospital would service sterilisation BOE 501 BOE TBJE A4+0( XJMM XPSL XJUIJO the Clinical Framework and will be contracted to provide these services but the methodology of how they will do this is yet to be determinedâ&#x20AC;&#x2122;.â&#x20AC;?

Marcus says he received platitudes from Health Minister Kim Hames who said the MHC would deliver an obstetrics and gynaecology service (inclusive of appropriate investigations, theatre and

outpatients services) to all eligible patients in the public hospital. )F RVPUFE GSPN B +VOF MFUUFS GSPN the Minister that said, however, â&#x20AC;&#x153;There is a very small number of procedures that SJGHC is unable to deliver including contraception, termination and sterilisation <y> 5IF SFRVJSFE QSPDFEVSFT UIBU DBOOPU be delivered by SJGHC will be delivered by other service providers on the MHC site.

Planning for the best delivery model is currently in progress.â&#x20AC;? The same comment was repeated two months later by Mr Ian Wight-Pickin, the Health Ministerâ&#x20AC;&#x2122;s Chief of Staff. â&#x20AC;&#x153;We should be able to sterilise female patients either electively or in parallel to another procedure,â&#x20AC;? Marcus said Mr Barnett had no reply to this at a meeting JO &MMFOCSPPL BCPVU "VHVTU "U the Mercy Hospital I was allowed to insert MirenaTM as a system to combat menorrhagia, so that could still be a loophole for contraception. But why should we practise through loopholes?â&#x20AC;? â&#x20AC;&#x153;Doctors should be free to investigate early pregnancies and if appropriate on eugenic grounds terminate pregnancy in the first

trimester, essentially as STOP under GA.â&#x20AC;? )F RVFSJFE XIFUIFS UIF GSFFEPN PG EPDUPST to manage patients at their local public hospital would be impinged on by the new management so they â&#x20AC;&#x153;cannot freely discuss with patients all potential managements [which] strikes me as not being able to fully professionally adviseâ&#x20AC;?.

He said employment contracts seem to be the order of the day now but when he was a VMO he was never thwarted form having full discussions with patients at Catholic hospitals, â&#x20AC;&#x153;though sometimes the accompanying nurse withdrewâ&#x20AC;?. O

Scan the QR to tell us what you think or email editor@mforum. com.au

SJOG Explains is declined (Hospital Policy) and with no fixed abode or regular GP, she is lost to follow-up and returns six months later 16 weeks pregnant. Using legal aid, she sues the doctor for not giving appropriate treatment to prevent pregnancy.

O Acute ectopic, declined sterilisation.

Woman booked for sterilisation elsewhere presents with acute ectopic and needs surgery under GA to deal with the ectopic.

OUTCOME. Requested sterilisation cannot be performed at the same time (Hospital Policy).

O Prevention of ectopic when treating heavy periods. Endometrial ablation for heavy periods in a woman still at risk of pregnancy. Laparoscopic tubal ligation is usually offered with ablation, to reduce the risk of tubal pregnancy; more so if other forms of contraception are contraindicated/likely to fail. OUTCOME. Any woman who wishes sterilisation as the preferred contraceptive method must have both procedures performed elsewhere (Hospital Policy).

medicalforum

Here are excerpts from the Media Statement given to Medical Forum by SJOGH, and provided by Dr Allan Pelkowitz Director of Medical Services at SJOG Midland Public and Private Hospitals. He was in the same role at Calvary Health Care, Canberra, a co-located public and private hospital operated by a Catholic not-for-profit group. â&#x20AC;&#x153;As each patientâ&#x20AC;&#x2122;s case is dealt with according [to] its specific circumstances, which are often DPNQMFY BOE SFMBUJWFMZ VOJRVF XF EP OPU believe that debating hypothetical scenarios through the media produces meaningful outcomes.â&#x20AC;? i3BUIFS XF IPQF UIF NFEJDBM DPNNVOJUZ will be given the opportunity to avail itself fully of the information presented here, as our intention is to reassure and inform them about our approach to operating St John of God Midland Public Hospital to ensure the best possible outcomes for all patients regardless of their circumstances, background or beliefs.â&#x20AC;? â&#x20AC;&#x153;Scenarios, not dissimilar to those you mention, are regularly managed with care, compassion and satisfactory clinical outcomes at the existing 21 Catholic-operated public hospitals around Australia, five of which run public emergency departments.â&#x20AC;?

â&#x20AC;&#x153;St John of God Health Care has well FTUBCMJTIFE QSPDFTTFT GPS RVJDLMZ BTTFTTJOH UIF appropriate response to each individual case.

This includes ensuring our accredited doctors and caregivers are fully informed about our approach to ethical health care delivery. The same situation will apply at Midland.â&#x20AC;? â&#x20AC;&#x153;Likewise, local GPs will be well informed about the services we will provide at the new hospital, allowing them to refer their patients appropriately.â&#x20AC;? â&#x20AC;&#x153;Specialists and GPs already understand that whether or not a treatment is provided depends on a number of factors, including whether or not the treatment is available at that facility and whether it is medically indicated.â&#x20AC;? â&#x20AC;&#x153;Patients will not be disadvantaged in any way because the State has already committed to fund the reproductive services we will not provide, in other facilities in the Midland area.â&#x20AC;?

See www.medicalhub.com.au for full version.

11

News & Views

Breaking the Silence on Sexual Assault Despite protests by thousands, violent crimes against women continue unabated.

In WA a team of doctors and professionals try to ease the pain.

The gang rape and subsequent murder of a young Indian woman in New Delhi in December made international headlines and prompted mass rallies across India from outraged citizens calling for sweeping law and police reform.

Closer to home, the rape and murder of Jill Meagher in suburban Melbourne in September also had hundreds of people protesting on the streets and prompted the development of a free phone app using GPS technology to report sexual assaults.

If one thing has been served by these horrendous crimes against women is that sexual assault is, if briefly, back in the spotlight.

In Western Australia, the incidence of sexual assault continues unabated.

Dr Christine Bassindale, the coordinator of medical and forensic services at the Sexual "TTBVMU 3FTPVSDF $FOUSF 4"3$ JO 4VCJBDP reflected on a 2010 report in Medical Forum UIBU QVU UIF OVNCFS PG QBUJFOUT VTJOH 4"3$ as between 340 and 400 a year.

Providing support to medical colleagues is an important part of our work. â&#x20AC;&#x153;The figures are still very similar. In 2012 we saw 324 people which was a slight decrease on the 2011 figures of 342. We donâ&#x20AC;&#x2122;t think for a moment that the incidence of sexual assault has decreased â&#x20AC;&#x201C; in fact itâ&#x20AC;&#x2122;s probably gone up because of the serious underreporting of the crime.â&#x20AC;?

A 2007 report from the Office of Crime Prevention said the rate of sexual assault in WA had been steadily increasing since 2004.

There were 1385 reported cases of sexual assault in 2003 and by the end of 2006 the number of reported cases increased to 1786 (Australian Bureau of Statistics, 2006).

Christine said that about half of the people XIP BSF USFBUFE BU 4"3$ IBWF TQPLFO UP police first, the other half are either selfreferrals or those who have been referred by hospitals or GPs, though she stressed that it varies from time to time. i4PNF QFPQMF DPNF UP 4"3$ QVSFMZ GPS UIFJS health needs â&#x20AC;&#x201C; to access health care and

12

counselling â&#x20AC;&#x201C; and donâ&#x20AC;&#x2122;t feel able to pursue the matter through the courts. However, we keep forensic evidence for about three months to give people the chance to decide if they want take the complaint further. Itâ&#x20AC;&#x2122;s a fine line.â&#x20AC;?

5IF NBOBHFS PG 4"3$ .T 5BOZB 5PXFST said the centre had a positive working relationship with police but emphasized that it was separate from the police. â&#x20AC;&#x153;Working well with police minimises the work that the complainant has to do, so itâ&#x20AC;&#x2122;s important to have a good working relationship, but there are a lot of people who are absolutely clear that they donâ&#x20AC;&#x2122;t want the police involved. We donâ&#x20AC;&#x2122;t exert any pressure on people to go to the police. People have a right to make a choice what path they want to go down.â&#x20AC;? $ISJTUJOF TBJE UIBU 4"3$ XBT OPU POMZ B hours service to victims of sexual assault but also doctors who may need advice if a patient makes a disclosure or an allegation of sexual assault. There are 12 doctors providing the 24-hours service and many more counsellors. â&#x20AC;&#x153;Providing support to medical colleagues is an important part of our work. We deal with these issues all they time but GPs may only deal with it once a year or few years, so to be able to access the service can be useful.

Itâ&#x20AC;&#x2122;s also important for doctors to know that 4"3$ EPFTO U KVTU QSPWJEF B NFEJDBM TFSWJDF but a free counselling service as well.â&#x20AC;?

This on-call support for doctors is particularly important for those in rural and remote areas.

5BOZB TBJE UIBU 4"3$ OPX USBJOT SVSBM nurses to do forensic examinations in rural areas. â&#x20AC;&#x153;This is to support doctors in regional &%T XIP EPO U IBWF UIF UJNF PS SFTPVSDFT to do 3-4 hour forensic exam. We provide a three-day intensive training program, which on completion the nurse will be signed off by the Commissioner of Police as TPNFPOF EFFNFE RVBMJGJFE UP QFSGPSN UIBU examination. So the doctor can do the initial medical and then the nurse can take over to do the forensic.â&#x20AC;?

Our therapeutic services handle any sexual assault, be it childhood sexual abuse or recent sexual assault. &% /VSTFT BSF BMTP CFJOH USBJOFE UP take mouth swabs and urine samples as preliminary tests.

4"3$ T DPNNJUNFOU UP FEVDBUJPO BOE training extends to the wider community with programs in schools and government and non-government agencies. Tanya TBJE UIBU 4"3$ XJMM SFTQPOE XJUI CPUI therapeutic and medical services to victims of sexual assault and individual and PSHBOJTBUJPOBM SFRVFTUT GPS USBJOJOH â&#x20AC;&#x153;Our therapeutic services handle any sexual assault, be it childhood sexual abuse or recent sexual assault, from Clarkson to 3PDLJOHIBN BOE FWFO JO QSJTPOT w O

By Ms Jan Hallam

FACTS: SARC SERVICES t 4"3$ QSPWJEFT B GSFF IPVS FNFSHFODZ NFEJDBM GPSFOTJD BOE DPVOTFMMJOH TFSWJDF JO .FUSPQPMJUBO 1FSUI GPS QFPQMF ZFBST BOE PWFS XIP IBWF CFFO TFYVBMMZ BTTBVMUFE XJUIJO UIF QSFWJPVT EBZT t 4"3$ BMTP QSPWJEFT DPVOTFMMJOH BDSPTT NFUSPQPMJUBO 1FSUI UP QFPQMF XIP IBWF FYQFSJFODFE TFYVBM BTTBVMU BOE TFYVBM BCVTF JO UIF QBTU t 4"3$ EPDUPST BSF BWBJMBCMF GPS DPOTVMUBUJPO XJUI EPDUPST BOE PUIFS IFBMUI QSPGFTTJPOBMT TFFLJOH JOGPSNBUJPO PO SFTQPOEJOH UP QBUJFOUT XIP IBWF FYQFSJFODFE TFYVBM BTTBVMU t 4"3$ PGGFST B SBOHF PG USBJOJOH BOE FEVDBUJPO QSPHSBNT GPS IFBMUI QSPGFTTJPOBMT BOE DBO develop specific programs on request. t 4"3$ IPVS FNFSHFODZ MJOF PS GSFFDBMM

8FCTJUF IUUQ LFNI IFBMUI XB HPW BV TFSWJDFT TBSD JOEFY IUN

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medicalforum

13

Guest Column

Sexual Assault â&#x20AC;&#x201C; the Silent Epidemic Ms Pip Brennan was asleep in her new home with her young child when a violent intruder irrevocably changed her life but she refused to be diminished.

I

tâ&#x20AC;&#x2122;s a womanâ&#x20AC;&#x2122;s worst nightmareâ&#x20AC;? â&#x20AC;&#x201C; itâ&#x20AC;&#x2122;s a phrase bandied about by police and later justice services in relation to my case. And yes, it was. As a university-educated, internationally travelled professional who was building a reputation as a community based volunteer, I did not ever, for one single moment, think anything like this could ever happen to me.

At the age of 36, having recently moved with my 3½-year-old child into a new home, I was sexually assaulted by an intruder in the wee hours of May 10, 2002. This violent, atypical incident propelled me on a journey of learning about the impact of sexual violence on women, and how overwhelmingly silent the curse on our society is. I learned about many other womenâ&#x20AC;&#x2122;s nightmares, which on closer inspection seemed a whole lot worse than mine.

The majority of women are assaulted by someone they know, or even love. While I suffered at my loss of the sense of goodness of human beings, I had no issue with the perpetrator in my case as I didnâ&#x20AC;&#x2122;t know who he was.

Time does not heal this wound. Like a cancer, surviving sexual assault seems to remain in your system, and more potently so if you go along with the need to be silent, leaving the wound to fester and grow. I waited more than nine months after the assault to attend a support group. I realised

how fresh I was when I entered the group with women who were dealing with rapes that had occurred in some cases more than two decades beforehand.

For some, their whole lives had bent around a wound that they could not bring themselves to admit was there. Their lives had seen a range of maladaptive strategies women can adopt to manage the effects of trauma; eating disorders, drug abuse, alcohol abuse, sexual acting out. None of which effectively manage the anxiety and depression. For me, I raged, raged, raged against the insult from day one, and while it was important for me to learn the importance of measured disclosure, I never had a festering wound. There is no ongoing deficit for me.

I was fortunate in so many aspects of this difficult journey. My GP explained to me that I had post-traumatic stress, and gave me something to go away and research and develop my own plan to ensure that post-traumatic stress did not develop into a disorder. Through my journey I met women with a range of what might seem to be very strange anxieties and hang-ups. To me they seemed to be caught in a constant time warp where innocuous situations were setting off alarm bells.

Being abused as a child heightens the likelihood of being assaulted as an adult.

Why, I wondered out loud, did the Sexual "TTBVMU 3FTPVSDF $FOUSF MPPL BGUFS TVSWJWPST of both abuse and assault? I was in a one-

PO POF DPVOTFMMJOH TFTTJPO BU 4"3$ XIFO * QPTFE UIJT RVFTUJPO #FDBVTF NZ DPVOTFMMPS advised, they are often the same person.

In other words, by being abused as a child, you heighten your risk of being assaulted as an adult. With all the alarm bells going off for the wrong reasons, the alarm bells may fail to go off for the right reason, leaving abuse survivors more vulnerable to assault.

I lived in the world 36 years before even knowing this.

As a very fortunate woman, I have enjoyed a very positive life. This one appalling incident in my life led me unwillingly to a better understanding of this most difficult of areas.

I am forever grateful to the many service providers who helped me in the different stages in the journey. I am also forever grateful for the wonderful fellow survivors I met through healing from this trauma.

I remain absolutely convinced of the importance of the recovery approach, believing that women can be whole again with the right support including ongoing counselling and well-conducted group UIFSBQZ 8F NBZ OPU FWFS CF RVJUF UIF TBNF again, but we need not be diminished.

ED: Pip Brennan has been working in the community sector since 1999, mainly in the area of womenâ&#x20AC;&#x2122;s health. She is currently managing a not-for-profit organisation, Community Midwifery WA. She continues to volunteer as a victim representative. O

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medicalforum

medicalforum

15

'Doctors Never Had Doctors Drum: Giving Doctors Voice Do A few people got hot under the collar and everyone enjoyed letting loose on this topic â&#x20AC;&#x201C; mixed responses from the 60 or so general practitioners and specialists at the recent inaugural Doctors Drum breakfast. On the panel, medicos from different walks of life, a consumer advocate, legal eagle, and financier all added flavour, in a relaxed style. The breakfast was great, the MC ran things on time, parking was easy, and virtually no politics â&#x20AC;&#x201C; a recipe for success! #FBDITJEF OFHBUJWF JPOT SFBE 3FOEF[WPVT Hotel, Scarborough) had everyone in good spirits for a stimulating and lively discussion LJDLFE PGG CZ UIF "#$ T 3VTTFMM 8PPMG 5IF panel was an interesting mix â&#x20AC;&#x201C; Ms Michele Kosky (consumer advocate), Dr Neale Fong, %S .JDIBFM 4UBOGPSE 4+0()$ $&0 %S Shelley Davies (GP), lawyer Ms Karina Hafford (Slater & Gordon*), and Mr John Boyle (Nab Health/Medfin*).

Loud and Proud

Doctors are a privileged lot, able to change, but are also discerning about it. The ADPOWFSTBUJPO PG UIF NFFUJOH GMPXFE JO BMM directions.

Neale and Michael both cited the shortage of doctors and rapid 2.5% population growth as good for the profession. â&#x20AC;&#x153;Thereâ&#x20AC;&#x2122;s always going to be work around for doctors and with an ageing population, every person over the age of 50 needs a doctor,â&#x20AC;? Michael said.

Karina, as a compensation lawyer, may have felt she was in the lionâ&#x20AC;&#x2122;s den. â&#x20AC;&#x153;I deal with people who have suffered catastrophic injury as a result of medical negligence. Now I know I have your attention! I have an important message: Apologising to someone does not mean admitting liability and often thatâ&#x20AC;&#x2122;s mostly what people want,â&#x20AC;? she emphasised.

She added we might think negligence claims have skyrocketed but numbers were stable and legislative changes made it hard for

complainants to win. Generally, the courts were supportive of doctors.

From the finance perspective John said the medical industryâ&#x20AC;&#x2122;s outlook was good, with the current shortage of doctors seen by marketing people as an upside. Doctors needed help to grow wealth.

Mind you, some GPs present were critical of the poor remuneration for their intensity of work; others recognised that a strong commitment to patients could impact poorly on their home life.

Panellist Michele said there were bigger issues than money. â&#x20AC;&#x153;There has been a deskilling of general practice and GPs are disrespected by medical specialists so GPs need to redesign the agenda and stop triaging for specialists.

GPs have to seize the time for themselves.â&#x20AC;?

Some GPs thought this an oversimplification and bureaucracy was strangling their work.

So, why bother?

After the event, we decided to use the air in everyoneâ&#x20AC;&#x2122;s wings and asked some to complete this sentence. â&#x20AC;&#x153;Doctors can feel proud becauseâ&#x20AC;Śâ&#x20AC;?

Q Left; Dr George Crisp, Dr James Salvaris, Prof Kingsley Faulkner, Dr Fiona Sharp and Dr Geoff Mullins

Our training was rigorous for the responsibilities. UWA can take credit.

But disease management of bureaucracy? Reinvest in general practice now and move into the urban landscape â&#x20AC;&#x201C; Dr Don Prendergast, Midland

Q Dr Michael Stanford and Mr John Boyle

Q The Panel in action.

Right: Ms Karina Hafford makes her point.

Q Dr Scott Blackwell Ms Giz Watson

Q Dr Fatin Wadji and Dr Cathy Parsons

Doctors Drum sponsored by: 16

medicalforum

It So Good?'

Midland GP Don Prendergast bemoaned the bureaucracy that resulted from â&#x20AC;&#x153;so-called health reformsâ&#x20AC;?. â&#x20AC;&#x153;If they all stopped tomorrow, we would still carry on just as before. We have to respond to public demand, but we need to be resourced better. And when it comes to chronic management, allied health is ripping us off.â&#x20AC;?

A professor in the room, Prof Kingsley Faulkner, the Director of Clinical Teaching at Notre Dame University, raised the issue of UIF MBDL PG RVBMJUZ UFBDIJOH TVHHFTUJOH UIBU while teaching shouldnâ&#x20AC;&#x2122;t be over-emphasised, it shouldnâ&#x20AC;&#x2122;t be overlooked either.

Neale put in a plug for the Curtin University bid for a third medical school, saying demand for doctors was driving more doctor training CVU UIBU EPDUPST XFSF OPU OFDFTTBSJMZ SFRVJSFE to do all teaching. â&#x20AC;&#x153;Weâ&#x20AC;&#x2122;ve got to seriously look at inter-professional education. Itâ&#x20AC;&#x2122;s working in aged care where medical students

are supervised by other professions. Not all medical students have to operate in a surgical theatre.â&#x20AC;?

This notion came too late for panellist Shelley Davies, who recounted her own recent experiences as a junior doctor and of students RVFVJOH PVUTJEF PQFSBUJOH UIFBUSFT IPQJOH UP be picked by the consultant surgeon.

Michael added that the problems of supply and the financial situation were best solved collaboratively. â&#x20AC;&#x153;We need a coalition of people â&#x20AC;&#x201C; GPs, government, the colleges and the community â&#x20AC;&#x201C; to work on these problems.

They are not intractable.â&#x20AC;? &WFSZPOF UIFO IFBEFE PGG GPS XPSL TPNF UIF wiser, all well fed and thought-provoked! O

WELCOME TO THE 21ST CENTURY! Dr Colin Hughes, from the Centrepoint Medical Centre in Midland, won the fabulous Doctors Drum Breakfast door prize of an iPad 2 donated by the Telstra Business Centre, Morley (contact Jasmine Lane, 9275 7451). Colin told Medical Forumâ&#x20AC;&#x2122;s Jenny Heyden (pictured with Colin) that the breakfast was a marvellous initiative, bringing together a well-balanced panel and doctors from different disciplines. â&#x20AC;&#x153;A special thanks to Telstra for donating the iPad and helping to bring at least one GP into the 21st century. It is much appreciated,â&#x20AC;? he said.

* Both companies were keen sponsors of the event.

Q Left: The Panel â&#x20AC;&#x201C; l to r, Dr Shelley Davies, Mr Russell Woolf, Ms Michele Kosky and Dr Neale Fong

Q Below: Dr Rob McEvoy, Dr Monica Lacey, Mr Siri Siriwardene, and Dr Rimi Roper

Q Dr Ryan Foo, Dr Don Prendergast and Dr Rohan Gay

They are still the only people to hold hospitals and our medical system together and despite financial, organisational, bureaucratic adversity, we still give a damn. â&#x20AC;&#x201C; Dr Harsha Chandraratna, Murdoch

Q Dr Lin Arias, Dr Angeline Barker, Ms Claire Turton, Dr Patrick Golden and Dr Harsha Chandraratna

They continue to assess, diagnose and treat patients regardless of the bureaucratic burden and the complaints about renumeration. Medicine and nursing are the most noble of human aspirations. â&#x20AC;&#x201C; Ms Michele Kosky, Nedlands medicalforum

Next Doctors Drum Breakfast!

Friday, June 28 3FOEF[WPVT )PUFM $20 a head <RVBMJGJFT GPS B EPPS QSJ[F>

%0$5034 5)& $"3& '"$503

17

Feature

WA Ink â&#x20AC;&#x201C; a Booming Business Tattoos are no longer the sole province of sailors and bikies. They have become a fashion statement or a badge of belonging, but they can also be a health risk.

The Consumer

Another friend had a small butterfly done on her ankle and it ended up looking like a dark splodge. That was a backyard job.â&#x20AC;?

A terrible family accident was the catalyst for Chloe Massarottoâ&#x20AC;&#x2122;s first visit to a tattooist when she was 20 yearsPME 'PVS ZFBST BOE B RVJUF B few tattoos later, Chloeâ&#x20AC;&#x2122;s GP is faintly amused when she walks into the surgery for a vaccination.

â&#x20AC;&#x153;I donâ&#x20AC;&#x2122;t think Iâ&#x20AC;&#x2122;ll ever regret any of mine. Itâ&#x20AC;&#x2122;s not like Iâ&#x20AC;&#x2122;ve got any weird stuff and Iâ&#x20AC;&#x2122;d never get a boyfriendâ&#x20AC;&#x2122;s name tattooed anywhere.â&#x20AC;?

Thereâ&#x20AC;&#x2122;s a generational aspect to permanently inked skin and even some younger doctors are stepping out in tattooed style. Within a professional environment discretion is sometimes SFRVJSFE

â&#x20AC;&#x153;In November 2009 my sister was hit by a drunk driver and spent six months in hospital. Sheâ&#x20AC;&#x2122;s in a XIFFMDIBJS OPX * IBE A1BUJFODF tattooed on the back of my neck because I needed a lot of it to deal with the whole thing. I just felt utterly helpless,â&#x20AC;? she said.

â&#x20AC;&#x153;Most of my tattoos are on the inside of my wrist so theyâ&#x20AC;&#x2122;re not that obvious.

My manager is fine with them but I have had comments from other staff members who reckon theyâ&#x20AC;&#x2122;re inappropriate. Amongst my generation theyâ&#x20AC;&#x2122;re so common now.â&#x20AC;?

â&#x20AC;&#x153;I told my parents before I had the tattoo done. They werenâ&#x20AC;&#x2122;t too impressed at the time but theyâ&#x20AC;&#x2122;re OK now. And my GP thinks my TRVFBNJTIOFTT XJUI WBDDJOBUJPOT is rather amusing given that Iâ&#x20AC;&#x2122;ve got so many tattoos.â&#x20AC;?

The Tattooist John Paradisi has been wielding the tattoo gun professionally in Perth for more than 30 years. First there was the Subway Tattoo Company, then Living Art Tattoo and now the Black Quill.

John regards himself as an artist.

There are many different stories behind a tattoo. â&#x20AC;&#x153;I know someone who got tattooed because he lost a bet,â&#x20AC;? added Chloe i)F T HPU A-FGU BOE A3JHIU JOLFE on his feet.â&#x20AC;?

Chloe has three stars on her shoulder which is a sign of the Q Chloe Massarotto shows off her inking. bond between her two sisters. All three girls have the same tattoo albeit on different parts of their B TPOH BOE A$BSQF %JFN JT XSJUUFO PO UIF anatomy. Birds are a persistent theme for other side. Iâ&#x20AC;&#x2122;ve also got an ambigram [written Chloeâ&#x20AC;&#x2122;s living art, as is the written word. script read in two different ways] on my hip. â&#x20AC;&#x153;I have an owl on my thigh and small birds Tilt your head to the left, Beautiful, and tilt it on my wrist but most of my tattoos are words. the other way, Disaster.â&#x20AC;?

Iâ&#x20AC;&#x2122;ve got Mum on one wrist and Dad on the Chloe says she thinks about it long and hard other, over my right ribs there are lyrics from before the ink hits the skin and adds that her tattooist came highly recommended and his fee would be the envy of some in the medical FACTS: Health Checks for Tatts profession. t 5BUUPP 1BSMPVST NVTU DPNQMZ XJUI UIF 8" )FBMUI "DU o 4LJO 1FOFUSBUJPO 3FHVMBUJPOT

t 8IJMF UIF JOEVTUSZ JT TFMG SFHVMBUFE MPDBM government environmental health officers EP TQPU DIFDLT BU MFBTU UXJDF B ZFBS t 6TFGVM XFCTJUF XXX QVCMJD IFBMUI XB HPW BV search for tattoo

** See clinical update for the latest in tattoo removals, P45. ** See E-poll on p27

18

â&#x20AC;&#x153;A good operator isnâ&#x20AC;&#x2122;t cheap. The birds on my wrist cost $150 each and the price varies according to size and complexity. Some tattooists charge by the hour, anything between $100-$150/hr. I put a lot of thought into each tattoo and Iâ&#x20AC;&#x2122;ll often sit on it for anything up to a year before I make a decision.â&#x20AC;? â&#x20AC;&#x153;Iâ&#x20AC;&#x2122;ve got a friend who hates the one sheâ&#x20AC;&#x2122;s got.

She had her ex-boyfriendâ&#x20AC;&#x2122;s name tattooed on her hand and now sheâ&#x20AC;&#x2122;s getting married to someone else. Sheâ&#x20AC;&#x2122;s lucky really, because they do fade away on your hands and fingers.

â&#x20AC;&#x153;When someone comes through the door I take a good look at them. Iâ&#x20AC;&#x2122;m pretty reluctant to go ahead if they havenâ&#x20AC;&#x2122;t got a clear idea of the sort of thing theyâ&#x20AC;&#x2122;re after. We do get people walking in affected by drugs or alcohol and we just show them the door,â&#x20AC;? John said.

There is a clearly displayed sign at Johnâ&#x20AC;&#x2122;s TUVEJP TUBUJOH A8F BDDFQU OP MJBCJMJUZ GPS B tattoo obtained under false pretences.â&#x20AC;&#x2122; â&#x20AC;&#x153;The legal age for a tattoo in WA is 18 and we check that rigorously but we do have younger kids coming in with their parents. Usually theyâ&#x20AC;&#x2122;ve grown up in families that are wellversed in the industry so they know whatâ&#x20AC;&#x2122;s going on. Iâ&#x20AC;&#x2122;m always very cautious if people want tattoos in certain places, like on their neck or near the face.â&#x20AC;?

Tattoo parlours in WA fall under the ambit PG UIF )FBMUI 4LJO 1FOFUSBUJPO 3FHVMBUJPOT 1998. (see box left) These guidelines, available PO UIF 8" )FBMUI XFCTJUF TFU PVU SFRVJSFE standards of infection control.

Individual tattoo parlours are scrutinised BCPVU UXJDF B ZFBS CZ MPDBM &OWJSPONFOUBM Health Officers, with the Black Quill coming under the gaze of Perth City Council, to ensure minimum standards of infection control such as basic hygiene, disinfection medicalforum

BOE TUFSJMJTBUJPO SFRVJSFNFOUT UP SFEVDF UIF spread of infectious diseases such as hepatitis B, C and HIV/AIDS. The website warns those considering going to amateurs or cheaper options overseas for tattoos that they place their health at risk.

According to John, the demand for tattoos is booming, but he sounds a warning about Bali tattooing. â&#x20AC;&#x153;Iâ&#x20AC;&#x2122;ve seen the industry grow from about six studios in the 1980s to more than 60 now.

The standard varies enormously and we do see some Bali horror stories. In fact, we fix a lot of them up. They go over there, party hard and then rush off and get a tattoo.â&#x20AC;? â&#x20AC;&#x153;I try to give as much guidance as possible but my philosophy is that everyone gets the tattoo they deserve. I had one woman who wanted her vagina turned into a butterfly.

Interestingly, she wanted me to do it for free.

I told her to go somewhere else.â&#x20AC;?

A skilled practitioner can resurrect a botched inking. The tattoo gun even has a place when it comes to hiding disfiguring marks. â&#x20AC;&#x153;Thereâ&#x20AC;&#x2122;s always something we can do with a tattoo thatâ&#x20AC;&#x2122;s gone horribly wrong. And Iâ&#x20AC;&#x2122;ve

Q Tattooist John Paradisi at work on an elaborate tattoo for client Claudette

had people come in with scars and burns but thatâ&#x20AC;&#x2122;s a different ball-game. It takes a lot of courage for them to walk through the door BOE * WF IFMQFE RVJUF B GFX PWFS UIF ZFBST w

of females in the industry now, in fact itâ&#x20AC;&#x2122;d be about 50/50. My daughterâ&#x20AC;&#x2122;s coming back to work here now that her kids are getting to school-age.â&#x20AC;?

Thereâ&#x20AC;&#x2122;s no formal training or accreditation for a tattooing career. And, just like everywhere else, the girls are making their mark.

â&#x20AC;&#x153;One thing Iâ&#x20AC;&#x2122;d say to doctors is that if tattoos are done in a professional studio thereâ&#x20AC;&#x2122;s no chance of blood-borne diseases. I love my job and Iâ&#x20AC;&#x2122;ve made a good living out of it. Itâ&#x20AC;&#x2122;s fed my family for 30 years.â&#x20AC;? O

i"MM UIF USBJOJOH JT EPOF JO IPVTF :PV XBUDI people sketching designs and learn from more experienced tattooists. There are a lot

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19

Guest Column

Inspiration from Tragedy When Mary Doe* discovered her husband had been sexually abusing their daughter, her fears and isolation prompted her to do something which has benefited her whole community.

I

canâ&#x20AC;&#x2122;t tell you, heâ&#x20AC;&#x2122;ll go to jailâ&#x20AC;?. These words, from the mouth of my distraught daughter one morning while driving up the highway after collecting her from school, will remain with me forever.

I had been called 20 minutes earlier by the TDIPPM QSJODJQBM SFRVFTUJOH UIBU * DPNF UP the school immediately to collect her as she had cut herself in front of other students.

What not again! This was the fourth time in as many weeks, what was going on? We had talked, I had taken her to counselling, what the hell was the problem with my daughter?

What wasnâ&#x20AC;&#x2122;t she telling me?

We were just an ordinary middle-class family â&#x20AC;&#x201C; husband, wife, two kids, two dogs, a couple of guinea pigs, small farm, both working, kids at school. Then in September 2009, our lives (as we knew them) changed forever.

During the months after my daughterâ&#x20AC;&#x2122;s disclosure and her fatherâ&#x20AC;&#x2122;s arrest for sexually abusing her, I remember having so many RVFTUJPOT JO NZ IFBE 8IBU * SFBMMZ OFFEFE to do was to talk with other mothers who had gone through similar circumstances.

How did they cope? How did their children cope? What happens in a court case? How do the other siblings that are not involved cope with losing their father? Questions only other parents could answer but client confidentiality prevented my counsellors from putting me in touch with them.

Whoâ&#x20AC;&#x2122;s to say they would want to talk to me anyway? &JHIUFFO NPOUIT BGUFS NZ EBVHIUFS T disclosure, I established Albany Wolfpack in conjunction with the amazing Jo, a Child Counsellor at the Child Sexual Abuse Treatment Service at Anglicare WA. I felt a strong desire to create a local support group so that other parents wouldnâ&#x20AC;&#x2122;t feel that they were alone.

I was overwhelmed by the number of sexual abuse cases here in Albany and thought, well if anything good was going to come out of our horrendous mess, let it be something that helps other people who may find themselves in the same situation. They can know they are not alone, and together, we can get through it.

Albany Wolfpack is for non-offending parents, family and carers of sexually abused children in and around the Albany area. We meet every second Thursday evening of the month at the Albany Anglicare offices.

We have a small group that regularly attends, all with different stories, issues and problems and we can each offer a variety of real life experiences and advice. We usually start the first half of our meeting with a casual chat then Jo joins us, presenting new information or research or just taking RVFTUJPOT GSPN UIF HSPVQ Together we talk about problems we might be having and work to resolve them.

Our goal is to promote the teaching of protective behaviours in schools. In my daughterâ&#x20AC;&#x2122;s case, had she known what was inappropriate and how to feel safe, her childhood would have been very different.

Contact albanywolfpack@gmail.com ED: *Nom de Plume for legal reasons. O

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21

Feature

Eating Orders:Tough Love, Persistent Care Are we on the threshold of a binge of eating disorders? Patients are getting younger and resources are sadly deficient but there is some help at hand.

Three Eating Disorder experts provide their insights. They all agree that current resources in Perth need to be improved, particularly for those patients over the age of 16. GPs are given the message that early detection is important, and to watch for the warning signs and keep asking questions but there is a catch – success in identifying cases may unearth more unmet need.

A/Prof Sue Byrne is a clinical psychologist based at UWA and the Centre for Clinical Interventions (CCI) in Northbridge – a psychosocial Q A/Prof Sue Byrne, research and psychologist training centre administered through the North Metropolitan Health Service. Acknowledging that GPs are on the frontline, she says she wants to help GPs to identify patients more easily and initiate early intervention.

“GPs need to watch and listen for the signs.

Any reported change in eating habits, irritability and a change in demeanour, excessive exercise or sudden disappearances to the toilet need to be explored further. :PV IBWF UP BTL RVFTUJPOT JU T OPU UIF TPSU of disorder where people will volunteer information. Anorexia nervosa is easier to pick up than bulimia because people are not likely to disclose bingeing and purging because they’re so ashamed of it,” Sue said.

“There’s a far better chance of recovery if we catch this disease before it’s gone too far down the track. It’s vital these young women, and nine out of 10 are female, are picked up as early as possible.”

The reason GPs are such an important part PG UIF FRVBUJPO JT UIF QBVDJUZ PG SFTPVSDFT JO Perth. i3FTPVSDFT GPS FBUJOH EJTDPSEFST JO 8" BSF hopeless, just ridiculous. There’s an excellent clinic at PMH, but for young people and adults we have one outpatient service in the public system. There’s a six-month waiting list to get into the CCI in Northbridge.

If someone needs to be hospitalised and they’re over the age of 16 they have to go to a psychiatric ward of an adult hospital.

In-patient programs are non-existent in Perth – it’s a total disaster!”

“We run training programs and workshops for GPs at CCI, but they’re a pretty hard bunch to get to because they’re so busy. We try to work closely with GPs because of the medical complications associated with eating disorders.”

She said the current diagnostic criteria are RVJUF TUSJDU GPS FYBNQMF UIF SJHJE EFMJOFBUJPO of a BMI of <17.5. The reality of eating disorders is a lot more complex than that.

“The next diagnostic manual will reflect some of the newer developments. For example, binge-eating hasn’t been looked at carefully until recently and it wasn’t being diagnosed properly. There’s much more awareness that it’s a clinically significant disorder. For children and adolescents, there’s TUSPOH FWJEFODF UIBU B AUPVHI MPWF A[FSP tolerance’ developed at the Maudsley Centre in London works well. And there are some

E-Poll: Diagnosing eating disorders "SPVOE IBMG UIF (1T BOE 4QFDJBMJTUT QPMMFE TBJE UIFZ GFMU QPPSMZ TLJMMFE UP NBLF B EJBHOPTJT of a problem that patients mostly hide anyway. Most families are on the doctor’s side but BCPVU B UIJSE PG EPDUPST GFFM DPNNVOJUZ SFTPVSDFT BSF MBDLJOH GPS B MPOH UFSN QSPCMFN XJUI B strong mental health component. Only 3% said there were no barriers to diagnosis.

Q

What are the biggest barrier(s) to doctors diagnosing an eating disorder [multiple choice]?

1BUJFOU JT TLJMMFE JO IJEJOH UIF GBDU

%PDUPS MBDLT TLJMMT JO BTLJOH UIF SJHIU RVFTUJPOT

The mental health nature of the problem

%PDUPS LOPXT UIFSF JT B MBDL PG USFBUNFOU SFTPVSDFT PODF VODPWFSFE

The long term nature of the problem

Resistance from the patients' families

Other

/JM o OP CBSSJFST UP EJBHOPTJT

3%

22

really interesting new developments at King’s College, also in London, focusing on neurocognitive treatments.”

ED: UWA is currently seeking volunteers for the SWAN Study (Strong Without Anorexia Nervosa). Contact: Dr Karina Allen: treatmenttrial-psy@uwa.edu.au 6488 7428

Q Ms Kate Fleming, nutritionist

Ms Kate Fleming is a nutritionist who works closely with Prof Byrne and at the Hollywood Clinic. Kate underscores the cultural fixation on food and the importance of early intervention.

“Food has become central in all our lives.

Chefs are the new rock stars! There’s a passionate interest in food and nutrition and, thanks to the internet, there’s a lot of both information and misinformation. For young people and adolescents there are strong social components linked with reward and gratification. It’s all part of our fast-paced life and food is only one part of that, but it’s a significant part,” Kate said.

“There’s fairly overwhelming evidence that B AGBNJMZ CBTFE NPEFM PG USFBUNFOU XPSLT well with patients under the age of 18. Family NFNCFST BDU RVJUF MJUFSBMMZ BT DBSFST BOE play a significant role in the recovery. It’s exhausting, because the average recovery time is between five and seven years. I have a male client who I’ve been seeing for eight years. &BSMZ JOUFSWFOUJPO JT DSJUJDBM CVU JU EPFT MFBE UP better outcomes.”

Diagnosis can be difficult and Kate encourages GPs to fully engage with their patients.

“I think some GPs may be reluctant to acknowledge a client has an eating disorder.

It’s an illness that you can’t always measure because the human body is highly adaptive to starvation. A person may look absolutely fine and still be very unwell. Test results may be RVJUF OPSNBM CVU UIBU EPFTO U NFBO UIFSF JTO U a problem.”

“There’s an uncertainty surrounding it, we don’t entirely know how to treat it successfully and there can be a veering away from actually DPNJOH PVU BOE TBZJOH AZPV EP IBWF BOPSFYJB and this is what we need to do’. Sometimes just letting the person know that there are support structures can be worthwhile.” medicalforum

Q Dr Sue Martin, General Practitioner

Dr Sue Martin is a Leederville GP with a postgraduate diploma in Primary Psychiatry. She also works closely with Sue Byrne at CCI and at WA Healthâ&#x20AC;&#x2122;s &BUJOH %JTPSEFST 3FTFBSDI $FOUSF

â&#x20AC;&#x153;I probably see a lot more eating disorders than most GPs. If youâ&#x20AC;&#x2122;re UBMLJOH BCPVU AEJTPSEFSFE FBUJOH o TLJQQJOH meals, over-eating and restricting intake â&#x20AC;&#x201C; it would be about 20% of my practice load.

There are males too, particularly under the age of 25. A lot of psychiatrists send me their patients and, if a GP feels out of their depth with this illness, theyâ&#x20AC;&#x2122;ll refer people as well.

We all feel confused and frustrated at times because itâ&#x20AC;&#x2122;s a very complex disease.â&#x20AC;?

Adding to that frustration is the fact that some patients can go to extraordinary lengths to conceal their weight. â&#x20AC;&#x153;Iâ&#x20AC;&#x2122;ve had patients who will drink lots of water before they come in to see me and others whoâ&#x20AC;&#x2122;ll hide weights underneath their clothing. :PV IBWF UP USZ BOE USVTU UIFN CVU TPNFUJNFT they make that very difficult. Itâ&#x20AC;&#x2122;s important to develop a good rapport and there are times when you have to go a little more gently than their medical condition dictates.â&#x20AC;? â&#x20AC;&#x153;My advice to GPs is not to underestimate UIF WBMVF PG DIFDLJOH IFJHIU BOE XFJHIU :PV might be very surprised when you do a BMI! And for younger children, PMH has BMI charts that are very useful particularly when you track it over a few months.â&#x20AC;? â&#x20AC;&#x153;The important thing is to keep them coming back. Itâ&#x20AC;&#x2122;s the follow-up thatâ&#x20AC;&#x2122;s hard because when they lose weight theyâ&#x20AC;&#x2122;re happy. Itâ&#x20AC;&#x2122;s doubly hard for GPs when the patient is over the age of 18 due to the lack of back-up. *U T FJUIFS UIF &NFSHFODZ %FQBSUNFOU PS B psychiatrist and the latter can take months to get an appointment. Self-harm and suicide are real risks, in fact the death rate linked with anorexia is about 10%. And once their BMI drops below 16 their ability to think rationally is almost non-existent.â&#x20AC;? O

FACTS: Eating Disorder Resources CCI Northbridge: www.cci.health.wa.gov.au 1I PMH Eating Disorder Clinic: XXX QNI IFBMUI XB HPW BV TFSWJDFT eating_disorders 1I Hollywood Clinic: www.hollywood.ramsayhealth.com.au 1I Eating Disorders Report 2012: www.thebutterflyfoundation.org.au National Eating Disorders Collaboration www.nedc.com.au

Case Study:

â&#x20AC;&#x2DC;A Hungry Body is a Happy Bodyâ&#x20AC;&#x2122; Freedom was 15-year-old when she began trying to control her changing world by controlling what she ate.

Dropping to a perilous 31kg, Freedom was in danger. Now a healthy 24-year-old woman she speaks candidly about her decline and recovery from the insidious, and sometimes fatal, Anorexia Nervosa. â&#x20AC;&#x153;This disease runs away with you, itâ&#x20AC;&#x2122;s all about control and then you become driven CZ JU *U T B VOJRVF JMMOFTT BOE FBDI QFSTPO experiences it differently. Itâ&#x20AC;&#x2122;s so much a part of you that itâ&#x20AC;&#x2122;s difficult to separate from it and, at the time, I wouldnâ&#x20AC;&#x2122;t have known who I was without the disease.â&#x20AC;? â&#x20AC;&#x153;It began in 2003, just before my 15th birthday when Iâ&#x20AC;&#x2122;d just changed to a new school. I was coming in as an outsider JO :FBS BOE B MPU PG GSJFOETIJQT BOE DMJRVFT IBE BMSFBEZ GPSNFE *U XBT B private, Anglican all-girls school where heterosexuality was the norm and I was only just coming to terms with my own sexuality. [Freedom is openly gay] My diary was stolen and read out to about half the year group. That was the trigger point.â&#x20AC;? â&#x20AC;&#x153;I had six months of self-harm and depression and then the eating disorder kicked in. I didnâ&#x20AC;&#x2122;t know how to change my behaviour and I made an effort to hide everything.â&#x20AC;? â&#x20AC;&#x153;I felt entirely out of control and, for me, controlling food was a way of regaining it. I had a regime combining excessive exercise and restricting food intake â&#x20AC;&#x201C; star jumps and sit-ups, sometimes more than 800 a day. I had a mental obsession with time-frames, periods when it was acceptable to exercise and eat. If I hadnâ&#x20AC;&#x2122;t eaten my lunch between 11.30am and 12.15pm then I wouldnâ&#x20AC;&#x2122;t allow myself to eat lunch. And Iâ&#x20AC;&#x2122;d make sure I was busy during that time, so then Iâ&#x20AC;&#x2122;d skip lunch.â&#x20AC;? â&#x20AC;&#x153;I did try to make myself vomit but couldnâ&#x20AC;&#x2122;t make it happen. Iâ&#x20AC;&#x2122;m glad because I think * E IBWF TQJSBMMFE EPXO WFSZ RVJDLMZ *U wouldnâ&#x20AC;&#x2122;t have ended well.â&#x20AC;?

i.Z NPUUP XBT AB IVOHSZ CPEZ JT B IBQQZ bodyâ&#x20AC;&#x2122;.â&#x20AC;? â&#x20AC;&#x153;In mid-2004, my GP sent me to a dietician and I think that was her way of trying to intervene without jeopardising our relationship. Iâ&#x20AC;&#x2122;d become a vegetarian and then a vegan and that made it easier to explain my weight loss. It was an ethically motivated decision, but it acted as a camouflage and it worked well.â&#x20AC;? â&#x20AC;&#x153;When I was at my thinnest I was 31kg.

Food had become a complete and utter obsession and Iâ&#x20AC;&#x2122;d torture myself by reading recipe books. There was a well-known young woman with anorexia named Bronte Cullis.

At one stage she dropped down to 38kg and I can remember being very pleased that I was thinner than sheâ&#x20AC;&#x2122;d been. Itâ&#x20AC;&#x2122;s a disturbing thing to look back and sometimes I feel ashamed that I put my parents through it all.â&#x20AC;? â&#x20AC;&#x153;In 2006 I had a light-bulb moment. Weâ&#x20AC;&#x2122;d moved to Perth and Iâ&#x20AC;&#x2122;d started university here and I started to thrive in that environment.

The vegan diet helped because it gave me a more holistic view of eating and reminded me that food was actually OK.â&#x20AC;? â&#x20AC;&#x153;Iâ&#x20AC;&#x2122;m a much stronger person now and I have a great relationship with my partner and my parents. I donâ&#x20AC;&#x2122;t think Iâ&#x20AC;&#x2122;ll ever have that acute weight loss again. Itâ&#x20AC;&#x2122;s an illness that leaves you with mental scars and thatâ&#x20AC;&#x2122;s not surprising because your brain has been conditioned into a highly damaging pattern of thinking, but I have coping mechanisms to deal with these issues now.â&#x20AC;?O

By Mr Peter McClelland

Top 25 Eating Disorder Blogs www.eatingdisorderhope.com

medicalforum

23

Feature

Turn Right for Medicine Three women explain their fascinating and varied journeys into medicine and the sacrifices they make to follow their dreams.

Q Dr Kim Badcoe, center, with daughters Lucy and Michelle.

Kim Badcoe, 53 Kim has been a customs investigation officer who has helped draft compensation legislation for the survivors of the Maralinga nuclear tests; a return to university saw her become a manager of software development in the State Government. So at 53 where else would she be than completing her second intern year as a junior doctor based at Joondalup?

The irrepressible Kim was bubbling with excitement when Medical Forum caught up with her at Glengarry Hospital where she is doing a term of rehab and palliative care. She had received word that she had been accepted for GP training next year. â&#x20AC;&#x153;Itâ&#x20AC;&#x2122;s all turned out how I wanted,â&#x20AC;? she said.

Studying medicine at any time of life is a hard gig but for the mother of three it meant giving up the security of a well-paid job to throw her growing family into the washing machine of a demanding university course.

Add the breakdown of her marriage in her fifth year, and from the outside it looks like a costly decision, but Kim has no regrets. â&#x20AC;&#x153;Medicine wasnâ&#x20AC;&#x2122;t good for my relationship but overall it probably was an advantage.

My kids are rapt â&#x20AC;&#x201C; they are so proud and supportive of me. My younger daughter is planning on being a doctor, my older EBVHIUFS JT UFBDIJOH EFTJHO BU 5"'& and my son has just finished a degree in nanotechnology and business. They were all there at my graduation last year.â&#x20AC;?

Medicine captured her imagination as a small girl when her father, Major Peter Badcoe, a distinguished veteran of the Vietnam War, gave her a book on field medicine in war zones. â&#x20AC;&#x153;I was fascinated by this book. I read it and reread it but then when I got to high school 24

I got distracted by friends them that Iâ&#x20AC;&#x2122;m only an intern. The upside and boys and didnâ&#x20AC;&#x2122;t study is that patients do listen more carefully to hard, so medicine wasnâ&#x20AC;&#x2122;t an what I say compared to the interns who option.â&#x20AC;? look about 16.â&#x20AC;? Kim is hoping to go into a coastal rural GP practice where she will get Life has taken her down to know her patients and their families and some fascinating roads but they get to know her. she was still searching for a path that would fulfil her.

Lisa Mumford, 28 â&#x20AC;&#x153;I only feel happy when Lisa is a fourth-year medical student I am challenged. I was at UWA, a part-time policewoman and driving down Marmion mother to 12-month-old Riley.

Avenue one day â&#x20AC;&#x201C; I was in my mid-40s â&#x20AC;&#x201C; and I heard Like Kim, Lisa had always wanted to do an advert on the radio medicine but didnâ&#x20AC;&#x2122;t get the grades at school for post-grad med and I so opted for the working life ending up UIPVHIU A* DPVME EP UIBU working in the coronial section of the police It was insane, which, of service. But there was a moment several years course, everyone pointed out to me. I had no biological science, I was middle-aged with a pile of kids.

I had to give up about a $1 million in salary to do it but I reckon itâ&#x20AC;&#x2122;s still a bargain. It was exactly the right thing to do.â&#x20AC;?

Kim described her university course as insanely hard and intense but her children would help, testing her at night and she ploughed on. â&#x20AC;&#x153;The UWA staff were also really supportive.

5IFSF XPVME CF EBZT XIFO * KVTU TBJE A* DBO U do thisâ&#x20AC;&#x2122;. My pharmacology lecturer said, A&WFSZPOF BU UIF TUBSU PG UIF ZFBS TBZT UIJT 8F only had two people fail last year, the odds are you can do this. Just relax and take it one step at a timeâ&#x20AC;&#x2122;.â&#x20AC;?

And her fellow students embraced her. â&#x20AC;&#x153;I was older than some of their mothers but I was invited to so many of their 21st birthday parties. As far as they were concerned I was just doing the same thing as them.

Sometimes I felt as old as Methuselah spending all day with 22-year-old, slim, Q Lisa Mumford with son Riley. gorgeous women with flawless skin, but you get over that.â&#x20AC;?

BHP XIFO TIF TUPQQFE BOE BTLFE IFSTFMG AXIZ Once Kim hit the hospital wards, the didnâ&#x20AC;&#x2122;t I do medicine?â&#x20AC;&#x2122;. enormity of a doctorâ&#x20AC;&#x2122;s life hit her. â&#x20AC;&#x153;I just stopped and thought, well thereâ&#x20AC;&#x2122;s i:PV KVTU DBO U UBLF ZPVS FZF PGG UIF CBMM GPS nothing stopping me now, so I applied a second because you can hurt someone straight away to study part-time going into BOE UIBU T B SFBMMZ GSJHIUFOJOH UIJOH :PV BSF science for 2½ years before being accepted surrounded by really supportive people but into medicine, working part-time as I go.â&#x20AC;? at the same time they are tired and stressed i&WFSZ ZFBS JU HFUT IBSEFS :PV UIJOL JU DBO U too and they donâ&#x20AC;&#x2122;t want you to keep making get any harder, but it does.â&#x20AC;? mistakes. I was a little OCD checking and Lisa is on maternity leave from the police rechecking. A couple of times Iâ&#x20AC;&#x2122;d go home service, so financially itâ&#x20AC;&#x2122;s tough on her and then come back in again to recheck.â&#x20AC;? and her husband but she says motherhood But there was a lighter side to her hospital has forced her to manage her time more experiences. efficiently and last year, with baby on her hip, â&#x20AC;&#x153;Most of the registrars and consultants are she achieved her best grades. younger than me and some patients just She is keen to return to a rural setting assume that the older person in the corner when her training is complete and is even scribbling notes is the doctor, so they ignore DPOUFNQMBUJOH BQQMZJOH GPS UIF 3VSBM $MJOJDBM the consultant. I have to keep explaining to medicalforum

Q Elise Brigden during her Kimberley placement week.

School next year.

Elise Brigden, 32 Now a final year Notre Dame medical student, Elise, who hails from Sydney, was an electrical engineer in the Royal Australia Navy for 10 years before deciding on her career switch. Always a high achiever at school, she defied everyone’s assumptions that she’d go from high school into medicine or law.

“I was more interested in doing something that was a bit more active and I wanted to challenge myself. I think I would have been wrong for medicine at that age. I wanted to join the navy to see the world!”

And see it she did, doing tours of duty to the Persian Gulf and numerous trips to South&BTU "TJB BOE UIF 1BDJGJD CVU B SPBE USJQ UP Toodyay with a car full of young doctors sowed the medicine seed.

“They were talking generally about their lives JO &% BOBFTUIFUJDT BOE BCPVU UIF UIJOHT they were having trouble with. I’m a bit of a problem solver and my job was becoming more and more management and less engineering, so medicine sounded attractive.”

Having passed with flying colours one of the most challenging of engineering courses, &MJTF TBZT NFEJDJOF UISPXT VQ EJGGFSFOU difficulties.

“I defy anyone to say that post-grad medicine is not challenging. It’s the volume that’s demanding rather than the concepts. :PV IBWF UP BNBTT TVDI B MBSHF WPMVNF of information each week and make the connections – that’s where it’s challenging.”

8IJMF &MJTF IBT ZFU UP EFDJEF PO XIFSF IFS future doctoring will take her, she’s relishing the chance to have a case list.

“Such a lot of what we do at the moment is learning focused because that’s what we’re here for, but I’m looking forward to being responsible for patient care. That’s been one of the huge changes of going back to study.

In the navy I ran my department and made decisions but that’s not me just now.” O

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25

Hollywood Private Hospital Monash Avenue NEDLANDS WA 6009 Telephone: 08 9346 6000 www.hollywoodprivatehospital.com.au 26

medicalforum

E-Poll

Doctors Facing the Hard Questions &VUIBOBTJB BOE UIF EJMFNNBT JU QPTFT the medical profession always make headlines. In Medical Forum we are always canvassing the view of our readership and last month we posed in an F QPMM UIF TBNF RVFTUJPO XF BTLFE EPDUPST in July 2008 regarding professional support for legislation on voluntary euthanasia.

Last edition 328 GPs and Specialists responded and it seems that while the number of doctors who donâ&#x20AC;&#x2122;t support euthanasia has remained almost the same, some of the undecided have migrated to the affirmative. O

Euthanasia

Q

Has a patient or relative every raised voluntary euthanasia as an acceptable option, in the course of your professional work? :FT

/P

6OEFDJEFE

Q

If legislation on voluntary euthanasia in WA could be drafted with suitable safeguards, do you think it would be supported by the medical profession?

:FT

/P

6OTVSF

This month we polled readers on a wide range of issues for our womenâ&#x20AC;&#x2122;s edition, ranging from post-natal depression, sexual assault and the services available for victims and decriminalisation of the sex industry XJUI B RVFTUJPO PO UIF OFX GBTIJPO statement, tattoos. There were 197 GPs (Male 55%, Female 45%) who responded.

Sexual Assault

Q

If a patient confides in you that they have been sexually assaulted, do you feel confident in assisting that person gather evidence and make a complaint? :FT

/P

6ODFSUBJO

&% /P TJHOJGJDBOU EJGGFSFODF JO NBMF WT GFNBMF SFTQPOTFT

medicalforum

Q Euthanasia featured in the recent state election.

Q

Did you know that the Sexual Assault Resource Centre (SARC) can offer any doctor phone advice 24 hours a day? :FT

/P

6ODFSUBJO

&% /P TJHOJGJDBOU EJGGFSFODF JO NBMF WT GFNBMF SFTQPOTFT

Postnatal Depression

Q

Which of these factors would you think play a major role in the development of postnatal depression in women [Choose 4 maximum]?

6ODFSUBJOUZ BCPVU QBSFOUIPPE due to inadequate modelling from FYUFOEFE GBNJMZ

1SF FYJTUJOH QSPCMFNT JO relationship(s) with people who are close.

Realistic fears around the impending childâ&#x20AC;&#x2122;s living environment.

Emotional or physical isolation.

Past traumatic events that re-surface during or after pregnancy.

Traumatising intervention in childbirth, past or current pregnancy.

Other.

6ODFSUBJO

1%

/POF PG UIF BCPWF

1%

Tattoos and You

Q

Permanent tattoos have become more fashionable in Australia and some people consider them a mark of individuality. Some wear them openly and others privately. For whatever reason, have YOU been tattooed? :FT

/P

Prefer not to say

Q

You answered yes to the first question, so our follow-up question is â&#x20AC;Ś What best describes your current attitude to YOUR tattoo? /P SFHSFUT SFBMMZ MJLF JU

1SFGFS UP LFFQ JU CVU XJTIFE JU XBT done differently.

1

Would remove it if this was easily done.

1

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1

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1

/POF PG UIF BCPWF

Other:

&% 0OMZ SFTQPOTFT UP UIJT RVFTUJPO TP BDUVBM OVNCFST BSF HJWFO

27

Guest Column

Decriminalisation Is a Health Issue â&#x20AC;&#x153;Are you sure you want to keep being a doctor? You could catch something!â&#x20AC;? Former sex worker now Magenta educator Rebecca Davies says doctors ask similar questions of sex workers.

D

octors and Sex Workers â&#x20AC;&#x201C; weâ&#x20AC;&#x2122;re really not all that different. We both work with people in an intimate capacity; some of us work in practice with others and some of us work on our own for ourselves. Some of us have fields of specialty, some work on the street, some of us travel for work, some of us work long hours. The pay scale has similarities too, but we certainly aren't treated the same! *G ZPV BSF XPSLJOH JO BO &NFSHFODZ Department, you could be exposed to a multitude of infections and BBVs, so you are taught how to minimise the risk of exposure.

Sex workers are also taught how to minimise risk of exposure through peer education.

The most recent research shows that sex workers in Australia have at least as low rates of STIs as the general population(1).

In Perth, condom use at work approaches 100%, with similar results across Australia.

It is also worth noting that these figures include migrant and FIFO (Fly In Fly Out) sex workers.

Despite this, we are often treated by medical personnel as if we don't know how to look after ourselves, that we have not made a rational choice to be in the job or that we are incapable of deciding what is best for VT 8F BSF BMTP BTLFE JSSFMFWBOU RVFTUJPOT CBTFE VQPO TUFSFPUZQFT TVDI BT XFSF ZPV TFYVBMMZ BCVTFE BT B DIJME iIPX NVDI BSF you paid?â&#x20AC;? or worse still, some doctors think

disclosure of our work is a good excuse to hit on us during a consultation.

Communication between our professions is vital. So if I hear someone using words like AQSPTUJUVUF BOE AQSPTUJUVUJPO SBUIFS UIBO ATFY XPSLFS BOE ATFY XPSL * BN VOMJLFMZ to disclose my sex work history and an opportunity is lost.

The media is hot on the heels of FIFO sex workers and I am perplexed as to why. It's not news. Sex workers go where the work is. Insinuations that FIFO sex workers are responsible for a rise in STIs is not supported by research (2).

Chances are youâ&#x20AC;&#x2122;ve met a sex worker and just don't know it. I worked in the WA sex industry for six years and was as much a part of the community as anyone else. I volunteered doing Meals on Wheels and helped out at the hospital canteen. I've been on the P&C at my daughterâ&#x20AC;&#x2122;s school. I've been a university student. Most people have no idea I was a sex worker.

We are a diverse community, just as the medical profession, and like you, expect to be treated with respect and dignity. We are also mothers, daughters, sisters, brothers, fathers and sons. We want the decriminalisation of our industry, so we can enjoy the same human rights and work protections as everyone else.

Decriminalisation is proven in practice to have the best health outcomes for both sex workers and the community, so this is as much a health issue as it is a human rights issue and as such should involve every doctor(3,4)

References 1 Donovan, B., et al. (2012). The Sex Industry in New South Wales: a Report to the NSW Ministry of Health. Sydney: Kirby Institute, University of NSW. 2 Donovan, B., et al. (2010). The Sex Industry in Western Australia: a Report to the Western Australian Government.

Sydney: National Centre in HIV Epidemiology and Clinical Research, University of NSW. 3 Bellamy, P. (2012). Prostitution law reform in New Zealand, Parliamentary Library Research Paper.

4 Ministry of Justice, (2008), Report of the Prostitution Law Review Committee on the operation of the Prostitution Law Reform Act 2003. O

E-Poll: Doctors on Decriminalisation

Q

Do you believe decriminalisation of the sex industry would improve health outcomes for sex workers?

:FT

/P

6ODFSUBJO

&% /P TJHOJGJDBOU EJGGFSFODF CFUXFFO NBMF BOE GFNBMF SFTQPOTFT

Q

What about those in the community who use sex worker services?

:FT

/P

6ODFSUBJO

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Guest Column

Showing â&#x20AC;&#x2DC;Love and Fairnessâ&#x20AC;&#x2122; For 15 years Mr Antoine Bloemen was circuit magistrate in the North-West and found different ways to serve justice while administering the law.

A

t the outset I would like to make it very clear that I am not writing as an expert or specialist. My views are based on 15 years of living and working with Aboriginal people in the Pilbara and Kimberley as the local Magistrate.

In 1995, when I was sent to the North-West, my circuit JODMVEFE ,BSSBUIB 3PFCPVSOF Newman and Marble Bar. After being there for a while I opened a court in Nullagine.

In travelling around the Pilbara and Kimberley I was shocked and dismayed at Q Magistrate Antoine Bloemen with two elders in the the living conditions of local Kalumburu community court.

Aboriginal people. Many of those appearing before me were for a broken leg when the malnourished and had little idea of personal only course is to set it and hygiene. Instead of a decent meal, many lived put it in a cast. on soft drinks, junk food and alcohol.

The Pilbara and Kimberley I decided that if I was going to spend some have few criminals but years of my life in the North-West, I would many alcoholics. Over do my utmost to help Aboriginal people. consumption of alcohol Q Antoine, Bishop of the Kimberley Christopher Saunders and then District Court The children who appeared before me were was and is one of the main Judge Peter Blaxell with four wardens and children at the presentation and often in poor health, suffered from foetal reasons why so many people blessing of the 30 bicycles at the Wirrrimanu/Balgo community in 2000. The alcohol syndrome and had limited literacy appear in court, not all of wardens rule was "no school, no bike". The bikes were donated by the legal and and numeracy skills. It made me sad to see so them Aboriginal. The curbs medical communities. many human beings living in such neglected PO MJRVPS PVUMFU IPVST IBWF conditions in a country like Australia. would tell them that I would deal with them helped curtail sights such as with love and fairness, but in return they would occur at places like Halls Creek where Most of the people I met were good of heart must give me and the court the same respect large groups of people from the desert would and very courteous, but I could see that and courtesy. Surprisingly, in every case, they wait hours for 10am opening. most had lost their dignity, self-confidence would come to attention and show respect. It and pride. There I was, a magistrate These changes have largely come about clearly indicates that if you show respect and administering the Common Law system in through the efforts of local community demand respect, people will react positively. a very different culture with its own Law. groups spearheaded by women elders.

While most people spoke several Aboriginal In 2008 I retired as Magistrate in the Pilbara I have formed a close relationship with MBOHVBHFT UIFJS &OHMJTI XBT MJNJUFE *O DPVSU BOE UIF ,JNCFSMFZ XIJDI BU TR LN many Aboriginal people in the Pilbara they would call me â&#x20AC;&#x153;bossâ&#x20AC;? which I hated. I was, in my time, the largest judicial circuit and Kimberley over the years. Most are would say I am not your boss; I'm a normal JO UIF XPSME *U JT OPX EJWJEFE JOUP UIF &BTU fine people. Many do not want to consume human being doing my job. and West Kimberly with a Magistrate in excess alcohol, but have no support or Kununurra and in Broome. I glance back When I sat in one of the six remote FODPVSBHFNFOU GSPN BOZPOF UP TUPQ &WFO at my time with a good feeling but admit communities, I invited several respected men after successfully completing a program at that I donâ&#x20AC;&#x2122;t know if I have made any lasting and women elders to sit with me. Before court one of the drug and alcohol rehabilitation DIBOHFT 5IBU RVFTUJPO * MFBWF GPS PUIFST UP started we would have an informal talk about centres, the lack of personal support, public decide, but I gave the people all I could. In community issues or things that they thought transport and work possibilities make it return, I have met and had the help of many I should know. During court I would ask difficult not to return to old habits. wonderful people, especially my wife, Anne, their advice in relation to the young people's However, alcoholism is hardest on the who has stood by me all the way. O family, upbringing and their thoughts on children. Many have no food, no care, no sentencing options.

ED: Antoine Bloemen continues to live and love, no discipline, no consistent parenting work in the Kimberley. He is a member of There is no juvenile detention in the Northand have been on their own from a very the Kimberley Training Institute Governing West so many sentences could not be early age. So why are we surprised that the Council and an independent director of implemented because of placement options Childrenâ&#x20AC;&#x2122;s Court list is so long? the Nyamba-Buru Yawuru, Ltd Aboriginal and supervision. So I always sought advice In my experience, what most children are corporation. from the elders and, in most cases, followed seeking is love and positive attention. Often, it. Why give an impractical sentence? It when appearing in court, they would hang would be like a doctor prescribing medicine onto their chair when asked to stand up. I medicalforum

31

Guest Column

Working the System After three years, Mr Kim Snowball has prematurely left the director-generalâ&#x20AC;&#x2122;s office. Here he looks back at the highlights and the challenges ahead.

M

y reason for working in the health sector has always been to improve health outcomes.

Thatâ&#x20AC;&#x2122;s not a 12-month project or even a term-of government plan, itâ&#x20AC;&#x2122;s a culture.

When you focus on that, issues come into sharp relief.

Aboriginal health is very obviously one of those issues. Itâ&#x20AC;&#x2122;s impossible to stand by while Aboriginal people suffer from diseases which have been eradicated to a large extent for the rest of the population. WA Health and Close the Gap have made probably the biggest investment of health funds, effort and resources into Aboriginal health outcomes, but most importantly itâ&#x20AC;&#x2122;s been a collaboration with Aboriginal people and organisations.

Thatâ&#x20AC;&#x2122;s been an enormous shift in thinking.

When I came into the role, the relationship between the department and Treasury and the Government was difficult and put a dark cloud over what we were trying to do as a health system. One of my first jobs was to stabilise the financial position and to forge

a new relationship with Government that focused on activity and delivery.

Government needed to know what they were getting for taxpayersâ&#x20AC;&#x2122; money. We had UP EFNPOTUSBUF UIJOHT MJLF IPX NBOZ &% presentations were being made and at what MFWFM PG RVBMJUZ *U XBT HPPE GPS FWFSZPOF Not only did the Government know what it was buying and investing in, it gave us an opportunity to hold people accountable in our hospitals and health service. We could TBZ AXF OFFE ZPV UP EFMJWFS NPSF FMFDUJWF surgery and within the boundaries of acceptable clinical waiting timesâ&#x20AC;&#x2122;.

Things like the 4-hour rule helped drive that. That was probably the biggest change in our hospitals in my term. I had the great joy of seeing figures from the Australia Institute of Health and Welfare which put WA Hospitals way ahead of the rest of the country. The credit for that goes to all our staff â&#x20AC;&#x201C; our doctors, nurses, support workers â&#x20AC;&#x201C; XIP IBWF DPNCJOFE UP TBZ AZFT XF EP OFFE UP DIBOHF IPX PVS &%T BOE IPTQJUBMT PQFSBUF UP improve our performances.â&#x20AC;&#x2122;

Other future challenges will be workforce related. The system is employing more medical and allied staff than the national average but we are way off the mark in general practice. We are going to have to have a radical growth in GPs to keep pace with the rapid population growth. And itâ&#x20AC;&#x2122;s not just a RVFTUJPO PG OVNCFST JU T BCPVU XIFSF UIFZ are needed to work.

General practice is a federal responsibility but we must take an interest because we are a system, regardless of who funds what part. If general practice is not working, other parts of the system have to pick that up.

My very loud message is that general practice is a priority for this State â&#x20AC;Ś thatâ&#x20AC;&#x2122;s where we should be concentrating our effort. There are other specialist priorities in WA but GP numbers stand out.

As I head out the door, one of the things Iâ&#x20AC;&#x2122;m most proud of is that I leave a health system which thinks and behaves like a health system and that can respond to the challenges ahead. O

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IT In Practice

AMAâ&#x20AC;&#x2122;s GP Desktop Practice Support Toolkit The federal AMA launched its GP Desktop Practice Support Toolkit MBTU ZFBS 'PS NFNCFS (1T XIP IBWF B MPHJO JU SFRVJSFT B CSPXTFS and creation of a desktop shortcut that links you to a variety of documents or websites presented to you as hyperlinks listed in an &YDFM TQSFBETIFFU 1SPUFDUJPO PG UIF TIBSFE &YDFM EPDVNFOU NFBOT you cannot customise the spreadsheet for your use and the indexing system takes some getting used to. Most importantly, there is no search GVODUJPO UIBU XPVME MJOL ZPV RVJDLMZ UP B EPDVNFOU UJUMF

PIVET MEDICAL CENTRE Specialists in Reproductive Medicine & Gynaecological Services

Gynae News

by Medical Director Dr John Yovich

Day-case Hysterectomy â&#x20AC;Ś whatever next !?

IVF in humans began with a â&#x20AC;&#x2DC;marriageâ&#x20AC;&#x2122; between reproductive scientist Robert Edwards (now Nobel Laureate) and the British pioneer of laparoscopic surgery, gynaecologist Patrick Steptoe.

When I travelled to the UK in 1976, I â&#x20AC;&#x2DC;shadowedâ&#x20AC;&#x2122; these men to learn their respective crafts.

During our test drive, when the AMA said it had placed the Academy of Science booklet about vaccination on the Toolkit site, we went MPPLJOH &WFOUVBMMZ XF GPVOE UIF IZQFSMJOL CZ USBDLJOH i3FGFSFODF Materialâ&#x20AC;? which was only on the home page, then â&#x20AC;&#x153;Factsheetsâ&#x20AC;? as a TVCIFBEJOH PO UIF OFYU QBHF UIF i*OGPSNBUJPO 0UIFS 3FTPVSDFTw page according to the tag at the bottom of the spreadsheet) where the document was listed under its name The Science of Immunisation: Questions and Answers. Clicking on the hyperlink downloaded (slowly) the 18mb high resolution version of the pdf document, when a much smaller 1mb version was available from www.science.org.au.

There are tabs that allow State-specific documents to be listed (e.g.

Advance Care Directive Form for WA). All hyperlinks connect back to the original source document, such as on the WA Health website but many of these downloads are pdfs and there is no back button in your browser that will take you to the homepage of the parent website. If you know how to fiddle with the url in the browser window, you can get there.

The secret to navigation in this spreadsheet format is to use the tabs at the bottom as much as you can, although be aware not all the subheadings on the first index page are presented as tabs. O

(BUF )PMMZXPPE 1SJWBUF )PTQJUBM .POBTI "WFOVF /FEMBOET 8" .BJM 10 #PY #SPBEXBZ /FEMBOET )FBMUIMJOL DPDQFSUI T: 6424 8596 ' 9389 1770 W: www.circleofcare.org.au We may have outgrown our Circle of Care logo, but we are still building on ZFBST PG FYQFSJFODF XJUI XFJHIU DPOUSPM TVSHFSZ JODMVEJOH Adjustable Gastric Banding and Sleeve Gastrectomy, our multidisciplinary team is founded on the basis that maintaining a healthy weight requires attention to what we eat, how we eat, why we eat, and IPX NVDI FYFSDJTF XF EP Jeff Hamdorf and Sue Taylor have gathered surgeons, primary care QIZTJDJBOT EJFUJUJBOT QTZDIPMPHJTUT BOE FYFSDJTF QIZTJPMPHJTUT VOEFS POF banner to provide the best outcomes, not just the most weight loss.

medicalforum

Laparoscopy was introduced to KEMH in 1971 where I learnt the WHFKQLTXHV GHVFULEHG E\ 6WHSWRH ² Ă&#x20AC;UVWO\ GLDJQRVWLF ODS G\H then lap steri and later follicle aspiration for IVF, extending to WXEDO WUDQVIHUV RI JDPHWHV *,)7 DQG HPEU\RV 35267 7(67

then more advanced procedures such as ventro-suspension and reversal of sterilisation. Many techniques were pioneered at PIVET and published.

The progression of laparoscopic surgery to myomectomies, full excisional surgery for endometriosis and hysterectomy started around 1990-1 at PIVET but as a relatively quiet advance, in the shadow of the IVF revolution. None-the-less, it is now more prominent as advances in instrumentation enable slick, speedy and uncomplicated surgery.

Advanced uterine manipulators have become inexpensive and disposable (e.g. the V-care device) and these, combined with improved bi-polar electrocautery systems, barbed V-lock sutures, high-powered electronic morsellation devices and intra-mural pitressin, means the vast majority of gynae cases can be conducted without blood loss as day-cases. We have OHDUQW WR SUHVHUYH WKH SHOYLF Ă RRU DWWDFKPHQWV DQG WKHVH are completely undisturbed in those having the Supraloop technique. Surgical skills take a long period to perfect, made much easier with smart young anaesthetists in support.

I have taught my laparoscopic skills to two PIVET gynaecologists, Ă&#x20AC;UVWO\ 3KLOLS 5RZODQGV DQG QRZ *D\DWUL %RUXGH ZKR DUH WDNLQJ the techniques to a higher level. We work together on the more complex cases. Hysterectomies are now 1 hour per case, home the very next morning (although same evening requests are common), and return-to-work is as soon as 10 days. We are amazed. An impressive evolution!!

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35

BENEATH the Drapes X Dr David Russell-Weisz will be acting Director-General of Health after Mr Kim Snowball departed from the post last month. %S 3VTTFMM 8FJT[ XJMM BDU JO UIF QPTJUJPO VOUJM "QSJM )F DPOUJOVFT BT $&0 PG UIF 'JPOB 4UBOMFZ )PTQJUBM DPNNJTTJPOJOH QSPKFDU X Dr Shane Kelly XIP IBT CFFO $&0 PG 4+0() 4VCJBDP GPS UIF QBTU FJHIU ZFBST IBT CFFO BQQPJOUFE $&0 PG UIF /PSUI .FUSPQPMJUBO Health Service.

X Dr Paul Mark, formerly Area Director of Medical Services for South Metropolitan Health Service, has been appointed Director of Clinical Services at Fiona Stanley Hospital.

6ROXWLRQ 3URYLGHUV IRU *HQHUDO 3UDFWLFH

H3,3 &RPSOLDQW &RPSDWLEOH 'LVSHQVHG $Q\ZKHUH

X Dr Hannah Seymour DPOTVMUBOU HFSJBUSJDJBO BU 31) JT UIF GJSTU Clinical Commissioning Lead at Fiona Stanley Hospital.

X Bethesda Hospital has won the 2012/13 Asia Pacific Hand )ZHJFOF &YDFMMFODF "XBSE )PTQJUBM SFQSFTFOUBUJWFT XJMM USBWFM to Shanghai this month to receive the award and showcase their infection control initiatives at the International Congress of the Asia Pacific Society of Infection Control.

X Mr Jason Loveridge has been appointed a non-executive director PG 3FTPOBODF )FBMUI X Ms Stacey Boyne QSFWJPVTMZ .BSLFUJOH 13 4+0( 4VCJBDP has moved to Diabetes WA. Catriona McNee previously at SJOG Murdoch moves to SJOG Subiaco.

X News of the death of former Qantas chief Mr James Strong hit Pain Australia heavily. Mr Strong was the inaugural chairman of the organisation. He was aged 68.

X Former facilities manager at Healthscope in Victoria, Mr Andrew Bond, has been appointed Director of Corporate Services and Hospital Development at the St John of God Midland Public and Private Hospitals.

X Specialist Pathologist Professor Vince Caruso was recently awarded an Order of Australia Medal (OAM) in the General Division for service to Medicine in the field of Pathology. An awards ceremony will be held at Government House this month.

X Ms Pam Lewis IBT SFTJHOFE BT &YFDVUJWF %JSFDUPS PG )PTQJUBM and Health Services at Mercy Hospital and Ms Elaine Pavlos has replaced her.

ED. Pam is now consulting privately part time.

Practice Tips Empower Staff to Perform %P ZPV TPNFUJNFT GFFM ZPV SF OPU HFUUJOH ZPVS TUBGG UP XPSL UP UIFJS GVMM QPUFOUJBM 5IBU ZPV KVTU LOPX UIFZ SF DBQBCMF PG NPSF CVU ZPV EPO U LOPX IPX UP HFU UIFN UP SFBMJTF UIFJS GVMM DBQBCJMJUJFT :PV DBO HFU NPSF GSPN ZPVS TUBGG CZ HJWJOH UIFN QFSNJTTJPO UP NBLF NJTUBLFT 8F BMM MFBSO UISPVHI PVS NJTUBLFT BOE XPSL JT XIFSF NBLJOH NJTUBLFT TIPVME CF BO FTTFOUJBM QBSU PG B MFBSOJOH FOWJSPONFOU .BLF ZPVS XPSLQMBDF B iTBGFw QMBDF GPS NJTUBLFT o UFBDI ZPVS FNQMPZFF IPX UP GJY IJT IFS PXO NJTUBLFT SBUIFS UIBO EJWJOH JO BOE GJYJOH UIFN ZPVSTFMG 5IJT XJMM OPU POMZ FNQPXFS ZPVS FNQMPZFF UP GJY GVUVSF NJTUBLFT CVU BMTP UP TIBSF UIF LOPXMFEHF XJUI PUIFS TUBGG NFNCFST &ODPVSBHF BO FYDIBOHF PG JEFBT CFUXFFO TUBGG NFNCFST o XIBU JT a problem for one may have already be solved by another. Permitting an open forum in which everyoneâ&#x20AC;&#x2122;s ideas are heard and considered empowers people to share their thoughts and leaves them feeling valued by the employer. " XPSLQMBDF JO XIJDI BO FNQMPZFF JT WBMVFE BOE OFWFS NBEF UP GFFM UIFZ IBWF NBEF B iTUVQJE NJTUBLFw XJMM TPPO IBWF UIF CFTU QFSGPSNJOH FNQMPZFFT XPSLJOH UP UIFJS GVMM QPUFOUJBM

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37

Guest Column

Postnatal Depression

By Dr Beate Harrison, Perinatal and Infant Psychiatrist, Clinical Director Raphael Centre Murdoch. Tel 6226 9455

P

ostnatal depression often starts in pregnancy yet late diagnosis of the disorder is common. This leads to poorer social, emotional and cognitive outcomes for the mother and infant. Clinical acumen and the use of simple validated screening tools during the antenatal and postnatal periods are important to prevent this.

New mothers at risk During the transition to parenthood and after childbirth, psychological distress and difficulties are common. Biological, hormonal, identity and relationship changes and challenges confer increased risk for mental health disorders.

While women are more prone to depression than men throughout their lives, a significant peak of first episodes occurs after childbirth. Up to 15% of new mothers meet criteria for postnatal depression.

Late presentation of depression is still an issue, despite campaigns such as Beyond Blue increasing awareness and reducing stigma, thus promoting help-seeking in this patient group.

Interventions by professionals 3FHVMBS DPOUBDU XJUI QSJNBSZ DBSF obstetric and paediatric health services offers early intervention opportunities.

Many obstetricians now screen early with well-validated and simple screening UPPMT TVDI BT UIF &EJOCVSHI 1PTUOBUBM %FQSFTTJPO 4DBMF &1%4 UIBU DBO BMTP CF used in the antenatal period.

0OMJOF USBJOJOH GPS UIF &%14 GPS (1T JT offered through the Beyond Blue website, allowing easy and valid administration in a primary care setting. A range of other psychosocial screening tools are also available.

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Patterns and their significance Antenatal onset of symptoms is common; around 40% of cases having onset during pregnancy.

During the postnatal period, it usually takes six months to diagnose depression, with a significant proportion of cases still unrecognised during the first year of the babyâ&#x20AC;&#x2122;s life. Chronic untreated symptoms bring a worse prognosis for the mother and compromise her relationship with her infant, with less responsive interactions as a result of the poor self-esteem, confidence and withdrawal seen during depression.

Cognitive and emotional issues can result for the infant in the longer term.

Around 15% of fathers can also develop postnatal depression. This co-existence of paternal and maternal mental health issues lengthens parental symptoms and lessens support for the infant.

Good clinical assessment is central to diagnosis of postnatal depression and should consider these risk factors: t B QSFWJPVT IJTUPSZ PG EFQSFTTJPO FTQ postnatal onset or as part of Bipolar Affective Disorder ) t B NFEJDBMMZ DPNQMJDBUFE QSFHOBODZ or delivery, t QSFNBUVSJUZ PS NFEJDBM DPNQMJDBUJPOT in the infant, t TPDJBM EJTBEWBOUBHF BOE t B IJTUPSZ PG DIJMEIPPE USBVNB PS GBNJMZ dysfunction. medicalforum

3FGFSSBM UP B TQFDJBMJTFE QFSJOBUBM BOE JOGBOU service can offer the mother, infant and family a range of outpatient treatments.

Individual psychotherapy, cognitive and behavioural therapy and interpersonal therapy are all effective in the perinatal period. Infant-parent and parenting therapy are useful to support relationship difficulties that might arise.

Careful use of medication during pregnancy or while breastfeeding recognises that untreated mental illness has a range of adverse obstetric and developmental outcomes; tertiary maternity hospitals have up-to-date information on current evidence and safety. O Web Resources Beyond Blue EPDS Training www.beyondblue.com.au Perinatal Psychotropic Medicine Information Service www.ppmis.org.au

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39

In Practice

Aged Care Views Dr Ken Cullen is finding it hard to retire gracefully. Except for the paperwork, he enjoys the two aged care facilities he looks after.

What trends has he noticed over 40 years? â&#x20AC;&#x153;Facilities have evolved from big old homes to purpose-built hotel-like accommodation with physios, OTs, visiting speech pathologists, dieticians, podiatrists, opticians, etc. Despite all this, there are still unhappy residents and families. The demands on carers are high and people going into aged care are a lot sicker than they were,â&#x20AC;? he said. i8IFO * GJSTU TUBSUFE BU UIF 34- DPNQMFY UIFSF XFSF B MPU PG PME veterans with only simple medical problems who couldnâ&#x20AC;&#x2122;t manage on their own â&#x20AC;&#x201C; almost like a boarding house where people could still get on a bus and go out.â&#x20AC;? /PU BOZNPSF )F DBO CF BU IJT CFE 34- BHFE DBSF GBDJMJUZ "$'

in Menora from 8am until 5pm â&#x20AC;&#x201C; a long trying day he admits but mentions spending extra time with patients and talking to relatives. â&#x20AC;&#x153;I look at medications I can cut out because I get sick of writing prescriptions and you often wonder if you are doing more harm than good â&#x20AC;&#x201C; but I donâ&#x20AC;&#x2122;t have any particular philosophy. I am guided by family wishes â&#x20AC;&#x201C; that might mean full-on care or, in many cases, just keep comfortable.â&#x20AC;? â&#x20AC;&#x153;I donâ&#x20AC;&#x2122;t get involved in the politics of it all but just do the job. Iâ&#x20AC;&#x2122;ve always felt that regular visiting would help. Mental health provides a wonderful service with visiting psychiatrists but a geriatrician to provide management advice and at the same time educate me, would be great.â&#x20AC;?

His wish list to stay in the game is less paperwork, relevant CPD, help with issues around medications, perhaps a specialist to come in and do some things, and nursing staff who can be relied on.

He wondered how many people are sent off in an ambulance from an aged care facility because they couldnâ&#x20AC;&#x2122;t get a GP to go there. While the hard-to-get locum and Silver Chain offer some services, often informal arrangements between the GP and experienced nurses allow things to be started prior to the doctorâ&#x20AC;&#x2122;s visit. Then again, he suspects an available GP might only stop half the hospital visits that follow falls in the elderly.

Two new things might interest Ken. The first is an attempt to cut down on ACF scripts. Legislation is coming this year to allow a standard Medication Chart in ACFs, a system already trialled interstate in August as the National Residential Medication Chart /3.$ CZ UIF "VTUSBMJBO $PNNJTTJPO PO 4BGFUZ and Quality in Health Care. The chart is to be used to authorise supply BOE DMBJNJOH PG 1#4 31#4 ESVHT GPS QBUJFOUT JO "$'T o OP XSJUUFO TDSJQU JT SFRVJSFE FYDFQU "VUIPSJUZ TDSJQUT BOE TDIFEVMFE ESVHT 4FF XXX DQB DPN BV BOE XXX TBGFUZBOERVBMJUZ HPW BV Dr Kathleen Potter (March edition Medical Forum) now has funding to extend her research nationally from WA, having safely reduced medications by 40% in her initial trial of ACF patients, with the assistance of their GP and a co-researcher geriatrician. O

By Dr Rob McEvoy

You can now prescribe exercise!

As part of our commitment to health of Western Australia the team at Obesity Surgery WA, is now offering exercise programmes at no cost.

To enrol, we need a referral to our practice for exercise. Everyone gets a health review to check their suitability and will get a personal plan or get to join one of our group sessions. The service is open to anyone who needs a little help to get fitter, even if they are not considering surgery. < Mr Harsha Chandraratna Surgeon Jo Climo > Clinical Nurse & Exercise Co-ordinator

Obesity Surgery WA (08) 9332 0066 SUBIACO

medicalforum

MURDOCH 41

CLINICAL UPDATE

Will she blame you if she gets flu?

S

Dr Donna Mak, Public Health Physician, Communicable Disease Control Directorate, Department of Health

he might well do, if you didnâ&#x20AC;&#x2122;t recommend flu vaccine as a routine part of antenatal care during the flu vaccination season (15 March to June/July).

In 2012, the World Health Organizationâ&#x20AC;&#x2122;s 4USBUFHJD "EWJTPSZ (SPVQ PG &YQFSUT 4"(&

on Immunisation recommended pregnant women as the most important risk group for seasonal influenza vaccination because of all the risk groups, pregnant women are the most likely to benefit.1 The Australian Government BOE UIF 3PZBM "VTUSBMJBO BOE /FX ;FBMBOE College of Obstetricians and Gynaecologists 3"/;$0( $PMMFHF 4UBUFNFOU $ 0CT

also recommend that all pregnant women be offered vaccination against influenza. )PXFWFS MFTT UIBO POF RVBSUFS PG pregnant women in WA were vaccinated against flu in 2012 â&#x20AC;&#x201C; a much lower uptake p than that achieved in the elderly (68%) and adults with chronic conditions (31%).2 Why? The single most important reason is that flu vaccine is not routinely recommended or offered by antenatal care providers.

Of over 400 randomly-selected women who delivered in WA in 2012, only 36% were advised by their antenatal care provider to IBWF GMV WBDDJOF BOE B RVBSUFS XFSF PGGFSFE flu vaccination at the clinic where they attended for antenatal care. Women who attended a GP or private obstetrician for most of their antenatal care were more likely to have been vaccinated than those attending public antenatal clinics.

How can we improve coverage?

'PSUVOBUFMZ MFTT UIBO B RVBSUFS PG XPNFO surveyed doubted the safety and efficacy of flu vaccine for themself and their baby, and UISFF RVBSUFST TBJE UIBU UIFZ XPVME BDDFQU vaccination if it was recommended by their antenatal care provider.

So, during the flu vaccination season (15 March to June/July), we need to: t 3PVUJOFMZ SFDPNNFOE GMV WBDDJOF UP pregnant women, and t 0GGFS WBDDJOBUJPO BU UIF UJNF PG antenatal care. References 1. WHO. Strategic Advisory Group of Experts (SAGE) on Immunization Statement, April 2012. www.who.int/ influenza/vaccines/SAGE_information/en/index.html 2. Taksdal SE, Mak D, Joyce S, Tomlin S, Carcione D, Armstrong P, Effler P. Influenza vaccination uptake in pregnant women in Western Australia. Communicable Disease Control Conference. 19-20 March 2013, Canberra, Australia. O

Medical Forum E-Poll *O "QSJM (1T SFTQPOEFE UP UIF RVFTUJPO BCPVU GMV WBDDJOBUJPO JO QSFHOBODZ XJUI 52% responding correctly that it is safe any time regardless of gestational age. We asked the TBNF RVFTUJPO UIJT NPOUI BOE EPDUPST SFTQPOEFE 5IJT ZFBS B TMJHIUMZ IJHIFS QSPQPSUJPO (58%) identified the correct answer

Q

When is it recommended to give influenza vaccine to a pregnant woman? (select one response)

3FTQPOTF 1. Never â&#x20AC;&#x201C; it is contraindicated in pregnancy 2. First trimester 3. Second or third trimesters 4. At any time during influenza season as long as the vaccine supply lasts and regardless of gestational age 5. Uncertain

April 2012 (n=92) 9% 2% 22%

April 2013 (n=197) 4% 7% 18%

52%

58%

14%

13%

Immunise Debate Response Scientists have upped the ante when it comes to capturing the minds of the public in the childhood immunisation stakes.

The Science of Immunisation: Questions and Answers, produced by the Australian Academy of Science and endorsed by the College of Physicians and the federal AMA presents counter-arguments to current myths gaining airplay. Doctors can download a pdf version or order handout copies for patients who want to know the current situation in immunisation science, including where there medicalforum

is consensus in the scientific community and where uncertainties exist (see www.science. org.au/policy/immunisation.html. Orders of three copies or less are free).

Some people of renown have put their names to the product, such as Prof Tony Basten AO, Ian Frazer AC and Sir Gus /PTTBM "0 $#& *U T B CPPLMFU UP IBOE UP conscientious objectors to vaccinations, if no one else, to detail the safety and efficacy of immunisation. The overall aim is to keep Australiaâ&#x20AC;&#x2122;s immunisation rates high. O 43

CLINICAL UPDATE

Tattoos and their removal I

made the mistake once of slagging off in company those who had tattoos, only to have both of my acquaintances lift their sleeves to reveal their own ink. Middle-class tattoos are becoming the norm now. It's our culture of individuality; we want to be part of the tribe too. It doesn't seem to matter if it's Maori tribal art, or koi swimming in a Japanese pond, or a butterfly representing your dead aunt. They are everywhere. In fact, nearly 30% of youngsters in Australia have tattoos and the trend is rising, particularly in women.

By Dr David Main, South Perth.

Tel 9368 6888

This includes the young doctors although it still seems to hold true that those being UBUUPPFE BSF NPSF AFEHZh JG UIJT NFBOT B higher likelihood of smoking tobacco, pot and having more sex(1). After getting a tattoo, people feel sexier and more interesting, and report higher self-esteem(2).

It's by no means new. They have dug up cavemen with tattoos. The Brits were inking their family coats of arms before Hadrian, now it's their football teams. The Japanese had a three strike policy for tattoos: one crime and you got a horizontal mark, a second crime and you got a curve, and the UIJSE UJNF UIF GJOJTIFE BSUXPSL SFBE AEPHh This association with being a crook lives on but that probably represents the old school, with jailbirds and gang members.

Tattoo removal Putting tattoos on is big business, and removing them is getting that way too, as up to 50% regret the choice (3). Grown up, got a job, and the tramp stamp is no longer in.

Before lasers, removing tattoos was hit and miss. Mostly miss. Tattoo pigment lies within EFSNBM GJCSPCMBTUT NPTUMZ BU UIF %& KVODUJPO but extending deeper into the dermis with time. It takes a lot of getting out. Grafting, excision, dermabrasion, or physical or chemical ablation were tried.

Strangely, we are now seeing lots of scarred tattoos from tannic acid injections and the like marketed under names like Tatt2Away.

Intense pulsed light (IPL), likewise cannot safely remove tattoos.

Laser tattoo removal Q-switched lasers are the gold standard for tattoo removal. Q-switching produces very short pulse widths (nanoseconds) to photo-acoustically shatter ink granules and minimally affect skin cells. Ink is then removed by phagocytosis.

A variety of wavelengths of visible and infrared light are used, the principles being complementary colours. A green laser (KTP) treats red ink, and red laser (dye or Alexandrite) is for green ink. Black ink, as the universal absorber, is treated with infrared :"( MBTFS BT MPOHFS XBWFMFOHUIT IBWF CFUUFS dermal penetration. &GGJDBDZ JT BDDFQUBCMF XJUI BEEFE considerations. Black tattoos fade slowly and almost completely over an average of 10-12 treatments at six week intervals. &BDI USFBUNFOU TFTTJPO UBLFT CFUXFFO minutes and an hour, depending on size and complexity.

medicalforum

Q Removing tattoos with a laser can be painful and requires repeat sessions.

Amateur tattoos, eyeliner and radiotherapy UBUUPPT GBEF NVDI NPSF RVJDLMZ (SFFO BOE sky-blue respond poorly though, and in many cases large, colourful tattoos such as sleeves are effectively unremovable. Other factors that lead to poorer outcomes include high ink density, distal location, and smoking.

Scarring incidence is low at around 5%.

Hypopigmentation is more common but often resolves over time. Darker skin types can show transient hyperpigmentation.

Laser treatment is painful, although topical &.-" DSFBN BQQMJDBUJPO NBLFT UIF procedure tolerable for most.

Further Reading Bernstein, E. Laser Tattoo Removal. Semin Plast Surg.

2007 August; 21(3): 175â&#x20AC;&#x201C;192.

Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/ PMC2884836/ References 1. Heywood W, et al. Who Gets Tattoos? Demographic and Behavioral Correlates of Ever Being Tattooed in a Representative Sample of Men and Women. Ann Epidemiol. 2012 Jan; 22(1):51-6.

2. Swami V. Marked for life? A prospective study of tattoos on appearance anxiety and dissatisfaction, perceptions of uniqueness, and self-esteem. Body Image. 2011 Jun;8(3):237-44.

3. Burris K, Kim K. Tattoo removal. Clin Dermatol.

2007;25:388â&#x20AC;&#x201C;392. O

The Future New research suggests that even shorter pulsed lasers (picosecond) may be more effective for many tattoos including green and blue. Picosecond lasers are now entering the market.

Other developments include the use of topical BEKVWBOUT TVDI BT JNJRVJNPE XIJDI NJHIU recruit more macrophages to the treatment site.

Finally, highly laser responsive ink has been available since 2009 (Infinitink). This is bioresorbable dye within PMMA beads. It has not caught on within the tattoo industry though.

Competing interests: Dr Main provides laser tattoo removal services.

Take Home Messages t 5IPTF DPOUFNQMBUJOH HFUUJOH UBUUPPFE BSF WFSZ MJLFMZ UP DIBOHF their mind afterwards. t &OTVSJOH BTFQUJD UFDIOJRVFT BSF used is important, especially overseas. t *G UIFSF JT BOZ DIBODF PG MBUFS SFNPWBM DIPPTF CMBDL BT DPMPVST are harder to remove.

45

LOW OW

HIGH

OUR CT SCORED LOWER

THAN THE NATIONAL DOSE REFERENCE LEVELS

In 2011, the Australian Radiation Protection and Nuclear Safety Agency conducted the Australian National Diagnostic Reference Level Survey. The data established a measure of multi-slice detector CT doses for current diagnostic imaging practice in Australia, allowing individual practices to compare their doses against those of their peers.1

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

1200

1000

1000 900

800 700

Imaging Central is the only private practice that offers a state of the art Siemens 128 slice CT delivering the same dose reduction technology as Princess Margaret Hospital for Children: SaďŹ re Iterative Reconstruction CARE Dose kV CARE Dose 4D Adaptive Dose Shield

450 400 248

236 188

200

0

At Imaging Central, it is easy to compare our dose achieved with others as we include it on every CT report.

612

600

600 563

Head

Neck

164

Chest

National Dose Reference Levels

Abdo Chest Lumbar Pelvis Abdo Pelvis Spine Imaging Central 2

1 Australian Government, Australian Radiation Protection and Nuclear Safety Agency., viewed 29th Jan 2013 http://www.arpansa.gov.au/services/ndrl/index.cfm 2 Imaging Central Practice Reference Level Dose measured from Oct - Dec 2012

Head to our website for more information about our dose reduction technologies 4646

.

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

CLINICAL UPDATE

Relevance of over-diagnosis in breast cancer screening

B

reastScreen Australia commenced in 1991 and currently screens women over the age of 40 for breast cancer, targeting women aged 50-69. Since national screening programs in the United Kingdom and Europe were established there has been debate in medical journals, at times acrimonious and deeply divisive, over the benefits and harms of population screening.

Moreover, it is not possible, at the time of a woman's diagnosis and treatment, to recognise which individual cases of â&#x20AC;&#x153;breast cancerâ&#x20AC;? will eventually prove to be classified BT APWFS EJBHOPTJT The UK independent breast screening review found that breast cancer screening extends lives through early detection and treatment.

The breast screening program has an obligation to provide the public with the best estimates of benefits and harms of breast cancer screening as a starting point for a broader discussion of informed decision making.

The BreastScreen Australia Evaluation, published in 2009, demonstrated that the national program has reduced breast cancer mortality by 28%, with a participation rate of 55%. The recent report of the independent UK panel on Breast Cancer Screening found that for every 180 women regularly invited to screening, one death would be prevented.

The detractors of population screening propose that the major harm to women is over diagnosis, leading to over treatment of breast cancer.

Over diagnosis refers to the detection of cancers in screening that would not have become clinically apparent in the womanâ&#x20AC;&#x2122;s lifetime in the absence of screening. Due to the invasive diagnostic procedures involved in diagnosis, and the physical and psychosocial impact of breast cancer treatment, over diagnosis may be considered a seriously adverse outcome of screening.

By Dr Liz Wylie Medical Director BreastScreen WA and Head of Radiology RPH. Tel 9323 6706

Q Mammography in action

The independent UK screening review panel found that there is a great deal of uncertainty in respect to the extent of over diagnosis in population screening programs. (1) The most plausible estimates of over diagnosis range from 1% to 10%.

Substantially higher estimates of over diagnosis reported in the literature are considered to be due to the lack of adjustment from breast cancer risk and/or lead time (2)

Cancer Australia is currently working with the Commonwealth Department of Health and Aged Care to improve information for women on the benefits and risks of screening with a view to revise client information to be made available mid-2013.

References: (1) Independent Breast Screening Review A report jointly commissioned by Cancer Research UK and Department of Health (October 2012) www.cancerresearchuk.org (2) Overdiagnosis in mammographic screening for breast cancer in Europe a literature review. Donella Puliti et al, and the EUROSCREENWorkingGroup. http://jms. rsmjournals.com/content/19/suppl_1/42.full.pdf+html

O

Declaration: No competing interests

Supporting women around childbirth

T

he Raphael Centre was officially opened in Fremantle before Christmas as part of the outreach program for SJOGH. It is still early days and patients do not have to be maternity patients at a SJOG hospital to access services. All services are bulk-billed and the use of Better Access to Mental Health and Mental Health Care Plans by referring GPs makes things more accessible for the disadvantaged.

The centre will have capacity for about 2000 TFTTJPOT QFS ZFBS XIJDI FRVBUFT UP BSPVOE 200 clients, each with 10 sessions available to them under Better Access.

Services target primarily women and their families, both preconception (e.g. past traumatic birth) or in the perinatal period (e.g. postnatal depression or anxiety), for the first four years of parenthood. To date, medicalforum

about half of the referred clients have been antenatal.

The spokesperson told Medical Forum their services are available to women and their partners for anxiety, depression, or grief and loss and concerns that may arise from any antenatal screening and diagnostic tests.

3FGFSSJOH EPDUPST TIPVME EFUFSNJOF GPS themselves if the Catholic ethos encroaches on advice given.

The community-based mental health clinic runs alongside adult counselling services at Ferns House in Fremantle, providing familyfocused therapies under Clinical Director psychiatrist Dr Beate Harrison. She is at the 3BQIBFM $FOUSF UXP EBZT B XFFL BOE IBT experience in mother-infant relationships, premature infants and parenting for mothers with perinatal psychiatric issues (see page P41).

The centreâ&#x20AC;&#x2122;s full-time Clinical Services

Q SJOGH Group Director of Mission Jennifer Stratton (left) and SJOG Murdochâ&#x20AC;&#x2122;s Manager Social Outreach and Advocacy Community Mental Health Peta Wootton.

Coordinator is a mental health nurse with rural and urban experience. She is assisted by three caregivers with both perinatal and infant health expertise.

4+0( )FBMUI $BSF $&0 %S .JDIBFM 4UBOGPSE said the centre opening was a response to an ever-increasing demand for these services, including those who might otherwise fall through the cracks of an increasingly overburdened public system.

47

Support Group

Ishar Multicultural Womenâ&#x20AC;&#x2122;s Health Centre I

t was Ishar was established in 1992 in response to the influx of humanitarian refugees and migrants from non-English speaking backgrounds who were settling in Balga, Nollamara, Mirrabooka, Koondoola, Girrawheen and Westminster within the City of Stirling.

It was the only Womenâ&#x20AC;&#x2122;s Health Centre specifically established for women from multicultural backgrounds. Ishar is now providing outreach services in the City of Wanneroo where another population of CaLD families is located.

The services at Ishar include: t 8FMM 8PNFO T $MJOJD DPOEVDUFE CZ female GP (for womenâ&#x20AC;&#x2122;s health problems only) t "OUF OBUBM DMJOJD TVQQPSUFE CZ GFNBMF GP and midwife t 1FSJ OBUBM TVQQPSU BOE IPNF WJTJUJOH by a social worker t 1IZTJPUIFSBQZ $MJOJD DPPSEJOBUFE CZ female physiotherapist t 0UIFS IFBMUI BOE XFMMCFJOH TFSWJDFT including yoga and exercise, nutrition and information sessions t 1TZDIPMPHJDBM DPVOTFMMJOH t $BSFS TVQQPSU BOE DPVOTFMMJOH for carers of people with mental health issues t 'BNJMZ TVQQPSU TFSWJDF JODMVEJOH sewing and craft classes, swimming lessons, and information sessions

t 08- 0MEFS 8PNFO T -JGFTUZMF

Program for women over 55 Ishar takes referrals from a number of GPs though it always seeks to expand and improve its interactions with the medical profession through offering a range of services.

It would like to be viewed as a highly skilled and professional organisation providing important and culturally sensitive health services for women from CaLD backgrounds.

Ishar provides a safe place in which to learn about the health and social systems of Australia, and to gain to participate in their new community. O

Women in High Heels

Ishar Multicultural Womenâ&#x20AC;&#x2122;s Health Service Background: &TUBCMJTIFE JO .JSSBCPPLB JO Current WA members: Budget: BOOVBMMZ GSPN %FQBSUNFOUT PG )FBMUI 'BNJMJFT )PVTJOH $PNNVOJUZ 4FSWJDFT BOE *OEJHFOPVT "GGBJST *NNJHSBUJPO BOE $JUJ[FOTIJQ 8" %FQBSUNFOU GPS $PNNVOJUJFT BOE PUIFST Contact details: .POEBZ 'SJEBZ BN QN "EESFTT 4VECVSZ 3PBE .JSSBCPPLB 8" .JSSBCPPLB -JCSBSZ #VJMEJOH 1I 'BY

&NBJM JOGP!JTIBS PSH BV XFCTJUF www.ishar.org.au

By Dr Nicole Leeks, Orthopaedic Surgeon

There is a strong genetic predisposition for the development of bunions â&#x20AC;&#x201C; obvious when I see young girls with bunions (as young as seven), who obviously have not experienced the "wonder" of "high heels".

I believe this genetic susceptibility is altered/modified by environmental influences (from long ago in medical school, is this called penetrance?). Girls or women with flat feet or pes planus are also at increased risk secondary to the midfoot pronation in the stance phase, which increases the forces through the first ray [metatarsal]. medicalforum

We know that wearing a heel excessively loads the forefoot but my feeling is that heels need to be worn all day, every day for an effect to occur and it may well only occur if that individual has flat feet and/or a genetic ssusceptibility.

Why are women so prone to W b bunion formation? Who knows?

Certainly, our k sshoe wear, even flat sshoes, do not have a wide toe box like w men's shoes and ttend to be

more rounded and contoured but female babies have a higher risk of developmental hip dysplasia and boys of clubfoot. Is it something to do with being female or male?

Many of the high shoes currently around are more of the platform variety as opposed to the classic '60s stiletto, which means that the forefoot is actually elevated to an extent. This would presumably reduce the forefoot load. &WFO BGUFS CVOJPO TVSHFSZ * BMMPX QBUJFOUT UP wear a high heel but counsel them not to wear them every day, all day, just to try and reduce the risk of recurrence. I have so many patients with bunions coming to see me who swear they have always worn sensible shoes! And how do we account for the men who turn up with the same problem?

In a nutshell, I think you are born with the risk, which can be exacerbated by inappropriate footwear!O 49

Lifestyle

ANDREWâ&#x20AC;&#x2122;S LAST FRONTIER

Mundaring medico Andrew Dunn looks back on a conference with a twist. No palm trees, no exotic cocktails but plenty of penguins and icebergs.

Andrew Dunn had visited every continent except Antarctica by the time he was 25. It took him another three decades to venture into the Southern Ocean. He and Sorrento GP Lawrence Wapnah travelled there exercising both mind and body aboard the Russian vessel, Akademik Sergey Vavilov. i5IF TIJQ XBT OBNFE BGUFS B /PCFM 1SJ[F XJOOJOH 3VTTJBO QIZTJDJTU *U XBT ESPQQJOH VMUSBTPVOE MJOFT LN CFMPX UIF TVSGBDF UP detect nuclear submarines. [Ours, not theirs.] * E XBOUFE UP HP UP UIF "OUBSDUJD 1FOJOTVMB FWFS TJODF * XBT B LJE *U T BO BCTPMVUFMZ stunning place with a mountainous volcanic landscape and an incredible coastline. :PV DBO TUBOE JO POF QMBDF BOE TFF NPSF UIBO QFOHVJOT BOE FMFQIBOU TFBMT w "OESFX TBJE i"T EPDUPST XF OFFE UP UBLF CSFBLT GSPN PVS CVTZ QSPGFTTJPOBM MJWFT *U T BMTP JOUFSFTUJOH UP see elephant seals fatter than some of our QBUJFOUT w "OESFX TUSFTTFE UIBU UIF USJQ XBT B MFHJUJmate and fully accredited medical conference 50

with a distinctly international flavour. i5IFSF XFSF BSPVOE EPDUPST B NJYUVSF PG "VTUSBMJBO ,JXJ "NFSJDBO BOE PUIFS MFTTFS beasts. (FOFSBM 1SBDUJDF *TTVFT would be an appropriate banner and, when we werenâ&#x20AC;&#x2122;t LBZBLJOH PS HB[JOH BU XBOEFSJOH BMCBUSPTTFT we were very busy DPOGFSFODJOH w 5IFSF XFSF BCPVU QBTTFOHFST BOE crew members aboard the good ship 4FSHFZ 7BWJMPW 5IF 4PVUIFSO 0DFBO JT B XJME UIJOH BOE TFBTJDLOFTT XBT B DPOTUBOU DPNQBOJPO "OESFX B CJU PG BO APME TBMU IJNTFMG IBT B theory about that. i5IF PDFBO XBT SPMMJOH CJH UJNF BOE TPNF PG UIF XBWFT XFSF TJY TUPSFZT IJHI * XBT POF PG UIF WFSZ GFX XIP XBTO U TJDL 5IF TFDSFU JT BMM UP EP XJUI QSPQSJPDFQUJPO BOE UIF NJYFE messages you get when the inner ear tells you youâ&#x20AC;&#x2122;re moving but the eyes tell you youâ&#x20AC;&#x2122;re OPU 5IF USJDL JT UP TUBZ BCPWF EFDL BOE MPPL BU TPNFUIJOH GJYFE FWFO B DMPVE .Z BEWJDF JT UP LFFQ MPPLJOH BU UIF IPSJ[PO PS GBJMJOH UIBU LFFQ ZPVS HPEEBN FZFT DMPTFE w *DFCFSHT BSF VOQSFEJDUBCMF BU UIF CFTU PG UJNFT o KVTU BTL UIF DBQUBJO PG UIF 5JUBOJD #VU JG ZPV SF B UISJMM TFFLJOH NFEJDP "OUBSDUJDB JT an irresistible destination.

Q From Top: Dr Andrew Dunn Kayaking in the Antarctic; Andrew with Dr Lawrence Wapnah; and Lawrence doing his Tony Abbot impersonation in the chilly waters of the Antarctic.

i8F XFSF PVU PO UIF XBUFS XIFO UISFF UTVnamis came through and the icebergs started SPMMJOH BSPVOE 5IBU T OPU HPPE JO B LBZBL "OE XIFO B LBUBCBUJD XJOE TIPPUT EPXO UIF side of a mountain it can go from calm to LN IPVS JO TFDPOET w i5IF MBOETDBQF JT SBX BOE QSJNBM 5IF TPPOFS 4PVUI (FPSHJB JT XPSME IFSJUBHF MJTUFE UIF

medicalforum

E-Poll:

The Best Gift for a Woman is...

Because...

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By Mr Peter McClelland

medicalforum

i" DIJME CFDBVTF TIF XJMM CF GVMGJMMFE w i" NJSSPS CFDBVTF UIFZ BSF QFSGFDU w i#FJOH TJOHMF MBUFS JO MJGF BT NZ HSBOENPUIFS UBVHIU NF ZPV DBO HP PVU NBTUFS BOE DPNF IPNF NJTUSFTT w i$PHOJUJWF CFIBWJPVSBM UIFSBQZ JO BO BUUFNQU UP DVSC UIFJS TQFOEJOHw 0S JG ZPV SF SFBMMZ TUSVHHMJOH XJUI UIJT HJGU UIJOH UBLF UIJT BEWJDF i(JWF B XPNBO B EPH CFDBVTF UIFZ BSF MPZBM EPOhU FYQFDU GBWPVST JO SFUVSO GPS BGGFDUJPO BOE FBU ZPVS QBSUOFST TPDLT TP ZPV EPOhU IBWF UP UPVDI UIFN w 51

Theatre

for whom the

Bell Tolls One of Shakespeareâ&#x20AC;&#x2122;s great plays performed by one of the great Shakespearean actors working today â&#x20AC;Ś and itâ&#x20AC;&#x2122;s happening this month in Perth.

4P NBOZ QFPQMF T GJSTU FYQFSJFODFT PG 4IBLFTQFBSF BSF PG UIF VOIBQQZ LJOE o CFJOH POF PG CPSFE BEPMFTDFOUT SFBEJOH B MJOF FBDI GSPN .BDCFUI *U DPVME IBWF TP FBTJMZ HPOF UIBU XBZ GPS NF UPP JG * IBEO U CFFO TIPXO JO B SBEJDBM GSFTI JOUFSQSFUBUJPO of )BNMFU XJUI B GJSFCSBOE "VTUSBMJBO BDUPS CZ the name of John Bell. *U TQBSLFE B IFSP XPSTIJQ PG +PIO #FMM BOE B MJGFMPOH MPWF PG 4IBLFTQFBSF UIBU IBT OFWFS dimmed. How could it possibly, when his QMBZT BSF TP HSJUUZ EJSUZ GVOOZ USBHJD o UIFZ are all about people scrambling over each other to find love, power, fame and fortune. +PIO #FMM BU NBZ OPU IPQ BSPVOE UIF TUBHF as Hamlet anymore but his sharp theatre NJOE OFWFS LFFQT IJN GBS GSPN UIF CPBSET *O 1FSUI UIJT NPOUI XF TIBMM TFF IJN BT 4IBLFTQFBSF T NPTU DPNQMFY PG DPNJD SPMFT UIF CFMMJDPTF 4JS +PIO 'BMTUBGG JO IJT PXO BEBQUBUJPO PG UIF UXP )FOSZ *7 QMBZT GPS IJT PXO #FMM 4IBLFTQFBSF 5IFBUSF $PNQBOZ He will be directed by one of his protĂŠgĂŠes, %BNJFO 3ZBO XIP BENJUUFE UP B GFX CVUUFSflies at the thought of directing his mentor. i8IFO IF HJWFT ZPV UIF DBMM BOE BTLT ZPV UP do it, itâ&#x20AC;&#x2122;s a pretty terrifying thing but only from UIF QFSTQFDUJWF UIBU IF T TVDI BO FYUSBPSEJOBSZ BDUPS BOE IJT LOPXMFEHF PG UIJT QMBZ JT QBSUJDVMBSMZ BNB[JOH )F T CFFO XPSLJOH PO UIJT QMBZ GPS B WFSZ MPOH UJNF o JU T POF PG IJT GBWPVSJUFT * UIPVHIU UP NZTFMG XIBU DBO * possibly offer this play and John Bell, but it is very hard to direct yourself in a play and he is BXBSF PG UIBU w 52

"DDPSEJOH UP %BNJFO BVEJFODFT IBWF B MPU UP MPPL GPSXBSE UP i5IF )FOSZ *7 QMBZT BSF RVJOUFTTFOUJBM 4IBLFTQFBSF o UIF DPNFEZ is hilarious, the pathos is profound and the dialogue and characters are e TPQIJTUJDBUFE *U T OPU UIF TJMMZ [BOZ Z comedy of the earlier plays. Then n alongside that there is soaring traggedy with clear psychological turnings, s, it offers so many options for interpree UBUJPOT w "U UIF IFBSU PG UIF QMBZ JT )BM UIF 1SJODF PG 8BMFT TPO PG )FOSZ *7 XIP IBT DPOUSPversially ascended to the throne after the EFQPTJUJPO PG IJT DPVTJO 3JDIBSE ** #VU JU T not so much a history lesson as an insight into power, corruption and big, difficult families. Hal wants to have fun, his father is furious, which tumbles Hal into the arms of TVSSPHBUF EBE UIF MPWFBCMF SPHVF 'BMTUBGG i*U T BO BNB[JOH QJFDF PG XSJUJOH w %BNJFO TBJE i*U JT B IJTUPSZ POMZ JO OBNF 8IBU 4IBLFTQFBSF JT SFBMMZ USZJOH UP EP JT HJWF VT B QMBZ BCPVU NPSBMJUZ )PX EP ZPV SBJTF B TPO how does a son grow up in the world without a moral compass when his real father and his TVSSPHBUF GBUIFS BSF UIJFWFT XIFSF EPFT UIJT CPZ MFBSO SJHIU GSPN XSPOH w i5IFSF BSF TPNF WFSZ NPEFSO DPODFQUT PG WJPMFODF BT XFMM *U JT B WJPMFOU NBTDVMJOF QMBZ *U RVFTUJPOT NBMF BHHSFTTJPO BOE UIF DPTU PG XBS PO UIF PSEJOBSZ DJUJ[FOT XIP BSF DPOTDSJQUFE BT 'BMTUBGG EFTDSJCFT UIFN BT cannon fodder. They are going to die and

there is no accordance of their sacrifice given CZ UIF GJHVSFT BCPWF UIFN w .BUU .PPSF QMBZT )BM BOE %BNJFO TBZT UIF close relationship between Matt and John ripples on stage. i0OF PG UIF SFBTPOT +PIO DBTU IJN BT )BM was because theyâ&#x20AC;&#x2122;ve had this long and joyPVT SFMBUJPOTIJQ PG XPSLJOH UPHFUIFS 0O UIF GJSTU EBZ PG SFIFBSTBM +PIO TBJE AUIJT TIPVME feel for the audience as if the two actors EPJOH )BM BOE 'BMTUBGG IBWF B QBMQBCMF IJTtoryâ&#x20AC;&#x2122;. That has been a plus the way they trust each other and play off each other. To watch that decompose in the second half toward that final rejection is a great moment of theatre." O

By Ms Jan Hallam

'PS ZPV DIBODF UP XJO UJDLFUT UP UIF "QSJM QFSGPSNBODF PG )FOSZ *7 TFF UIF DPNQFUJUJPOT 1

medicalforum

BIG NA M E

BIG FL AVOUR

Elicure 2012 Cabernet Franc 5IF &MJDVSF SBOHF BSF TUZMFE UP FYQSFTT UIF UFSSPJS PG UIF SFHJPO BOE XIJMF QPXFSGVM it should not dominate. This wine is bright and youthful, the nose showing touches of redcurrant, camphor and cloves. The flavours of ripe mulberry, redcurrant and ESJFE IFSCT HJWF B MJOHFSJOH GJOJTI FOIBODFE CZ UIF GJOF HSBJOFE HSJQQZ UBOOJOT *U T OPU BT GMPSBM BOE IFSCBM BT UZQJDBM WBSJFUBM $BC 'SBOD CVU JU T B OJDF GVMM CPEJFE XJOF XIJDI TIPVME ESJOL XFMM GPS TJY ZFBST PS NPSF

By Dr Craig Dummond, Master of Wine

Elicure 2010 Grenache Shiraz )FSF T B USBEFNBSL CMFOE PG UIF SFHJPO *UT BSPNBT BSF HFOFSPVT TBWPVSZ BOE SVTUJD 5IFSF JT MPBET PG TPGU KBNNZ GSVJU BOE XBSN BMDPIPM XJUI CMBDLDVSSBOU TQJDZ BOE IFSCBM GMBWPVST *U T ESJOLJOH XFMM OPX BOE XJMM EP TP GPS B GFX NPSF ZFBST UP DPNF * MPWF UIJT WBSJFUBM CMFOE GPS EBZ UP EBZ ESJOLJOH BOE JUhT JEFBM GPS B CBSCFDVF

The long-established premium wine district of McLaren Vale almost borders Greater Adelaide these days and is well worth a visit when next in Adelaide. Being located on the Fleurieu Peninsula exerts a moderating effect on this warm Mediterranean climatic region.

Hence the wines are in the true traditional Aussie style â&#x20AC;&#x201C; big, rich, ripe and complex, though they avoid the overripe â&#x20AC;&#x2DC;jammyâ&#x20AC;&#x2122; characters.

Shiraz and Grenache have been the backbone of the region but the Cabernet varieties are also very signiďŹ cant.

Aurum Release 2010 Shiraz /PX XF HFU JOUP UIF CJH TUZMFT 5IJT XJOF JT EFFQ GVMM CPEJFE XJUI EBSL QMVN FBSUI BOE MFBUIFS PO UIF OPTF GPMMPXFE CZ KVJDZ QMVN BOE EBSL DIFSSZ GMBWPVST BOE DFEBSZ PBL *U TIPVME IBWF B DFMMBS MJGF PG NPSF UIBO ZFBST XJUI JUT SJQF DPODFOUSBUFE GSVJU CBMBODFE XJUI JUT BDJE CBDLCPOF JNQBSUJOH EFGJOFE TUSVDUVSF Grand Royale 2010 Shiraz 5IF A(SBOEF 3PZBMF TFSJFT JT -BWJOBhT JDPOJD XJOFT BU UIF UPQ PG UIFJS RVBMJUZ QZSBNJE 5IJT TIJSB[ JT NBTTJWF " CSPPEJOH HJBOU o JU T SJQF PBLZ DPODFOUSBUFE BOE QPXFSGVM 'SVJU DIBSBDUFST BSF TUJMM WFSZ QSJNBSZ BU UIJT UJNF QPJOU XJUI ESJFE DVSSBOUT USVGGMFT CMBDL QFQQFS BOE B UXJTU PG CJUUFS DIPDPMBUF 5IFSF JT MPBET PG UPBTUZ PBL BOE CJH DIVOLZ UBOOJOT +VTU B CBCF JU XJMM BXBLFO PWFS GJWF ZFBST BOE ESJOL XFMM GPS NPSF UIBO Grand Royale 2010 Cabernet Sauvignon

Lavina Wines is a serious player in McLaren 7BMF 5IJT GBNJMZ PXOFE PQFSBUJPO QSPEVDes a range of wines including premium ACPVUJRVF XJOFT XIJDI BSF SFWJFXFE JO this tasting, and also a large volume of TVC CSBOET BOE CVML XJOFT GPS EPNFTUJD DPOTVNQUJPO BOE FYQPSU Premium production is enhanced by hand QJDLJOH BOE B NFDIBOJTFE TPSUJOH UBCMF o B UFDIOJRVF QPQVMBS JO 'SBODF CVU JO NZ PQJOJPO VOEFS VUJMJTFE JO "VTUSBMJB 5IJT eliminates contaminated and damaged CVODIFT GSPN UIF GFSNFOUBUJPO 'SPN UIFSF UIF CFSSJFT BSF DPME TPBLFE JO PQFO GFSNFOUFST GPS B XFFL EVSJOH XIJDI UJNF a natural fermentation commences, and PWFS TFFEFE XJUI B DPNNFSDJBM ZFBTU "GUFS GFSNFOUBUJPO HFOUMF CBTLFU QSFTTJOH UBLFT place and the wine is matured in selected 'SFODI PBL CBSSFMT GPS NPSF UIBO UXP ZFBST

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Wine Review

Lavina

5IJT JT BOPUIFS CJH ZPVUIGVM XJOF *U TIPXT B CFBVUJGVM EFFQ DSJNTPO DPMPVS B CPVRVFU CVSTUJOH XJUI DBTTJT WJPMFUT BOE NJOU *O UIF NPVUI DBTTJT BOE NVMCFSSZ XJUI UIBU DIBSBDUFSJTUJD .D-BSFO 7BMF EBSL DIPDPMBUF DBCFSOFU DIBSBDUFS 5IF UBOOJOT BSF TVQQMF WFMWFUZ BOE GJOF UIF GJOJTI MPOH BOE ESZ * WFSZ NVDI FOKPZ UIJT XJOF OPX o NZ GBWPVSJUF PG UIJT UBTUJOH o CVU * XPVME BMTP HJWF JU B MJGF PG ZFBST

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53

Satire

Midlife Crisis?

Yes We Can!

At last a party to cater for the needs of the â&#x20AC;&#x2DC;previously-nowâ&#x20AC;&#x2122; generation, and our resident satirist Wendy Wardell is just the person to lead them.

Now that we're in the final feverpitched five-month lap of the Federal election campaign, I'm throwing in my ten cents worth. After all, lack of an intelligent contribution hasn't held anyone else back so far. *hN DPOTJEFSJOH SVOOJOH GPS FMFDUJPO BT the sole representative of the Mid-Life Crisis Party. This is a political movement to address the interests of the bored, disaffected middle-aged. People who once had lives but who are now in danger of following )PNF BOE "XBZ CVZJOH B 7PMWP PS QIPOJOH JO UP UBML CBDL SBEJP 5IFZ NBZ CFDPNF TVDI FNQUZ IVTLT UIBU theyâ&#x20AC;&#x2122;ll fill the void by voting for the Logies or ironing their underwear. Hell, maybe FWFO PUIFS QFPQMFhT VOEFSXFBS *hWF TFFO the future and it contains /FX *EFB "N * TDBSFE :PV CFU My election platform will be the establishment of a Ministry for Mid-Life, charged with ensuring equality of access to all the

GVO TUVGG *G XF DBOhU TUBZ VQ MBUF FOPVHI UP reclaim the night, we can at least politely BTL GPS UIF FBSMZ FWFOJOH 8F SF QFSGFDUMZ MPDBUFE /FX :PSL NBZ CF UIF $JUZ 5IBU /FWFS 4MFFQT, but Perth is definitely the 1MBDF 5IBU 1SFGFST UP #F JO #FE CZ 5FO *hMM CF EFNBOEJOH XFhSF HJWFO SPDL DPODFSUT at reasonable hours and segregated overBHF BSFBT JO USFOEZ ESJOLJOH FTUBCMJTINFOUT 8FhWF BMSFBEZ TFFO UIF SFUVSO PG UIF SPDL bands of our youth who set aside their perTPOBM EJGGFSFODFT UP IJU UIF SPBE 4VSF UIFZ IBE MJUUMF DIPJDF UIBOLT UP QPPS TVQFSBOnuation returns and their earlier reliance on OPTUSJM CBTFE JOWFTUNFOUT #VU MJLF UIF SFTU of us, they can now appreciate the need for an afternoon nanna nap and a gig that finishes before the Berocca wears off. *hE MJLF UP TFF OFXFS BDUT UPP POFT UIBU BSF currently barely getting started by the time -BUFMJOF GJOJTIFT BOE UIF DPDPB IBT LJDLFE JO *G WFOVFT PGGFSFE BO FBSMJFS TFTTJPO GPS PWFS T UIFZ DPVME TBWF FOPVHI PO IJSFE NVTDMF UP IBWF 4U +PIO "NCVMBODF BOE an emergency chiropractor waiting in the wings. Other than an increased danger of FMFDUSJD TIPDL GSPN OZMPO USPVTFS GSJDUJPO in the Mosh Pit what could possibly go wrong?

0VS LJET XPVME PG DPVSTF CF BQQBMMFE BU BOZ idea of partying alongside our generation, BOE UIF GFFMJOH JT FOUJSFMZ NVUVBM *hWF TFFO XIBU SPBNT /PSUICSJEHF MBUF BU OJHIU BOE it's an assault my eyeballs can do without. *hE QSFGFS UP FOKPZ UIF WJUBMJUZ PG UIF 1FSUI pubs and clubs in the company of people who appreciate the role of a nice cardigan JO UIFJS GBTIJPO XBSESPCF UIPTF GPS XIPN dressing up for a night out doesn't stop at a small length of elastic. * BMTP XBOU UP FYQFSJFODF BHBJO UIF KPZ PG DPOWFSTBUJPO DPOEVDUFE PWFS B GFX ESJOLT PO B 4VOEBZ BGUFSOPPO BU B WPMVNF MFTT UIBO B #SJBO #MFTTFE JNQFSTPOBUJPO PG B Rise up and join me, all you mid-lifers who aren't yet ready to wear your trousers at BSNQJU IFJHIU BOE HFU ZPVS BESFOBMJOF GJY GSPN UVSOJOH ,FOOZ ( VQ UP 7PUF .JE -JGF $SJTJT 1BSUZ "U MFBTU UIFO ZPV MM LOPX XIBU LJOE PG DSJTJT ZPVhSF electing. O

54

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Competitions

Entering Medical Forum's COMPETITIONS has never been easier!

Simply visit www.medicalhub.com.au and click on the 'COMPETITIONS' link (below the magazine cover on the left).

Theatre: Death of a Salesman 5IJT JT POF PG UIF HSFBUFTU QMBZT PG UIF UI DFOUVSZ BOE TUJMM resonates in a world where buying the dream is still a potent force. Willy Loman has spent his entire life as a travelling TBMFTNBO DIBTJOH IJT GPSUVOF BOE OFWFS TVDDFFEJOH /PX suffocated by debt, discarded by his boss and losing his grasp PO SFBMJUZ IJT IPQFT SFTU PO IJT TPO #JGG #MBDL 4XBO 5IFBUSF Company has assembled a strong cast for this great play.

May 4, Heath Ledger Theatre, 7.30pm

Operamania Movie: Drift Weâ&#x20AC;&#x2122;ve watched every move as this film evolved on our doorstep, now we can see the finished product as Myles 1PMMBSE 4BN 8PSUIJOHUPO BOE 9BWJFS 4BNVFM SFDSFBUF T Margaret River in a drama that combines big waves and the CVTJOFTT UIBU TVSSPVOET UIFN 5IF TUPSZ DFOUSFT PO UIF ,FMMZ CSPUIFST "OEZ BOE +JNNZ XIP IBWF POF HSFBU QBTTJPO SJEJOH CJH XBWFT %SJGU DIBSUT UIF USBOTGPSNBUJPO PG TVSGJOH T MBJECBDL MJGFTUZMF JOUP B HMPCBM QIFOPNFOPO In Cinemas May 2

Lovers of Russian high arts will be in a state of bliss XIFO UIF DPNCJOFE GPSDFT PG UIF .PTDPX /PWBZB 0QFSB BOE UIF *NQFSJBM 3VTTJBO #BMMFU UBLF UP UIF TUBHF of the Perth Concert Hall for a night of dramatic arias BOE QBT EF EFVY .PSF UIBO BSUJTUT XJMM CF UPVSJOH &YQFDU UP IFBS UIF NVTJD PG 5DIBJLPWTLZ 1VDDJOJ .P[BSU 7FSEJ BOE +PIBOO 4USBVTT QMBZFE CZ B 3VTTJBO PSDIFTUSB *U JT B TVNQUVPVT QSPEVDUJPO UIF MJLFT OPU seen before in Perth on the one stage.

April 7, Perth Concert Hall, 7.30pm

Movie: The Company You Keep " UBVU UJHIU UISJMMFS GSPN BDUPS EJSFDUPS 3PCFSU 3FEGPSE IBT BO BNB[JOH DBTU PG 4IJB -F#FPVG 4VTBO 4BSBOEPO +VMJF $ISJTUJF #SFOEBO (MFFTPO 3JDIBSE +FOLJOT BOE 4UBOMFZ 5VDDJ 8IFO B GPSNFS NFNCFS PG UIF SBEJDBM QSPUFTU UFSSPSJTU PSHBOJTBUJPO UIF 8FBUIFS 6OEFSHSPVOE 4BSBOEPO UVSOT IFSTFMG JOUP UIF '#* #FO 4IFQBSE -B#FPVG BO BHHSFTTJWF ZPVOH KPVSOBMist, starts searching for leads on the other members.

In cinemas, 19 April

Theatre: Bell Shakespeareâ&#x20AC;&#x2122;s Henry 4 *G ZPV TFF KVTU POF 4IBLFTQFBSF QMBZ UIJT ZFBS NBLF JU this one. This is not just one of the Bardâ&#x20AC;&#x2122;s best plays but XJUI UIF HSFBU 4IBLFTQFBSFBO BDUPS +PIO #FMM UBLJOH PO UIF JDPOJD DPNJD SPMF PG 'BMTUBGG JU XJMM CF B QSPEVDUJPO UP UFMM UIF HSBOELJET BCPVU 5IJT TUPSZ PG QPMJUJDT MFBEFSship, families and betrayal has the lot.

April 11, Heath Ledger Theatre, 7.30pm

Easter Cheer with Hillsviewedico

e is one m Dr Penny Ro BOE IFS X JOFT T X IP LOPX tion si po le ab envi sheâ&#x20AC;&#x2122;s in the JDBM FE JUI POF PG .

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Z MF X -B . U 4VSHFS Z JO es in w e Hillsview has won th JU HPJOH UP PQFO JT E BO O EP[F r he of gathering for a Easter ness nd fo a FMMFT 'SFODI s ha BOJB BOE -BTD clan. Penny TN 5B

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MEDICAL F ORUM

WINNER FROM THE FEBRUARY ISSUE

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t 1SJNBSZ $B SF $IBOHFT t 5SFBUNFOU 5SFOET t 1SBDUJDF 5 FDIOPMPHZ t $IJME "CVT F t & 1PMM A%P DUP *U 4P (PPE ST /FWFS )BE

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Lincoln â&#x20AC;&#x201C; movie: %S .JL 1BSPMB %S 1BVM -BJENBO %S #JMM 5IPOH %S "OESF $IPOH %S %POOB .BL %S :PIBOB ,VSOJBXBO O %S "OOF #SBEZ %S %BWJE 8SJHIU %S 4VF .BSUJO The Sweeney â&#x20AC;&#x201C; movie: %S 1FUFS .FMWJMM 4NJUI %S $BSPMJOF $IJO %S +BTPO $IJO %S 4BZBOUB +BOB %S -BXSFODF $IJO %S "MJTPO 1IJMMJQT %S $IBSMFT $SPNQUPO %S 4JNPO 8FJHIU %S %BWJE 4UPSFS %S 1BUSJDL -BJ Save Your Legs â&#x20AC;&#x201C; movie: %S 5SJYJF %VUUPO %S &MFBOPS ,PBZ %S (MFOEB ,IPP %S 3JNJ 3PQFS %S 1IBOJ #BMBTB %S )FMFO .FBE %S ,FJUI "OBOEB %S 4JNPO .BDIMJO %S :JFO $IJO %S +VMJB $IBSLFZ 1BQQ %S )VJ +FSO -PI %S ,BUSJOB (V[EFS %S -ZEJB 1FUFS %S 'SBOL 8JMMJT %S +VMJF $PQFNBO Two Gentlemen of Verona â&#x20AC;&#x201C; theatre: %S $BSPM %FMMBS %S ,BSFO 1SPTTFS Kupenga Kwa Hamlet â&#x20AC;&#x201C; theatre: %S #BSSZ -FPOBSE %S 5IPNBT -FF I Give It a Year â&#x20AC;&#x201C; movie: %S ,BWJUB ,BOPEJB %S +FOOZ 4UFENPO %S .FJMZO )FX %S ,FOESJDL -JOH %S /BSFMMF 7VKDJDI %S &SJD ,IPOH %S -ZOFUUF 4QPPOFS %S "WSJM $IPOH %S )FMFO $MBSLF

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55

funnyside e Q Q Horsing Around " XPNBO IBT CFFO UBLFO JOUP IPTQJUBM BGUFS eating horse meat burgers from Tesco. Her condition is said to be stable.

Tesco Quarter Pounders: The affordable way to buy your daughter the pony she's always wanted!

Q Q You Know

Youâ&#x20AC;&#x2122;re a Doctor When â&#x20AC;¦

y XIFO ZPV TIPVU BU UIF 57 EVSJOH NFEJDBM shows to correct their pronunciation. Then give up correcting and just wince instead. y XIFO ZPV LOPX TPNF PG ZPVS QBUJFOUT better than your own family. y XIFO ZPV CFBU "-- UIF RVJ[ DPOUFTUBOUT on the medical questions. y XIFO ZPV DBO XBUDI UIF TMPX NPUJPO replays during a football game, determine UIF OBUVSF BOE FYUFOU PG UIF JOKVSJFT BOE are right most of the time in predicting the SFTVMUT PG UIF .3* y XIFO QFPQMF CFHJO disrobing in your local TVQFSNBSLFU UP TIPX ZPV how well their incisions have healed. y XIFO QFPQMF UIJOL ZPV SFBMMZ want to see what they blew out of their nose. y XIFO ZPV WF IBE UP EFDJEF whether eating or going to the bathroom is more important because you donâ&#x20AC;&#x2122;t have time to do both. y XIFO ZPV DBO TMFFQ standing up. y XIFO ZPV BSF CFJOH DIBSHFE UXJDF UIF BNPVOU ZPVS OFJHICPVS JT GPS B CSBLF KPC y XIFO ZPV BSF BGSBJE UP UFMM QFPQMF XIBU you do for a living at school functions. y XIFO XJUIJO B GFX NJOVUFT PG NFFUJOH TPNFPOF ZPV BTL UIFN UP UBLF PGG UIFJS DMPUIFT MJF EPXO BOE MFU UIFJS LOFFT GBMM apart, and they do so.

Q Q Careful at Bathtime %VSJOH B WJTJU UP NZ EPDUPS * BTLFE IJN "How do you determine whether or not an older person should be put in an old age home?"

"Well," he said, "we fill up a bathtub, then XF PGGFS B UFBTQPPO B UFBDVQ BOE B CVDLFU to the person to empty the bathtub."

0I * VOEFSTUBOE * TBJE " OPSNBM QFSTPO XPVME VTF UIF CVDLFU CFDBVTF JU JT CJHHFS than the spoon or the teacup." /P IF TBJE " OPSNBM QFSTPO XPVME QVMM UIF QMVH %P ZPV XBOU B CFE OFBS UIF window?"

56

Had some burgers from Tesco for my tea MBTU OJHIU * TUJMM IBWF B CJU CFUXFFO NZ teeth.

I'm so hungry I could eat a horse... " DPX XBMLT JOUP B CBS #BSNBO TBZT iXIZ UIF MPOH GBDF w $PX TBZT i*MMFHBM ingredients, coming over here stealing our KPCT w These Tesco burger jokes are going on a bit. Talk about flogging a deadâ&#x20AC;¦ NO! NO! NO! NO! To beef or not to beef. That is equestrian.

Q Q Sex Education Little Tony was nine years old and was staying with his grandmother for a few days. He'd been playing outside with the PUIFS LJET GPS B XIJMF XIFO IF DBNF JOUP UIF IPVTF BOE BTLFE IFS i(SBOENB XIBUhT JU DBMMFE when two people sleep in the same room and one is on UPQ PG UIF PUIFS w 4IF XBT B MJUUMF UBLFO BCBDL but she decided to tell him UIF USVUI i*UhT DBMMFE TFYVBM JOUFSDPVSTF EBSMJOH w -JUUMF 5POZ TBJE i0I 0, w BOE XFOU CBDL PVUTJEF UP QMBZ " GFX NJOVUFT MBUFS IF DBNF CBDL JO BOE TBJE BOHSJMZ i(SBOENB JU JTOhU DBMMFE ATFYVBM JOUFSDPVSTF *UhT DBMMFE CVOL CFET "OE +JNNZ hT .VN XBOUT UP UBML UP ZPV w

Q Q Thrillseeking Grannies

4MPXFS UIBO UIF TQFFE MJNJU /P TJS * XBT EPJOH UIF TQFFE MJNJU FYBDUMZ LJMPNFUFST BO IPVS UIF PME XPNBO TBZT a bit proudly.

The Police officer, trying to contain a DIVDLMF FYQMBJOT UP IFS UIBU JT UIF highway number, not the speed limit. " CJU FNCBSSBTTFE UIF XPNBO HSJOT BOE UIBOLT the officer for pointing out her error. #VU CFGPSF * MFU ZPV HP .BhBN * IBWF UP BTL *T FWFSZPOF JO UIJT DBS 0, 5IFTF XPNFO TFFN BXGVMMZ TIBLFO and they haven't made a peep UIJT XIPMF UJNF UIF PGGJDFS BTLT "Oh, they'll be all right in a minute officer.

8F KVTU HPU PGG )JHIXBZ

Q Q Driving Doctors Nuts .Z OFJHICPVS XBT XPSLJOH JO IJT ZBSE when he was startled by a late model car that came crashing through his hedge and ended up in his front lawn.

He rushed to help an elderly lady driver out of the car and sat her down on a lawn chair. )F FYDMBJNFE :PV BQQFBS RVJUF FMEFSMZ UP be driving."

8FMM ZFT * BN TIF SFQMJFE QSPVEMZ *hMM CF OFYU NPOUI BOE * BN OPX PME FOPVHI UIBU * EPOhU FWFO OFFE B ESJWFShT MJDFODF BOZNPSF 5IF MBTU UJNF * XFOU UP NZ EPDUPS IF FYBNJOFE NF BOE BTLFE JG * IBE B ESJWFShT MJDFODF * UPME IJN ZFT BOE handed it to him. )F UPPL TDJTTPST PVU PG UIF ESBXFS DVU the licence into pieces, and threw them in UIF XBTUF CBTLFU TBZJOH h:PV XPOhU OFFE UIJT BOZNPSF h TP * UIBOLFE IJN BOE MFGU

4JUUJOH PO UIF TJEF PG UIF IJHIXBZ XBJUJOH to catch speeding drivers, a Police Officer TFFT B DBS QVUUFSJOH BMPOH BU LN I 4BZT IF UP IJNTFMG 5IJT driver is just as dangerous as B TQFFEFS 4P IF UVSOT PO IJT MJHIUT BOE pulls the driver over.

"QQSPBDIJOH UIF DBS IF notices that there are five old ladies, two in the front seat BOE UISFF JO UIF CBDL XJEF eyed and white as ghosts.

The driver, obviously confused, says to him 0GGJDFS * EPOhU VOEFSTUBOE * XBT EPJOH FYBDUMZ UIF TQFFE MJNJU 8IBU TFFNT UP CF UIF problem?"

"Ma'am," the officer replies, "you weren't TQFFEJOH CVU ZPV TIPVME LOPX UIBU ESJWJOH slower than the speed limit can also be a danger to other drivers."

medicalforum

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medical forum

ANAESTHETIST WANTED MT LAWLEY Dynamic specialist anaesthetist(s) SFRVJSFE UP SFQMBDF SFUJSJOH NFNCFS Share rooms with long established hospital based group.

There will be no joining fee.

Accreditation at Mercy Hospital is mandatory.

Computerised billing system with excellent administrative/secretarial support.

'PS GVSUIFS JOGPSNBUJPO QMFBTF DBMM -PSSBJOF on (08) 9370 9733

BOARD MEMBER WANTED BOARD MEMBER WANTED Fremantle Womenâ&#x20AC;&#x2122;s Health Centre seeks a female GP (VR) as a Board member.

This is a voluntary position that would suit someone with expertise in womenâ&#x20AC;&#x2122;s health medicine and an interest in the governance of a not-for-profit organisation. FWHC is a community facility providing medical and counselling services, health education and group activities.

The Board currently has 8 members who are responsible for the governance and strategic direction of the organisation and meets monthly.

For more information check www.fwhc.org.au or Contact Diane Snooks 9431 0500 / director@fwhc.org.au

FOR LEASE NEDLANDS Hollywood Medical Centre â&#x20AC;&#x201C; 2 fully furnished consulting suites on first floor, available for lease.

Some secretarial support available JG SFRVJSFE Phone 0414 780 751 MURDOCH Murdoch Specialist Centre Brand new stylish large rooms.

Please email you interest to: admin@sleepmed.com.au NEDLANDS Medical Specialist Consulting Rooms Fully serviced rooms and facilities for Specialist Consulting are available in Suite 31, Hollywood Specialist Centre, 95 Monash Avenue, Nedlands.

"OZ FORVJSJFT DBO CF EJSFDUFE UP Mrs Rhonda Mazzulla, Practice Manager Suite 31, Hollywood Specialist Centre 95 Monash Avenue Nedlands, WA 6009 Phone 9389 1533 Email: suite31.hollywood@bigpond.com DAWESVILLE Opportunity for two GPâ&#x20AC;&#x2122;s t TRN .FEJDBM $FOUSF t *O OFX 4IPQQJOH $FOUSF t $PNQMFUJPO +VMZ t $BUDINFOU QFPQMF t 6O TFSWJDFE BSFB Ross on 0409 887 641

ROCKINGHAM Sessional room for rent in specialist medical centre in central Rockingham.

Choice of two rooms, medical or allied health with communal patient waiting room.

Reception staff not available.

Sessions are four hours and currently available a.m. and p.m. $120 plus GST per session for allied health room and $160 plus GST per session for medical consult room, negotiable.

Contact Julie Neet, Practice Manager at julieneet@drbillpatton.com.au Telephone 9528 1511 (select option 0) Tuesday â&#x20AC;&#x201C; Thursday mornings after 9.30 am BANKSIA GROVE City of Wanneroo - WAâ&#x20AC;&#x2122;s fastest growing local government authority Opportunity for 3 â&#x20AC;&#x201C; 4 GPâ&#x20AC;&#x2122;s t 8JUIJO B %JTUSJDU PG 8PSLGPSDF 4IPSUBHF t TRN .FEJDBM $FOUSF t $PNQMFUJPO +VMZ "VHVTU t -BSHF DBUDINFOU Ross on 0409 887 641 YOKINE â&#x20AC;&#x201C; Suit a Medical Specialist Suite 10 DR 7 Medical Centre, 162 Wanneroo Road, YOKINE Quality Suite, well located in purpose built medical centre, on busy road & close to all amenities.

Has a large established doctors surgery, pharmacy, physiotherapist, dentist and many more.

The centre comprises 17 strata lots.

5IF TVJUF IBT BO BSFB PG TRN Completely fitted, carpeted and air-conditioned and will suit most medical purposes.

Phone: Valma 0458 088 899

FOR SALE OR LEASE

Rare opportunity to secure a long term future in West Leederville.

Property located on McCourt Street Subiaco â&#x20AC;&#x201C; Available 1/5/2013 Well Presented premises â&#x20AC;&#x201C; 113 m2 with ample off Street parking.

"MM FORVJSJFT UP #SBE 1PUUFS o 9315 2599 / 041118 5006.

FOR SALE MEDICAL SUITE(S) 10 McCOURT STREET WEST LEEDERVILLE 5IFTF XFMM MPDBUFE TRN NFEJDBM TVJUF T

with two car bays each are opposite St John of God Hospital and ready for immediate occupation.

GORDON TUCKER R/E 0408 093 731 gtrealestate@iinet.net.au

LOCUM WANTED PERTH -PDVNT "TTPDJBUFT XBOUFE Perth Medical Centre, Hay Street Mall.

Busy accredited privately owned practice, private billing, flexible hours.

Excellent remuneration for suitable candidates.

Phone: 9481 4342 Mobile: 0408 665 531

RURAL POSITIONS VACANT MIDLAND Consultant Psychiatrist - Private Practice We have a fully serviced new room in an established clinic in Midland.

We would like to have a Consultant Psychiatrist join our practice. The rooms are fully serviced and reception will collect fees and process patients.

The lease of the rooms is negotiable and very reasonable so we can attract a specialist into a high need area. www.cygnetclinic.com.au Phone: 9467 7676 Fax: 9463 6311 Email: admin@cygnetclinic.com.au JOONDALUP Modern sessional suites available in Joondalup CDB. 4FDSFUBSJBM TVQQPSU BWBJMBCMF JG SFRVJSFE Phone 9300 3380

MARGARET RIVER -POH FTUBCMJTIFE BDDSFEJUFE GBNJMZ practice seeks GP or trainee to replace retiring Doc. Anaesthetics, Obstetric and surgical scope available but not essential.

Some afterhours commitment - not onerous.

Phone Sally 08 9757 2733 for more info ALBANY 73 (1 SFRVJSFE UP KPJO PVS %PDUPS CVTZ friendly family practice.

Full or Part time.

We are Accredited, computerised, full nurse support, experienced Admin team.

Excellent remuneration. Clinipath pathology on site.

Phone Gaye - Practice Manager 9841 6711 Email: admin@hillsidefp.com.au

URBAN POSITIONS VACANT

MANDURAH SPECIALIST CENTRE Fully furnished consulting suites are now available on a sessional basis in the new Mandurah Specialist Centre.

3FDFQUJPO TVQQPSU BWBJMBCMF JG SFRVJSFE Phone: Graeme Dedman on 0413 065 009 Email: graemed@wacardiology.com.au

SOUTH PERTH 73 (1 SFRVJSFE '5 15 Excellent River location in South Perth.

Non-corporate, private billing, fully computerised.

Friendly and efficient support staff.

F/T registered nurse and onsite pathology.

For more information contact Paris on 9367 1185.

Email: bhabibi@bigpond.com

WEMBLEY DOWNS Inviting an enthusiastic Female GP to join this long established, non-corporate, private billing practice with a huge well established patient load.

Email: managerbmc@gmail.com

MURDOCH Doctor Required for Stress Testing Supervision WA Cardiology offers the most extensive cardiology testing services in Western Australia and is committed to providing the highest standards in patient care, diagnosis and GP support.

Medical Practitioners who share in this vision are invited to join our team of Doctors supervising exercise ECGs, exercise echocardiograms and Dobutamine echocardiograms at our various sites.

Training is provided and excellent remuneration based on a fee for service basis is offered.

Applicants must possess valid unconditional registration with the Medical Board of Australia and working rights within Australia.

To register your interest, please contact Graeme Dedman (General Manager) on 0413 065 009 or Email us at admin@wacardiology.com.au.

MT HAWTHORN Mt Hawthorn Medical Centre, a non-corporate accredited long established practice situated in a fast growing inner city suburb of Perth, seeks a part time or full time VR GP to join this highly desirable practice. Fully computerised, Nurse Assistant.

Phone Rose 9444 1644 ARMADALE Wanted VR/Non VR Female Doctors DWS/Aon Area Outer Metropolitan Perth Phone: Kerry 9498 1099 Email: sevilledrive@medicalcentral.com.au HILLARYS Exciting Opportunity.

Join us in our brand new General Practice located NOR. Non-corporate.

8F SFRVJSF B GVMM UJNF PS QBSU UJNF GP for our practice.

Hours to suit. /P FWFOJOH PS XFFLFOE XPSL SFRVJSFE The practice is fully computerised and XFMM FRVJQQFE Private Billing and some bulk-billing Full-time Nursing support.

Pathology on site.

Please contact Practice Manager on 9448 4815 or Email: smc@westnet.com.au FREMANTLE (FOFSBM 1SBDUJDF JO 'SFNBOUMF SFRVJSFT 73 (1 FTor PT for privately owned family practice.

Accredited, computerised with fulltime Nurse support available.

65% of billings.

Phone: Practice Manager 9336 3665

MAY 2013 - next deadline 12md Monday 15th April - Tel 9203 5222 or jen@mforum.com.au

medical forum WINTHROP/MURDOCH Full time/Part time VR GPs needed to join Hatherley Medical Centre.

No longer Corporate and reopening in March 2013 with very experienced GP. Had been open for over 20 yrs and become a successful 8 doctor practice.

Services a large private billing underserviced area.

1VSQPTF CVJMU DFOUSF XFMM FRVJQQFE XJUI on-site procedural room, large nursing station, pathology, physiotherapy, pharmacy and dental.

Please call 0400 364 901 and get in early.

INGLEWOOD/BEDFORD (1 SFRVJSFE " SFBEZ NBEF QSBDUJDF UP walk into.

Part-time and hours negotiable.

Busy private billing, non-corporate practice on the Inglewood / Bedford border.

Full time nurse and pathology on site.

Friendly and generously staffed.

Phone Steve, Carl or our practice manager Denise on 9271 9311 Email: salisburymed@iinet.net.au

LANGFORD Due to one of our long term GPs taking BO FYUFOEFE TBCCBUJDBM JO -BOHGPSE Medical Centre is looking for a full time GP to commence now.

8F BSF B NPEFSO XFMM FRVJQQFE accredited mixed billing practice.

4JUVBUFE TPVUI PG UIF SJWFS -BOHGPSE JT POF of the closest practices to the CBD that still RVBMJGJFT BT B EJTUSJDU PG XPSLGPSDF TIPSUBHF 'PS DPOGJEFOUJBM FORVJSJFT QMFBTF DPOUBDU PM Mariette on 9451 1377 BEACONSFIELD Well established, niche family friendly practice seeking VR Female GP to work flexible days and hours.

Fully computerised and accredited.

Good mix of private and bulk billing.

1MFBTF DPOUBDU 1SBDUJDF .BOBHFS -JOEB PO 9335 9884 or Email: centralavenuemc@optusnet.com.au BENTLEY GP VR â&#x20AC;&#x2DC;with/without a viewâ&#x20AC;&#x2122; needed for privately owned family orientated practice.

NJOT GSPN 1FSUI $#% "(1"- BDDSFEJUFE fully computerised using MD/Pracsoft.

Private billing.

Supported by clinical and CDM nurses operating from purpose built practice.

We offer 65% of billings.

Contact Alison on 0401 047 063 MT LAWLEY Edith Cowan University, Student Health 4FSWJDFT .U -BXMFZ DBNQVT Part time VR GP with an interest in 8PNFO T BOE 4UVEFOU )FBMUI SFRVJSFE 8FMM FRVJQQFE NFEJDBM DFOUSF BDDSFEJUFE excellent work environment, Registered Nurse support, flexible work arrangements.

For information: Dr Robert Chandler Phone: 08 6304 5618 E-mail: r.chandler@ecu.edu.au

FREMANTLE Fremantle Womenâ&#x20AC;&#x2122;s Health Centre SFRVJSFT B GFNBMF (1 73 UP QSPWJEF medical services in the area of womenâ&#x20AC;&#x2122;s health 1or 2 days pw.

It is a computerised, private and bulk billing practice, with nursing support, scope for spending more time with patients, and provides recently increased remuneration plus superannuation and generous salary packaging.

FWHC is a not-for-profit, community facility providing medical and counselling services, health education and group activities in a relaxed friendly setting.

Phone: 9431 0500 or Email: Diane Snooks - director@fwhc.org.au or Dawn Needham clinical-manager@fwhc.org.au

BIBRA LAKE PT/FT VR GP with/without view to replace PT female Dr in a small privately owned 2 person accredited private billing practice JO #JCSB -BLF The practice is computerised, and has nursing and pathology support.

For further information contact Ashley on 0417 181 070 Email: ashleyr@iinet.net.au WEMBLEY GP wanted for long established private, accredited Wembley Practice.

Sessions are negotiable but ideally Thurs/ Fri am or Mon to Fri pm or part thereof.

Our practice is fully computerised using Med Director/Pracsoft.

Practice Nurse on site, pathology and theatre.

Adjacent services include Physiotherapist, Podiatrist, Psychologist and Dietician including diabetic educator.

Please phone Pauline on 9381 9010 Email: wembleygp@westnet.com.au

PALMYRA 1BMJO 4USFFU 'BNJMZ 1SBDUJDF SFRVJSFT B full or part-time VR GP. We, at this privately owned fully serviced computerised practice enjoy a relaxed environment with space and gardens.

Earn 65% of mixed billings.

For further information call -ZO PO 9319 1577 or Dr Paul Babich on 0401 265 881.

JOONDALUP CANDLEWOOD MEDICAL CENTRE (1 SFRVJSFE UP KPJO PVS GSJFOEMZ UFBN GPS After Hours work immediate start Weekdays 6 â&#x20AC;&#x201C; 9pm and Saturday 12 - 5pm Very Attractive remuneration 1SJWBUFMZ PXOFE "(1"- BDDSFEJUFE general practice Fully computerised Contact Michelle 08 9300 0219 SORRENTO V/R GP for a busy Medical Centre in Sorrento.

Up to 75% of the billing Contact: 0439 952 979

PERTH CENTRAL 73 (1 'VMM 5JNF PS 1BSU 5JNF SFRVJSFE GPS GP owned practice in an excellent location (centre of Town).

8F BSF GVMMZ FRVJQQFE BOE IBWF FYDFMMFOU nursing and admin support. On site allied health, pharmacy and pathology.

Mixed billing. Fully accredited.

Contact practice manager Bili.

Phone: 9419 2122 Email: chishamave@westnet.com.au DUNCRAIG DUNCRAIG MEDICAL CENTRE SFRVJSFT a female GP. Flexible hours, excellent remuneration.

Modern, predominantly private billing practice with full time Practice Nurses.

Open 364 days: M-F 7.30am/9pm, Sat/ Sun/PH 8am/6pm, Fully computerised.

Please contact Michael on 0403 927 934 Email: Dr Dianne Prior: dianne@duncraigmedicalcentre.com.au DALKEITH 5IF %BMLFJUI .FEJDBM $FOUSF SFRVJSFT B ' 5 or P/T GP to join busy privately owned and operated General Practice in the beautiful leafy suburb of Dalkeith.

We are fully computerised with Best Practice.

We have a dedicated team of doctors and staff and we are predominantly a privately billing practice.

5IFSF JT OP BGUFS IPVST PS PO DBMM SFRVJSFE Flexible hours and excellent remuneration is offered to the accepted applicant.

Please contact Trish at dalkmc@bigpond.com WHITFORDS GP - F/T OR P/T. 8F BSF GVMMZ DPNQVUFSJTFE XFMM FRVJQQFE accredited practice.

Friendly practice Nurse and admin staff to support at all times, including Careplan/ Health Assessment Nurse.

Medical Centre has on site pathology, pharmacy and physiotherapy.

1MFBTF DPOUBDU +BDRVJ 1SBDUJDF .BOBHFS on 9307 4222 Email: jmarkouloop@iinet.net.au BENTLEY Rowethorpe Medical Centre is a nonprofit, friendly practice seeking a part time GP to provide visits to our onsite residential aged care facilities.

Practice-based consultations are also available. t 'VMMZ DPNQVUFSJTFE t /FXMZ SFOPWBUFE QSFNJTFT t .PEFSO FRVJQNFOU t 0OTJUF QBUIPMPHZ t )PVST UP TVJU ZPV 'PS FORVJSJFT QMFBTF DPOUBDU +BDLJF PO 6363 6315 or 0413 595 676 THORNLIE '5 15 (1 SFRVJSFE GPS B GSJFOEMZ OFX rapidly growing medical centre.

Computerised, non-corporate and no BGUFS IPVST SFRVJSFE Outer-Metro area 17km from Perth. Pay 65% of receipts. $POUBDU %S +PIO ,V PS %S 4BOESB -PL on 9267 2888 or Email: thornliemedicalcentre@hotmail.com

81

MT LAWLEY Position for a full time GP, working as a selfemployed contractor in our accredited, fully computerised independent practice.

Excellent working environment, with modern facilities.

Quality nursing staff and an onsite diabetes educator/dietician.

Adjacent to the practice we have a pharmacy, and allied services, consisting of audiology, pathology, physiotherapy, podiatry, dental, and cardiology.

Visit our website: www.3rdave.com.au and if interested, ring us on (08) 9272 5533.

Please ask for Practice Manager Rachael Hadlow.

Alternatively, you may send an email to rhadlow@3rdave.com.au DIANELLA /PO $PSQPSBUF QSBDUJDF SFRVJSFT ' 5 BOE P/T VR GPâ&#x20AC;&#x2122;s to join 6 female and 1 male doctor team.

Our newly extended, long established, accredited, fully computerised practice is supported with 4 excellent nurses and 5 very friendly admin staff.

Our practice is mostly private billing and we offer excellent remuneration.

Please contact Practice Manager on 9276 3472 Email: dfmc@dianellamedical.com.au

INGLEWOOD Interested in trying skin cancer medicine?

6OJRVF PQQPSUVOJUZ UP KPJO B CVTZ OPO corporate skin cancer practice.

Friendly atmosphere with strong emphasis PO RVBMJUZ BOE QBUJFOU TFSWJDF Flexibility to explore any area of skin cancer medicine, ranging from comprehensive skin cancer checks, dermoscopy, and minor to more advanced surgical procedures.

Continuing education and training provided.

Fully computerised, with modern facilities and nurse support.

Suit part time VR doctors looking for reduced paperwork ,flexible hours and above average income.

Please contact admin@skincheckwa.com.au MANDURAH (1 0CTUFUSJDJBO SFRVJSFE QBSU UJNF to join our friendly team with a view to partnership.

Excellent location, close to hospital and train station.

Midwife assisted.

Fully computerised.

Contact Practice Manager Vicki PH: 9535 4100 Email: practicemanager@mandurahobstetrics.com MIRRABOOKA 'VMM UJNF 1BSU UJNF (1 SFRVJSFE GPS a very busy practice in Mirrabooka.

VR prefered.

75% Private and Bulk Billing Applications can be made via Email: mds@mirrabookadoctors.com.au or calling 0400 814 091

MAY 2013 - next deadline 12md Monday 15th April - Tel 9203 5222 or jen@mforum.com.au

82

medical forum AGED CARE SEEKING

Medical Practitioners for Aged Care Service - Compassion â&#x20AC;&#x201C; Efficiency Medical Practitioners for Aged Care (MPFAC) is seeking Medical Practitioners to join our expanding service to Residential Aged Care Facilities (RACP) throughout the Perth metro area. Our aim is to provide a compassionate and evidence based medical care to RACP. t .1'"$ QSPWJEFT GMFYJCMF XPSL PQUJPOT t 3FNPUF MPH JO UP QBUJFOU SFDPSET and appointment scheduling t /VSTJOH BOE "MMJFE )FBMUI Care support t .1'"$ NFUIPEPMPHZ VUJMJTFT UIF doctorâ&#x20AC;&#x2122;s time and resources more effectively t &GGJDJFOU PQFSBUJPOBM TVQQPSU FOTVSFT rewarding outcomes for doctor For more information or confidential interview please contact Rollo Witton â&#x20AC;&#x201C; CEO Mobile 0417 921 632 Email: rollo@gpagedcare.com.au

BYFORD 'VMM UJNF (1T SFRVJSFE Byford is a rapidly growing area and is continuing to expand.

1SBDUJDF JT GVMMZ FRVJQQFE XJUI consulting rooms, 2 treatment rooms & employs 2 nurses.

Onsite Pathology, Podiatrist, Chiropractor, Masseur and Dentist Excellent terms and conditions are negotiable We are an area of unmet need with a district of workforce shortage.

Contact: David Cowden Email: byfordfp@westnet.com.au Fax 9525 0093 Phone: 0413 273 778 BYFORD GPâ&#x20AC;&#x2122;s Afterhour Clinic (1 T SFRVJSFE GPS OFX "GUFSIPVS $MJOJD in Byford area excellent terms and conditions hours are negotiable We are an area of unmet need with a district of workforce shortage.

Contact: David Cowden Email: byfordfp@westnet.com.au Fax 9525 0093 Phone: 0413 273 778

MOSMAN PARK FREMANTLE Part time or Full time (preferably VR) GPs wanted.

ELLEN HEALTH is a doctor-owned and managed General Practice operating from two locations in port city of Fremantle.

Well established patient base, offering a broad suite of services including nutrition and lifestyle, specialised pregnancy and midwifery care, community mental health nursing and skin clinic consultations.

If you were to join our team we will offer you: t " HSPXJOH EBUBCBTF PG 1SJWBUF Billing patients t " QSPGFTTJPOBM BOE EFEJDBUFE support team t " MJGFTUZMF UBJMPSFE UP UIF MPDBUJPO t )PVST PG XPSL UP TVJU PVS CBMBODFE lifestyle approach - Practice hours are Weekdays 8am-6pm, Saturday, 8am-4pm - No after hours, on-call or hospital work SFRVJSFE BU UIJT UJNF t )JHI MFWFM PG FBSOJOHT Contact Practice Manager Bridie Hutton 0413 994 484 Email: bridie.hutton@ellenhealth.com.au MOSMAN PARK A friendly, non-corporate, fully computerised practice in Mosman Park is looking for a GP to work part or full time.

Hours and days flexible.

Remuneration - 70% of gross billings.

Tel: Jacinta on 9385 0077 EDGEWATER Outer Metro Practice.

1BSU UJNF 73 (1 SFRVJSFE GPS PVS QSJWBUFMZ owned, well established, fully computerised, accredited, non-corporate practice.

Fully supportive with practice nurse and friendly work environment.

Please provide CV to: edgewatermedical@westnet.com.au (Donna Gaynor)

Fantastic opportunity in excellent area for F/T or P/T GP Close to beach, shops and trains.

Ample space for your car, bike or surfboard.

Flexible hours to suit your lifestyle.

Baby-sitting service an option.

This is a GP owned group practice with all support services.

Freshly refurbished with all new computers and furniture.

Contact David Mortley on 9384 4426 or Email: mpmg@bigpond.net.au

WEST PERTH GP sessions available at our privatebilling, accredited and fully computerised general practice.

Our busy practice serves a young, professional demographic as well as providing specialist sexual health services.

This represents an exciting opportunity for an enthusiastic practitioner to join our friendly team.

Morning and afternoon sessions are available. Experience in family planning, sexual health and mental health would be an advantage.

Contact Stephen on 0411 223 120 Email: stephen@westperthmedicalcentre.com.au WANNEROO '5 15 'FNBMF (1 SFRVJSFE GPS OPO corporate family practice delivering excellent healthcare to our local community in Wanneroo (Perthâ&#x20AC;&#x2122;s northern suburbs, approved DWS area).

Our practice is fully computerised (Pracsoft and Medical Director), paperless and accredited.

We have a wonderful reception team, professional Practice Managers, and full nursing support.

Contact: Jody Saunders 0410 617 094 or Cheryl Barber 08-9405 1234 E-Mail CV to jsaunders.wthc@gmail.com or cbarber.wthc@gmail.com

PERTH APPLECROSS FT GP wanted.

A rare opportunity to join Reynolds Rd 7 Day Medical Centre has just presented itself as a long term colleague moves out of general practice.

Commencing now, donâ&#x20AC;&#x2122;t miss out on your chance to join this private billing, vibrant practice with immediate access to a full patient data base. $POGJEFOUJBM FORVJSJFT UP UIF QSBDUJDF manager 9364 6633.

BAYSWATER Wanted General Practitioner (VR) F/T PS 1 5 SFRVJSFE XJUIJO PVS GSJFOEMZ OPO corporate medical practice.

We are a fully computerised, wellFRVJQQFE UFBDIJOH BDDSFEJUFE HFOFSBM practice seeking an enthusiastic person to join our team with a view in assisting our growing patient load.

We are a proudly independent practice which offers a friendly environment, flexible working hours, pleasant rooms, great staff, with wonderful patients.

Email resume to: manager@walterrdegps.com.au or Fax: 9279 1390

Australian Skin Cancer Clinics Specialise in Skin Health in Western Australia t $"//*/(50/ t -&..*/( .63%0$)

Great opportunities for experienced GPs to join these two busy Australian Skin Cancer Clinics. t 'MFYJCMF XPSLJOH IPVST UP TVJU your lifestyle; t (SFBU FBSOJOH QPUFOUJBM t .PEFSO XFMM FRVJQQFE DMJOJD t 1SPGFTTJPOBM BENJOJTUSBUJPO BOE practice management staff; These are not DWS listed sites.

For more information please contact Fiona James on 0447 006 846 or fiona.james@ipnet.com.au www.ausskinclinics.com.au WOODLANDS P/T or F/T VR GP wanted to join happy, non-corporate, mainly private billing practice.

Good mix of patients, no weekends or afterhours.

Great location, RN support.

Would suit female GP. Contact help@thewoodsmedical.com.au or 9204 3900 MANDURAH Mandurah coastal lifestyle 40 minutes from Perth.

73 OPO 73 EPDUPS SFRVJSFE TIPSU UFSN PS long term.

No weekends or after hours.

Good remuneration.

Clinic has full time nurses, pathology, psychology, hearing centre, dermatologist and orthotics.

Contact practice manager Elaine 9535 8700 Email: elaine@mandurahdoctors.com.au

Become part of the Perth Bigger Picture!

-POH FTUBCMJTIFE BOE QSJWBUFMZ PXOFE Perth Medical centre is centrally located, accredited, fully computerised and privately billing.

We have recently renovated so come and join our team and you will be busy from day one.

We have an interesting and truly diverse mixture of clientele; young and old, blue and white collar, travellers and residents.

You will have plenty of opportunity to develop an interest in whatever branch of practice you choose with the backup of a team of locally trained colleagues.

We also have a team of RNs leading our chronic disease management program.

We are a social group who support one another, are flexible with hours and believe in maintaining balance to avoid the rush hour, reduce your carbon foot print and keep fit; bus, train or cycle to work.

Check us out www.perthmedicalcentre.com.au Interested?

Call our practice manager Anne on (08) 9481 4342 or Dr Phil A/H 0411 108 883

KARDINYA ,FMTP .FEJDBM (SPVQ SFRVJSFT 1 5 BOE or F/T GP This long established privately owned and managed mixed billing practice offers great opportunity for doctor with interest in CDM and minor surgical procedures.

-PDBUFE JO ,BSEJOZB JO OFXMZ SFGVSCJTIFE premises with onsite pathology and allied health with growing patient base.

Currently supported by 7 GPâ&#x20AC;&#x2122;s and 3 RNâ&#x20AC;&#x2122;s . www.kelsomg.com.au Please call 0419 959 246 for further information.

GOLDEN BAY 15 GFNBMF (1 SFRVJSFE Fully computerised, DWS, private/ bulkbilling, Fully accredited, Practice Nurse, onsite pathology.

Contact: Sheelagh 08 9537 3738 Email CV to: pracman@eftel.net.au GREENWOOD Greenwood / Kingsley Family Practice We are seeking a full time/part time GP to join our growing team.

We are a flourishing, non-corporate and predominantly private-billing practice with a strong focus on chronic disease management with a dedicated EPC nurse, podiatrist, chiropractor, pathology and pharmacy on site to facilitate the team care arrangement.

The practice offers an excellent work environment and attractive remuneration.

There is computerised dermoscopy and a GVMMZ FRVJQQFE QSPDFEVSF SPPN PO TJUF For further information please ring 0402 201 311 or Email: kingsleypractice@gmail.com to arrange to visit us for a no obligation meeting and confidential discussion.

MAY 2013 - next deadline 12md Monday 15th April - Tel 9203 5222 or jen@mforum.com.au

medical forum

Enjoy the best of both worlds A unique FIFO or permanent opportunity exists for a general practitioner to become part of a medical practice in the Goldfields town of Leonora. Servicing a population of 1,500, you will have the opportunity to join an accredited, computerised practice.

The position, which offers diversity, is flexible with the opportunity to work in a fly in/fly out capacity from Perth one week on/one week off or take a permanent role in the town.

The package will include a salary of approximately $350,000, a fully furnished 5x2 house with pool and car. Hospital admitting rights are required as well as detention centre visits and some emergency work.

For further information please contact Rural Health Select on 08 6389 4500 or email recruit@ruralhealthselect.com.au quoting RHWLEO1.

CVS are a leading cardiology practice that provides high quality diagnostic stress testing services.

We are seeking medical practitioners who meet the following pre-requisites: Â&#x2021; 5HJLVWUDWLRQ ZLWK WKH $XVWUDOLDQ 0HGLFDO %RDUG Â&#x2021; 0HGLFDO ,QGHPQLW\ ,QVXUDQFH Â&#x2021; /LIH 6XSSRUW 6NLOOV RU H[SHULHQFH Â&#x2021; +LJK UHJDUG WR GHOLYHU RXWVWDQGLQJ SDWLHQW FDUH ,I \RX PHHW WKHVH SUH UHTXLVLWHV ZH ZHOFRPH \RX WR MRLQ RXU WHDP RI VSHFLDOLVHG 0HGLFDO 3UDFWLWLRQHUV 6WUHVV 3K\VLFLDQV $V D 6WUHVV 3K\VLFLDQ \RX ZLOO ZRUN ZLWK VWDWH RI WKH DUW GLDJQRVWLF HTXLSPHQW FRQGXFW TXDOLW\ VSHFLDOLVW WHVWLQJ DQG LPSURYH \RXU GLDJQRVWLF (&* VNLOOV $Q DWWUDFWLYH UHPXQHUDWLRQ SDFNDJH ZLOO EH RIIHUHG WR VXFFHVVIXO FDQGLGDWHV DV ZHOO DV H[SHULHQFLQJ H[FHOOHQW MRE VDWLVIDFWLRQ DQG ZRUNLQJ FRQGLWLRQV CVS locations include: Joondalup, Karrinyup, Nedlands, Midland, Mt Lawley, Leeming, East Fremantle and Rockingham.

3OHDVH SKRQH $GDP /XQJKL WR GLVFXVV RSSRUWXQLWLHV DW &96 RQ 1300 887 997 or 0402 825 570 RU YLD H PDLO info@cvs.net.au

Are you looking to buy a medical practice?

www.ruralhealthselect.com.au

Make a difference in country WA

As WAâ&#x20AC;&#x2122;s only specialised medical business broker we have helped many buyers find medical practices that match their experience.

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

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Travel and accommodation covered Administration support provided Upskilling available Locum subsidy available

For further information please contact Rural Health Select on T 08 6389 4500 | E locums@ruralhealthwest.com.au.

Suite 27, 782 - 784 Canning Highway Applecross WA 6153

Ph: 9315 2599 www.thehealthlinc.com.au

85% take home,

www.ruralhealthselect.com.au 8JUI B SFQVUBUJPO CVJMU PO RVBMJUZ ality of service, Optima Press has the WKH resources, the people and the e commitment to provide every client y client with the finest printing and value DOXH IRU for money.

9 Carbon Court, Osborne Park 6017 Tel 9445 8380

Brad Potter on 0411 185 006

Weâ&#x20AC;&#x2122;ll take care of all the bits and pieces and youâ&#x20AC;&#x2122;ll benefit from our experience to ensure a smooth transition.

If you can help a rural and remote community, contact us today! z

To find a practice that meets your needs, call:

Youâ&#x20AC;&#x2122;ll get a comprehensive package on each practice containing information that you and your advisers need to make a decision.

Rural Health Select has vacancies for locums throughout Western Australia.

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enjoy ďŹ&#x201A;exible hours, less paperwork, & interesting variety...

Equipment Provided - WADMS is a Doctorsâ&#x20AC;&#x2122; cooperative Essential qualifications: s General medical registration. s Minimum of two years post-graduate experience. s Accident and Emergency, Paediatrics & some GP experience. sĂĽ sĂĽ sĂĽ sĂĽ

Fee for service (low commission).sĂĽ Non VR access to VR rebates.

8-9hr shifts, day or night. sĂĽ Bonus incentives paid.

24hr Home visiting services. sĂĽ Interesting work environment.

Access to Provider numbers.

Contact Trudy Mailey at WADMS

(08) 9321 9133

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

MAY 2013 - next deadline 12md Monday 15th April - Tel 9203 5222 or jen@mforum.com.au

Supplement your income: Are you working towards the RACGP? â&#x20AC;&#x201C; 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.

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medical forum FOR SALE

Brand New State of the Art Medical Centres opening May:

HIDDEN VALLEY FOREST RETREAT

Armadale & Cannington

Four standalone architect-designed lodges with an on-site ďŹ tness centre nestle on 110 acres in the beautiful Margaret River wine region, with outline permission to build six more and a design for a 9 or 18-hole private golf course.

Candiid Candidates idates must have FRACGP or equivalent.

Centre rees are are lo ar oca c t in DWS areas.

Centres located To ďŹ nd o out more ofďŹ ce@apollohealt ofďŹ ce@apollohealth.biz | 08 6142 9275

Contemporary lodges built with luxury in mind

The partially reticulated property boasts three vineyards, each producing wine grapes.

Interested parties contact: Sally & John â&#x20AC;&#x201C; Hidden Valley Forest Retreat â&#x20AC;&#x201C; Tel: (+61 8) 9755 1066

www.yourhiddenvalley.com

Looking for a work life balance?

GP Opportunities Available in WA

General Practitioner â&#x20AC;&#x201C; Street Doctor Perth Central & East Metro Medicare Local Ltd (PCEMML) operates a mobile medical service, known as StreetDoctor.

This service provides primary healthcare to homeless and disadvantaged populations of Perth.

We are currently seeking an experienced Vocationally Registered General Practitioner to work at one of our Street Doctor Clinics held at a youth drop-in centre, located in Northbridge. The clinic is held on Monday afternoons between 1.00pm â&#x20AC;&#x201C; 4.00pm.

If you have an interest in working in community health and have a true passion for helping people in need we would like to hear from you. For further information please contact Tracey Snowden (08) 9376 9200.

To apply please forward your current CV to hr@pcemml.org.au

s 'ARDEN #ITY -EDICAL #ENTRE s +INGSWAY -EDICAL #ENTRE s -IRRABOOKA -EDICAL #ENTRE s .ORANDA -EDICAL #ENTRE s 6ICTORIA 0ARK -EDICAL 'ROUP IPN is a highly diverse and collaborative service provider.

You will enjoy: s #LINICAL INDEPENDENCE s &REEDOM mEXIBILITY s 6ARIABLE COMMERCIAL TERMS TO SUIT YOU s -ODERN WELL EQUIPPED CLINICS Limited positions available. &OR A POTENTIAL PARTNERSHIP WITH )0.

PLEASE CONTACT esther.mortimer@ipnet.com.au or 0418 371 724. !LL DISCUSSIONS WILL BE CONlDENTIAL www.ipn.com.au

LIFESTYLE AND CAREER

!

BEAUTIFUL BUNBURY BUNBURY Opportunity awaits your practice.

1/138 Spencer Street South Bunbury t . $POTVMUBODZ TQBDF 8JUI $BS CBZT t ;POFE NFEJDBM SPPNT t QFS NPOUI QMVT WBSJBCMF PVUHPJOHT QMVT (45 t 1SFWJPVTMZ PQFSBUFE BT B 3BEJPMPHZ DFOUSF t 5IF QSPQFSUZ QSFTFOUT BT OFX t &RVJQQFE XJUI .BMF 'FNBMF BOE TUBGG UPJMFUT BT XFMM BT EJTBCMFE GBDJMJUJFT t )BWF OFX DBSQFUT UISPVHIPVU #F RVJDL BT PQQPSUVOJUJFT MJLF UIJT EPO U DPNF BMPOH WFSZ PGUFO JO UIF 4PVUIXFTU regional City of Bunbury Phone: Patrick Williams on 0407 990 886 Email: pat@sdea.com.au Bunbury Office 13 Stirling Street, Bunbury WA 6230 Phone: 9721 3533

Specialist and allied health opportunities!

A great opportunity for the right clinicians to own and operate their own practice or if preferred we can employ!

We have a combination of single rooms with dedicated reception or individual tenancies available â&#x20AC;&#x201C; come and have a look and choose for yourself!

Opens late April/early May Project Manager: Jill Riggall 0437 516 850 jill.riggall@breckenhealth.com.au GPâ&#x20AC;&#x2122;s are encouraged to contact Dr Brenda Murrison 0418 921 073 brenda.murrison@breckenhealth.com.au

MAY 2013 - next deadline 12md Monday 15th April - Tel 9203 5222 or jen@mforum.com.au

Sometimes, it feels like weâ&#x20AC;&#x2122;re living in a photo album. The alarm goes off, my H\HV RSHQ DQG , FDQ SLFWXUH WKDW ÂżUVW morning we moved in. Boxes strewn across the room, paper everywhere and oh, how weâ&#x20AC;&#x2122;d laughed. Âł:KRÂśV JRLQJ WR ÂżOO DOO WKLV VSDFH"´ \RX said, dancing around the room. ,Q D EOLQN WKH QXUVHU\ ZDV ÂżOOHG ZLWK WKH cries of a new baby and the playroom with the sounds of laughter. So many birthday parties in the kitchen, debates across the table, holiday dinners. That

time Bob, dropped the lamb roast on WKH Ă&#x20AC;RRU Âą LW ERXQFHG WZLFH HYHU\RQH was certain of that.

You and I sat on the back verandah, sipping wine and startled at the silence. ³:KHUH GLG HYHU\RQH JR"´ \RX VDLG reaching out and squeezing my hand.

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the aisle. The kids with their families, settling in for the holiday break.

My eyes open and I see you watching me in the moonlight. â&#x20AC;&#x153;The babyâ&#x20AC;&#x2122;s FU\LQJ ´ The bed creaks. Our daughter pads across the hall to the nursery. You reach for my hand and I smile, thinking of all that weâ&#x20AC;&#x2122;ve built along the way.