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CONTENTS CLINICAL FOCUS

FEATURES

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Working With St Bart’s

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Awareness Cambodia

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Ear Health Solutions

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the Murray

NEWS & VIEWS Letters t"EWBODFE)FBMUI%JSFDUJWFT )BWJOHUIF$POWFSTBUJPO  .S$ISJTUPQIFS.D(PXBO t$IBOHJOHUIF.JOETFU  "EK"1SPG:BTNJO/BHMB[BT t%PDUPST*NQPSUBOU3PMF UP4UPQ&MEFS"CVTF  .T1BVMJOF#BHEPOBWJDJVT t"HFJOHJO#VTTFMUPO  %S"MBO+BNFT t8FSF/PU"MMPO0VS-BTU -FHT %S"EFMF5IPNBT

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Editorial: Communication and Confidence

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Have You Heard?

10

Satire: Holidaying at Home

38 Yellow Fever

Vaccination %S"JEBO1FSTF

39 Risks from

‘Voluntourism’ %S%BWJE3VUIFSGPSE

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42 Autism Spectrum

Disorder 1SPG"OESFX8IJUFIPVTF

E-POLL & EVENTS

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Medicolegal Q&A: Happy Snapper Pitfalls

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Doctors Drum: GPs & Specialists – Partners in What?

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e-Poll: Communication Between Doctors

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e-Poll: Role of Health Consumers in Care

LIFESTYLE 46 Rocky Horror Show

39 Tips to

48 e-Poll:What’s on

Prevent Jetlag 42 Beneath the Drapes

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43 Music and Medicine

GUEST COLUMNS 19

Empathy Helps Communication

Your Mind When Work Isn’t? 48 The Funny Side 49 Wine Review:

Bunn Vineyard %S-PVJT1BQBFMJBT

50 Photography:

Holiday Road

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33 Grasping the

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35 Times They

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44 Cruising Down

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Chikungunya: Chicken What?

s Xman s g i t e e Gr ture Fea 23-31

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An Athiest in the Choir Loft %S%POOB.BL

53 Community Singing %S"OHFMB$PPOFZ

54 Competitions

Pages

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PUBLISHERS

Letters

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 reflect the views of the authors. Readers should independently verify information or advice. Publication of an advertisement or clinical column does not imply endorsement by the publisher or its contributors for the promoted product, service or treatment. Advertisers are responsible for ensuring that advertisements comply with Commonwealth, State and Territory laws. It is the responsibility of the advertiser to ensure that advertisements comply with the Trades Practices Act 1974 as amended. All advertisements are accepted for publication on condition that the advertiser indemnifies the publisher and its servants against all actions, suits, claims, loss and or damages resulting from anything published on behalf of the advertiser. EDITORIAL POLICY This publication protects and maintains its editorial independence from all sponsors or advertisers. GRAPHIC DESIGN Thinking Hats 2

Having the conversation

Changing the mindset

Dear Editor, Your story about Advanced Health Directives is timely [Planning for the End, November]. The significance of advance care planning for people with chronic and terminal disease is still poorly understood within the community at large. If the issue is raised at all, it may occur within the specialist palliative care context, such as Silver Chain’s Hospice Care Service, as a part of personcentred and holistic assessment and care planning. However, even as the person approaches their death, the discussion of advance care planning and the role of an advance health directive may be met with surprise and consternation. The core of advance care planning is ‘having the conversation’ about end-of-life wishes and treatment preferences between the individual and those who are close to them, that is, those likely to be the decisionmakers should the person be unable to make a decision when it is needed most. Sometimes just having the conversation may be enough as it may confirm an unspoken understanding already shared by all concerned. However, for many this may not be as straightforward. Family members may have differing views or feel hesitant and reluctant about making decisions in the absence of clearly documented wishes. Hence the value of translating these critical conversations into a clear and unambiguous written document completed with consultation and input from the person’s general practitioner. This is the function of an Advance Health Directive, and clearly even when the person’s wishes and preferences are shared and well-understood, there is merit in taking the next steps of writing these down and making sure the document is ready and available when required. Community education and engagement is paramount in combination with the education and support of health professionals. With strong support from service providers, primary care and peak organisations and the Colleges, the incorporation of advance care planning knowledge and skills into contemporary professional practice will be achieved.

Dear Editor, Thank you for the insightful comments in the articles about palliative care [November]. I particularly make reference to the comments of Dr Gary Geelhoed, Chief Medical Officer of WA Health, where he cites the situation of individuals dying in an acute environment rather than a more appropriate setting. This continues to be an important challenge in the WA health care sector. We have a very real opportunity to achieve a significant mindset shift amongst clinicians in public and private hospitals about understanding the timeliness of making a decision (and communicating effectively with the patient and family) when ‘curative’ treatments come to an end and an effective plan of palliative care takes over. There is evidence that this decision-making is prolonged, leading to ongoing costly treatments (and potentially lengthened hospital stays) as well as providing a false hope that the malignant disease or chronic condition will be ‘cured’. Community attitudes are changing and they need to be supported with a higher level of awareness and appropriate action amongst hospital-based clinicians. Adj A/Prof Yasmin Naglazas, CEO, Bethesda Hospital ED. Bethesda Hospital provides palliative care services.

Doctors’ important role Dear Editor, I was heartened to see the issue of elder abuse canvased in your magazine [Standing Up for Abused Elderly, November]. Abuse can take many forms though, thankfully, it’s receiving increasing attention from doctors and allied health professionals.

Mr Christopher McGowan, CEO, Silver Chain Group Continued opposite

Star

Joke Night Before Christmas

interrupted with this trivial question, so he snaps at her, “Put them by the front door, and stop bothering me. I’m trying to get some work done.” He starts back to work, but a few minutes later an elf barges in. “Santa, we got all the toys wrapped, what should we do with them?” Santa snaps, “Stick ‘em in the sleigh! Can’t you see I’m trying to get ready? I don’t want any more interruptions!”

It was Christmas eve, and Santa was really busy making his list and checking it twice, when there came a knock at the door.

But sure enough, as soon as he starts back to work, there is another interruption. An angel, standing at the door, says, “Santa, I have your Christmas tree. Where would you like me to put it?”

His wife comes in. “Where do you want me to put your boots and gloves?” Santa is annoyed by being

And that is how the little angel came to be on top of the Christmas tree.

medicalforum


Apology and Retraction TO:

The Australian Medical Association (WA) Incorporated Mr Paul Boyatzis Associate Professor Rosanna Capolingua Professor Bernard Pearn-Rowe

We, Dr Robert McEvoy, Ms Jenette Heyden and Rakabee Pty Ltd (being the company through which we publish Medical Forum WA magazine (Magazine) and maintain the website at www.medicalhub.com.au (Website) published an article in April 2011 concerning the AMA WA, Mr Boyatzis, Associate Professor Capolingua and Professor Pearn-Rowe. We each now accept that the article contained some material that was without foundation and that we unreservedly retract and which may have led readers to draw damaging conclusions about AMA WA, Mr Boyatzis, Associate Professor Capolingua and Professor Pearn-Rowe. We apologise for any damage the article has caused AMA WA, Mr Boyatzis, Associate Professor Capolingua and Professor Pearn-Rowe. We also accept that Mr Boyatzis, Associate Professor Capolingua and Professor Pearn- Rowe were hurt and distressed by some subsequent articles we published and we regret this.

Dr Robert McEvoy

Ms Jenette Heyden

Rakabee Pty Ltd

Date: September 2013

Letters It is particularly important that medical professionals are aware of the options and the consequent actions if they suspect that an elderly person is being abused, or may be at risk of that occurring. In WA, the Guardianship and Administration Act 1990 provides protective legislation enabling seniors to prepare for future contingencies and providing relevant agencies scope to intervene if an individual is at risk. Better health care and improved lifestyles mean people are living longer and most wishing to live independently in their own homes. There are some things a capable elderly person can do for themselves. In particular, two very useful tools are Enduring Power of Guardianship and Power of Attorney. medicalforum

These are binding legal documents enabling adults to choose who they would like to make decisions on their behalf should their mental and/or physical capacities be compromised in the future. The nominated person has the protection of an official role and the capacity to intervene if they have concerns about a person’s well-being. In the case of a Guardian, they can make both medical and more general lifestyle decisions. This could conceivably take the form of preventing a person who may be causing problems from visiting an elderly individual. An Attorney, on the other hand, usually has a closer focus on property and finances. On a day-to-day basis this may mean something as simple as ensuring that the bills are paid. Additionally, they

can intervene if there is any suspicion of financial impropriety. For the medical professional, the first step is to discuss any concerns with the elderly person. This can, of course, be difficult particularly if the perpetrator of abuse is a family member. The other relevant factor is mental impairment and, if this is a real concern, an administrator can be formally appointed by the State Administrative Tribunal (SAT). If, for any reason, an Enduring Guardian or Attorney is unable to continue in the role (or is acting improperly) an application can be made to the SAT. More letters P4 3


Letters Continued from P3 Most importantly, a similar application can be made to the SAT if a doctor feels an individual is no longer able to provide informed consent to medical treatment. www.publicadvocate.wa.gov.au 1300 858 455 Ms Pauline Bagdonavicius, WA Public Advocate

Ageing in Busselton Dear Editor, I read your recent article regarding ageing studies in Western Australia with interest [How We Research Ageing, November]. I would like to draw attention to another important study, the Busselton Healthy Ageing Study, which began in 2010. This study of the baby boomer population of the Busselton Shire is examining the cumulative effects of multi-morbidity on physical and cognitive function in people born between 1946 and 1964. The cohort will be followed as they age to determine the interactions of different diseases (rather than the comorbidities of single diseases) and how we determine whether we age well, or otherwise. By mid-2014, over 4000 participants will have completed four hours of health and

function assessment, an overnight sleep study and have serum, DNA and RNA stored. Follow-up will be roughly five yearly. Analysis of the first 2000 participants shows that the Busselton population is unfortunately representative of the Australian population generally, with high levels of obesity and overweight, inactivity, anxiety, depression, sleep apnoea, diabetes and reduced bone density. Forty percent of men and 25% of women have four or more risk factors for chronic diseases. How these combine in the future will be principal focus of the study. Dr Alan James, Chairman, Busselton Population Medical Research Institute

We’re not all on our last legs Dear Editor, I think your most recent magazine theme of ‘Ageing Disgracefully’ presented an unbalanced view for the majority of seniors. Most of us live active fruitful and fulfilling lives to a great age, and we don't come to the notice of the medical world unless something untoward happens. Medical students who spend time in our practice are amazed by the ‘other side’ of ageing. These are people who they never see in their hospital rotations.

Living life to the full requires physical and mental capacity. Increasingly, over 50s are being more responsible in their lifestyle choices and modern medicine has helped control chronic issues such as diabetes, arthritis and hypertension, which allows us to live our lives in a way that our parents could not even imagine. As the baby boomer bubble looms, it is important to encourage seniors to stay actively involved in the community either voluntarily or on a part-time basis thus living the motto ‘use it or lose it’. The more we get off our duffs and stay physically and mentally active, the less likely we are to be a recipient of the services outlined in last month's magazine. My husband and I have a vision to inspire seniors to live active and fulfilling lives until the day they die. We are soon to publish a book, Travel Secrets For Seniors, which gives information for seniors to travel safely as well as independently in a way that is aligned with their interests and values, not what is considered suitable for their age group. We have met many amazing role models, including one lady in her 80s, who travelled to the North Pole. We also shared a rafting trip down the Colorado River through the Grand Canyon with a couple, both in their 80s. Dr Adele Thomas, GP, Subiaco

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

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Editorial By Dr Rob McEvoy Medical Editor

Communication is Down, So Is Confidence

It was the latest Doctors Drum that got me thinking. Communication has changed and a lot of people appear unhappy about the changes. Groups outside medicine are feeling the same pressures that doctors do. I remember Beyond Blue’s Jeff Kennett suggesting the reason why so many people are getting depressed is they cannot handle the pace of change. That’s one point. The second is that communication has broken down, and is awaiting some re-birth. While things like the PCEHR offer promise, doctors are under information overload and need solutions now. IT offers much but seems to ask that we do things more accurately and with more speed – that’s more pressure. Doctors are looking for timely problem solving. More direct involvement of the consumer is the third point. Even the forces of conservatism, like Premier Barnett, are feeling the pinch. Having your nose rubbed in broken election promises, decisions that seem to lack consensus, dealing in secrecy, and bending to the will of lobbyists are now

brought into the open. The average Joe Bloggs can assess if they are losing political voice. So it is with health decisions affecting Joe et al. Doctors are faced with a more informed and less accepting public. It is no longer acceptable to couch things in terms of a 1% risk if the consumer sees themselves as potentially in the 1%. Rightly so – we have to offer more. The “statins” saga suggests the medical profession no longer holds the high ground and our motives are being questioned on this and many other things. Doctors who respond in the media come under similar scrutiny, including from colleagues. The wielding of influence is an important issue in so many respects. It was interesting to read the reported comments of resigning CCC head Roger Macknay who said that some who deal with government set out to corrupt public officers. He said we live in an age where slack processes make this easier, especially where lobbying organisations have big budgets, delegated powers and inadequate supervision. In his case, according to the

Our care surrounds you... 6

parliamentary committee overseeing the CCC, an uncooperative police force meant corrupt people were getting a better run. Mr Macknay’s warning comes at a time when leadership in public health is under the spotlight. It is a concern that government has been unable to replace Kim Snowball. Only older experienced people seem up to the task. However, the bureaucratic and regulatory onslaught that is government’s response to overload, impacts adversely on confidence. When I forgetfully left the hose on, flooded the pond and killed half the gold fish, my response was to rush inside, download the Mini-Mental State Examination and prove I could pass it (with flying colours, I might add!). At the back of my mind was my parent’s Alzheimer’s and performance anxiety as a gardener. I can sense a collective anxiety amongst many health professionals; anxiety that they are not up to the task even though they took up medicine to help people. While they waiver, those in it primarily for the power, money and influence grow in confidence. O

hollywoodprivatehospital.com.au

medicalforum


Chikungunya: Chicken what?

By Dr Smathi Chong, Clinical Microbiologist & Infectious Diseases Physician

Chikungunya* is a mosquito-transmitted disease caused by the chikungunya virus, an alphavirus related to the endemic Ross River virus and Barmah Forest virus. It was first identified in Tanzania in the 1950s but in recent years has caused large outbreaks in South Asia, Southeast Asia, the Indian Ocean Islands and the South Pacific.

date of symptom onset helps determine the most appropriate test and its interpretation.

So far this year, over 50 cases of chikungunya have been reported in WA (more than the last five years combined), which accounts for almost half of all cases reported in Australia. All the cases diagnosed in WA have been acquired outside the state, mostly in returned travellers from Bali.

Treatment

The virus is transmitted by Aedes aegypti and Aedes albopictus mosquitos, not present on mainland WA (although Aedes aegypti is found in Queensland).

Clinical features Incubation period. The incubation period is short, usually 2-10 days. Thus, fever starting more than two weeks after leaving an endemic area is very unlikely to be due to chikungunya (or dengue).

Dengue Compared UÊ Êv>ۈۈÀÕÃÆʜÛiÀÊxääÊV>ÃiÃʘœÌˆvˆi`ʈ˜Ê7ʈ˜Ê Óä£ÓÆʀ{ääÊV>ÃiÃÊÀi«œÀÌi`ÊÜÊv>ÀÊ̅ˆÃÊÞi>À° UÊ ÃœÊÌÀ>˜Ã“ˆÌÌi`ÊLÞÊ̅iÊAedes aegyptiÊ>˜`Ê Aedes albopictusʓœÃµÕˆÌœÃʈ˜ÊÌÀœ«ˆV>Ê>˜`Ê ÃÕL‡ÌÀœ«ˆV>Ê>Ài>ÃÊܜÀ`܈`i° UÊ -ˆ“ˆ>ÀÊVˆ˜ˆV>Ê«ˆVÌÕÀi\ʅi>`>V…iÊÜˆÌ…Ê ÀiÌÀœ‡œÀLˆÌ>Ê«>ˆ˜ÊˆÃÊV…>À>VÌiÀˆÃ̈VÆÊÀ>Ã…Ê ÕÃÕ>ÞÊ>Êvˆ˜iÊL>˜V…ˆ˜}ʓ>VՏœ«>«Õ>ÀÊ À>Å]Ê܅ˆiÊ>Ê«iÌiV…ˆ>ÊÀ>Åʓ>Þʈ˜`ˆV>ÌiÊ Ì…Àœ“LœVÞ̜«i˜ˆ>ÆÊÃiÛiÀiʓ>˜ˆviÃÌ>̈œ˜ÃÊ ˆŽiÊŜVŽÊœÀʅ>i“œÀÀ…>}ˆVÊVœ“«ˆV>̈œ˜ÃÊ ­“ÕVœÃ>ÊLii`ˆ˜}ʈÃʜ“ˆ˜œÕîÊV>˜ÊœVVÕÀ° UÊ œÕÀÊÃiÀœÌÞ«iÃÊ܈̅ʘœÊVÀœÃÃʈ““Õ˜ˆÌÞ°Ê ,iˆ˜viV̈œ˜Êˆ˜VÀi>ÃiÃÊ̅iÊÀˆÃŽÊœvʓœÀiÊ ÃiÛiÀiʓ>˜ˆviÃÌ>̈œ˜Ã°Ê/…ˆÃʈÃʏiÃÃÊ Vœ““œ˜Êˆ˜ÊÌÀ>ÛiiÀÃÊ­Vœ“«>Ài`Ê̜ʏœV>Ê ÀiÈ`i˜ÌîÊ՘iÃÃÊvÀiµÕi˜ÌÞÊۈÈ̈˜}Ê `i˜}ÕiÊi˜`i“ˆVÊVœÕ˜ÌÀˆiÃ°Ê UÊ >LÊ`ˆ>}˜œÃˆÃ\Ê i˜}ÕiÊÃiÀœœ}Þ]Ê`i˜}ÕiÊ -£Ê>˜Ìˆ}i˜Ê>˜`ÊëiVˆvˆVÊ`i˜}ÕiÊ* ,ÆÊ Ãˆ“ˆ>ÀÊLœœ`ÊV…>˜}iÃÊ>ÃÊV…ˆŽÕ˜}՘Þ>]ʜvÌi˜Ê ܈̅ʓœÀiÊÃiÛiÀiÊ̅Àœ“LœVÞ̜«>i˜ˆ>°

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Leucopenia (including lymphopenia and neutropenia) is seen, as is thrombocytopaenia. Mild to moderate liver function test abnormalities may be seen but severe transaminitis is rare and other causes should be sought.

DD of Fever & Rash in a Returned Traveller

Management is supportive and symptomatic as there are no specific antivirals available.

UÊ «>ÀۜۈÀÕÃ

The arthritis that can follow acute infection with chikungunya may be alleviated by cold compresses and analgesics. Hydroxychloroquine has been suggested for the chronic phase however a rheumatologist review would be recommended if this is required.

UÊ ,œÃÃÊ,ˆÛiÀÊۈÀÕÃ

Prevention

UÊ >À“>…ÊœÀiÃÌÊ6ˆÀÕÃ

Mosquito bite prevention is key -- Aedes mosquitos tend to bite during the day, especially during the hours after dawn and before dusk. Further advice may be sought as part of a comprehensive travel medicine consultation. There are no vaccines available.

UÊ “i>Ïià UÊ ÀÕLi>

UÊ “>>Àˆ> UÊ "̅iÀÃ\Ê,ˆVŽiÌÌÈ>]Êi«ÌœÃ«ˆÀœÃˆÃ]Ê ,…iՓ>̈VÊviÛiÀ]ÊiÌV UÊ

œ˜‡ˆ˜viV̈œÕÃ\Ê>iÀ}Þ]Ê>Õ̜‡ˆ““Õ˜i

Symptoms and signs. Chikungunya presents much like dengue (see inset) with an abrupt onset of fever, joint symptoms and a rash. The fever usually lasts 2-5 days. The rash is often an itchy maculopapular rash but may be bullous, especially in children. One main distinguishing feature is the tendency to a prolonged debilitating arthritis with significant pain and swelling, especially of the small joints of the hands and feet. This can persist for weeks to many months. Immunity. Reinfection with chikungunya is not thought to occur because protective immunity develops after infection.

Laboratory diagnosis Guided by clinical suspicion and travel history, a definitive laboratory diagnosis can be made using serology and PCR from blood. A follow-up convalescent serum sample is often required to demonstrate rising antibodies to confirm recent infection. The

Both dengue and chikungunya are notifiable diseases to the WA Health Department * Chikungunya is not a Korean side dish (!) but is now the only word from the Makonde language of eastern Africa in the English dictionary. It translates roughly as ‘that which bends up’, which probably refers to the posture of the prostrate sufferer.

Take Home Messages UÊ ˜Ê>ÊÀiÌÕÀ˜i`ÊÌÀ>ÛiiÀÊ܈̅ÊviÛiÀ]Ê >À̅À>}ˆ>ʳɇÊÀ>ÅÊ̅ˆ˜ŽÊ`i˜}ÕiÊ Ê V…ˆŽÕ˜}՘Þ>° UÊ >LÊVœ˜vˆÀ“>̈œ˜ÊLÞÊÃiÀœœ}ÞÊEÊ* ,°Ê ºvÊޜÕÊvœÀ}iÌʅœÜÊ̜ÊëiÊˆÌ]ʍÕÃÌÊV>Ê ˆÌÊ ÊۈÀÕð» UÊ i˜}Õiʓ>Þʅ>ÛiÊÃiÛiÀiÊ “>˜ˆviÃÌ>̈œ˜Ã UÊ …ˆŽÕ˜}՘Þ>ʓ>Þʅ>ÛiÊ «Àœœ˜}i`Ê>À̅ÀˆÌˆÃ UÊ /Ài>̓i˜ÌʜvÊLœÌ…ʈÃÊÃޓ«Ìœ“>̈VÊ >˜`ÊÃÕ««œÀ̈Ûi

7


Have You Heard?

Statin Static The “statins” TV saga prompted many press releases from within the medical fraternity, mostly pointing to the risks of ceasing medication and highlighting bias in the TV report. However, our bias meters were working overtime on some of the press releases. The FRACGP release, in contrast, mentioned the need for cholesterol to be considered alongside other risk factors, and acknowledged consumer concerns raised in the Catalyst program around things like inappropriate usage of statins, the need to promote non-drug interventions, concerns about drug company influence on clinical trials and doctors, the need for open disclosure standards, and changing ‘disease definitions’ that results in more drug use.

were eight colleagues delivering babies at Armadale Kelmscott Memorial Hospital (still the same today), but his contribution of 400 deliveries a year back then is down to about 300. AKMH reported a record 235 babies born last July and O&G Director Dr Liza Fowler praised everyone involved. Two new O&G specialists have arrived since 2012 in Drs Ken Nathan and Dr Ljiljana Ilic-Jeftic, and the hospital is at capacity for obstetrics now. Gary’s married to GP Dr Christina Raja and completing the medical family is daughter, Caitlyn, who is doing her intern year and his son who is sitting his fifth year exams.

Big, bigger, biggest Medical Forum has received conflicting comment on the projected demands for the new Children’s Hospital, due to open in 18 months. Some are getting sick of negative comment. Dr Hames’s office says with current PMH occupancy around 78%, and 50% more clinical and research area (including a bigger ED), the new hospital should keep up with demand until 2021. In line with a push into communities, the new hospital would link to six satellite metro hospitals with dedicated paediatric beds. It will have parent beds in each standard inpatient room. No doubt there will be pockets of underservicing based on supply and demand around staff and funding.

Research or perish

South-East baby boom When we interviewed GP Obstetrician Dr Gary White in March last year, there

AMA WA & Ors v Medical Forum & Ors – Defamation Proceeding In April 2011, Medical Forum published an article concerning the AMA WA, Mr Boyatzis, Associate Professor Capolingua and Professor Pearn-Rowe. The Proceedings have been settled on commercial terms satisfactory to all parties and without any admissions or concessions as to liability.

Thanks to all readers for their continuing interest in Medical Forum magazine.

8

Forming a working party or committee may have been replaced by research when it comes to dithering in making decisions at a government level. As competing interests grow for the health dollar, expect a lot more research. NHMRC three-year funding has gone to Curtin’s School of OT and Social Work to see how oldies facing end-of-life decisions can be prevented from presenting to EDs. It will also tell us if communitybased palliative care reduces ED costs. Anecdotally, the answers may be obvious – "yes" if GPs run it, and “ring an ambulance” coming from the person unable to attend.

Consumers hit the Web A new consumer-focused DoH website for WA has been launched (www. healthywa.wa.gov.au).When we looked, it had a lot of unique WA info and a lot of health information duplicated on other government websites. The service and content search functions are welcomed, although the latter is tied into HealthDirect nationally and lobs services from NSW if you can’t find what you want locally. The PainHealth website (http://painhealth.csse. uwa.edu.au) is proving popular for those with chronic pain, with about 4000 hits per day (1 million overall) and visiting browsers from 82 countries. The pages on low back pain, self checks, fibromyalgia, and pain management modules have been most popular, which says a lot.

Unis join forces Next year, Murdoch University takes over from Curtin Uni in teaching Notre Dame medical students the core first and second year units of biochemistry, physiology, anatomy and pathology. Students will use Murdoch facilities at the South Street campus, just a hop and a skip from SJGM and FSH, with teaching “to complement the specialities” found at those hospitals. We have heard rumours around contract renewals at FSH and elsewhere omitting academic loadings and short-term contract staff – which included one OT assistant known to us – getting the chop as part of the 500 staff cull at Charlies, all to reduce costs.

Wii, Apps and MBS In this electronic age, we are told that a weather video game on Wii Fit, played on the Nintendo Wii (30 minutes, three times per week), improved balance and gait speed in people aged 65 to 84. This sure beats whingeing about the grandkids! And the TGA has said it will look more closely at smartphone Apps that are involved in “diagnosis, prevention, monitoring, treatment or alleviation of disease” (i.e. not the information ones). Unfortunately, medical software falls into a grey area often (b.p. monitors during exercise are not on the TGA hitlist) and Apps capable of giving risky false reassurance could be targeted. We have learnt that 900,000 medical apps are on the Apple AppStore and 750,00 on Google’s Google Play store so the TGA has its work cut out (given that the FDA reviews about 20 apps a year). Meanwhile, a Northern Terriorty GP from the UK has written a small program to assist GPs navigate the 200 most common MBS schedule items – just $14, MBS Item Browser can be purchased from Dr Edgell at http://mbsib.com.au/

Nip, tuck, holiday Health insurer NIB has been in the spotlight over its cosmetic tourism packages to tap into a growing market for offshore cosmetic procedures. We understand NIB aims to sell packages comprising flights, accommodation and surgery at an average price of $8000, with post-op care provided by Australian surgeons. NIB, which is publicly listed and has $1billion in premium revenue, opened a WA office in Garden City not long ago. O

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A New Age has arrived! From September 2013, three New Oral Anticoagulants (NOAC’s) were added to our armamentarium. A large body of evidence from randomised trials and community experience supports guideline recommendations for the use of NOACs in preference to vitamin K antagonist (warfarin) for (non-valvular) Atrial Fibrillation (table 1).

NOACs vs. warfarin

Stroke/SE

Superior/non-inferior

Intracranial bleeding

Superior

Sometimes NOACs need to be (temporarily) ceased for those undergoing a procedure. To plan elective interruption we have to consider drug half-life, procedural bleeding risk and residual drug levels immediately before surgery (flowchart).

Procedural Bleeding Risk

Standard

Major bleeding Superior/ no difference Mortality

Hold 2-3 Drug Half-lives

Superior/ no difference

As with many new treatment modalities in cardiology (remember the introduction of drug-eluding stents?), it will take some time to get used to the ‘management’ of the many patients that will be on these NOACs. Table 2 summarises dose selection of these drugs in eligible patients with AF.

Table 2: Recommended Dose Selection Dabigatran 150mg bid in most cases 110mg bid if age ≼75, concomitant interacting drugs Moderate renal impairment (30-49ml/min).

15mg od if moderate renal impairment (30-49ml/min). Apixaban

Dr Janssen runs weekly clinics in Kalgoorlie and monthly clinics in Geraldton. He teaches medical students in rural areas as well as at SJOG Hospital, Subiaco. He is based at Western Cardiology in Joondalup but also consults and provides inpatient care at SJOG Hospital, Subiaco. Johan provides Telemedicine consultations: his Skype address is Westerncardiology.johan; and these consults can be booked through his Joondalup office +61 8 9300 2545.

Re-starting the NOAC after a procedure? High

Hold 4-5 Drug Half-lives and check drug levels

The drug half-life for Rivaroxaban and Apixaban is around 12 hours (25-35% metabolised as renal clearance); for Dabigatran it depends on creatinine clearance (80% metabolised as renal clearance): CCL>80ml/min, 12 hrs; 50-80ml/min, 15 hrs; 30-50ml/min, 18 hrs; <30ml/min, 24+ hrs. To measure whether your patient is using the NOAC or to check if there is an effective dose of the NOAC â&#x20AC;&#x2DC;on boardâ&#x20AC;&#x2122; we can use readily available non-specific assays like aPTT, PT and TT (table 4). On very rare occasions it might be necessary to use a specific assay (check with a haematologist).

While warfarin was often restarted the day after a procedure, knowing it would take a few days to reach a therapeutic level, NOACs will be therapeutic within approximately two hours after taking the first dose. It is therefore important NOT to re-start NOACs before you are satisfied the wound has healed sufficiently (i.e. as a rule of thumb, on day three postsurgery). Common sense should prevail with specific procedures like polypectomy where the stem of the polyp has a broad base and hence a fair bleeding chance.

Bridging of anti-coagulation with heparin/clexane? Although it lacked solid evidence of efficacy and safety, it was usual practise to cease warfarin 7 to 10 days before procedures and then â&#x20AC;&#x2DC;bridgeâ&#x20AC;&#x2122; patients with heparin infusions or clexane sc injections. This now ceases with the introduction of the NOACs; as the mode of action is much faster and half-live better predictable, management will be more smooth and safe!

Conclusion

Table 4: Test Selection

Rivaroxaban 20mg od for most

About the author

Temporary cessation

Table 1: Effects of NOACs on key clinical outcomes in AF Outcome

Dr Johan Janssen, Cardiologist

Dabigatran Rivaroxaban Apixaban Drug Specific Hemoclot Assay*

Anti-Xa

Anti-Xa

No effect

No effect

Non-specific Assays aPTT

5mg bid for most 2.5mg bid if 2 of 3 criteria met- age>80, weight<60kg, creatinine>133Îźmol/L Ref: Camm JA, et al. EHJ 2012

PT TT

* Mass spectrometry can be used to measure drug levels

The arrival of the NOACs on the PBS heralds a New Age in the management of our patients with atrial fibrillation. As with all new treatment modalities, it is still the responsibility for the clinician to ensure appropriate patient and dose selection, and management of interruption to optimise clinical outcome for patients. When in doubt, contact the prescribing cardiologist!

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9


Humour

See Perth and Die Where else would resident Medical Forum satirist Wendy Wardell find herself over the long summer holidays than right here at home.

A

s summer holidays approach, tourism bodies across Australia are desperately trying to persuade us to holiday at home. For me, they're preaching to the converted. I take the motto 'It's better to travel hopefully than to arrive' to the next level by hoping not to have to go anywhere at all. If I suddenly yearn to recreate the budget travel experience, I'll fast for a day while locked in the boot of a Toyota Yaris, squashed up to an oversized bag of sweaty gym gear. Sometimes I’ll get an upgrade to Business Class in a BMW if the boot's not too full of golf clubs and Louboutin shoes. The Beemer driving style makes the journey more thrilling too; you don't have to be at 30,000 feet to appreciate turbulence. By staying at home my accommodation is more spacious than a hotel room and I don't have to spend an hour trying to figure out how the shower works. There is no mini-bar; only full sized bottles. I never get anyone banging on the door desperate to clean the room, whatever state of undress I'm in. The only real downside is the lack of any frisson of excitement on stealing the bathrobe, which I clearly remember buying in Target in 2008. I'm also having little success in training the cat to leave a chocolate on my pillow at night. I tried the authentic method of exploiting child labour

but she just kept eating the chocolates. 'But what about the experience of immersing yourself in a way of life different to our own?' I hear you ask. If you believe that to be lacking in WA you've clearly never spent an afternoon in the Rockingham branch of Centrelink. It's not even necessary to go abroad to experience overpriced and over-rated dining, now that Perth is world-class in this department and can throw in snarling service to boot. A coffee and cake in the Western suburbs can set you back the equivalent of an Eiffel Tower entry fee and be delivered with an attitude of dismissive superiority that would give a Parisian fashionista a run for her money. Our tourist attractions may not be on a par with the temples of Angkor Wat or Disneyland, but, unlike the Seven Wonders

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of the World, you're never going to see The Bell Tower and Adventure World on the Discovery Channel, so you might as well experience them in person. Furthermore, by holidaying at home you don't have to deal with strange foreigners – only those foreigners you're already accustomed to. Fortunately, the feisty reputation of Western Australia's aquatic inhabitants limits the number of American tourists with their loud voices and even noisier trousers. Americans all worry that that they might die of tourism rather than have a traditional demise at the hands of a disgruntled work colleague instituting his own assertive HR policies. It seems churlish to point out that relative to walking down some US streets, it's safer to go swimming in Shark Bay with a flesh wound and a dead seal strapped to your back. For those who actively aim to dabble in danger though, our mosquitoes now carry a range of exotic diseases formerly only available in more remote tropical regions. Just having a barbecue can mean dicing with death from sun exposure, insect bite, exploding gas cylinders and sausages burned to a carcinogenic cinder. Eat your heart out, Bear Grylls. And, no, that's not a serving suggestion. O

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11


Feature

The Best Job in the World It may not have been the retirement Sheryl Whitford (Dr Sheryl Seabrook) envisaged, but working on the Board of St Bart’s has been one of the experiences of a lifetime. The rewards of being involved in St Bartholomew’s House in East Perth and helping to reconnect the lives of homeless people are boundless, says the retiring Board member and retired GP. After an association of more than 10 years, Sheryl is on a promise to spend more time with her children and grandchildren scattered in Melbourne and London, but it is with some reluctance that she leaves the community of St Bart’s. “I’ve received more benefit from my involvement than I would have thought possible. I’ve met some marvellous people, both on the Board and in the community, and it’s been a privilege to get to know some of our residents.” And she doesn’t have enough superlatives to describe the dedication of the staff, who turn up all hours to help out. “These workers are among the lowest paid in the community and yet their commitment is extraordinary. They have inspired me. I have been so lucky in my life and career and working with St Bart’s has been a great opportunity to give back.” There have been great changes at St Bart’s, which began 50 years ago on the verandah of the then Anglican archbishop’s house when he found homeless men asleep there. So he threw open the doors of the church hall.

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“The men in transitional care have six months, and case workers help these men devise a plan to find accommodation, get a bond together, maybe sort out legal issues and set up links with Centrelink, which a lot of them don’t have. All the basics we take for granted because we have addresses.”

QDr Sheryl Seabrook

For many years, St Bart’s operated from premises in Brown St, East Perth, but after a significant campaign and serious fundraising which included $23m and $7.3m from the state and federal governments respectively, $2.8m from Lotterywest and $1m from St Bartholomew’s Foundation an innovative social housing facility in Lime St opened its doors in August, 2012. Here the St Bart’s team shares space with the men and women occupying beds and rooms in the crisis care and transitional services, and its aged-care and independent living units – all up about 150 people. Sheryl says the focus for all of them is to reconnect with the community. “There are 12 crisis care beds, just for men over the age of 18, and 42 men in transitional accommodation. The men in crisis care have accommodation for two weeks and in that time staff help them to recover so they feel strong enough to make decisions about the future.”

“Finding long-term accommodation, however, is one of the most serious challenges in Perth. If it’s taking longer than six months, we try to find alternatives. We work hard to reconnect homeless people with their family, if they have one, and we have had some great successes there, but whatever is done, it is at the individual’s direction.” “We don’t impose. Homeless people have rights to privacy, respect and dignity, like everyone else. However, everyone is expected to behave appropriately in our facilities, and that means no drugs, alcohol or actions that might give other residents anxiety. Even then, if there’s a breakdown and someone is asked to leave, they are always welcome back if they want to change.” St Bart’s also has links with community housing where they act as supportive landlords for couples and families, and people living with mental illness, helping them to manage their money to pay their rent and generally help them pick up their lives and contribute to society. “There are thousands of people needing a helping hand often with issues out of their Continued P14

Issues Around Homelessness There were no significant differences in the responses to these question, across the three main craft groups of GPs, Specialists and DITs (233 respondents).

Q

How much do these statements reflect your views on homeless people in WA, ‘living on the streets’?

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

Homelessness is primarily a mental health problem.

7%

33%

21%

34%

5%

Homeless people often reject non-institutional support available to them.

3%

36%

34%

23%

3%

The biggest barrier to successfully helping homeless people is the complexity of their problems.

17%

56%

14%

11%

1%

The homeless would do better if they used self-help more.

5%

27%

33%

32%

4%

ED. The responses on homelessness show a significant proportion of doctors uncertain regarding questions of mental health, wilful rejection of help and self-help with up to a third unable to decide on their answers. Anecdotally, homeless people are disconnected from others and receive few offers of non-institutional support, whereas 40% of our respondents believed the homeless received and rejected such support. Nearly 75% of doctors believed it was the complexity of people’s problems that was the biggest barrier to helping them, whereas the sector would probably offer the fragmentation of care and lack of facilities as the biggest barriers. 12

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13


The Best Job in the World Continued from P12 control. The census before last put the homeless population of WA at about 13,000. There is a significant element of mental illness (diagnosed and undiagnosed) and that may or may not be associated with drugs and alcohol.” “But for many it’s a cascade that can start with one event such as losing a job, falling ill, or being injured. They are unable to pay rent, their relationships break down, they can’t get help from the bank, they lose their house and contact with the community.” “By the time we meet these people, their sense of despair and loss of self-respect and dignity sends them spiralling. We see it time and time again. The frightening new development is that this scenario is becoming true for more and more women, especially those single and over the age of 50.” “These women may even be working but are paid so little that they can’t afford their rents.” “At the north block of the Lime St facility we have independent living units for women and men but our services are always full – about 500 people all up throughout our residential and community housing services – and there’s a huge waiting list.” While Sheryl doesn’t resile from the enormity and complexity of the issues confronting the homeless, she says St. Barts’ services are now established and are extremely well run. The St Bart’s board is keen to replace Sheryl

QLime Street Bulding and a resident at St Barts (right)

with another doctor because of the benefit medical experience can bring. “Particularly in the areas of service delivery and an understanding of the issues that residents face in trying to reconnect with the community,” Sheryl said. “Doctors also understand illness, especially mental illness and the impact of drugs and alcohol. Even the impact of loneliness and rejection and knowing that giving someone a roof and support can have huge benefits to their health.” The future also brings the prospect of research, especially in the area of social return on investment – proving to governments and donors alike that the services of St Bart’s help keep people functioning in and contributing to the community rather than in jail or hospital or sleeping rough. The ultimate goal would be

the prevention of homelessness. “We know anecdotally what our outcomes are but it’s important to demonstrate them. We don’t expect 100 per cent success, because we are dealing with human frailties and not everyone makes it. But given a chance, so many people blossom. They feel for the first time in a long time, secure and safe; and with help can take back control of their lives.” “Being a Board member does involve a bit of time, but the rewards are great. I have met some wonderful people and had some special experiences. You just need to put your hand up.” O

By Ms Jan Hallam ED: If you are interested, please contact St Bart’s acting CEO, Mr John Berger on 9323 5100 or chairman Mr Andrew Birch

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Feature

Awareness Cambodia Working in South-East Asia has given Emergency Physician Dr Kerry Hoggett a very different perspective on the problems of our First World health system. Dr Kerry Hoggett is an Emergency Medicine physician at RPH with a subspecialty in Clinical Toxicology. She travels to remote areas in both Cambodia and Myanmar conducting training programs and health clinics with a strong focus on fostering local expertise. “I’ve been to Myanmar four times in the past 18 months under a joint arrangement with the Royal Australian College of Surgeons, the Australasian College of Emergency Medicine and the Hong Kong College of Emergency Medicine.” “For Myanmar in particular, we’re keen to introduce the specialty of Emergency Medicine. And we do toxicology teaching as well.” Kerry expands on the strong sociocultural differences between countries such as Australia and the developing world. “I’m always shocked when I arrive back in Perth! In fact, I find it more of a problem coming home than anything I experience over there. The people in rural Cambodia

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QDr Kerry Hoggett with a patient at the Operation Nightingale clinic.

have next to nothing and they’re grateful for any help whatsoever. Conversely, you come back to Australia and see people with so many opportunities making poor health decisions.”

of medical resources, the Awareness Cambodia program is making an impact.

“Some of the things they complain about are absolutely insignificant compared with the Cambodians.”

“I’ve seen the local doctors develop their skills to a marked degree, even since June last year. They had no real concept of emergency medicine but, with our current training programs, the local doctors are becoming highly effective teams.”

Despite the severity of the problems associated with poverty and a paucity

“We’ve worked with the same group of doctors and medical students for the

Medical Volunteers Abroad There were 233 responses from GPs (41%), non-GP Specialists (37%), DITs (14%) and ‘Other’ doctors (8%).

Questions around this topic produced some interesting craft group differences but the 77% agreement with question 3 is of particular note, and perhaps a reflection of changing community attitudes where helping people to help themselves is seen as more beneficial.

Q

Overseas medical relief programs that WA doctors volunteer for – how much do these statements reflect your views?

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

One big attraction of these overseas programs is that more can be achieved for every health dollar used, compared to WA.

17%

42%

30%

8%

3%

Proceduralists involved are motivated partly by access to more interesting operative cases.

9%

49%

27%

12%

3%

I judge the value of any program by how much it trains local people to do the health work.

29%

48%

18%

4%

1%

I could give my time and lost income if an overseas medical relief program could use my unique skills.

15%

51%

20%

12%

2%

ED. Craft Group Differences: Giving time. 70% of non-GP Specialists agreed or strongly agreed they “could give my time and lost income if an overseas medical relief program could use my unique skills”, whereas 55% of GPs and 81% of DITs felt the same way. The next question is what defines “could” in each group. Certainly, over half of WA doctors seem willing to embark on overseas volunteer work at their expense. Motivation. Around 50% of non-GP Specialists (and DITs) agreed or strongly agreed that “proceduralists involved [in volunteer overseas work] are motivated partly by access to more interesting operative cases” whereas a larger 65% of GPs pointed to this as a motivating factor. Dr Kerry Hoggett would argue that her motivation is to help these developing countries find self-sufficiency and she takes an active role in training future doctors in Cambodia. 16

medicalforum


QAustralian medical team: Top row L-R: Dr Kerry Hoggett (Emergency Physician and Clinical Toxicologist), Emma Larter (RN), Nancy Kennedy (RN) and Dr Mark Flynn (GP). Bottom row L-R: Erin Clapham (RN), Dr Lester Mascarenhas (GP) and Dr Gary Hewett (dentist and CEO of Awareness Cambodia).

last couple of years and we can see real progression in that group, too.” Awareness Cambodia began in 1996 and the current CEO and founder is Dr Gary Hewett, a Perth dentist. “Gary went there, saw the poverty and started an orphanage for children of HIV parents. He broadened that out into education and health with local doctors providing free medical clinics in the provinces.” There are a number of different programs operating health clinics in the Kompong Speu region using Cambodian doctors and nursing staff. The local people struggle with illiteracy, poor nutrition and inherited debt that translates into substance and domestic abuse coupled with serious health issues. “We go out with local medical staff under the supervision of the health department to do vaccinations and health checks. It’s all part of Operation Nightingale and a lot of it is in quite remote provinces. Nonetheless, it’s safe and I’ve never felt in any danger.” Kerry came to Perth from Queensland as a teenager, completed her secondary

medicalforum

education and seized a career option denied to older members of her family. She studied medicine at UWA and post-graduate training here and in New Zealand. “I’ve always wanted to do medicine and have never wanted to be anything else. Both my mother and grandfather would’ve loved to have been doctors but they never had the opportunity.” Kerry has a strong commitment to provide a platform for local people, in both Cambodia and Myanmar, to develop their own health resources. It’s far more than going into a developing country, ‘practising’ procedures and flying home again. “It’s far better to leave a legacy, from a medical perspective, that’s sustainable rather than taking sophisticated equipment into these places and then taking it all home with you. For me, it’s important to be involved with projects that develop local services enabling local people to take over when we leave.” “Long-term projects are much more rewarding. We have a scholarship program at the moment where we hope to put young people living in provincial areas through medical school. That will flow back into improved health outcomes in remote and rural areas.”

QComplications

This patient did not have any paperwork and lived in a remote village. He had travelled to Phnom Penh and paid for the initial operation. It appears that he had not received any post-op care after the posts were inserted into his leg, which were to be removed in another five months. The patient complained of not having any money to make the journey to Phnom Penh for surgery to remove the posts. The Dr Hoggett and the ACI team cleaned his wounds and gave him antibiotics. Kerry expects to be travelling to Cambodia and Myanmar for the next decade and has some career advice for young medical students. “Enjoy your career, it’s flexible and you can turn it into anything you want. Take every opportunity that’s offered and grab it with both hands. It’s such an amazing experience to do things outside your day-today activities.” www.awarecam.org.au O

By Mr Peter McClelland

17


Doctors Drum

‘GPs and Specialists – Partners in What?’ Doctors Drum Giving Doctors Voice The importance of networks, communication breakdown, information overload, compassion fatigue, public system pressures, referral decisions were just a few of the topics under the spotlight at the final Doctors Drum breakfast for 2013. The room was packed with an even split of GPs and specialists to discuss the topic ‘GPs and Specialists: Partners in What?’ with a panel comprising fertility specialist Dr Simon Turner, general physician and member of the MDA National board A/Prof David Watson, GP Sean Stevens, GP obstetrician Dr Penny Wilson, Connect Groups CEO Ms Antonella Segre and Slater & Gordon Senior Counsel Ms Karina Hafford.

ll o P e

Communication, or lack thereof, between the branches was a hot topic. One GP said that while she felt communication between her practice and private specialists was effective and accessible, the situation was little short of appalling when it came to communication with the public system. She cited the poor standard of letters from Emergency Departments and the unacceptable delays in that letter arriving as key reasons why the relationship was almost non-existent. The guest column opposite is by a young RPH intern, who was at the Doctors Drum, and he offers another perspective on this relationship and what can be done to smooth the communication channels. A consumer advocate in the room urged doctors to keep patients in the communication loop. “People have been self-managing their health for centuries until the medical profession decided to

disempower them by taking ownership of everything. We have to start giving ownership back and empower people to become partners in their own care and be part of the conversation.” Younger doctors in the room raised the potential of new media to help bridge communication and knowledge gaps. Do you admit to a patient that you don’t know? The answer from some wise heads was, ‘of course, but you then say you will find out’. The information revolution has changed medical practice and one of the guests at the breakfast writes a column on P20 exploring how wonderful it is to embrace it – without losing common sense. While the consumer representative on the panel described how isolating consumers felt in the medical process and needed Continued P20

This e-Poll has some fascinating results, including comparisons between GPs and Specialists. A resounding two thirds of GPs and Specialists say there is a problem of communication between GPs and Specialists adversely affecting patient management. Interestingly, in the next question, 81% say the problem is fixable.

Q

Communication between doctors over patient management - what are your views?

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

A big contributor to difficulties in patient management is difficulties in communication between doctors.

16%

48%

12%

22%

0%

Any poor communication is a product of our times and cannot be easily remedied.

2%

8%

9%

63%

18%

Public hospitals fragment care through poor communication with community doctors.

20%

51%

15%

13%

1%

Both GPs and Specialists are pretty well ‘on the same page’ when it comes to patient care.

5%

39%

29%

24%

4%

Establishing a network of doctors you know early in your career is important.

19%

58%

16%

8%

0%

Many of the questions were sparked by issues raised at the latest Doctors Drum breakfast. There were 233 responses from GPs (41%), non-GP Specialists (37%), DITs (14%) and ‘Other’ doctors (8%). Thanks to all those who took part within the allocated six days (and congratulations to Dr PR who was our prize winner from amongst the 168 optional entries). Craft Group Differences: Awareness of the ‘public hospital fragmentation’ issue is strong across all groups, with GPs more strongly agreeing with this idea (73%) vs Specialists (64%). DITs were most in agreement (78%). DITs did not agree so much (25%) with the perception that GPs and Specialists held (~44% each), that they were on the same page when it comes to patient care. Across the board, similar proportions held undecided views, but DITs indicated the strongest disbelief in this concept (53%) versus the other craft groups (~24%). Do DITs know something the other groups don’t? Question 5 results are slightly skewed by DITs more strongly believing in early establishment of a network (87% strongly agree or agree) compared to the other craft groups (~72%). In both cases, the early personal network is given strong importance, which is something that those attending the Doctors Drum intimated may be under threat with the influx of OTDs and interstate graduates in our public hospitals. 18

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Guest Column

Empathy Builds Communication Junior doctor Dr Rodney Peh was at the Doctors Drum breakfast and thinks increased collegiality might improve how doctors communicate.

W

hen a patient becomes unwell and requires hospital admission, GPs may dread the process. As often happens, there can be two sides to the story.

Aside from their concern over the health of their patient, communication between hospital specialist teams and community GPs is often poor. GPs may encounter rude or disrespectful registrars when phoning for advice, have unclear follow-up plans upon discharge or not hear the outcome of a specialist appointment in a timely manner. Medications might have been initiated or ceased without clear explanation, and the patient may not understand their diagnosis or the results of their investigations. From the hospital viewpoint, sometimes communication from the GP is a hastily prepared letter that omits important details of examination and/or investigations. Hospital staff may feel patients have been dumped on them without adequate workup. Long term medications may not have a clear indication, and the past medical

history is incomplete. For inpatient teams, an accurate summary from the GP detailing complaint, investigations, medical history and medications is of great value. Different things impact negatively on communication between hospital and GP. First, delay in letters from specialist clinics is due largely to a bottleneck when converting dictations to typed letters. Most registrars dictate letters on the day of appointment but it may be weeks or months before the typed draft is ready for review and editing. Weâ&#x20AC;&#x2122;re encouraged to dictate them rather than type them ourselves, to save personal time. Second, focus has shifted slightly from the patient to bed management. Inpatient medical teams are constantly being pressured to vacate beds according to targets (e.g. 10am discharge), for â&#x20AC;&#x153;funding purposesâ&#x20AC;?. This impacts on the quality of the discharge summary, including errors of omission. Unprofessional conduct between doctors is not to be tolerated. When GPs call, they require specialised advice on complicated patients, and rudeness by hospital doctors

QLeft: Dr Thomas Woods and Mr Malcolm Davis QBelow: The Doctors Drum Breakfast Panel. (From left) Dr Simon Turner, Ms Antonella Segre, Dr Penny Wilson, Dr Sean Stevens, A/Prof David Watson and Ms Karina Hafford

cannot be excused. Factoring into any unsatisfactory phone conversation might be a stressed registrar who is hard to reach (e.g. in clinic, managing ward patients or scrubbed in theatre). They may be inappropriately short whilst studying for exams, tired from overnight on call, hungry from missing lunch, unsure of themselves because they are very junior. Part of the solution for poor communication might lie in collegiality. In large cities, GPs and hospital doctors donâ&#x20AC;&#x2122;t know each other. In country towns, they have a much healthier relationship as they both attend medical gatherings, and often country GPs work part-time in a rural/regional hospital. As a junior doctor, I have lots of respect for experienced GPs â&#x20AC;&#x201C; the knowledge they share, the stories they tell and the care they give. Ultimately, we shouldnâ&#x20AC;&#x2122;t lose sight of who weâ&#x20AC;&#x2122;re here to serve. GPs know the patient, whilst specialist teams know the disease. Together, improved communication will enhance job satisfaction and further patient care. O

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Doctors Drum

ll o P e

Q

The role of health consumers (patients) – do these statements reflect your point of view?

Strongly Agree

Agree

Neutral

Disagree

Strongly Disagree

GPs rely on patient feedback in judging specialists they have referred to.

16%

61%

17%

6%

0%

The profession is less focused on the needs of the 'whole person' in dealing with patients.

11%

43%

17%

26%

3%

Today, the patient is less responsible for their own health than in past years.

12%

33%

16%

36%

3%

In most cases, specialists who write back to referring doctors should send a copy of that letter to the patient.

10%

22%

22%

37%

9%

Health professionals have taken too much control off patients who are coping with chronic disease.

6%

22%

27%

40%

5%

ED. A resounding majority of both Specialists (74%) and GPs (83%) recognise that patient feedback is critical to any referring GP in judging the performance of a specialist. While doctors are equally divided on whether patients take more or less responsibility for their health these days, the majority (54% vs 29%) agree doctors are less involved in holistic care than they used to be. The minority (28% vs 45%) said doctors take too much control off patients with chronic disease. QFar left: Dr Julia Charkey-Papp, Dr Hilary Fine and Mr Mitch Messer QLeft: Dr Joe Kosterich, Dr Olga Ward and Dr Cynthia Innes

QFar left: Dr Mike Allen and Mr Guy Callender QLeft: Lively discussion at Doctors Drum QBelow: The Panel's table

Doctors Drum: GPs & Specialists Continued from P18 compassionate doctors to go on the journey with them, some doctors felt overwhelmed by that responsibility and trying to leave something in the tank for their own family. Regular time out was vital, to prevent ‘compassion fatigue’, said one GP. “I think

we fall into the trap that we think we are indispensable and that our patients will fall apart without us. It’s not the case.” The discussion has prompted another doctor to write about why she became a doctor. You can read that column opposite on P35. Another supported her position saying, “If the patient isn’t at the centre of our practice, then something’s wrong.” O

DOCTORS DRUM

at the guest s Drum r u o Be ctor 14 Do March 5. 0 2 t s n fir fast o Break egister at .au R com rum. d s r o t doc

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What a Privilege Ophthalmologist Dr Jane Khan wonders if doctor burnout accounts for a lack of empathy. E-Poll doctors seem to agree.

T

he recent 'Doctor's Drum ' by Medical Forum had the topic 'GPs and Specialists - Partners in What?' The conversation concentrated largely on how specialists and GPs communicate (or don't) and there was a general feeling of doctors being overworked and being just too busy to communicate with anyone, least of all their colleagues. (Patients were barely mentioned in the conversation.)

I have concerns about how the discussion went and my overriding thought was, if we are complaining about having too many patients then we are essentially complaining about our core business (in private) or â&#x20AC;&#x2DC;raison d'ĂŞtreâ&#x20AC;&#x2122; (in the public sector). If we are not communicating with our colleagues about our patients then we are certainly not doing the best we can for our patients.

Q

I wonder if many doctors are feeling burnout. Perhaps this is what leads them to take for granted their position and, dare I suggest, this might lead to a certain degree of arrogance? On the subject of burn-out there are many courses and articles in the literature and on the web. Unfortunately, we are all too busy burning out to pay much attention to them! However, one did catch my eye by Dr Dike Drummond (www.thehappymd.com/blog/ bid/290755). He describes the need to have enough energy in the bank and that energy comes in three â&#x20AC;&#x153;flavoursâ&#x20AC;?: t 1IZTJDBM&OFSHZoZPVSCBTJDiHFUVQBOEHPw t &NPUJPOBM&OFSHZoZPVSBCJMJUZUPCF emotionally available and compassionate. t Spiritual Energy â&#x20AC;&#x201C; your connection to your purpose in your work â&#x20AC;Ś Your â&#x20AC;&#x153;WHYâ&#x20AC;?.

Is one big barrier to meeting health demands the burnout of compassionate doctors?

Yes

63%

No

19%

Uncertain

18%

We should perhaps always remind ourselves WHY we are doing this in the first place. Being an ophthalmologist I can look to some icons in my field. Fred Hollows, who pioneered the trachoma eradication program and established general medical and eye care for remote communities both in Australia and overseas, was quoted as saying, "I believe that the basic attribute of mankind is to look after each other". I think he really had a sense of how privileged we are as doctors to be able to do this. I try to remember this when I see my patients. This can be challenging in the overloaded public clinics and patients are not there by choice. In this situation I try and step into the patient's shoes â&#x20AC;&#x201C; they have something wrong, they are worried, they are depending on me to at least try and help. I should be saying 'Wow, what a privilege' and when we see it like this it is humbling. Equally, in the private sector the patient has chosen to see me and reveal their problem to me â&#x20AC;&#x201C; what a privilege. O

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Feature

Finding Solutions that Last After years of researching the health of children living in poverty, researcher A/Prof Deborah Lehmann realises the importance of advocacy and implementation. looking in ears. We had a funded ear health coordinator but that funding has dried up. Our qualitative evaluation was very positive from the community and health workers. We found that health workers needed on-the-job support and over time they have become passionate, but this takes time.”

A/Prof Deborah Lehmann is a Principal Research Fellow in infectious disease epidemiology at the Telethon Institute for Child Health Research. Her research may have won her many accolades – Order of Australia, Public Health Association of Australia Community Award, the Telethon Institute's Consumer and Community Participation Award and the Fiona Stanley Medal for Research – but it has also taught her the value of early intervention and lifestyle factors in preventing serious ear disease in Aboriginal children. However, when one of your research conclusions is “there has been little improvement in ear health in the past 20 years” how do you translate research into fresh community outcomes? Advocacy and implementation then become the keys to success, and she recognises there are barriers to be overcome to bring about longlasting change. “One thing isn’t going to fix all. My priority is dealing with housing and crowding, hand hygiene, keeping kids away from smoke, and having regular early ear checks,” she said. “Basically, ear disease is a disease of poverty, so we have to address the distal factors that relate to dispossession, daily racism that people face, and certainly crowding, which is a big deal. If you can reduce the number of people in a house you can reduce the bacteria transmitted and help reduce the disease.” These findings emerged partly from research done in Kalgoorlie, where they monitored children from birth to age two. “These kids are getting ear problems soon after they are born and often they have no symptoms until they get an ear discharge, and by then it’s too late. We still haven’t got the magic bullet in terms of a vaccine – we might reduce the need for grommets by about 20%, at the very best, and vaccines that can be given early to a pregnant woman or a newborn child need to be considered.” She said that while maternal hygiene is important, evidence for ear benefits from breast feeding is not strong, so boosting immunity through vaccination is one option that has parallels with her work in Papua New Guinea where overcrowding was also related to a very high carriage of bacteria at an early age.

Encouraging self-determination She acknowledges the importance of involving Aboriginal communities. 22

She emphasised that a local coordinator was key and you could sense her frustration over the next hurdles – finding the political will and know-how to follow through.

QWenxing Sun (research assistant), A/Prof Deborah Lehmann, Margaret Wallam (research assistant), Dr Francis Lannigan (ENT surgeon), Ruth Monck (ear health coordinator), and (seated) Geraldine Hogarth (Aboriginal Health Worker and ‘champion’). Photo taken in Leonora in 2010

“Aboriginal people have known about ear diseases for ages. Parents have asked what we’re going to do about it so their kids could do well at school.” “I absolutely agree with Max Kamien [Letters, October edition] about some type of dedicated ear health worker with the necessary support – this is what happened in the Goldfields following on from a pilot health promotion research project.” “The health promotion campaign was a multipronged approach with the local community – getting kids seen regularly; health promotion using soap-making workshops, the Big Ear [an inflatable model ear which people can walk through], musicals; and training. The thing to push is to find ‘champions’, and help people access both services and antibiotics as required. Three ENT visits per year does not deal with the burden of disease.” “We have to train Aboriginal people because they are the ones who are going to help solve these problems; trained people

Deborah’s Inspiring People t (FSBMEJOF)PHBSUIJO-FPOPSBoBO Aboriginal health worker who is highly respected in the community and is passionate about ears. t 5IF/51NBUFSOBMBOEDIJMEIFBMUI program in Kalgoorlie, which has a walk-in Wednesday clinic and a young Aboriginal grandma who has taken it upon herself to have the kids' ears checked.

Community benefits from research? “We have to continue advocating. We are passionate people. We’ve applied for funding to train Aboriginal people both in the field and vaccine trials, as well as push the delivery of health services. In terms of prevention, we know that things have improved in urban areas so you no longer get the 30% high rates of perforation of ear drums seen in rural and remote areas.” There is still a need to organise surgery for children with holes in their eardrums but that’s a separate story. If they do nothing, the consequences are pretty dire. Anecdotal stories abound of the effect of deafness on learning, and the resultant waywardness of adolescents and adults who end up in the justice system. “There is no doubting that, although it is not often picked up. Nothing is standardised until we hit school, and kids who can’t hear in the classroom are going to run amok. I would sit in with Harvey Coates in clinics in Kalgoorlie and you can tell by the way otherwise healthy kids were behaving in the room that they had an ear problem. In that study, 60% of these supposedly normal Aboriginal kids had some degree of hearing loss from six to 18 months of age. Parents of kids who had grommets put in said it was quite amazing the way their child was looking around and absorbing things afterwards.” O

By Dr Rob McEvoy medicalforum


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Grasping the Workforce Nettle It’s time to change the paradigm of training and employing doctors, but, as WAGPET CEO Dr Janice Bell argues, it will take political and professional will.

F

or every complex problem there is a solution that is simple, neat and wrong”. So said the grumpy H.L. Mencken, but he had a point. With health workforce, there are many proposals that are simple, neat and wrong simply because the nettle has not been grasped firmly enough.

structure, but it does have boundaries and rules. Some rules are obvious, some are not. What emerges from the grey box is as fine as anywhere in the world – but now the input is three times as many students, and the output is more doctors the community needs in both skill and locality.

Workforce is a means, not an end. The end is that our communities access affordable appropriate health care. That care won’t necessarily be from a doctor, but clinical governance suggests usually there will be a doctor involved – directly or indirectly, proximally or virtually.

The grey box cannot currently deliver on these quantity and quality imperatives. We should in my view, train – and indeed employ – most doctors where the patients are, in their community, in complex healthcare settings populated by multiskilled teams, and not so predominantly in tertiary teaching hospitals.

It is only in real life that a doctor becomes one. It is through supervision, education, mentoring and feedback we acquire our capability, and the right to raise the shingle.

This would need the support of new – and old – employers, accreditors, workforce planners, educators, supervisors, funders and, of course, communities.

No one leaves medical school able to practise without this training, legally or professionally. Between studentship and independent practice there is a ‘grey box’ where this training occurs. The box doesn’t have a clear roadmap or a transparent

Because of the scope and importance, redesigning the grey box will likely require a ministerial review. We've known for nearly a decade this challenge was before us, but advanced warning was not enough. We need the political, professional, ethical

will to shine a light in the grey box, to ask more of it and of all the components within it, and of some outside it. It is not just a case of doing more of the same, with the same, and hoping the funding will come and the box won’t fold. I am sure the workable solution within our grasp will be more than the sum of the current parts, a solution of genuine collective impact, not simply the result of coordination or collaboration. We won't simply add more doctors, add more money; it's primarily about making the best use of doctors and money already in the system. Sure, it’s complex. We are talking about community demand, medical school supply, health jobs to be done, possibly fewer career choices, changing models of care, training on the job, blended funding, multiple disparate credentialing authorities and entrenched ways of thinking. The investment has been made by students and taxpayers. The opportunity to get it right now is extraordinary. The nettle is waiting to be grasped. O

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Times They Are a Changing Dr Cynthia Innes was at the Doctors Drum event and makes these observations on how differences have evolved in the profession and how we have adapted.

I

sound like a war veteran saying “In my day…” but having survived 40 years of general practice, it has a similar ring. Back in the 1970s, CTs and ultrasounds were just on the horizon. The general population, mainly elderly, before preventative medicine was a reality, sought their Aldomet and “Modagon” (invariably mispronounced), the new beta blockers had to be initiated by a cardiologist and tests for cholesterol? When did that begin?

Back then doctors were considered to be all-knowing with GPs being demigods and specialists, gods, with much less room for debate regarding patient management. Panaceas continued to change their spots: from barbiturates to Valium and onto SSRIs. (What happened to TM and Ainslie Meares’ bible, Relief Without Drugs? Some loss of wisdom fell on the wayside there). More women appeared in medicine and patients learnt that the gods also procreate; they, too, need to rush off to their own

sick child or pick them up from school and generally demonstrate they have another life. I remember the resentment when I had to cancel a clinic to attend my father’s funeral. I also remember the day when one of my patents said to me, “Not until I saw you at the supermarket did I realise that doctors ate!” Despite our huge advances in technology, pathology tests and diagnostic tools adding to our knowledge base, oddly enough there is a general realisation that the gods are less omnipotent. So often a question finds me replying, with no qualms, “Ask me that in five years’ time, I might give you a different answer”, and feeling quite comfortable in sharing that we are all together on a perpetual learning curve. It is interesting and exciting that our patients conduct their own research of sorts as together we seek help versus hindrance from Professor Google or evidence-based results from the Cochrane Library. It is heartening to be sharing a more bipartisan approach in patients’ health.

The down sides? More knowledge breeds more anxiety, more people with long lists of problems to sort out at the rate of knots (I miss the old oral thermometer that gave a two-minute reprieve so I could write a script, or think, or go to the toilet!). Debates change. HRT for instance and now cholesterol, or whether jogging up a hill or potting your petunias make a difference to longevity. There is more confusion out there, fed by the ‘health gurus’ – some do have something worthwhile to say, while others are downright dangerous. Oh, and litigation? Back in the ’70s it happened only in the US unless something really drastic like the wrong leg was amputated! My philosophy lecturer suggests we keep asking the question, “What would a wise person do?” In this time of rapid change, wisdom and common sense must prevail. Yes. the times they are changing…mainly for the better. O

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Medicolegal Q&A

Happy Snapper Pitfalls…

Q

“I work in private practice. Recently, I got out my mobile phone and snapped a photo of a patient’s condition. The picture spoke a thousand words, so I thought it would make a good medical record and I could use it to discuss the case with another doctor. After emailing it to myself, I saw the quality wasn’t crash-hot. What’s the medicolegal angle on this?”

A

Ms Morag Smith, Avant’s Senior Solicitor, answers the question for Medical Forum.

The use of mobile phones to take clinical photos – specifically not obtaining consent to do so – is an increasing medico-legal risk for doctors. In fact, a recent Australian study indicated that non-compliance with written photo consent requirements is endemic.1

quality, it still forms part of the medical record. With any imaging, aim to take a quality photo (see the digital photography guide published by the Telehealth department at Royal Perth Hospital for useful tips 3).

Before taking a clinical photo, informed consent should be obtained from the patient. The discussion needs to include how the photo may be used and who it may be distributed to. Also explain that the photo will be securely stored by your practice in accordance with privacy policies. Specific consent forms like the ones used by WA Health for public patients are a good example of what needs to be developed.2

Finall if you intend to use Finally, th the photo for a non clinical purpose, inform the patient and obtain their consent and take steps to avoid photographing anything that easily identifies the patient, such as their face, a ttattoo, or something in the background.

Privacy is closely linked to consent. The National Privacy Principles (in the Privacy Act 1988) apply to patient information, including clinical photos. This means that clinical photos can only be used for the purpose it was collected for. If a clinical photo is stored or distributed incorrectly, you could face a complaint to the Information Commissioner and a possible fine. For example, this means you cannot use a photo for educational purposes unless the patient has consented. It is tempting just to delete a photo on your phone, but important to remember that, once taken, it forms part of the patient

What are the essentials? file and should be available for disclosure if required. This means storing the photo in accordance with your relevant record retention policy. You’d be best to email the photo to a secure email (or use a USB cable to directly download to your computer and delete the images from the USB), then connect it to the patient’s file before immediately deleting the photo from your phone. Prompt deletion will reduce the risk of misuse and the risk of unauthorised third parties viewing the image.

Image securely stored on patient file Delete photo on mobile phone 1 Clinicians and their cameras: policy, ethics and practice in an Australian tertiary hospital. Aust Health Review 19 June 2013 2, 3 Digital photography in wound management: Telehealth/Medical Administration, Royal Perth Hospital O

Bear in mind that even if the photo is poor

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37


CLINICAL UPDATE

Yellow fever vaccination

By Dr Aidan Perse, Travel Doctor Fremantle. Tel 9336 6630

Y

ellow fever vaccination prevents a severe mosquito-borne viral disease with a significant fatality rate and no specific treatment. The maps show the areas within the two continents affected by the disease; healthy travellers visiting affected areas need the vaccine and most have no problems. One dose provides immunity for life but the certificate is officially valid for 10 years. route expose them to yellow fever at all. The Emirates, a desert region, has no mosquitoes and no requirement for YF certificates. South Africa on the other hand, have adopted a very strict interpretation of the WHO maps and insist on a YF certificate from travellers, even in transit; failure to do so may result in refused entry, vaccination on the spot or quarantine for a week at the traveller’s expense.

Recently, the WHO downgraded risk in a few areas (e.g. Tanzania), and graded other areas as low risk (e.g. parts of Zambia and Argentina). The intention was to avoid unnecessarily vaccinations but unfortunately these changes brought unintended consequences (see below).

The paperwork

The official Yellow fever Certificate, with internationally accepted format in English and French, is sought by Australia in late 2012 countries with mosquitoes adopted the WHO changes and warm climates that as intended, and would not do not have the disease, QYellow fever virus transmission risk in South Africa – Vaccination generally not recommended expect a certificate. O when people enter from in Zambia and Tanzania Yellow fever countries. An ED. Because of the potentially severe like illness, known as neurotropic or internationally accepted Yellow fever waiver reactions, the Health Department restricts viscerotropic disease, which can be fatal. is issued if someone cannot be vaccinated YF vaccination to licensed clinics that (We have seen a case of both in our clinic, because they are immunocompromised (e.g. have adequate experience and appropriate and fortunately both survived). Similarly, as a result of treatments or illnesses). resuscitation facilities. anaphylaxis is a rare reaction but requires The vaccination a half hour wait in the clinic before leaving About 1 in 4 healthy people given the (egg allergy is an absolute contraindication). vaccine get a short-lived flu-like reaction. YF Vaccination: Main Points Advanced age, pregnancy and many Rarely this can progress to a Yellow fever chronic illnesses result in relative UÊ 9iœÜÊviÛiÀʈÃÊ>Ê«œÌi˜Ìˆ>ÞÊv>Ì>Ê immunosuppression; a waiver may be ˆ˜viV̈œ˜Ê̅>Ìʜ˜ÞʜVVÕÀÃʈ˜Ê«>ÀÌÃʜvÊ issued after taking the disease risk of the vÀˆV>Ê>˜`Ê-œÕ̅Ê“iÀˆV>° trip into account, for which a detailed UÊ ÕV…ÊœvÊ̅iÊܜÀ`ÊVœÕ`ÊLiÊ>vviVÌi`Ê discussion with someone specialising in LÞÊÞiœÜÊviÛiÀÊۈÀÕÃÊLÕÌʈؽÌÊqÊ̅iÃiÊ travel medicine can lead to a negotiated VœÕ˜ÌÀˆiÃÊ>ÀiʓœÃÌʎii˜Ê̜ÊÃiiÊ>Ê9iœÜÊ iÛiÀÊ iÀ̈vˆV>Ìiʈ˜ÊÌÀ>ÛiiÀÃÊi˜ÌiÀˆ˜}Ê informed decision. (Remember to avoid vÀœ“Ê`iÈ}˜>Ìi`ÊÞiœÜÊviÛiÀÊVœÕ˜ÌÀˆið giving another live vaccine first.)

Special considerations The main dilemma of YF vaccination arises for those on low or no-risk itineraries that simply need the certificate; the vaccine risk significantly outweighs the risk of the disease. The determining factor is the itinerary after departure from the YF affected area.

QYellow fever virus transmission risk in South America 38

To give an example, a traveller visiting Victoria Falls in Zambia and the game parks of Tanzania, have different vaccination requirements depending on whether they travel via Dubai or Johannesburg, even though neither

UÊ 9ÊÛ>VVˆ˜iÊVœ˜Ì>ˆ˜ÃʏˆÛiÊ>ÌÌi˜Õ>Ìi`Ê ÛˆÀÕÃÊqʈÌʈÃʘœÌÊÃ>viÊ̜ÊÛ>VVˆ˜>ÌiÊ>˜Ê ˆ““Õ˜œVœ“«Àœ“ˆÃi`ʈ˜`ˆÛˆ`Õ>]Ê>˜`Ê Ã…œÕ`ʘœÌÊLiÊ}ˆÛi˜Ê܈̅ˆ˜Ê>ʓœ˜Ì…Ê œvʜ̅iÀʏˆÛiÊÛ>VVˆ˜iÃÊ­i°}°Ê,Ê œÀÊÛ>ÀˆVi>®° UÊ iVˆ`ˆ˜}Ê܅i̅iÀÊ>˜Êˆ˜`ˆÛˆ`Õ>Ê ˜ii`ÃÊ̅iÊÛ>VVˆ˜iʈÃʘœÌÊ>Ü>ÞÃÊ>ÃÊ ÃÌÀ>ˆ}…ÌvœÀÜ>À`Ê>Ãʜ˜iʓˆ}…Ìʈ“>}ˆ˜i°

Author competing interests: No relevant disclosures.

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CLINICAL UPDATE

Risks from â&#x20AC;&#x2DC;voluntourismâ&#x20AC;&#x2122;

By Dr David Rutherford, Travel Medicine Physician, Fremantle. Tel 9336 6630

T

here are travel health implications for those who volunteer overseas, and they can be complex. Often a travel holiday is combined with volunteer work and includes health care, teaching, construction and animal handling. There may be interaction with isolated communities, and work in settings like orphanages.

Case Report: Jack 19-year-old male, medical student. Jack plans a trip to Cambodia with his local church group, during his gap year. His orphanage work includes helping build a school, teaching English and trekking. He will live in the village and is travelling in July. School/Uni students are particularly tricky given their age, inexperience as travellers, and often have anxious parents. The priorities include good general preventative travel advice as well as other recommendations, including: t 6QEBUFESPVUJOFWBDDJOBUJPOT JODMVEJOH%51 BSHVBCMZ%51*17 because of construction. t $IFDL)FQ#TFSPMPHZBOEVTFUIJTBTBMFWFSGPS45*BEWJDF t ..3WBDDJOBUJPOBTXPSLJOHXJUIDIJMESFO QMVT*OGMVFO[B vaccination so he doesnâ&#x20AC;&#x2122;t take it with him. t )FQ"JOKFDUJPOBOEUZQIPJEWBDDJOBUJPO BOEQFSIBQTPSBMDIPMFSB vaccination (Dukoral) given his inexperience and hands on work.

Tips for Jet Lag International flying on long sectors across different time-zones is not for the faint-hearted. Captain Neville Reed, a senior pilot with South African Airways, has some good advice. â&#x20AC;&#x153;When youâ&#x20AC;&#x2122;re heading east itâ&#x20AC;&#x2122;s usually more difficult because youâ&#x20AC;&#x2122;re going against the movement of the sun and the day is considerably shortened. Thatâ&#x20AC;&#x2122;s why youâ&#x20AC;&#x2122;ll find, when youâ&#x20AC;&#x2122;re trying to adjust to a different time zone, that itâ&#x20AC;&#x2122;s easier to delay the time you go to bed and the time you get up than to bring it forward.â&#x20AC;? â&#x20AC;&#x153;Itâ&#x20AC;&#x2122;s important to remember that itâ&#x20AC;&#x2122;s very easy to slip into significant sleep-debt and it can become cumulative very quickly.â&#x20AC;?

Fact Box: Jet Lag Factors affecting fatigue UĂ&#x160; /iÂ&#x201C;ÂŤiĂ&#x20AC;>Ă&#x152;Ă&#x2022;Ă&#x20AC;iĂ&#x160;>Â&#x2DC;`Ă&#x160;Â&#x2026;Ă&#x2022;Â&#x201C;Â&#x2C6;`Â&#x2C6;Ă&#x152;Ă&#x17E;Ă&#x160;Â?iĂ&#x203A;iÂ?Ă&#x192;Ă&#x160;Â&#x2C6;Â&#x2DC;Ă&#x160;Ă&#x152;Â&#x2026;iĂ&#x160;V>LÂ&#x2C6;Â&#x2DC;° UĂ&#x160; Â&#x2C6;Ă&#x20AC;VĂ&#x20AC;>vĂ&#x152;Ă&#x160;Â&#x2DC;Â&#x153;Â&#x2C6;Ă&#x192;i]Ă&#x160;Ă&#x203A;Â&#x2C6;LĂ&#x20AC;>Ă&#x152;Â&#x2C6;Â&#x153;Â&#x2DC;]Ă&#x160;Ă&#x152;Ă&#x2022;Ă&#x20AC;LĂ&#x2022;Â?iÂ&#x2DC;ViĂ&#x160;>Â&#x2DC;`Ă&#x160;Ă&#x192;i>Ă&#x152;Ă&#x160;`iĂ&#x192;Â&#x2C6;}Â&#x2DC; Managing fatigue UĂ&#x160; Ă&#x152;Ă&#x152;iÂ&#x201C;ÂŤĂ&#x152;Ă&#x160;Ă&#x152;Â&#x153;Ă&#x160;Ă&#x20AC;iVÂ&#x153;Ă&#x203A;iĂ&#x20AC;Ă&#x160;Ă&#x192;Â?iiÂŤĂ&#x160;`iLĂ&#x152; Inflight rest UĂ&#x160; Ă&#x201C;äÂ&#x2021;{äĂ&#x160;Â&#x201C;Â&#x2C6;Â&#x2DC;Ă&#x2022;Ă&#x152;iĂ&#x160;Â&#x2DC;>ÂŤĂ&#x192;Ă&#x160;>Ă&#x20AC;iĂ&#x160;Â&#x201C;Â&#x153;Ă&#x192;Ă&#x152;Ă&#x160;LiÂ&#x2DC;ivÂ&#x2C6;VÂ&#x2C6;>Â?°

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Given it is wet season he may need a Japanese encephalitis vaccine and malaria prophylaxis, depending on accommodation and areas involved. Other considerations include: meningococcal vaccination (acwy) because of his age and activities; rabies avoidance/vaccination; raise awareness of HIV and TB in the orphanage setting; and appropriate back up antibiotics for travellerâ&#x20AC;&#x2122;s diarrhoea and a basic first aid kit.

$BTF3FQPSU+PZFBSPME3/ Going to Kenya for two weeks, then as a theatre nurse in Nairobi and rural clinics there. Immune to hep B, MMR, and Varicella. Jo is typical of the large group of voluntary overseas healthcare workers (medical student electives included) â&#x20AC;&#x201C; they are relatively easy to prepare as they are usually well vaccinated, experienced and generally have good awareness of the health issues. As well, they often have easy access to medical care on site, although resources are scarce. As well as country specific recommendations that include yellow fever and malaria outside Nairobi, there are exposures from her work commitments. Important additional risks include HIV PEP (post exposure prophylaxis), TB screening before and after, meningococcal (acwy) disease from direct contact, influenza and polio. Author competing interests: No relevant disclosures.

â&#x20AC;&#x153;Unplanned pregnancy & family planning servicesâ&#x20AC;? Our experienced Dr Marieâ&#x201E;˘ team provides caring and non-judgemental support and services. Surgical & medical abortion on Contraceptive inserts STI checks Vasectomy Decision-based counselling g 24 hour aftercare

DR0194

Sometimes adventure travel is included. The settings can be urban or quite remote. The trips can be from a few days to months. Accommodation ranges from hotels to a village stay. Volunteers range from highly qualified, well-travelled professionals, to mission workers or naive students. The upshot is that each traveller and trip needs very careful consideration to give appropriate vaccinations, malaria prophylaxis, and advice that includes what to look for on return. Travel risk becomes part of the pros and cons of â&#x20AC;&#x2DC;voluntourismâ&#x20AC;&#x2122;, and travel insurance is a must. These examples highlight some of the common issues, which go beyond simply country-specific recommendations.

Part of the Marie Stopes International global partnership Model pictured for illustrative purposes only

8 Sayer Street Midland WA 6056 www.drmarie.org.au

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CLINICAL UPDATE

Insomnia â&#x20AC;&#x201C; when sleep hygiene is not enough

By Mr Paul Jeffery, Clinical Psychologist. 5FM

W

e recognise chronic insomnia as longstanding difficulty in falling asleep, staying asleep, or waking too early, accompanied by subjective distress about tiredness and its impact on day-time functioning. The concept of sleep hygiene (i.e. habits that can enhance or detract from satisfactory sleep) was first written about in 1939, and encouraging beneficial sleep hygiene is often first line treatment. Unfortunately, the evidence indicates that confining management to sleep hygiene has little benefit for individuals experiencing primary insomnia.

Bio-psycho-social models of insomnia have highlighted how multiple factors can predispose, precipitate and maintain insomnia, and that what starts the process may not be what maintains it. For example, an acute stressor may create worry and tension that initially robs someone of sleep. The individual may start to worry about not sleeping, develop a conditioned association that bed-time equals arousal, and engage in unhelpful behaviours to cope with not sleeping that exacerbate the problem (watching the clock, going to bed early, limiting day-time activity etc.). Randomised controlled trials for primary insomnia indicate that cognitive behavioural therapy that includes sleep restriction and stimulus control are effective in the long term, relative to medications. Sleep restriction involves setting a regular wake-up time and limiting the amount of time in bed initially to increase sleep drive and sleep efficiency. It

can seem counter-intuitive and sometimes aversive to patients at first, however with support it is very effective. Stimulus control involves breaking the association between the bed and increased arousal. More recently developed cognitive therapies also attend to the worry and anxiety that plagues those with insomnia. Individuals can bring to bed a â&#x20AC;&#x153;busy mindâ&#x20AC;?, worries about the day, and worry about not sleeping. Interventions such as asking people to allocate â&#x20AC;&#x153;worry timeâ&#x20AC;? and problem solving can be effective. Education about sleep is crucial for reducing worry in insomnia â&#x20AC;&#x201C; yes, prolonged sleep deprivation can be deleterious for health but patients often benefit significantly from education and reassurance, for example, telling people it is quite normal to not achieve the commonly held ideal of â&#x20AC;&#x153;8 hours uninterrupted sleepâ&#x20AC;?. Shifting a patientâ&#x20AC;&#x2122;s unrealistic expectations about sleep can be

just as powerful as trying to improve their sleep directly. Even when sleep disturbance is driven by other factors (i.e. circadian rhythm disorders, mental illness, parasomnias, sleep disordered breathing, shift work) there is often a role for behavioural interventions as part of a multimodal approach. For example shiftworkers may benefit from understanding and implementing regular sleep routines, strategic napping, limiting time in bed and limiting exposure to sunlight post-shift to combat excessive tiredness. In relation to sleep apnoea, motivational interviewing at the beginning of CPAP treatment enhances adherence more than counseling after the patient has started to falter. The author acknowledges the assistance of clinical psychologist Dr Melissa Ree. O Author competing interests: No relevant disclosures.

EYE SURGERY FOUNDATION 0VS7JTJPO*T*NQSPWFE7JTJPO

Eye Surgery Foundation Re-opens Its Doors After 18 months of expansion, the Eye Surgery Foundation has amalgamated two buildings and re-commenced surgical procedures in November. The new day hospital is twice the size â&#x20AC;&#x201C; four operating theatres, a dedicated Laser room with a Femtosecond Laser, two recovery rooms, large reception, and a spacious staff room. The Licensing Standards and Review Unit, a division of the Health

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

Dr Blasco Dâ&#x20AC;&#x2122;Souza Tel: 9258 5999 %S(SBIBN'VSOFTT Tel: 9440 4033 %S%BWJE(SFFS Tel: 9481 1916 Dr Boon Ham Tel: 9474 1411 Dr Philip House Tel: 9316 2156

Expert Day Surgery

Department, congratulated the Eye Surgery Foundation on such a superb facility; the architect was P.D (Phil) Faigen. All our Surgeons and staff are happy to be â&#x20AC;&#x153;home againâ&#x20AC;? after being temporarily located in other hospitals.

Supporting Ophthalmic Teaching and Research

Dr Brad Johnson Tel: 9301 0060 Dr Jane Khan Tel: 9385 6665 Dr Ross Littlewood Tel: 9374 0620 Dr Nigel Morlet Tel: 9385 6665 Dr Robert Patrick Tel: 9300 9600

Dr Jo Richards Tel: 9321 5996 Dr Stuart Ross Tel: 9250 7702 Dr Angus Turner Tel: 9381 0802 Dr Michael Wertheim Tel: 9312 6033

5FM&JOGP!FZFTVSHFSZGPVOEBUJPODPNBV42 ORD STREET WEST PERTH WA 6005

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41


CLINICAL UPDATE

Autism Spectrum Disorder â&#x20AC;&#x201C; communication

By Prof Andrew Whitehouse PhD, Head Developmental Disorders Research (SPVQ 5*$)3

A

utism Spectrum Disorder, or ASD, is the newly official term for individuals previously diagnosed with Autistic Disorder, Aspergerâ&#x20AC;&#x2122;s Syndrome and Pervasive Developmental Disorder â&#x20AC;&#x201C; Not Otherwise Specified.

People with ASD are diagnosed based on the clinical observation of social and communication behavioural impairments, and repetitive behaviours and restricted interests. The prevalence of ASD is currently considered to be in the vicinity of 1-2% of the population, and clinicians are odds-on to encounter at least a handful of people with ASD throughout their career. Patient interactions are at the very heart of clinical decision making, and therefore people with ASD present a challenge to this process. How is one able to make clinical decisions about a person with a disorder, if interactions are compromised by the very nature of that disorder? Here are a few tips that I hope may facilitate interactions with these wonderful people: t "4%JTBIVHFMZWBSJFEDPOEJUJPO4PNF individuals will never learn to use

X At the RACGP national conference, Broome GP Dr Rebekah Adams was announced GP Registrar of the Year; Esperance GP Dr Donald Howarth was acknowledged for Excellence in Clinical Supervision; Dr Emma Griffiths won the GPET-Ochre Health Training Award; and Curtin Universityâ&#x20AC;&#x2122;s Prof Moyez Jiwa was awarded the prize for Excellence in Population Health. X Senior paediatric nurse Ms Sue Peter is the 2013 WA Nurse of the Year. Ms Ruth Letts was inducted to nursing and midwiferyâ&#x20AC;&#x2122;s Hall of Fame. X The University of Notre Dameâ&#x20AC;&#x2122;s Rural and Remote Health Placement Program [see June edition] was awarded a national university teaching award. Among those acknowledged by Education minister Christopher Pyne were Prof Donna Mak, Ms Marianna Mattes, Prof Jennifer McConnell, Dr Dianne Ritson, A/Prof Chris Skinner, Prof Alan Wright and A/Prof Isle McFerrall.

42

functional language and will remain in the care of others, while others will be without intellectual disability, independent, and able to very articulately describe their symptoms. Identify as early as possible where on the spectrum your current patient fits, and adjust your communication accordingly. t $BSFHJWFSTDBOCFZPVSCFTUGSJFOET*G the patient with ASD is not independent, then rely heavily on their caregiver. They often have extraordinarily intimate knowledge of the patientâ&#x20AC;&#x2122;s bodily functions. Caregivers will also often be able to help interpret the communication of those patients with limited functional language. In essence, trust caregivers. t 6OEFSTUBOEUIFTZNQUPNTPG"4%1PPS eye contact is often a symptom of ASD, rather than an indication of deceit. Poor social skills, such as not answering direct

X Former MHR for Brand, Ms Judi Moylan, has been appointed President of Diabetes Australia. Look for Judiâ&#x20AC;&#x2122;s guest column in the February edition of Medical Forum. X Ms Freya Shearer has won a Rhodes Scholarship to study Global Health Science and Research in Public Health at Oxford University. X St John of God Health Care (SJGHC) has bought the 205-bed Mercy Hospital in Mt Lawley from MercyCare. Ownership will be transferred in the first half of 2014. X Among those receiving an Action on Alcohol Awards from the McCusker Centre for Action on Alcohol and Youth were Ms Maureen Carter (FASD campaigner from Fitzroy Crossing), and Dr Tina Lam. X Recipients of Seniors Week awards include Curtin Universityâ&#x20AC;&#x2122;s Prof Gill Lewin, Amana Livingâ&#x20AC;&#x2122;s Enrichment program and Prof Osvaldo Almeida, from WACHA. X Linear Clinical Research (Linear), owned by the Perkins Institute of Medical Research (formerly WAIMR), is the first

questions or talking nonstop about a favourite topic, are common in ASD and do not represent avoidance. Repetitive hand, finger or body mannerisms can be soothing to some people with ASD and should not to be taken as rudeness. t 3FNFNCFSTFOTPSZEJGGJDVMUJFT" common feature of ASD that is not often discussed is sensory difficulties. People with ASD can display hypo- or hypersensitivity to a variety of environmental stimuli (noise, light, touch). Be cognizant of this possibility, and when in doubt ask the caregiver. t "OYJFUZBOEEFQSFTTJPOBSFDPNNPO People with ASD are at far greater risk of internalising disorders. There may be occasions where a clinician needs to tease out which symptoms are related to anxiety/depression and which are related to the ASD. O

healthcare and biotechnology entrant to win the Premierâ&#x20AC;&#x2122;s Award for Excellence. X The NHMRC has announced $559m in funding for 2013 â&#x20AC;&#x201C; $33.1m for WA researchers, including Prof Tim Davies, Prof Graeme Hankey, Prof Steve Stick and Prof Peter Leedman. X Mr Brad Potter has won the national Business Broker of the Year award for the third consecutive year. X Curtin University has recognised these nine healthcare community leaders: Rockingham GP Dr Fiona Ronsberg, ophthalmologists Dr Tze Lai and Dr Robert Kilpatrick, anaesthetist Dr David Sleator, Director of Cardiology at JHC Dr Jenny Deague, Director of Anaesthesia at JHC Prof Michael Veltman, orthopaedic surgeon and rheumatologist Prof Markus Melloh, Director of General Medicine at Albany HC Dr Alasdair Millar, and reconstructive surgeon Prof Robert Pearce. X Ms Natalie Watts is the 2013 WA Practice Manager of the Year. Natalie is practice manager at Lockridge General Practice.

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News & Views

Music from the Heart It will come as no surprise to many that music has healing properties. Since the advent of sophisticated imaging we can actually see the effect structured noise we call music has on our brains â&#x20AC;&#x201C; our mood and cognitive centres all spark better listening to riffs from our favourite musicmakers. Cardiologist Dr Johan Janssen is interested in taking it further. He is fired by Daniel J. Levitinâ&#x20AC;&#x2122;s provocative book, The World in Six Songs, which explores the evolution of music and brains. Levitin posits the theory that music â&#x20AC;&#x153;is not simply a distraction or a pastime, but a core element of our identity as a speciesâ&#x20AC;? and paved the way for language, co-operative behaviour and information sharing. QDr Johan Janssen

PIVET MEDICAL CENTRE Specialists in Reproductive Medicine & Gynaecological Services

FERTILITY NEWS

T-model Uterus â&#x20AC;Ś readily correctable by hysteroscopic metroplasty I have previously presented cases of subtle uterine anomalies, now describing 3 types: 1. Mercedes-BenzFRQĂ&#x20AC;JXUDWLRQ â&#x20AC;&#x201C; subseptate

Johan thinks there is a seventh song where music treats the body. â&#x20AC;&#x153;At a recent cardiology meeting in Amsterdam, an entire forum was devoted to the effect of music therapy on endothelial function in patients with coronary artery disease. We can now measure the endothelial function and see if it changes when exposed to certain music.â&#x20AC;? It is considered that if music, by stimulating the release of beneficial hormones, can reduce the stiffening of the endothelium, it in turn reduces the build-up of foam cells, microphages and plaque â&#x20AC;&#x201C; the markers of heart disease.

Fig 1. 3D ultrasound of T-Model uterine cavity. A

Which is where â&#x20AC;&#x2DC;Waltz Kingâ&#x20AC;&#x2122; Andre Rieu, a neighbour of Johanâ&#x20AC;&#x2122;s in his hometown of Maastricht, Netherlands, comes in. Beloved and followed by millions, Rieu played at the Perth arena in October and if the theory runs true to course, hearts werenâ&#x20AC;&#x2122;t just pumping from excitement, they were also waltzing with health. â&#x20AC;&#x153;There is no evidence for this but maybe itâ&#x20AC;&#x2122;s why Andre Rieu is so popular!â&#x20AC;? Johan says.

2. T-ModelFRQĂ&#x20AC;JXUDWLRQ²VKDUS isthmic shoulders 3. Mazda-LogoFRQĂ&#x20AC;JXUDWLRQ²FRPELQHV broad septum with sharp shoulders Given the conservative view that subtle uterine anomalies are of uncertain relevance, we initially adopted a watching brief when high-resolution 3D ultrasound VFDQQLQJVWDUWHGWRGHĂ&#x20AC;QHWKHVHDQRPDOLHV quite often in subfertile patients.

B

Music therapy can then take its place alongside other lifestyle factors such as diet and exercise that improve cardiovascular function. However, thereâ&#x20AC;&#x2122;s a lot of structured noise out there. Is there one type of music more efficacious than another? Johan is exploring the theory that waltz music, with its smooth three beats in the bar, releases more positive endorphins than other types.

by Medical Director Dr John Yovich

Fig 2. Hysteroscopic views showing sharp left isthmic shoulder (a), easily incised (b).

For each anomaly we have seen pregnancies arise and sometimes proceed to term, but the accumulating data over 35 years reveals a sadder story â&#x20AC;&#x201C; persisting infertility, recurrent miscarriages LQERWKWKHĂ&#x20AC;UVWDQGVHFRQGWULPHVWHUVDQG pre-term deliveries.

When I started to undertake hysteroscopic metroplasty procedures 20 years ago, the remarkable feature noted was that the septum and isthmic regions were essentially avascular, and the key to surgery was to trim these anomalous areas back WRDQLGHQWLĂ&#x20AC;HGYDVFXODUOD\HU,QVRGRLQJLWDOVREHFDPHYLVLEO\ apparent that the post-surgical uterine cavity â&#x20AC;&#x153;sprang openâ&#x20AC;? to adopt a normal globular shape.

â&#x20AC;&#x153;I believe music is an under-recognised instrument in the medical profession for overall patient care. Too many people are focused on their little part of the body and forget the holistic approach.â&#x20AC;? QAndre Rieu

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â&#x20AC;&#x153;Iâ&#x20AC;&#x2122;m going to advise patients to listen to two hours a day to Rieu and check their bio markers. We need a measurable outcome, and when we do, we can push to incorporate music in treatment, which could have a big impact on cardiovascular disease.â&#x20AC;? O

Fig 4. James (7 months) visiting PIVET 2 months ago.

The pictured case tells a happy outcome. Mum had subfertility DQGODWHĂ&#x20AC;UVWWULPHVWHUSUHJQDQF\ORVVHVEXWFRQFHLYHG spontaneously after corrective surgery. She had an entirely normal pregnancy and delivery. Nowadays our approach at PIVET is to offer corrective hysteroscopic metroplasty prior to GHĂ&#x20AC;QLWLYHIHUWLOLW\WUHDWPHQWVLQFDVHVRIVXEIHUWLOLW\RUUHFXUUHQW miscarriage as well as for cases of repetitive implantation failure at IVF.

NOW AT 3 LOCATIONS LEEDERVILLE, JOONDALUP & BUNBURY

For ALL appts/queries: T:9422 5400 F: 9382 4576 E: info@pivet.com.au W: www.pivet.com.au

43


Travel

Cruising

Down the River There is no better way to de-stress than to jump on a boat and slip the mooring. With a houseboat, you get the best of both worlds.

Meandering along the Murray River, at a gentle 4 knots/hour, with a chorus of corellas, sulphur-crested cockatoos, pink and grey galahs and pelicans keeping watch from overhead or the riverbank – as a restful getaway, this house-boating gig is hard to beat. Our group of four began the journey at Mannum, 82km east of Adelaide, leaving behind a wet and windy August in Perth for a pleasantly mild August in South Australia. We were prepared for cold and wet but we struck a perfect week, which showed off the mighty Murray at its best. Swollen from consecutive floods, the Murray hasn’t been in such good nick for years. It’s an impressive river, stretching 2375km from the Australian Alps in New South Wales to Lake Alexandrina in South Australia. For most the part it wends its

way through the inland plains of NSW, Victoria and SA.

Travelling instructions Picking up the houseboat at Mannum, there were few restrictions … chug along wherever you like, stop wherever you like or where you can and return the houseboat back to the launch point when your hire re period expires. Once you’ve paid the tariff (which varies depending on the number of berths and time of year, but expect around $1950 and $2500 for a 2-6 berth) you only have to pay for the fuel you use. Mannum, itself, is worthy of a wander with a particularly interesting museum. The town was founded in 1840 and by 1852 was the centre of the Murray River transport system with the famous great paddle steamers plying goods and people along the river, opening up country to rive farming and the Gold Rush. far There are some beautifully Th restored examples of river res times past to be seen. tim

Easy sailing Ea Bu the whole intention of But th this holiday was loafing it, no not hoofing it, so it wasn’t lo long before the guidebook was ditched and the b boat’s manual was front b aand centre. Truth is, sailing it is dead easy. You i don’t need a skipper’s d tticket and the houseboat drives like a brick so b you y have time to make a cuppa after turning the wheel and waiting for the boat to respond. The only trick is getting used to the outboard motors being your rudder and 44

stopping mechanism. And they are extremely comfortable. Bedrooms are situated at opposite ends with a bathroom of three star equivalent in the middle, some have an outdoor barbecue for long leisurely lunches and good kitchen facilities. At night, because there is literally nowhere else to go, movie nights and games nights are de rigueur. As the houseboat putters along, every conceivable habitation from old shacks to new mansions line sections of the river, and then, in between, pristine nature is home to an extraordinary array of wildlife, especially birds of every shape and colour. After a couple of days of eating, sleeping and drinking with the challenge of the odd board game left behind by previous houseboaters or a DVD, it’s good to pull up at any one of a number of jetties along the way or a patch of uninhabited river bank with a handy tree to jump out and stretch the legs. There are the occasional local kiosks, pubs and walkways along the way but mostly it’s self-catering, blissful isolation. There are supermarkets at Mannum and Murray Bridge for supply shopping and some stores will deliver to your boat for a fee, while the boat vendors sell ice for the on-board Esky or firewood. We went off-season in winter and it was picture perfect. However, the river is a known haunt for jet skis and power boats during peak holiday periods, so if you don’t want to add water sports to your holiday

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c checklist and desperately want s some peace and quiet, check o out the cheaper off-season.

How to get there H M Most people will start their holiday from Adelaide. Some tour d operators provide packages that o take ta care of you between airport arrival and houseboat boarding ar (e.g. Unforgettable Tours put (e you on a bus at Adelaide airport, to tour the Barossa before your Mannum boarding www. murrayriver.com.au/mannum/houseboats/). If you are entering or exiting from Melbourne, treat yourself to a regional stopover. We hired a car and stopped at Bendigo in central Victoria for a couple of days and had a fascinating time wandering through the historic city, visiting its old pubs and the Chinese museum and going underground for a mine tour. There are a lot of houseboat operators with a range of packages and prices. To get an idea of what’s on offer, get the booklet South Australian Houseboat Holidays [www.houseboatbookings.com], remembering they do not list some of the more competitive houseboat holidays, such as Kia Marina Houseboat Hire 8km north of Mannum. O

By Mr Keith McCann

There’s nothing remotely like the Outback. The SUV that combines outstanding off-road capability with superb car-like handling. With a powerful Boxer engine and the legendary traction and control of Subaru All-Wheel Drive, the Outback takes everything we learnt on the way to winning six World and ten consecutive Australian Rally Championships and reshapes it for the modern SUV. Featuring a bold new exterior, 5-star ANCAP safety, 213mm of off-road clearance and luxurious, well-appointed interior, you’ll feel right at home in the Outback – even when you’re miles from it. Available in petrol and new Auto Diesel (with up to 1,000kms1 on a single tank), the new Outback is the Real Thing. For those who refuse to compromise, the new Subaru Outback isn’t just an SUV, it’s the Driver’s SUV.

In 2014, we will be starting a regular travel feature every month inside Medical Forum. Email words and pictures to Jan Hallam at editor@mforum.com.au 1. Based on a highway cycle of 5.8L per 100km and fuel capacity of 64L tested in accordance with ADR81/02.

medicalforum

45


Musical Theatre

Letâ&#x20AC;&#x2122;ss Do Let the Ti Time Warp, Again The exuberant Rocky Horror Show is back, 40 years older but hopefully not any wiser.

There is just one show on earth that can entice normally upright and sober medical practitioners to pull on a pair of ďŹ shnets, squeeze into a corset and prance around the dance ďŹ&#x201A;oor. And thatâ&#x20AC;&#x2122;s just the fellas â&#x20AC;&#x201C; and you all know who you are. 8FMM OPXTZPVSDIBODFUPNJYJUXJUIUIF professionals and the thousands of other 3PDLZ )PSSPS fans when the show hits the Crown Theatre in February in the 40th anniversary production starring heartthrob Craig .D-BDIMBOBTUIF4XFFU5SBOTWFTUJUF 'SBOL /'VSUFS .FEJDBM 'PSVN caught up with Erika )FZOBU[  XIP QMBZT UIF TFYZ 'SFODI NBJE Magenta and itâ&#x20AC;&#x2122;s not with a little trepidation that she takes up the role in the iconic show. She knows that there will be more than a thousand people every night who know her part as well as she does. â&#x20AC;&#x153;I think thatâ&#x20AC;&#x2122;s a huge attraction of doing the TIPX o HSPXO TIPX o JU JU JOWJUFT JOWJUFT QFPQMF QFPQMF XIP XIP IBWF IBWF HSPXO

up watching the show to be involved. It XJMM CF B PODFJOBMJGFUJNF FYQFSJFODF UP be part of 3PDLZ )PSSPS. Thereâ&#x20AC;&#x2122;s a reason why people have remained so loyal to it for so long â&#x20AC;Ś and keep coming back again and again. It does stand the test of time.â&#x20AC;? 5IF GPSNFS NPEFM UVSOFE 57 IPTU UVSO actor was recently on stage as the blonde fitness instructor Brooke Wyndham in the musical adaptation of the film, -FHBMMZ #MPOEF. By her own admission it was no big stretch for the blonde actress, even though physically demanding. Magenta is a different kettle of fish. â&#x20AC;&#x153;It one of the things I love the most about 3PDLZ )PSSPS o TUFQQJOH JOUP B EJGGFSFOU looking character with crazy magenta wig BOE TFYZ NBLFVQ y JUT TVDI B USBOTGPSmation. You can learn your lines and songs but itâ&#x20AC;&#x2122;s only when I put on the wig and costume that I really transform into this glorious domestic slave.â&#x20AC;? Her big break came in 2006 on the Reality 57TIPX *U5BLFT5XP, a singing show that

QErika Heynatz

has the celebrity mentored by a professional singer. In Erikaâ&#x20AC;&#x2122;s case it was opera stud David Hobson. â&#x20AC;&#x153;I had no idea who he was and he knew nothing about me but it ended up being an JODSFEJCMF FYQFSJFODF XIFSF XF UPPL PVU first prize. We were worlds apart and we had to fight to find the middle ground but the contrast between us made for a great creative collaboration.â&#x20AC;? The win launched her musical career with of a contract from EMI and roles in musical theatre. 8IFO TIF IFBET UP 1FSUI JO +BOVBSZ GPS rehearsals, it will be a homecoming of sorts for Erika. â&#x20AC;&#x153;My dad was in the navy and we lived in Rockingham, so it will be great to return to some of my childhood haunts along the coast.â&#x20AC;? Another Time Warp, perhaps! O

By Ms Jan Hallam

WIN For your chances to win tickets to 3PDLZ)PSSPS4IPX, turn to $PNQFUJUJPOT 1 46

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Humour

ll o P e

"When I forget about work my mind turns toâ&#x20AC;Ś"

Everyone needs a break, so it was only right to ask the 233 respondents to let their hair down and complete this sentence We had 155 responses and not surprisingly sleep and other activities that happen in a horizontal position ďŹ gured prominently. Consider this picture: â&#x20AC;&#x153;When I forget about work my mind turns toâ&#x20AC;Śwhen my stallion was calling out to all the mares how he had just won another big competition. I was about to tell him â&#x20AC;&#x2DC;Life isn't just about jumping and sexâ&#x20AC;&#x2122; and then I realised!â&#x20AC;? Of course, itâ&#x20AC;&#x2122;s a perfect illustration of the importance of sport and physical activity in our psychosocial wellbeing. Some thought the couch and the Ashes Series, or the HPMGDPVSTFJOQSFQBSBUJPOGPSUIFOFYU64 Masters, or an endorphin-charged run, DZDMF PSTBJM UIFJEFBMFYQSFTTJPOTPGUIF work-life balance. Truth be told, these activities may also help hose down some PGUIPTFVOSFBMJTUJDFYQFDUBUJPOTTFUCZPVS equine friend. 1IZTJDBMBDUJWJUZJTBMTPBNFBOTUP challenge ourselves. One doc pondered â&#x20AC;&#x153;how I can average 40km/h in the 93km cycle leg of the Ironman70.3 Mandurahâ&#x20AC;?, while another was polishing his motorcycle and dreaming of emulating adventurer Charley Boorman. For many, physical activity in spare time was moving hand to mouth to administer

funnyside e

Escape, in all its forms loomed large, be JUDBNQJOH PWFSTFBTUSBWFMoGSPNUIF highlands of Scotland to the quiet fishing FYQFEJUJPOUPBCFBDIPSQPPMTPNFXIFSF One doctor put them all together: â&#x20AC;&#x2DC;Legs (love women) Pegs (love the outback camping stuff) and Kegs (love an amber ale)â&#x20AC;&#x2122; Some didnâ&#x20AC;&#x2122;t need to go far to escape, with their thoughts turning to â&#x20AC;&#x153;how to tackle the snail epidemic, should I go for the branded fertiliser or the generic, how to tackle the ants ruining my driveway, why are the gardenias always yellow?â&#x20AC;? or â&#x20AC;&#x153;How great life is...and my green swimming pool.â&#x20AC;? We were thrilled to read that some of you indulge in the best GPSNPGFTDBQFoUIFEBZESFBNBUXPSL

Others seem to get the same effect from sunshine, singing, reading, wood turning, dress designing, embroidery and -FVOJHTEVDLT PI BOEEJE XFNFOUJPOTFY However, leading the field by a country mile was family. Kids, wives, husbands, grandchildren oXFSFUIFDPSFGPDVTPGEPDT thoughts. The beach, the travel, the holidays, the mountains and the view were all made more vibrant and real by sharing them with loved ones. And not to be underestimated, the unmitigated pleasure of: â&#x20AC;&#x153;Watching Fireman Sam and The Wiggles with my three-year old grandsonâ&#x20AC;?BOEi6MUJNBUF'SJTCFFw All this made the â&#x20AC;&#x153;1001 jobs other jobs *EPGPSGBNJMZw UIFiVONFU/&"5&% targetsâ&#x20AC;? and the â&#x20AC;&#x153;ineffable mysteries of .FEJDBSF XIBUJUFNOVNCFSXPVME+FTVT CJMM UIBUNVDIFBTJFSUPCFBS HAPPY HOLIDAY!

QQAnimal Crackers

with a German shepherd and Iâ&#x20AC;&#x2122;m as nervous as a cat.â&#x20AC;&#x2122;

Two dog owners are arguing over whose dog is the most clever.

How do you know that Santa is a man? /PXPNBOXFBSTUIFTBNFBUUJSFFWFSZZFBS

â&#x20AC;&#x2DC;I know,â&#x20AC;&#x2122; says the second owner.

Why did the turkey cross the road?

â&#x20AC;&#x2DC;How do you know?â&#x20AC;&#x2122;

"SFZPVLJEEJOH *UT$ISJTUNBToIFTIPVME run a mile.

â&#x20AC;&#x2DC;My dog told me.â&#x20AC;&#x2122;

The 3 stages of man: t )FCFMJFWFTJO4BOUB$MBVT t )FEPFTOUCFMJFWFJO4BOUB$MBVT t )F*44BOUB$MBVT

8IJMFFYJTUFOUJBMMZTQFBLJOH BMJFOTDPVME learn an important lesson in Mindfulness from this doctor: â&#x20AC;&#x153;My thoughts turn to ice or jello, initially? Spiritual Quotient = God consciousness / selfconsciousness. So simply allow our ice or jello consciousness to melt away!â&#x20AC;?

â&#x20AC;&#x153;My thoughts turn to what is flying about around outside my office. I am constantly thrilled by the variety.â&#x20AC;? We EPOUUIJOLUIJTJTFBSMZXBSOJOHPGB6'0 JOWBTJPO#65JGJUXFSF UIFSFBSFNBOZ docs whose brain plasticity is up to the challenges filling their wandering minds with thoughts of Sudoku and â&#x20AC;&#x153;wrestling with the issue of dark matterâ&#x20AC;?.

â&#x20AC;&#x2DC;My dog is so smartâ&#x20AC;&#x2122;, says the first owner, â&#x20AC;&#x2DC;that every morning he waits for the paper boy to come round. He tips the boy and then brings the newspaper to me, along with my morning cup of coffee.â&#x20AC;&#x2122;

QQBonBon Humour

48

sustenance in the form of the last piece of chocolate before the start of a diet, or a cheeky pinot, or chardonnay, or sparkling, or red or...

A French poodle and a collie were walking down the street. The poodle turned to the collie and complained, â&#x20AC;&#x2DC;My life is such a mess. My owner is mean, my girlfriend is having an affair

â&#x20AC;&#x2DC;Why donâ&#x20AC;&#x2122;t you go see a psychiatrist?â&#x20AC;&#x2122; asked the collie. â&#x20AC;&#x2DC;I canâ&#x20AC;&#x2122;t,â&#x20AC;&#x2122; replied the poodle. â&#x20AC;&#x2DC;Iâ&#x20AC;&#x2122;m not allowed on the couch.â&#x20AC;&#x2122; An adorable little girl walked into my pet TIPQBOEBTLFE A&YDVTFNF EPZPVTFMM rabbits?â&#x20AC;&#x2122; â&#x20AC;&#x2DC;Yes,â&#x20AC;&#x2122; I answered, and leaning down to her eye level I asked, â&#x20AC;&#x2DC;Would you like a white rabbit or would you prefer to have a soft, fluffy black rabbit?â&#x20AC;&#x2122; She shrugged. â&#x20AC;&#x2DC;I donâ&#x20AC;&#x2122;t think my python really cares.â&#x20AC;&#x2122;

medicalforum


2012 Bunn Cabernet Sauvignon

By Dr Louis Papaelias

A rich, ripe full-flavoured wine with plenty of cassis and berry flavours. Deceptively easy to drink even en at this young age. It has the structure to age and will be even better in five years.

Does red wine cause headache? I have heard a lot of people say that it does. I have also heard many say that it is bunkum. Itâ&#x20AC;&#x2122;s the amount of alcohol you drink that causes the vasodilatation and headache they would say. Some put it down to histamines in wine. Others point to the sulphite content as the culprit.

2012 Bunn Shiraz This wine is similar in nature to the above but with the spice and liquorice typical of Shiraz. Despite the power there is a suppleness and balance which makes for attractive drinking now but even better in a few years.

2010 Bunn Cabernet Sauvignon

Personally, I have become aware over recent years that certain types of wine, mainly red, will predictably bring on a headache within an hour or so of consumption. And I am talking here about no more than two standard drinks as the trigger.

A rustic nose redolent with ripe berries; an impressive palate, rich and full with abundance of powdery tannin. Very supple and easy to drink. Very good length and will age.

I became particularly keen when offered to review the wines from Bunn Winery in Albany. Not only do they practise biodynamic farming and viticulture without irrigation but they also produce preservative-free wines. Wild natural yeasts are allowed to ferment the grape juice and as I understand it, sulphur dioxide is not added during the winemaking process. The end result is a range of distinctively individual wines with a degree of flavour suppleness not often seen. All the wines had a delicious savoury quality, ideal for consumption with food.

2010 Bunn Shiraz

The wines are made from dry grown Cabernet Sauvignon and Shiraz vines, planted in 1997 and 1998 on rocky lateritic soils. Low yields result in highly flavoured must juice that is treated in a very traditional fashion by Mike Garland, the current winemaker. He is also responsible for the highly fancied Castelli wines in Denmark and prior to that turned out some very fine wines under the Garlands label, which has been favourably reviewed in these pages. All in all, this is a seriously well-made set of wines with an individual stamp of their own. The words suppleness and savoury kept cropping up as I tasted the wines. Oldworld in style and excellent food wines and the best part â&#x20AC;Ś NO HEADACHE!

medicalforum

Wine Review

Naturally

Bunn

This has a a rustic nose due to natural yeast fermentation and impact from a plump fruity spice palate and, again, a suppleness and seamless character that lingers in the mouth. Lip smacking is a descriptive term that comes to mind. Like the previous wines it will undoubtedly age nicely for a few years.

2008 Bunn Shiraz Made by founding wine maker Rob McNamara this has a funky nose with ripe, maturing Shiraz liquorice aromas. Rich sweet fruit palate with real depth and power. Impressive and delicious. Will age further if desired.

WIN a Doctor's Dozen! Who is the current winemaker at Bunn Vineyard? Answer:

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

ENTER HERE!... or you can enter online at www.MedicalHub.com.au! Competition Rules: One entry per person. Prize chosen at random. Competition open to all doctors or their practice staff on the mailing list for Medical Forum. Competition closes 5pm, December 31, 2013. To enter the draw to win this month's Doctors Dozen, return this completed coupon to 'Medical Forum's Doctors Dozen', 8 Hawker Ave, Warwick WA 6024 or fax to 9203 5333.

Name:

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Please send more information on Bunn Vineyard offers for Medical Forum readers.

49


Photography

1.

Hitting the Road

3.

2.

4.

50

medicalforum


Photography

6. 5.

It’s a wonderful world out there, full of amazing sights, and we are incredibly fortunate to have some top-notch photographers within the ranks of the profession showing us just how amazing. The theme for the end-of-year photography spread was “Holiday Road” which was interpreted both literally and figuratively but all of them evocative of time and place and the people and creatures that comprise our world. Here's our selection: 1. Urologist Dr Rob Davies:

4. Mandurah GP Dr Tony Tropiano:

7. Hills GP Dr Andrew Dunn:

A study in concentration planning the day ahead at Disneyland, Anaheim, California (Olympus E-M5 20mm f1.7 1/400) and the object of affection after the end of a busy day. (Olympus E-M5 12mm f2 1/50)

On holiday at Yellowstone National Park in Wyoming.

Sent this picture of a breaching whale off the Galapagos Islands taken by his psychologist son James.

2. Occ/Health consultant Dr Bryan Rostin: A unique view of the Peel-Harvey Estuary from the window of an aircraft

5. Margaret River GP Dr Peter Durey:

8. Mr Clive Addision:

Alistair MacLean made the Eiger in the Swiss Alps famous in his thriller Eiger Sanction; Peter is famous for just being there but resisting the urge to yodel.

First night in Hawaii turned on a spectacular sunset, not to be repeated during the ensuing fortnight. Worth having a camera in your pocket to capture these occasions. (Canon SX 260)

6. Hills GP Dr Carol McGrath: 3. Dr Donna Mak: Avenue of wandoo trees in the Julimar Forest, between Chittering Valley and Bindoon. Taken on the Camino Salvado, from Perth to New Norcia.

The round-the-clock peak hour in Hanoi. Nerves of steel required. (Panasonic Lumix DMC-FZ50 f/4 ISO 100)

8.

7.

medicalforum

51


Church Choirs

An Athiest in the Choir Loft Singing in a choir is an epiphany that transcends religion, which is why Dr Donna Mak writes that she wouldn’t miss Sunday service at St Thomas in Claremont despite the doubts and questions.

I am the only atheist in the St Thomas Catholic church choir. I sang alto in the school choir. Being a Methodist school, we sang hymns and carols, and everything from 16th century madrigals to Rodgers and Hammerstein. I could sing in tune, but was never one of the ‘goldengirls’ selected for solos. They were always sung by sopranos with soaring voices – never by altos who hold the harmonies without which any choir would sound hollow. After leaving school I was too preoccupied with study, motherhood and work, to sing. However, my inner alto always searched for the harmony and sang along with it in preference to the melody coming from the car radio. Then in 2009, Jane Curtney, who shares my office at Notre Dame School of Medicine, invited us to Christmas carols at

St Thomas church where she is one of the choir’s conductors. I went out of curiosity more than anything else. I didn’t expect to be blown away, or for the alto to burst out, demanding to sing. But the combination of religious music and a capella harmonies transported me 30 years back in time to the joys of singing at school. I gathered up the courage to ask Jane if an atheist could join her choir. Without knowing it I had already passed the audition – singing Advance Australia Fair at the last medical school graduation while standing next to Jane. Singing from a musical score after a 30-year hiatus felt like speaking my mother tongue when visiting my birthplace. At bit hesitant at first, then it all comes rushing back. I practise at home with a ‘Disney Princess’ electric piano handed down from my teenage daughter. It’s not much to listen to. Alto parts are notoriously boring – often we sing the same two or three notes

for a whole song. But at church, this harmony weaves with that of the sopranos, tenors and basses into an ever-changing, multidimensional soundscape descending from the choir loft to envelope all within earshot. If art is the residue of passion, then liturgical composers must be extremely passionate because some harmonies are so beautiful that I break into a smile each time I sing – even when the lyrics speak of bleeding heads and fore-tastes of death! At Easter and Christmas we sing in Latin, Greek, French, German and Spanish, as well as English. John, a bass and professor of European languages, not only teaches us the correct enunciation of these foreign words, but also translates them into English. But for me, the explanations only generate more questions. What is Jesse’s tree? Was he Jewish? Why don’t we sing in Latin every Sunday? He and the other choristers answer each of my questions patiently. No one seems annoyed by my ignorance or curiosity. At Christmas in 2010 I sang a mezzo-soprano solo in Latin. Despite my atheism, I feel as much a member of St Thomas’ choir as everyone else. Perhaps they share the perspective of my friend Mary Wikcs, physician and Ursuline nun. She responded to my news of joining a Catholic church choir by saying ‘I shall picture you, little atheist, singing at Christmas Mass and smile...’ O

52

medicalforum


Community Choirs

Sing it Loud Despite years of denial, Dr Angela Cooney says she couldn’t resist the siren song in her genes and three years ago joined a choir. Blood will out. My mother’s father was a piano teacher and my mother was in a choir when I was a teenager which I thought was unutterably lame, as was anything my parents did! Even my sister was in a choir until she slipped and broke her ankle and couldn’t drive anymore. Three years ago I decided that I wanted to join a choir, too. My musical tastes run more to indie rock than classics and I’m still unable to explain what it is that draws me to this group activity. I suspect it’s similar to why a dog howls when it hears an ambulance siren. For three hours every Wednesday evening a group of adults aged between 19 and 80 meet to do the choirmaster’s bidding. His name’s Perry, a young bloke who looks a bit like my eldest son. We try our hardest to please him and he is usually very patient, but occasionally we succeed in pissing him off by not concentrating. Some of us can

read music, some can’t. There are some amazingly strong voices and many (like me) who don’t aspire to be soloists but are more than happy to add to the sound. Who are we? We’re retirees, teachers, librarians, physios, public servants, architects, mothers, nurses and doctors. We all want the same thing, to produce something beautiful that is both inside and outside ourselves. Sometimes it sounds like this: ‘lux_ae_ter_ na_lu_ce_at_e_is_lux_ae_ter_na.’ Perry coaches us in Italian, Latin and German because much of what we sing isn’t in English. Our repertoire includes religious music, show tunes, traditional Christmas carols and modern choral works. Even pieces that initially seem cheesy, tedious, boring or much too difficult become transformed by Perry’s vision and our collective efforts into something joyous, significant and beautiful. Of course, that’s after lot of bum notes, frustration and extra rehearsals. The journal New Scientist reports that individuals in a choir synchronise their heart

rhythms while singing. Maybe this is a physiological reflection of those times when, as musician Brian Eno puts it, ‘we immerse [ourselves] into the community and stop being me for a little while and become us.” For most choirs the ultimate goal is performance. The choirmaster’s got a bent for musical theatre, so he’s very focused on how we relate to the audience, not just with voice but also with movement and facial expression. As a doctor I can do this kind of thing in my sleep. Displaying empathy and emotion in an exaggerated fashion is what I do all day long. It’s called acting! And this isn’t to mislead patients, quite the opposite. It’s to reaffirm to my patients how important they are to me and how much I care about them. There’s been a lot of research into the psychological benefits of choirs. I haven’t read any of it. I just know that there’s something compelling and deeply satisfying when I spend time synchronising my pulse with people who used to be strangers and have now become friends. O

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53


Competitions

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

Theatre: Horrible Histories: Live On Stage â&#x20AC;&#x201C; Awful Egyptians

Event: The Illusionists 7FHBTIJUT1FSUIBUUIF$SPXO5IFBUSFJO+BOVBSZXJUI this high-octane, contemporary magic show which IBT TPME PVU BSPVOE UIF XPSME %POU FYQFDU UP TFF any rabbits in hats, but do brace yourself for jaw-dropping acts of levitation, mind-reading, disappearance BOE FTDBQFT 5IF *MMVTJPOJTUT o "OUJ$POKVSFS Dan Sperry, Inventor Kevin James, Mentalist Philip Escoffey, Gentleman Mark Kalin, Escapologist Andrew Basso, Trickster David Williamson and Enchantress Jinger Leigh will have you spellbound. Crown Theatre, Medical Forum tickets January 18. Season continues until January 25

Winner Doctors Dozen Christmas Lif t-off with Higher Plane Job, who Dr Marie t B (1 JO  QSBDUJDFT BT /BSSPHJO  JT #BMMBKVSB BOE cely chilled ni partial to a summer. in n illo Sem ry drops cu er When the m e in a more to s rn tu e st r fatherâ&#x20AC;&#x2122;s win her ta to sample he ed sed us t ea ie pl ar ly M lar earthy red. sheâ&#x20AC;&#x2122;s particu e grew up and VTFIFS sh DB re CF he O w [F nd %P Holla %PDUPST F)JHIFS1MBOF Christmas. UPIBWFXPOUI with her over ay st to g llin ve tra be ill w family

We all want to meet people from history. The trouble is, everyone is dead! So, prepare yourself for )PSSJCMF)JTUPSJFT-JWF On Stage! and discover the mysteries of Ancient Egypt with the ground-breaking Bogglevision 3D special effects. From the GBTDJOBUJOH 1IBSBPIT UP UIF QPXFS PG UIF QZSBNJET  EJTDPWFS the foul facts of death and decay with the meanest mummies JO&HZQU ZFBSTBOEVQ  His Majestyâ&#x20AC;&#x2122;s Theatre, Medical Forum family ticket for four, Friday, January 3, 6pm. Season continues until January 10

Movie: The Railway Man 5IF 3BJMXBZ .BO  TUBSSJOH 0TDBS XJOOFST $PMJO 'JSUI  /JDPMF ,JENBO BOE +FSFNZ *SWJOF  JT CBTFE PO &SJD -PNBYT CFTUTFMMJOH NFNPJS PG UIF TBNF OBNF -PNBY XBT POF PG UIPVTBOET PG"MMJFE108TPOUIF5IBJ#VSNBSBJMXBZBOEIJTFYQFSJFODFT left him traumatised and shut off from the world. Years later, he NFFUT1BUUJPOBUSBJOBOEGBMMTJOMPWF#VUUIFEFNPOTUISFBUFO to come between them. In cinemas from December 26

Musical Theatre: Rocky Horror Show -FUTEPUIF5JNF8BSQyBHBJOBOEBHBJO GPSZFBSTJOGBDU Yep, itâ&#x20AC;&#x2122;s back for this significant anniversary with heartthrob $SBJH.D-BDIMBOBTUIFEFWJMJTIQFSWFSTF'SBOLhOh'VSUFSBOEB cast of Australian musical theatre stars. Come dressed in your favourite character and get set to wiggle the hips and be part of Rocky Horror history. Crown Theatre, February 14, season continues until March 7

Kidsâ&#x20AC;&#x2122; Theatre: Dr Seussâ&#x20AC;&#x2122; Cat in the Hat Based on the all-time favourite book by Dr Seuss, The Cat in the Hat is now a magically witty play for children produced CZ UIF /BUJPOBM 5IFBUSF PG (SFBU #SJUBJO 8JUI NJTDIJFWPVT humour and madcap style, The Cat in the Hat introduces his new friends to a crazy afternoon of fun. A holiday treat for littlies and grown-ups alike. Heath Ledger Theatre, Medical Forum tickets for 9.30am, January 22. Season continues to January 29

Movie: The Book Thief

MEDICAL F ORUM $10 .50

This beloved book by Markus Zusak is now a film starring (FPGGSFZ 3VTI BOE &NJMZ 8BUTPO XJUI 4PQIJF /FMJTTF BT -JFTFM 5IF TUPSZ JT TFU JO /B[J (FSNBOZ BOE OBSSBUFE CZ UIF PWFSXPSLFE DIBSBDUFS  %FBUI )F UFMMT UIF TUPSZ PG -JFTFMT friendship with a Jewish man and how they defy the odds. In cinemas, January 9

WINNERS FROM THE OCTOBER ISSUE Music â&#x20AC;&#x201C; Royal Concertgebouw Orchestra: Dr Rob Kirk Music â&#x20AC;&#x201C; Andre Rieu: Dr Bev Hewitt Musical Theatre â&#x20AC;&#x201C; South Pacific: Dr Jenny Fay Music â&#x20AC;&#x201C; Pipe Organ Plus:%S.JDIBFM+POFT %S,FWJO,XBO %S%BWJE8SJHIU %S1FUFS.FMWJMM4NJUI %S/BJ-BJ Movie: The Counsellor:%S4IBXO1PXFMM %S4BSBI,VSJBO %S,BUISZO#VSSPVHI %S.FMBOJF$IFO %S,BNMFTI #IBUU %S4V[BOOF.D&WPZ %S+BOF(JCTPO %S"NJS5BWBTPMJ %S1BVM,XFJ %S+PIO8JMMJBNT %S%JBOB)BTUSJDI Movie â&#x20AC;&#x201C; The Butler:%S(BWJO-FPOH %S3PTFNBSZ2VJOMJWBO %S%POOB.BL %S&SJDB-VLF %S4UBOMFZ,IPP Dr Bastiaan de Boer, Dr Carol McGrath, Dr Christina Wang, Dr Andrew Toffoli, Dr Dorothy Graham

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Major Sponsors

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October 2013 www .mforum.com.au

medicalforum


medical forum FOR LEASE MURDOCH Brand new Medical Suite for Lease at the new Wexford Medical Centre. 106 sqm, complete fit-out and one car bay. Ready to lease by March-April 2014. Please contact: reception@ccwa.net.au WEST LEEDERVILLE Sessional rooms available, mornings or afternoons. Close proximity to SJOG. Ample parking (12 bays) Contact Liz 0438 924 710 MURDOCH Murdoch Specialist Centre, brand new stylish large rooms. Please email you interest to admin@sleepmed.com.au AVELEY Suitable for dental practice and/or allied health services (eg. Physiotherapy, Psychology, Podiatrist, Radiology etc). Medical centre located in the same building. Located in a fast growing community beside a shopping centre, close to secondary schools, primary schools, church and Child Care Centre. Contact: 0400 814 091

WEST LEEDERVILLE Specialists Consulting Suite Part or Whole Building (up to 250 sq m) Onsite Parking Easy Access to Freeway and Bus /Train Services Phone: 9380 6457

JOONDANNA New medical centre in Joondanna. Only 5km from CBD. Excellent position on Wanneroo Rd, with ample parking. Suit GPs and / or allied health. Pharmacy and pathology on-site. For further details, contact Wesley Williams Ph 0414 287 537 Email williams.wesleyk@gmail.com

NEDLANDS Hollywood Medical Centre Sessional suites, $300 per session including reception & patient payments. Full service extra cost. Various days available. Contact Sue at admin@cardiovascularcare.com.au/ 9389 8658 MIDLAND Sessional Suites for lease. Morning or Afternoon sessions available in our Specialist Medical Practice. Receptionist available. Please Phone Brenda 0414 845 478 SOUTH FREMANTLE Consulting Rooms available in prestigious South Freo location. Conveniently located on South Tce, just a few hundred yards from Fremantle Hospital. Interested medical/allied health practitioners seeking consulting rooms with reception facilities for full occupancy or one or more days per week are encouraged to apply. Attractive sub-letting arrangements available for a furnished or unfurnished room with onsite parking. Room available March, 2014, but other day occupancy arrangements now available. Two senior Clinical Psychologists run a well-established practice here consulting to adults, adolescents and children. Contact Administrator Jodee on 9433 6002 or email reception@fremantleclinicalpsychology.com.au

URBAN POSITIONS VACANT WILLETTON Full time or sessional VR GP to work in busy established private billing practice South of the River. All afternoon sessions available immediately. Looking to extend to After-hours/ Sundays in near future with great remuneration potential. Fully computerised, modern treatment room facilities and full time nursing staff to assist with all procedures and EPC clinics. Please call Sonia: 0408 904 532 or Jega: 9310 1234

Osborne City MURDOCH New Wexford Medical Centre – St John of God Hospital 2 brand new medical consulting rooms available: t TRNBOETRN t %VFGPSDPNQMFUJPO.BSDI t DBSCBZQFSUFOBODZ Lease one or both rooms. For further details contact James Teh Universal Realty 0421 999 889 james@universalrealty.com.au

OSBORNE CITY

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

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

FORRESTFIELD GP (VR) required for privately owned practice. Flexible hours. Accredited, computerised, practice nurse, on-site pathology and DWS. Contact Ed 0414 428 789 CLARKSON Wanted GP Full time (VR). Fully computerised, accredited, noncorporate, friendly practice. Practice nurse, pathology, pharmacy. Close to transport. DWS practice. Good rates. Contact Mark 0403 179 402 Email : markpol@iinet.net.au BALLAJURA Northern Suburbs: DWS Area: Ballajura Permanent/part time GP wanted Ballajura Medical centre Mixed billing, busy practice, nursing staff, Best Practice, lots of potential. Female GP will be preferred 0488 222 238/chibilitism@yahoo.com NORTH PERTH View Street Medical requires a GP F/T or P/T. We are a small, privately owned practice with a well-established patient base, computerised & accredited with nurse support. Ring Helen 9227 0170

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

APPLECROSS Full Time GP wanted - Weekend sessions also available. 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, don’t miss out on your chance to join this private billing, vibrant practice with immediate access to a full patient data base. Confidential enquiries to the practice manager 9364 6633 VR GP Required for NEW PRACTICE located in an ASGC-R2 location east of Perth. This brand new practice is the perfect opportunity for a GP to work in the inner regional area of Perth located approximately 45 mins from the CBD. This large community with no current servicing GP’s is located next door to a busy pharmacy and can accommodate 2 full time GP’s. Admin and nursing services will be provided along with pathology onsite. Relocation incentive may apply to this location. For more information please call 0419 959 246 Email: admin@ppdgroup.com.au FREMANTLE Fremantle Women’s Health Centre requires a female GP (VR) to provide medical services in the area of women’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 JOONDALUP CANDLEWOOD MEDICAL CENTRE GP required to join our friendly team for After Hours work immediate start Weekdays 6 – 9pm and Saturday 12 - 5pm Very Attractive remuneration Privately owned, AGPAL accredited general practice Fully computerised Contact Michelle 08 9300 0999

WOODLANDS Woodlands Family Practice Great opportunity for PT/FT VR GP in a recently extended busy privately owned practice. Call Dr Mary McNulty on 9446 2010 Email: mary@wfpwa.com.au

FEBRUARY 2014 - next deadline 12md Wednesday 15th January - Tel 9203 5222 or jen@mforum.com.au


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GOLDEN BAY PT female GP required. Fully computerised, DWS, private/ bulkbilling, Fully accredited, Practice Nurse, onsite pathology. Contact: Sheelagh 08 9537 3738 Email CV to: pracman@eftel.net.au SOUTH PERTH VR GP required Excellent River location in South Perth. Non-corporate, private billing, fully computerised. F/T registered nurse and onsite pathology. For more information contact Paris on 9367 1185. Email: bhabibi@bigpond.com BIBRA LAKE GP - F/T OR P/T Computerised, well equipped, accredited private billing family practice. Nurse and pathology support available. Interest in women’s health desirable. For further information contact Dr Rodrigues on 0417 181 070 Email: bibramed@iinet.net.au

BALGA Balga Plaza Medical Centre has now opened in the Balga Plaza shopping centre and is steadily growing. We are in the process of expanding, and looking for enthusiastic GPs to be part of this exciting process. Generous locum percentage offered and interest in ownership considered. Contact - balgaplazamedical@gmail.com Phone: 0427 794 419 CHURCHLANDS Herdsman Medical Centre Due to the recent sudden passing of one of our GP colleagues, we are seeking a full time General Practitioner. We have an established patient base and are committed to high quality family medicine. Special interests are welcomed. No Botox or Naturopathy. Fully Private billing practice as of 1.11.2013. Interest in both male and female health welcome. Hours 30 - 40 hours per week. We have a full time practice nurse and our practice is fully computerised. Please send your CV to

PEARSALL Pearsall Medical Centre is looking for a VR full-time GP. This privately owned and managed practice will offer up to75% billing to the right doctor. Other locations North available. Please contact Phil on 0422 213 360 Email: phil27bc@gmail.com MADDINGTON Maddington (DWS) is looking for a VR full-time GP. This privately owned and managed practice will offer up to75% billing to the right doctor. Other locations South available. Please contact Phil on 0422 213 360 Email: phil27bc@gmail.com KINROSS Kinross (DWS) is looking for a VR fulltime GP. This privately owned and managed practice will offer up to75% billing to the right doctor. Various locations North, South available. Please contact Phil on 0422 213 360 Email: phil27bc@gmail.com

PERTH CBD Full and part time VR GPS to join our busy inner city practice located in the Hay Street Mall. Non corporate, mainly private billing, accredited, fully computerised with full admin and nursing support and on-site pathology. Flexible hours and high earning potential for suitable candidates Please contact Debra on 0408 665 531 to discuss or Email: drogers@perthmedicalcentre.com.au

CLOVERDALE PT/FT VR General Practitioner required for established practice. Predominantly bulk-billing, Full-time RN. Non-Corporate Medical Centre situated in a Medical Complex. Located next door to Chemist, Physiotherapist and Pathology. Remuneration of 65% of income. Phone Anne 0421 128 144

practicemanager@herdsmanmedical.com.au

BAYSWATER Wanted General Practitioner (VR) F/T or P/T required within our friendly non corporate medical practice. We are a fully computerised, wellequipped, teaching, accredited general 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

or call Dr Cameron Gent at the practice on 9383 7111 All enquiries treated with absolute confidentiality.

We make Aged Care work for GP’s Medical Practitioners for Aged Care (MP+AC) is seeking doctors to join its team providing medical services to residents of various Residential Aged Care Facilities throughout the Perth metro area. Our efficient service delivery model maximises the doctor’s earning potential. t'MFYJCMFTFTTJPOT.POEBZUP'SJEBZ t(SFBUBENJOTDIFEVMJOHTVQQPSU t3FNPUFMPHJOUPQBUJFOUSFDPSET t3/QSPWJEFECZ.1 "$UPBTTJTUEPDUPS t#FUUFSVUJMJTBUJPOPGEPDUPSTUJNF t1BZNFOUPGHSPTTSFDFJQUT t&RVJUZJOWPMWFNFOUQPTTJCMF For more information or confidential discussion about work options please contact Rollo Witton – Chief Executive Officer - MP+AC Tel: 9389 8291 or Mobile: 0417 921 632 or Email: rollo@mpfac.com.au

WINTHROP/MURDOCH Full time VR doctor required for Hatherley Medical Centre in Winthrop. Busy all Private Billing practice with full nursing back-up. Will suit enthusiastic Young male with very good earning potential. For more information contact Peter McCarrey on 9310 4400 Please send your CV to admin@hatherleymedical.com.au

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

CURRAMBINE Sunlander Medical Centre is seeking a General Practitioner to join our Mixed Billing Practice. Prime location 25 minutes from Perth CBD and 5 minutes from the beach. VR and non-VR considered. Full Time and Part time positions available. On-site Registered Nurse, Perth Pathology, and X-Ray dept. Dentist and Physiotherapist within office and we are located next to a Pharmacy. Contact: Sirov Maharaj on 0438 740 307 or sunlandermedical@gmail.com

CANNING VALE Non VR or VR GPs wanted for bulk billing medical centre in Canning Vale. DWS location, 17 mins from Perth CBD 75% billings * Billings similar to that of a mixed billing practice. Generous relocation fee. Full time nurse for EPC and on site pathology/allied health. Contact: g_vinu@yahoo.com

KARDINYA Kelso Medical Group requires P/T GP (DWS after hours only). This long established privately owned and managed mixed billing practice offers great opportunity for doctor with interest in CDM and minor surgical procedures. Located in Kardinya in newly refurbished premises with onsite pathology and allied health with growing patient base. Currently supported by 5 GP’s and 3 RN’s . www.kelsomg.com.au Please call 0419 959 246 for further information. CARINE Okely Medical Centre NOR Due to doctor moving south, we need a PT/FT VR GP to join our friendly, well established, mostly private billing practice with allied health next door. Excellent remuneration and very good patient base. Pls contact Dr Kiran on 0401 815 587 or Email: CV to kiranpkumar@hotmail.com

ARE YOU

READY FOR

BENTLEY GP VR needed for privately owned family orientated practice. 15mins from Perth CBD, AGPAL accredited, fully computerised using MD/ Pracsoft. Private and Bulk Billing. Supported by clinical and CDM nurses operating from purpose built practice. We offer 65% of billings. Contact Alison on 0401 047 063 BULLCREEK Come and join us in our New General Practice located SOR. Non-Corporate AGPAL Accredited Practice. We require a Full-Time or Part-time VR GP for our Surgery. The surgery is computerised, with Private and Bulk-billing. Practice Nurse available part-time. Please contact the Practice on 9332 5556

A CHANGE?

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

9791 8133 or 0418 921 073

FEBRUARY 2014 - next deadline 12md Wednesday 15th January - Tel 9203 5222 or jen@mforum.com.au


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

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

General Practitioner – Street Doctor Perth Central & East Metro Medicare Local Ltd (PCEMML) operates a well-established mobile medical service, known as the ‘StreetDoctor’. This service provides primary healthcare to homeless and disadvantaged populations of Perth. We are currently seeking an experienced passionate Vocationally Registered GP to work at our Clinics located at an Indigenous drop-in centre and at a youth drop-in centre, located in Midland. These clinics are held on Tuesdays during the day and will be available as of January. 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 regarding this rewarding opportunity please contact Tracey Snowden hr@pcemml.org.au To apply please forward your current CV to hr@pcemml.org.au

Looking for a sea change? We may have the job for you. If you have finished your GP training or looking for a subsequent term placement or an experienced GP looking for a change for the better, phone Jill on 08 97521133 or email jill@busseltondoctors.com.au. Busselton is located on the pristine shore of Geographe Bay in the Margaret River Wine Growing region, just a short 2 hour drive from Perth.

FEBRUARY 2014 - next deadline 12md Wednesday 15th January - Tel 9203 5222 or jen@mforum.com.au

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Are you looking to buy a medical practice? To find a practice that meets your needs, call:

As WA’s only specialised medical business broker we have helped many buyers find medical practices that match their experience.

Brad Potter on 0411 185 006

You won’t have to go through the onerous process of trying to find someone interested in selling.

MEDICAL SUITE – For Lease Spencer Street South Bunbury

You’ll get a comprehensive package on each practice containing information that you and your advisers need to make a decision.

Purpose built medical suite vacant and available now. Reception/waiting/office/staff area, 2 consulting rooms, executive office, treatment room. On-site parking.

We’ll take care of all the bits and pieces and you’ll benefit from our experience to ensure a smooth transition.

More information and photos at... www.comrealty.com.au/2397320 Details and inspection... Mike Jenkins 0418 931 373

Suite 27, 782 - 784 Canning Highway Applecross WA 6153

Ph: 9315 2599 www.thehealthlinc.com.au

Stress Physician | Mandurah | Part time CVS are a leading cardiology practice providing high quality diagnostic stress testing services. We are seeking medical practitioners to work at our new Mandurah clinic one or two days per week. We welcome you to contact us if you have: • Registration with the Australian Medical Board • Medical Indemnity Insurance • Life Support skills or experience • Commitment to outstanding patient care As a Stress Physician, you will work with state of the art diagnostic equipment, conducting quality specialist testing and developing your diagnostic ECG skills. Training will be provided and an attractive remuneration package and working conditions are available. CVS East Fremantle, Joondalup, Karrinyup, Leeming, Mandurah, Midland, Mount Lawley, Nedlands, Rockingham.

Exciting E Exci xc ti ting ng gG GP P Op Oppo Opportunities p rttunities in Subiaco po biaco Are you a VR General Practitioner looking for a new challenge in the heart of Subiaco? St Francis Medical is a brand new, purpose built, privately owned General Practice. Benefits: ‡ Highly experienced Nursing and Admin Team ‡ Fully computerised and paperless office, with full IT support ‡Walking distance to public transport, key hospitals and allied health ‡ Onsite Pathology ‡ 5 consulting rooms, including a 2 bed treatment room ‡ Parking Provided Opportunities: ‡ Full and part time opportunities are available ‡Welcome $$ bonuses available for extended commitments

TM

For a confidential discussion, please contact Kerry on 0455 368 793 www.stfrancismedical.com.au

85% take home,

Jandakot Half-time position in Jandakot for an experienced GP to oversee development of multidisciplinary GP clinics provided to remote communities by RFDS from Derby, Port Hedland, Kalgoorlie and Meekatharra. Key priorities include e-health, quality improvement and chronic disease management systems. This role would be ideal for a GP who will support hard-working colleagues in practical ways and is ready to develop leadership and management skills. Hours are flexible to enable the successful applicant to maintain clinical sessions in Perth or remote FIFO. Phone: 9417 6393 Email: medical@rfdswa.com.au

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

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

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

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

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)

FEBRUARY 2014 - next deadline 12md Wednesday 15th January - Tel 9203 5222 or jen@mforum.com.au


medical forum

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For Sale/For Lease Opposite Bentley Hospital There are plenty of options with these three properties. Buy; lease; move right in; refurbish, extend, or redevelop. The choice is yours. Located directly opposite the Bentley Hospital they present an outstanding opportunity to establish a medical practice or allied health service. Total land area is 3,483m2 with large frontages to both Mills & Doust Street. The individual lot details: 21 Mills Street â&#x20AC;&#x201C; 1,449m2*NQSPWFNFOUTJODMVEFDPNNFSDJBMPGžDFTPGN2DBSCBZT VOEFSDPWFS

23 Mills Street - 1,063m2%FWFMPQNFOUTJUFXJUIQPUFOUJBMDPNNFSDJBMVTF 45$"  25 Mills Street â&#x20AC;&#x201C; 971m2 Purpose built consulting/treatment rooms with ample parking

Offers invited. For brochure and further details phone Jason Hughston on 9473 7777 or 0408 902 907 jhughston.victoriapark@ljh.com.au

ljhooker.com.au FEBRUARY 2014 - next deadline 12md Wednesday 15th January - Tel 9203 5222 or jen@mforum.com.au


Sunshine Summit 2014


Medical ForumWA 12/13 Public Edition