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FEBRUARY 2016 www.mforum.com.au
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Dr Brien Hennessy Avant member
This year, many doctors like you will face a medico-legal
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08 6189 5700 *IMPORTANT: Professional indemnity insurance products are issued by Avant Insurance Limited, ABN 82 003 707 471, AFSL 238 765. The information provided here is general advice only. You should consider the appropriateness of the advice having regard to your own objectives, ﬁnancial situation and needs before deciding to purchase or continuing to hold a policy with us. For full details including the terms, conditions, and exclusions that apply, please read and consider the policy wording and PDS, which is available at www.avant.org.au or by contacting us on 1800 128 268.
Doctors – a Price on Your Head? The medical profession is caught up in the great ethical dilemma of the redistribution of wealth. It is hard to argue against ‘money buys justice’ but does the profession want to go down the same road as lawyers? Reformists say no; pragmatists say it seems to be heading that way; conservatives want more. But conservatives are also traditionalists and doctors have traditionally not drawn a line between the haves and have-nots. Will those who primarily follow income (‘money buys health’) win the day? We hope not because it will change the face of medicine forever and there is no coming back. Trust and credibility are at stake. Money speaks The most impactful trend today is speed and depth of communication. We get stories such as a Perth surgeon and his wife being kidnapped for ransom. Oxfam says there is a ‘crisis of inequality’, where about 3.6 billion people live on the same income as 62 of the planet’s wealthiest. Bupa says it will start educating members on how much they should pay for procedures to prevent price gouging. And so on. Given that Aussies reportedly spent $3.29b online over Christmas, it is hard not to argue that, overall, Australians can afford extra on health – it just has to be their priority. But are these spenders simply hedonists without a need for ongoing health care? Remember it took the national folate-fortiﬁed bread strategy in 2009 to give those who didn’t consume fresh fruit and vegetables protection from neural tube defects. The Australian community as a whole would have beneﬁted from this at outset without medical researchers ﬁrst demonstrating the failings of the costly awareness campaigns. Doctors hold the cards Capitalism is not doing a crash-hot job of it. In a world that measures success by wealth, the Donald Trumps around us cannot buy better health care for the majority. The US is a glaring example. It comes down to the local community of doctors and who we allow to lead us. Governments follow voter sentiment and health consumers say they want better access. Yes, I hear doctors say, but to what? Better care? This is where the private-public debate over the Midland hospital is a good example. At the launch, the local politician put great store on getting private-like care in a public hospital. We are still working out what that means but the Catholic Church alone should not deﬁne it – it’s a minority group that has lost credibility in areas of duty of care, transparency and accountability.
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How we pursue doctors Last edition we proﬁled the case of the Medical Board, AHPRA and a doctor’s MDO spending over an estimated $500,000 of our hard-earned and three years of stress in an unsuccessful attempt to deregister this doctor who apparently earns an average GP salary practising niche medicine. Who beneﬁted in this case? The Board did not convince the judge that the public needed protection from the doctor. Of particular concern is the apparent broader fear shown to AHPRA and the Medical Board. From what others tell us it extends to the lawyers at MDOs and the doctors they support. If you are a doctor being investigated by someone you feel is not versed in what you do, without justiﬁable patient complaint, then you are readily excused for feeling intimidated – particularly if it takes years to exonerate you. We have been told, but not independently conﬁrmed, that health consumers are encouraged by their lawyers to submit a complaint to AHPRA and if it says there is a case to answer, the lawyer will join the patient in pursuing it. If this is true, we can only imagine the time and expense that vexatious complaints are adding to the process. And it is not hard to imagine most doctors failing the ‘medical records’ test at some stage so it seems an invitation for Dr Rob McEvoy health consumers to ‘test the waters’. Falling between the cracks Forced to take sides, it seems organisations like the AMA and relevant colleges take the broader political view, so personal support may feel lacking, particularly for doctors practising outside the mainstream. Fortunately, people who know the adversarial legal ‘game’ are emerging to support well-meaning doctors who are getting burnt by the process. One conclusion we draw is that to be fair to both the medical expert witness and the doctor under investigation, the lawyer’s brieﬁng notes to an expert witness should always be subject to FOI, assuming expert witnesses inﬂuence the ﬁnal decision. It comes under ‘transparency and accountability’.
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FEBRUARY 2016 | 1
February 2016 10
FEATURES 10 Spotlight: PIAF Director Wendy Martin 17 Trailblazer: Dr Cathryn Milligan 18 WAPHA and the PHNs 21 Cardiologists in Mandalay 22 Travel Smart Back to School NEWS & VIEWS 1 Editorial: Doctors – A Price on Your Head 4
6 8 12 27 27 31
Dr Rob McEvoy Letters: Health Practitioner Ombudsman’s View Ms Samantha Gavel Negotiate Not Litigate Ms Cheryl McDonald The Act and Carers Ms Morag Smith Wasting Skills of Older Docs Dr KC Wan Heavy Hand Makes Hard Work Dr Paddy Hanrahan Curious Conversations Dr Ben Roestenburg Medical Board Sets Nitschke Free Have You Heard? Medicolegal: Your MDO and Risk Mr Chris Mariani Beneath the Drapes Abortion Law Reform
LIFESTYLE 42 Social Pulse: Christmas 2015
47 48 49 50
SJG Murdoch, Clinipath, Ramsay, SJG Mt Lawley, SJG Subiaco, SKG, Hollywood Fertility Competitions Funny Side Old Kent Wines Review: Dr Martin Buck What’s On: Perth Showstoppers
GUEST COLUMNS Dr Jenny Brockis 8 What Smart People Make Silly Decisions 24
Dr Ainslie Waddell How Lucky Am I?
A/Prof Helen Hodgson Spending and Saving in Retirement
Senator Rachel Siewert Action to Stop Abuse of Disabled
MAJOR SPONSORS 2 | FEBRUARY 2016
6 1 0 2 Innovations & TRENDS
Dr Gordon Harloe National Award for Training
Dr Johan Janssen Nutrigenomics – HEART of the Matter?
Prof Daniel Fatovich How EDs Deal with Dangerous Patients
Dr George Sim Trends in ENT
Dr Cliffe Neppe Obs & Gynae Trends
Prof Karen Simmer Neonatal Care
C/Prof Mark Thomas Against the Tide
Ms Jo Beer Bugs, Genes & Sugar
Dr Senq Lee Rheumatology Trends
Dr Stefan Ponosh New Vascular Solutions
Dr Jim Goodbourn Engaging ‘Frequent Flyers’
Dr Astrid Arellano Lyme Disease in Australia
Dr Mark Hanikeri Malignant Melanoma Surgery
MARCH 10 See P10
INDEPENDENT ADVISORY PANEL for Medical Forum John Alvarez (Cardiothoracic Surgeon), Peter Bray (Vascular Surgeon), Chris Etherton-Beer (Geriatrician & Clinical Pharmacologist), Joe Cardaci (Nuclear & General Medicine), Alistair Vickery (General Practitioner: Academic), Philip Green (General Practitioner: Rural), Mark Hands (Cardiologist), Michele Kosky AM (Consumer Advocate), Olga Ward (General Practitioner: Procedural), Piers Yates (Orthopaedic Surgeon), Stephan Millett (Ethicist), Kenji So (Gastroenterologist) MEDICAL FORUM FEBRUARY 2016 | 3
Letters to the Editor
Ombudsman’s view ED: We wrote to the National Health Practitioner Ombudsman and Privacy Commissioner, whose key role is to handle complaints about the administration of the National Scheme, and asked her to comment on our December edition article Deﬁciencies Not a Competency Issue – any aspects, particularly transparency, access under FOI to lawyer brieﬁng notes for expert witnesses, and fairness to GPs working within a special interest area. Their website (www.nhpopc.gov.au) says 23% of complaints are from health practitioners. She kindly provided this response.
investigate notiﬁcations under the national law, and how decisions are made by the board following consideration of the matters raised. We examine whether AHPRA and the board have followed due process and taken into account relevant considerations. We generally request that people provide AHPRA with an opportunity to resolve their complaint through its internal complaint handling process before referring the matter to the NHPOPC to investigate.
It would be inappropriate for me to comment on the speciﬁcs of the case, as I am not familiar with the details and the matter has been heard by a Tribunal. In more general terms, I can advise that Section 3 (2) (a) of the Health Practitioner National law (the national law) states that the main principle for administering the Act is that the health and safety of the public are paramount. The national law therefore allows for the board to conduct an investigation into a health practitioner without receiving a notiﬁcation. Section 99 of the national law also provides for the right of appeal by health practitioners against decisions which affect their registration. I understand from reading the article that this has occurred in this case. [ED. Our article was about the hearing to deregister the medical practitioner, not an appeal.]
If a health practitioner has concerns about the administrative actions of AHPRA or the board in dealing with a registration or notiﬁcation issue, they can lodge a complaint with my ofﬁce. Administrative actions include actions taken by AHPRA to assess and
så 4HEåROLEåOFåCARERSåMUSTåBEåRECOGNISED by a treating team and they should be included in the assessment, planning, delivery and review of services that impact on their role; and
The NHPOPC ofﬁce can be contacted by telephone on 1300 795 265, or by email at email@example.com. More information about the ofﬁce, including our 2014-15 Annual Report, is available at www.nhpopc.gov.au.
så 4HEåVIEWSåANDåNEEDSåOFåCARERSåMUSTåBE taken into account along with the views, needs and best interests of people receiving care when decisions are made that impact on carers and their role.
Ms Samantha Gavel, National Health Practitioner Ombudsman and Privacy Commissioner, Melbourne
Under the WA Act, a “carer” is deﬁned as an unpaid individual who provides care and assistance to a person with a disability or who has a chronic health or mental illness.
The requirement to be respectful of the role of carers in discussions about care is reﬂected in the Medical Board of Australia’s Code of Conduct. However the Code goes further to state that any information provided should be with the consent of the patient.
Dear Editor, RE: Deﬁciencies Not a Competency Issue (December edition).
The WA Act applies to all state Government funded health and disability service providers and requires each service provider to comply with the WA Carers Charter. In relation to service delivery, the Charter states that:
The Act and carers ED: In last month’s Letters, Ms Rosie Barton from Carers WA wrote that including the carer in the patient’s care and/or endof-life plan is a requirement of the Carers Recognition Act. We asked Avant senior solicitor Ms Morag Smith to explain its implications.
Dear Editor, The Carer’s Recognition Act 2004 (WA), introduced on 1 January 2005 and similar legislation passed by the Commonwealth in 2010, were ushered in to raise awareness of the contribution made by unpaid carers to patients with disabilities or chronic health or mental illnesses and outline their obligations and responsibilities. Health practitioners should be aware that the WA Act requires carers to be included in discussions about the patient’s care and/or end-of-life plan.
If you haven't got anything nice to say about anybody, come sit next to me. Alice Roosevelt Longworth
The WA Act does not alter the duty of conﬁdentiality and if a patient asks you not to share information with their carer you must respect their decision. In accordance with the Act, however, if the patient withholds consent or is unable to consent you can release information that is necessary for the carer to support and care for the patient. Ms Morag Smith, Senior Solicitor, Avant ........................................................................
Wasting skills of older docs Dear Editor, I write in response to the article Deﬁciencies Not a Competency Issue (December edition). Senior doctors are deemed incompetent and the onus is on us to prove otherwise before renewal of registration by the Medical Board of AHPRA. Doctors facing retirement cannot renew registration without showing competence by fulﬁlling CPD requirements and recency of practice. Are we being denied natural justice? A medical practitioner who commits a medical practice offence has a right of appeal and the onus of proof of incompetence is on AHPRA. continued on Page 6
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4 | FEBRUARY 2016
Major Sponsor: Clinipath Pathology
National Award for Clinipath Pathology Clinipath Pathology has been providing high quality diagnostic pathology services to the WA community for over 20 years. Two of our key values are Commitment to Service Excellence and to be enthusiastic about Continuous Improvement. Many organisations have such core values, however Clinipath Pathology has a practical education and development program that ensures we maintain and consistently deliver quality service. The recent national recognition of how these values have been applied and the opportunities created for our staff is cause for celebration. National Recognition In November, 2015, Clinipath Pathology won the Australian Federal Government's Australian Apprenticeships – Employer Award. This extensive examination of the very best Australian organisations and people was established in 1994 as part of the Australian Training Awards – the peak, national awards for the vocational education and training (VET) sector. It recognises individuals, businesses and registered training organisations for their contribution to skilling Australia. At Clinipath Pathology, we place great value on service excellence and continuous improvement – values that are paramount when creating relevant and quality training opportunities for our employees. We were honoured to be recognised amongst strong competition across all industry sectors, and are very proud of our achievement and our people, who have enthusiastically embraced the opportunities offered to them. Ongoing development and training isn’t new to the medical profession. Continuing Professional Development (CPD) is part of our ongoing commitment as clinicians so we remain current, informed and can provide the very best care to our patients. We identiﬁed gaps and potential for improved training and education of our Pathology Collectors and Specimen Reception staff. These are crucial areas of patient service, particularly for collectors who may be the only point of contact that patients have with Clinipath Pathology. Collectors often start their career with little medical industry experience, and on-the-job training is the norm. We made a conscious decision to ﬁll this gap by providing industry speciﬁc traineeships. This empowers our employees through education, and has improved the quality processes of our pathology collection and
L to R: Beryl Avenell, Sarah Marchant, Hon Liza Harvey, Ann Poole, Rita Welsh & Margaret Poole. Patient Services Management Team: Clinipath Pathology Traineeship Graduation Ceremony, August 25, 2015
specimen reception at the laboratory. Five years down the track, by winning the peak national VET award, we have not only “ﬁlled the gap” but have raised the bar. Innovative Approach Our Pathology Collectors' customised training program is the ﬁrst of its type in the Western Australian Pathology industry. It complements our requirement for all Pathology Collectors to have a Certiﬁcate III in Pathology Collection. In addition, each staff member then undertakes a Certiﬁcate IV in Laboratory Techniques. This broadens the individual’s knowledge and practical expertise. Our model also includes a tailored Certiﬁcate IV qualiﬁcation for staff within the Specimen Reception department of our laboratory. Training Journey for Life With over 350 collection staff working offsite, the logistics of providing in-depth training, while continuing the day-to-day business of supporting our patients and referrers, presented unique challenges. This was efﬁciently managed by working with a Registered Training Organisation (RTO), LabTech Training (LTT), which delivered training to staff at our collection centres during the quieter times of the day. This approach has been hugely successful and brought with it a training culture within the practice. Our staff work collaboratively on their programs and obtain constant support from their training mentors.
Main Laboratory: 310 Selby St North, Osborne Park General Enquires: 9371 4200
Patient Results: 9371 4340
For information on our extensive network of Collection Centres, as well as other clinical information please visit our website at
Supporting our Diverse Workforce About 70% of our 350 Pathology Collectors are mature age employees, and about 17% of this cohort is over 60. Many of our employees started their career at Clinipath Pathology with no qualiﬁcations. Through their efforts and the training we have provided, they have progressed to supervisory positions within the Practice. We encourage our employees to embark on a training journey for life. We believe this has led to a happier, more engaged workforce with increased commitment to providing quality service. In recognition of this, in 2014 we were awarded the WA Chamber of Commerce and Industry’s Outstanding Employer of MatureAge Apprenticeships and Trainees award. Recognising our Achievements We are justiﬁably proud of achieving local and national recognition. We believe our achievements have made a tangible difference to the quality of our service. We have found that staff who are recognised for their experience and achievements, and offered self-development, progress their careers - regardless of age – and they adopt a positive attitude and become passionate about service. This directly translates to the high quality service and patient care we continue to provide to the West Australian community.
Dr Gordon Harloe
Letters continued from Page 4 It is getting worse as revalidation will soon be required by AHPRA. AHPRA has recently announced there will be no changes following the recent review of national registration by Kim Snowball. Soon, I will be joining the many senior doctors who have given up – this is a waste of valuable medical expertise as most of these doctors supervise or mentor trainees. Dr KC Wan, FAFOEM, Consultant Occupational Physician ........................................................................
Heavy hand makes hard work Dear Editor, My brief letter about my personal difﬁculty communicating with the Chair of the Medical Board (August edition) brought interesting responses – two letters, one not for publication, and neither addressed directly to me. From them I have not learned anything new about the Medical Board and AHPRA in WA (or any modern Australian bureaucracy for that matter). The AHPRA State Manager who wrote in reply to my letter in Medical Forum would have been more helpful if she had actually discussed the difﬁculties one encounters when trying to contact individuals within AHPRA or the Board. A/Prof Collins mentions processes being "fair and legally robust", with "fair decision making" and "natural justice" for doctors. My colleague’s experience, which prompted my interest in AHPRA and the Board, saw no evidence of any of this. Late in 2014 she was notiﬁed about a telephoned complaint – a failure to diagnose lung cancer – that would be the subject of a formal investigation and
report to the Board. My colleague regarded this as a vexatious complaint because the last interaction with the patient had been to tell them the good news they did not have cancer. One would assume this could be dealt with quickly without any fuss, and that perhaps penalties for making a false statement would apply to the complainant, as they would to any doctor being investigated who made a false statement. Despite informing AHPRA of this, a full investigation continued requiring copious documentation and considerable anxiety until six months later my colleague was told they had neither failed to diagnose, nor made a late diagnosis of, chronic lung disease. When we pointed out that the original complaint was about cancer, with no mention of chronic lung disease, we were informed that further discussion between AHPRA and the complainant had shown the patient was "confused" when making the original complaint. When I suggested that the AHPRA investigator should have informed my colleague of the actual complaint being investigated, the reply was that she had been informed in the letter clearing her of the charges, six months after investigation began. So much for natural justice. My colleague was placed in the truly Kafkaesque situation of having to explain something that did not happen, and then being cleared of something of which she had not been accused. Despite the involvement of our medical defence organisation, AHPRA stands by everything they did. I feel deeply sad for anyone involved with AHPRA – it and the Board seem devoid of decency and common sense.
Negotiate not litigate Dear Editor, I read with interest the medicolegal feature Deﬁciencies not an Incompetency Issue (December) and in my view this case has not set a legal precedent as such, but I would hope the Board has reﬂected on its decisionmaking processes in this matter, which pushed the complaint to ‘hear and learn’! The costs incurred by the Board would have been signiﬁcant and I would hope the experience would have a knock-on effect for future ﬁles where negotiated outcomes should be considered seriously. From a medical defence perspective, one of the most disappointing aspects of this ﬁle is the costs incurred by the community and the MDO to litigate the complaint where, sadly, common sense did not prevail. In our view, sensible discussions between informed parties with an agreed outcome is better for all – the Board could be satisﬁed that the public is protected and emotional and ﬁnancial cost is minimised. It is vital that practitioners with special interests are able to practise as this has been shown to be of great beneﬁt to those patients requiring that special care. There are obviously ways for this to occur which does not place the community at risk. Ms Cheryl McDonald, National Manager Claims & Legal Services, MIGA
Dr Paddy Hanrahan, South Perth ED: We asked the Medical Board to comment on the report “Deﬁciencies Not a Competency Issue” (December edition) but it declined.
A New Career in Caring Begins It’s a new stethoscope and a world of possibilities for newly graduated Dr Ben Roestenburg. How does it feel to be a brand-new doctor with a New Year ahead of you?… Incredible! I’ll admit to a healthy degree of apprehension as I step up to the responsibility of caring for patients, but I know I’ll be well-supported. If I could have a six month holiday anywhere in the world it’d be… Something adventurous like trekking the Milford Sound in New Zealand. I’ve been fortunate to see a fair bit of the world and I can’t wait to travel with my kids.
6 | FEBRUARY 2016
A person I really admire is… There are many, but my stand-out is Julian Burnside QC. He is a passionate humanist, an outspoken advocate for refugees and he’s prepared to stand by his convictions. The worst experience of my life was… I really can't put that in print! But I can say that my worst and best experiences are when I get that ﬂash of realisation that I don’t know everything, that I’m not centre of the universe and that I’m responsible for writing my own future. One of my favourite pieces of music is… Bach's Cello Suite No. 1 in G. I love the haunting sound of the cello and in skilled hands it’s capable of an incredible range of sounds.
Major Sponsor: 8FTUFSO$BSEJPMPHZ
Nutrigenomics - to the HEART of the matter?
"CPVUUIFBVUIPS Genetic variations in genes encoding for apolipoproteins, some enzymes and hormones can alter individual tendencies towards cardiovascular disease. Some of these variants are susceptible for dietary intervention; for example individuals with the E4 allele in the apolipoprotein E gene show higher LDL levels with increased fat intake compared with those with other (E1, E2 and E3) alleles receiving equivalent amounts of fat (3).
Nutrigenomics is suitable for cardiovascular medicine, potentially enabling both prevention and treatment of cardiovascular disease (CVD) by optimizing an individualsâ€™ dietary intake. Nutrigenomics looks at the effects of dietary nutrients and other food components on gene expression and gene regulation. It also matches the individualâ€™s nutritional requirements based on their genetic make-up (a personalised diet) as well as looking at the association between diet and chronic diseases such as cancer, type-2 diabetes, obesity and CVD.
Sodium chloride is the only dietary risk factor well deďŹ ned to predispose to hypertension. However, blood pressure responses to increases and decreases in dietary salt intake may be heterogeneous, as only about 15% have sodium-sensitive hypertension. For the other 85%, eliminating salt from the diet has no effect on their blood pressure (4). There are some reports about the encoding epithelial sodium channel (ENaC) subunits and interactions between polymorphic variants of these genes and dietary factors.
Nutrigenetics, looking at it another way, identiďŹ es how the personâ€™s genetic make-up co-ordinates his or her response to various dietary nutrients, revealing why people respond differently to the same nutrient (1). This concept of diet inďŹ‚uencing health is not new. In 400BC Hippocrates advised: â€œleave your drugs in the chemistâ€™s pot if you can heal your patient with foodâ€?. Table 1 shows some well-known interactions. Table 1: Inherited genes and food interactions Genetic condition
Foods to avoid
Defective aldehyde dehydrogenase enzyme (Asian population)
Those containing lactose or galactose, including all milk and milk products
Lactose intolerance (shortage of the enzyme lactase)
Milk and milk products
Food containing the amino acid phenylalanine (e.g. ďŹ sh, chicken, eggs, cheese, milk, dried beans, nuts, tofu).
CVD is the primary diet-related chronic disease of modern time and can be characterised as a group of multifactorial conditions associated with obesity, atherosclerosis, hypertension and thrombosis. Atherosclerosis constitutes the key element in the pathogenesis of CVD and it can be regarded as a complex combination of lipid transport and metabolism disorder with chronic inďŹ‚ammation (2). Permanently elevated levels of total cholesterol, LDL cholesterol and triglycerides predispose to the development of atherosclerotic plaques, whereas increased levels of HDL cholesterol appear to be protective.
Although remarkable progress has been made, the search for biological mechanisms that underly gene-diet interactions represents a major challenge. It is generally accepted that cellular processes from gene expression to protein synthesis and degradation can be regulated by dietary components; however, there is a very limited understanding of the nutrient and non-nutrient related networks (5). Far more research is needed before personalised nutrigenomic diets become a reality. At present, very few diet-gene interactions yield speciďŹ c useful advice and even fewer genetic variants can be screened
Dr Janssen was born in The Netherlands and studied medicine at Maastricht and cardiology under Professor Hein Wellens, specialising in electrophysiology and interventional cardiology. As an A/Professor he worked at the Academic Hospital in Maastricht and Rotterdam, then Saudi Arabia before joining Western Cardiology in Perth. Dr Janssen runs weekly clinics in Kalgoorlie and monthly clinics in Geraldton. He teaches medical students in rural areas (Rural Medical School UWA and Notre Dame) as well as at SJOG Hospital, Subiaco and Midland. 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.
for. Nutrigenomic prescriptions will probably depend on age and other physiological changes such as pregnancy. The potential beneďŹ ts from Nutrigenomics are tremendous: safe limits for essential macro-nutrients like carbohydrates, proteins and fats, and micro nutrients like vitamins and minerals better understood; diseases avoided or ameliorated; unnecessary dietary supplements avoided; a freeing up of the diet of non-responders; and lifespan might be extended. However, it raises numerous ethical questions, such as whether genetic proďŹ ling should be available only to those who can afford it. Perhaps that is the heart of the matter.
References 1. Ioannidis JPA et al: Prediction of Cardiovascular Disease Outcomes and Established Cardiovascular Risk Factors by Genome-Wide Association Markers. Circ Cardiovasc Genet. 2009;2:7-15 2. Glass CK et al: Atherosclerosis: the road ahead. Cell 2001; 104:503-16. 3. Mahley RW et al: Apolipoprotein E: far more than a lipid transport protein. Ann Rev Genomics Hum Genet 2000;1: 507-37 4. Luft FC et al: Heterogeneous responses to changes in dietary salt intake: the salt-sensitivvity paradigm. Am J Clin Nutr 1997;65(Suppl. 2): 612S-7S 5. Panagiotou G et al: Nutritional systems biology: definitions and approaches. Annu Rev Nutr. 2009;29:329-339
7JTJUXXXXFTUFSODBSEJPMPHZDPNBV 14 Cardiologists, together with Ancillary Staff, provide a comprehensive range of private Adult and Paediatric Services
Main Rooms: St John of God Hospital, Suite 324/25 McCourt Street, Subiaco 6008 5FMt$PVOUSZ'SFF$BMM 6SCBO#SBODIFT Applecross, Balcatta, Duncraig, Joondalup, Midland & Mount Lawley Regional: Busselton, Geraldton, Kalgoorlie, Mandurah & Northam MEDICAL FORUM
FEBRUARY 2016 | 7
Why Smart People Make Silly Decisions Dr Jenny Brockis looks at why those with smart brains are prone to make decisions that disappoint others. We've all seen it. Those times when a decision made by someone we thought had a modicum of common sense left us shaking our heads wondering, "What were they thinking?" Sometimes we may even acknowledge we can make those sorts of errors ourselves! Why does this happen? Is it because selfinterest, lack of awareness or power plays gets in the way? Or is it because we choose to go along with the small band of others who share their world perspective, so it must be right.
Humans make decisions based less on logic, reasoning and analysis and more on emotion that is coloured by our perspective, values and belief systems.
Even the smartest brains are fallible, imperfect and prone to thought glitches because we all share one thing in common. We are human and humans make decisions based less on logic, reasoning and analysis and more on emotion that is coloured by our perspective, values and belief systems.
Whilst that bucket is conveniently topped up overnight, it is still ﬁnite, meaning that unless we take time out to restore and replenish by getting enough sleep, uncoupling from our hard core focused work intermittently, and pulling in for a pit stop to refuel we risk making some really bad decisions.
Doctors are required to make an extraordinary number of important decisions every day. The average Joe makes around 30,000 decisions daily, either at a conscious or subconscious level, each one requiring a dollop of cognitive energy from our willpower bucket.
Studies have shown how decisions passed down by Judges are inﬂuenced by the time of day and how hungry they are! Next time you ﬁnd yourself before a Parole Board you might want to consider that.
Even when we do the right things to minimise the risk of dropping a clanger, humans are not immune. Would the world have been different if Thomas Austin hadn't decided it was a great idea to release those 24 rabbits in Victoria for hunting? What matters is self-awareness: to recognise when we are being persuaded to follow a line of thinking that doesn't match our values and beliefs; to notice when our thought patterns are stuck, denying us the opportunity to consider alternatives; or to recognise when fatigue might be causing us to default to decisions that require less critical thinking that might not deliver the best outcome. The danger lies in choosing to ignore those intuitive warning signs or allowing self-interest and pursuit of power to cloud our judgement. Ed. Dr Jenny Brockis is the author of Future Brain (Wiley)
Medical Board sets Nitschke free ee Over the Christmas break you may have seen the 2015 Australian ﬁlm Last Cab To Darwin. It had some iconic Australian actors, outback scenery and raw humour. The interesting part for doctors was the ﬁlm was based on the real-life story of terminally ill Broken Hill taxi driver Max Bell, who drove his cab over 3000km to Darwin. He wanted to end his life after the 1995 introduction of the Northern Territory’s Rights of the Terminally Ill Act. Dr Philip Nitschke helped four people end their lives in the 11 months it was legal to do so in the NT. Dr Nitschke visited Perth not long after he returned from overseas to ﬁnd that lawyers had negotiated 25 conditions on his registration, which were imposed by the national Medical Board.
attempt to restrict the free ﬂow of information on end-of-life -of-life choice." There are those amongst ngst us who say the medical profession n should never be part of the argument about dying – that baby boomers who feel el they have had a good innings will sort it out and lobby hard. Maybe then we will stop op reading the occasional horror stories ries of elderly people taking their lives es in ways no one would wish. FOOTNOTE: Philip Nitschke hke will be taking the show that hat had last year’s Edinburgh h Fringe Festival in a spin to o the Melbourne International nal Comedy Festival in April.
He said support for his ongoing involvement in Exit International was strong and the Medical Board conditions so onerous that he had no choice but to burn his medical registration card and end his medical career. With this goes any hold the Medical Board has over Philip Nitschke who said, "The conditions the board has sought to impose on me ... amount to a heavy handed and clumsy
8 | FEBRUARY 2016
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Art, Passion and Conversation Taking over the reins of the Perth Festival is both thrilling and terrifying for new incumbent Wendy Martin. The curtain goes up on February 12. There’s a strong thread of creative story-telling in Perth International Arts Festival (PIAF) 2016. It marks the debut for new Artistic Director, Wendy Martin, who brings a journalist’s eye, a sense of adventure and a passion for igniting tantalising chemistry between artist and audience.
something of an impresario who ran the Tivoli circuit in Sydney and Melbourne. He would get on a boat and go to New York and London in the 1950s and ﬁnd acts to bring back to Australia. And then my dad took it over when he was only 24 and eventually went on to become the CEO of the Sydney Opera House.”
“As a director you want to present material that people will love, but it’s equally important to seek out and present work that might just change an audience’s perception of what ‘performance’ actually is.”
“I was very privileged to work for the ABC and SBS. I was in my early 20s and my job was to read books, go to the theatre, watch ﬁlms and go to art galleries. It enabled me to meet just about every major Australian artist across all the art forms. It was a fantastic education!”
“The opening address at the Writers Festival by Roman Krznaric, the cultural thinker and founder of the Empathy Museum, will highlight the importance of the simple art of conversation and its power to bring about social transformation.”
Everything has a story
Opening night jitters
“My background in arts journalism shapes the way I put a festival together. I’m always looking for a narrative thread and interesting angles. Everything in the PIAF program has a rich story behind it.”
Wendy concedes that her role as artistic director comes with a degree of stress, but the serious butterﬂies make their presence felt when the lights go down and the curtain goes up.
“We’ve got a highly visceral and interactive dance experience from Brazilian choreographer Lia Rodrigues called Pindorama. The audience will be watching it unfold from both around and within the performance and, as the PIAF program says, it’s ‘at times disarming, at others comforting’.” Faces, places and spaces “It’s interesting to see so many artists working in site-speciﬁc venues that are quite unconventional. There’s a play involving ﬁve young Muslim women set in the Queen St Gym called No Guts, No Heart, No Glory that takes place within the ropes of a boxing ring.” “There’s a real sense of adventure in the 2016 PIAF program with a strong Indigenous presence. We’re hoping the people of Perth will ﬁnd artistic performances everywhere they look.” Wendy’s artistic CV is an interesting one. Putting on shows is in her DNA and previous roles at our national broadcasters have honed her skills at seeking out stories that are both relevant and full of imagination. “My grandfather, who came from Perth, was
There was one aspect of Wendy’s role that proved disarmingly simple. “Every person I approached to come to the Festival and perform, without exception, said they’d love to be here. PIAF has a great reputation internationally and the artists who’ve been here before have had wonderful experiences. Word gets around!” “And, if you’re coming from the northern hemisphere, a Perth summer is pretty compelling.” “One of the great things about the Festival is that there are so many different artistic platforms. There’s music, dance, theatre, books and writing. The Sunday Series in late February explores the creative vision of some of the participating artists and will be a real highlight.”
“One thing I don’t enjoy is sitting in the theatre on the ﬁrst night of a performance. The artists are up there on stage because I’ve invited them with the audience all around me who’ve been encouraged to come and see a work that I think is wonderful.” “I want them to love it, but there’s nothing I can do about it. That, for me, is a stressful moment.” “When Festival 2016 is all over I hope the audience has had a wonderful experience. I hope they’ve seen things of great beauty and glimpsed another perspective that might make them look differently at their world.” “But most of all I hope they’ve had, and continue to have, wonderful conversations.”
By Peter McClelland
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Have You Heard?
Retired by the ballot box MDOs, as ‘mutuals’, say they are owned by their member doctors and seek to serve them well. When (the minority of) members take part in elections, is their say ‘euphemised’ by rhetoric? When MDA members recently voted Dr Maher onto the MDA Board to replace Dr Capolingua at the MDA National mutual board elections, we received a media release that announced Dr Capolingua had retired from the board. As this seemed different to being voted off by policyholders at an election, we investigated, to ﬁnd that the MDA National constitution talks of board members whose three-year term expires as “retiring”. If you stand for re-election and fail you are retired! We think member powers deserve more consideration. Its’ a bit like saying
the only nominee for a position is “elected unopposed” when no election amongst the broad membership is held.
Who you gonna call? The MDA National report, printed in Melbourne, delivers the usual ﬁnancials and proﬁles of organisation heavies. As well as emphasising growth (12%) and a sound ﬁnancial position ($15m surplus), MDA National’s stated point of difference is its education and hands-on help for doctors. Interestingly, only 25% of those seeking clinical advice had ethical dilemmas in mind; and GPs were ahead of surgeons, and doctors in training in seeking general medico-legal advice (48%, 15%, and 10%, respectively). When it came to actual cases
Simply PEaCHS Rural Health West hosted the inaugural Paediatric Emergencies and Clinical Healthcare Scenarios (PEaCHS) workshop at the Busselton Health Campus before Christmas. Emergency physicians Dr Colin Parker, Dr Simon Wood and Dr Yuresh Naidoo led the workshops for the 16 delegates who were all GPs from across the South West region including Bunbury, Margaret River and Busselton. The workshop will be held again this year in Broome, Geraldton and Perth.
dealt with, GPs (41%) were ahead of surgeons (22%), anaesthetists (7%), O&G made only 4%, while ED doctors were alongside dermatologists (1%). The all-important Cases Committee for WA, which inﬂuences how MDA takes on your problems, is comprised of Dr Rod Moore, A/Prof Max Baumwol, Dr Fiona Bettenay, Dr Reg Bullen, A/Prof Rosanna Capolingua, Dr Michael Gannon, C/Prof Guy van Hazel, Dr Tim Jeffrey, Dr Andrew Miller, C/Prof Alan Skirving and A/Prof David Watson. The composition of this committee will not be changing.
IMGs specialist training Last year, we asked Government to provide numbers of IMGs working in public hospitals in WA. This was prompted by the complaints of the lack of specialist training places for WA graduates. As simplistic as it seems, we chose the number of IMG senior registrars per discipline, as an indicator of those likely to occupy a training post. The breakdown of IMGs per discipline shows IMG senior registrars in brackets: General Medicine 160 (6); Emergency Medicine 133 (11); Anaesthetics & Pain Medicine 62 (41); Intensive Care 44 (14); Medical Administration 43 (1); Psychiatry 37 (8); General Surgery 31 (3); General Practice 22 (7); Neonatal Medicine 21 (9); and O&G 21 (1). This comes at a time when there is a general decline of limited IMG registrations, though areas of need are a different matter.
State of our workforce Left: Paediatrician Dr Colin Parker
In December the AIHW published its annual workforce report which showed only slight
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increases from 2013 ﬁgures. The last head count was 8343 doctors in WA, 2768 of them GPs and 2810 specialists. Where the stats get interesting is in the gender and age proﬁles. More women are training to be specialists – in 2014 52% of the positions were ﬁlled by women, but there is still a long way to go for parity once fully ﬂedged. In 2014 women accounted for 27.8% of specialists. In general practice it’s 39.8%. And the profession is getting older. There is only 13.8% under the age of 30, not surprisingly 51.9% of those are in the hospital system and 33.7% are in specialist training. General Practice has 36.5% of its workforce over the age of 55. Just over half the specialists in WA worked in the public sector (1389 FTE positions).
GPs still in the Chain In our earlier conversation with Medical Director of Silver Chain’s Home Hospital (HH), Dr Daryl Kroschel, he detailed WA Health’s contract with them to care for early-release patients from hospital. Who else used HH services? Apparently at least 60 referrals a month from GPs and residential aged care facilities, the most common entry point from the community into HH. Treatments included cellulitis, lacerations, skin tears, wounds, constipation, acute urinary retention, catheter issues including suprapubic, chest infections and exacerbations of COPD, cellulitis, IV hydrations and PEG tube re-insertions. HH will conduct GP education events in 2016.
especially its home hospital services, as government seeks to cut down avoidable hospital admissions. In fact, Board Chair Anne Skipper says that 30% of hospital admissions are unnecessary. Does Silver Chain do it better? About 41% of income comes as HACC grants ($102m), 36% from State Health ($89m), and 10% as other Commonwealth grants. About 1% of income is donations ($3.3m) and Silver Chain raises $23m in care fees. On the expenditure side, 79% of costs are for the 3200 employees (with 7% as “other”, the next biggest category). In WA: the Hospice Care service says 69% of its clients die at home; and about 50% of services are wound care for which nursing staff spend an average 33 minutes, every 19 days per client, averaging 19.3 visits. While this ﬁlls the year nicely for each client, we would like to know the daily travel time for staff in their 1080 vehicles and the time efﬁciency of visits.
Ovarian cancer CBT study
Every sperm is sacred
At St John of God Subiaco Hospital, Dr Paul Cohen is setting up a pilot study to examine if Mindfulness-based cognitive therapy (MBCT) helps ovarian cancer survivors manage their fears of the cancer recurring. He is seeking volunteers for an eight-week MBCT course run by Cancer Council WA. Information is available from the Clinical Trial Unit on 6465 9204.
The window of the Silly Season just keeps getting bigger and bigger. How else can we legitimately report on wonder undies (and publish a picture of a man in his jocks) if not for this latest breakthrough from Paris, the fashion capital – and now sperm-friendliest city in the world. Sperm can now stay safe from wi-ﬁ and cell phone radiation tucked up safe in specially formulated boxers until required for duty. Silver ﬁbres are woven through the cotton fabric activating the force ﬁeld. We won’t be so obvious as to point out the loopholes but Instagram and Facebook are sure to!
Top heavy with heavies
Silver Chain growth
Healthway legislation was caught up in political argy bargy at the end of last year, so a frustrated Dr Kim Hames wants readers
Still on Silver Chain, its 2014-15 annual report is out and its popularity is clearly growing,
continued on Page 14
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Have You Heard? continued from Page 13 to know that “The passage of the Western Australian Health Promotion Foundation Bill 2015 will be a top priority when Parliament resumes in February.” The interim board of the DG of Health, Dr David Weisz (with his nominee Prof Bryant Stokes), Mr Duncan Ord, DG of the DCA, Ms Emma White, DG of Child Protection and Family Support, Mr Ron Alexander, DG of Sport & Recreation, and Ms Ricky Burges, CEO of WALGA, will continue, possibly at the Minister’s pleasure. Under the legislation, the board will be reduced from 11 to seven and appointed by the Minister. Rumours of a more community-based group appear to have been grossly exaggerated!
Patent rings new year WA-based regenerative cell biotech Orthocell started the year in ﬁne fashion with the announcement that the US had accepted its patent for its “cell factory” technology. As reported throughout the year, the fundamentals of the product have withstood the recent market storms and this nod from the US regulatory authorities has been enough to send its shares up by nearly 20%. It was 54 cents when we went to press. The company is led by chair Dr Stewart Washer and MD Paul Anderson and based at Murdoch University.
Ode to a Nightingale While the opening of the new Anne Leach wing at Hollywood Private Hospital has made it the second biggest hospital in WA with 750 beds after FSH (783 beds), it was to its roots it turned to for its name. At a ceremony just before Christmas the wing was ofﬁcially dedicated to nurse Anne Leach, who saw war service in the Middle East in the 1940s and then became sister-in-charge of Hollywood Repatriation Hospital, which Ramsay Health bought in 1994. It continues to care of military veterans’ health. Mrs Leach, who is now 101 years old, was the guest of honour at the event, which was also attended by the Health Minister Dr Kim Hames, RSL state president Mr Graham Edwards, Ramsay chair Michael Siddle, CEO of Ramsay Australia Danny Sim, and hosted by Hollywood CEO Mr Peter Mott. The new wing has added 30 beds and six theatres to the hospital. In his dedication speech, Dr Hames said that he copped a lot of ﬂak for encouraging public-private partnerships in the hospital sector, but no one would want to see the Ramsay-run Joondalup Health Campus administered any other way. Mr Siddle told the audience that WA led the country in public-private partnerships and he wished other states would follow suit.
Ramsay's Kevin Cass-Ryall and Peter Mott with Mrs Anne Leach
Money well spent The world is more transparent thanks to the magic of the internet. We were contacted by a researcher who accessed papers which showed the consultant fees paid to Banscott Health Consulting (headed by previous DG of WA Health, Alan Bansemer). This is what we found: The company, which was established in 2002, has received $3.5m for 18 or so contracts from the Department of Health spanning 2007-13, which seem to be Commonwealth, some awarded by restricted tender. There are no aspersions cast that the Government didn’t get value for money. His commissioned reports for the Commonwealth that call for reforms include
one on mental health in the NT (Building Healthier Communities), and the more recent Delivery of Health Services in Tasmania in response to long waitlists and access blocks and after a $325m Commonwealth injection. Alan was a distinguished career public servant, coming with an economics and business background from Adelaide. He was DG of Health here from 1995-2001. His 2001 retirement was lauded by Health Minister Bob Kucera after six years as DG, about a year after he appointed Dr David Russell-Weisz as the inaugural Director of Medical Services for the North West.
Alan served eight years as the Deputy Secretary to the Commonwealth Government Department of Human Services and Health, and was chair of the Medicare Schedule Review Board and General Practice Consultative Committee. He also advised the Australian Health Ministers’ Advisory Council, Health Insurance Commission (now Medicare Australia) and the Australian Institute of Health and Welfare among others. Then there is his breeding of stud horses at his Namerik stud in the Serpentine.
Thumbs up for folate results A WA study found the prevalence of spina biﬁda and related anomalies (neural tube defects) in Aboriginal babies has fallen by 68% since mandatory fortiﬁcation of all wheat ﬂour for bread-making was introduced by the Federal Government in Australia in September 2009. Telethon Kids Institute researchers Prof Carol Bower and Prof Fiona Stanley played a signiﬁcant role in inﬂuencing that policy decision. When promotional campaigns didn’t hit their mark, fresh fruit and vegetables were scarce, and prepregnancy became the targeted period, national fortiﬁcation was key. In the Aboriginal population, where folate levels are lower than in the non-Aboriginal population and neural tube defects twice as common, about half of all pregnancies are unplanned. According to the press release, this policy has helped save families and children from the challenges associated with a severe disability.
TGA warn on Champix The TGA has stepped up its warning on the potential psychiatric risks with the drug varenicline (marketed here as Champix) which helps people to stop smoking. New Product Information (PI) highlights these risks and also warns that consuming alcohol can also increase the potential for psychiatric symptoms. Doctors are urged to advise patients of this double risk.
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Teaching and Knowledge Exchange GP Dr Cathryn Milligan has learnt much from opening her Margaret River surgery to registrars and medical students for the past 10 years. The award reads ‘2015 RACGP General Practice Supervisor of the Year’, and Margaret River GP Dr Cathryn Milligan is the proud recipient. We phoned when she was manoeuvring her car, with accompanying ‘beeps’, in a local car park. She earned the award by mentoring general practice registrars and medical students and inspiring them to a career in general practice (with two graduate GPs staying on to work in her practice). What has her 10 years of 1-2 registrars each year taught her? “Aside from their youth, they bring their training from the hospitals, so their protocols are quite crisp and up-to-date. I ﬁnd that useful to bounce off. I teach them how to use protocols as guidelines rather than rules. It works well,” she said, adding relatively advanced skills are required where she works. “Some may not work as fast as others but they have usually done two or three years in the hospital system and have done some rotations, so their fundamentals are quite sound when they get here – they just need to reﬁne that to general practice.”
Dr Milligan in her garden and with husband Mark Leavesley at the RACGP award ceremony.
Talking to Cathryn you get the idea that she learns a lot while teaching. Different strokes, different folks “It’s quite a collegiate environment and they are never working alone. They know they can pop their head out and ask someone. The things that stump them are things like rashes that you don’t usually see in hospital, and gynaecological problems. But I’m quite astounded at how good they are.” Cathryn is the sole principal at Margaret River Surgery, having just bought out another doctor. She says the people she works with are professional and committed, so they take ownership on a professional level. She has been at the practice for 19 years. While many equate Margaret River with ‘lifestylers’, she is still learning from the registrars about work-life balance. “I watch and learn from them. We all work only four days a week but we all do anaesthetics, obstetrics and ED – we take time off after being on call. The younger ones haven’t done the hours we did when training and they just get tired and don’t want to do what we think is quite normal, which helps us think it through.” She takes registrars at all points of training. Most of her consulting is women’s health and obstetrics. With no surgeon in town and the Bunbury surgeon no longer visiting for elective caesareans, the time is ripe for an advanced GP obstetrician to move there.
The generational differences – she admits she is old enough to say that – shows itself strongly in the registrar’s IT skills, with many routinely touch typing. Registrars do a lot of online training, travel less (which helps them) and manage some group teleconferencing and Skyping from Margaret River, although she feels face-to-face with trainers in Perth is important. The health consumer complaint of doctors too distracted by computer screens is overrated, she said. “I used to write notes. You have to look at both, whether typing or writing notes, so patient time is just a time management thing.” Life experience counts Because the practice takes medical students as well, she has noticed that since the universities changed to postgraduate intakes, quite a few are a bit older and have had careers before, and the extra life experience is good for their general practice work. She is waiting to see things trickle on to the GP registrars. She is used to any ﬁshbowl effect that a doctor living and working in a rural town gets. In fact, she says living in the community makes rural practice “quite inspiring”.
“And I feel more represented by the college. They are developing a proﬁle which is important. They are trying to provide a voice as well as the AMA – the AMA is the go-to organisation for government but ACCRM, Rural Health West, RACGP, RDA are all good and seem to work together. The proﬁle of general practice is improving.” She admits that although the isolation has decreased thanks to emails and other good communication tools, rural practice remains busy, which makes it harder for full time country GPs to get involved in the community. “I think you have to be prepared to step back from clinical practice a bit to be involved in organisations.” “I feel I’ll have a presence here for a long time. I like to be busy and I have multiple interests. I do like my work and haven’t put a time frame on it but imagine I will start to cut back in ﬁve years.” Her four children have all left home but being on-call one weekend in three means she gets to Perth about once a month to see the family.
By Dr Rob McEvoy
FEBRUARY 2016 | 17
Are PHNs the Hope of the Future? !SĂĽTHEĂĽ0(.SĂĽENTERĂĽTHEĂĽSECONDĂĽSIXĂĽMONTHSĂĽOFĂĽTHEIRĂĽYOUNGĂĽLIVES ĂĽWEĂĽTALKĂĽTOĂĽLearne Durrington ĂĽ THEĂĽ#%/ĂĽOFĂĽTHEĂĽBODYĂĽOVERSEEINGĂĽTHEIRĂĽESTABLISHMENTĂĽANDĂĽOPERATIONĂĽINĂĽ7! still grapple with this issue in the UK where clinical commissioning has been going on for ďŹ ve years. Itâ€™s the nature of the business and weâ€™re a smaller pond.â€?
The Primary Health Networks were born on July 1 last year with a lot riding on their success: Federal and state politicians looking for a solution to the growing drain on their health budgets; governments and clinicians hoping for some inroads into the waste of fragmentation; GPs needing to be part of the solution and consumers simply wanting good, timely access to health services and continuity of care.
â€œWe have had to manage this already which has seen change of directorship [Medical Forum understands that Dr Andrew Png, who was on the original WAPHA planning board, stepped down because he was a director of the contracted NFP service company, 360 Health.] The board is acutely aware that transparent and ethical behaviour is critical to our future, notwithstanding that itâ€™s the standard. We have to report openly on these issues to the Commonwealth.â€?
So, not much pressure then! Everyone has an opinion on the PHNs. The crude dumping of Medicare Locals after less than three years; the shufďŹ‚ing of deckchairs required for parties to tender; the subsequent scramble to fulďŹ l the Governmentâ€™s exacting demands in a ridiculously tight timeframe. Then there are those watching from ringside seats â€“peak NFP and consumer bodies, private health insurers, clinical colleges and lobby groups not to mention big business, especially those involved in eHealth â€“ who are all scrutinising the PHNsâ€™ progress through their own particular ďŹ lters. All eyes on WAPHA Learne Durrington, former CEO of the Perth Central East Metropolitan Medicare Local, is acutely aware of the challenge. As CEO of the WA Primary Health Alliance (WAPHA), the successful tenderer for all three WA PHNs and the only combined bid, she knows this is a bold experiment for everyone. Medical Forum spoke to Learne late last year and to give readers an indication of the fast-speed of change in the sector, within four weeks, the PHNs had been handed signiďŹ cant funds to fulďŹ l the Governmentâ€™s mental health and alcohol and drugs (AOD) reform packages. These were not unexpected and are certainly well within the mandated PHN remit which focuses on commissioning local services in the areas of mental health, Aboriginal & Torres Strait Islander health, population health, health workforce, eHealth and aged care. Yet it is a sure signal of what the Government expects the PHNs to achieve in just 2Â˝ years. Learne said WAPHA was determined to demonstrate to the Commonwealth what can be done using the WAPHA management model. â€œWe may not be able to do all of it but we want to showcase a good start and have an impact,â€? she said. To give themselves half a chance to get on their feet, WAPHA has rolled over the previous Medicare Local service contracts until June 30 2016, and what will follow will be an open tender process. So how will the WAPHA management model work?
18 | FEBRUARY 2016
Former CEO of the Perth Central East Metropolitan Medicare Local, Learne Durrington
â€œWAPHA is starting from a clean slate and we are very clear on its role â€“ we are planners and commissioners and we wonâ€™t have any role in service delivery. In developing a new organisation we are keen not to repeat the concerns that were levelled at MLs.â€? Governance and structure WAPHA is the peak body overseeing the work of the three WA PHNs. The inaugural WAPHA board (see below) has been appointed initially from representatives of the consortium of organisations (a number of which were former Medicare Locals) that mounted the bid. WA is an isolated place so there are many familiar faces. Learne acknowledges that its directors are all individuals who â€œwear multiple hatsâ€? so managing conďŹ‚icts of interest (perceived or material) are a priority. â€œOur reputation will be built on our ability to manage that well. We need to be very transparent and that policy will translate to the commissioning committees as well. They
â€œThe Constitution is clear that we establish a skills-based board and not a representative board, which will eventually be determined by a member vote at the AGM. WACOSS is similarly set up.â€? â€œWe have invited peak organisations (not individuals) to become members of WAPHA. Largely those groups will represent the core activities (listed above) of the PHNs â€“ we need 11 groups which will help inform our strategic development and direction. We want to reach the broader sector but how we do that effectively becomes important because we want to make sure the system connects.â€? Under the rules of the Australian Charities and Not-for-proďŹ ts Commission (ACNC) WAPHA will be required to lodge an annual report on its activities and those of all three PHNs and Learne said a public report would also be produced. It is also reporting quarterly to its sole funder, the Federal Government. As to the issue of commercial stakeholders, Learne said it was too early for that discussion. â€œThere is no doubt that particularly health insurers are concerned about the impact on their business of increased hospital costs. There is already a trial under way in WA between two health insurers and the State government where they co-commission services so weâ€™d like to see how that works.â€?
WAPHA Board Chair: Dr Richard Choong (GP; Past President AMA WA President, Chair AGPAL) Dr Marcus Tan (GP; CEO Health Engine, SMHS Governing Council, AMA WA Asst Secretary) Dr Damien Zilm (GP; Chair GoldďŹ elds Esperance General Practice Network; WAGPET Board) Mr Tony Ahern (CEO of St Johnâ€™s Ambulance; Council of Ambulance Authorities; Elderbloom Community Care Centres Board) Ms Anne Russell-Brown (Semi-Retired; Former WA Director Mission Australia; Former Group Director Social Outreach for St John of God Health Care) Mr Steven Wragg (Pharmacist; President of Pharmacy Guild, MD Professional Pharmacy Services Group, MD Gregâ€™s Discount Chemist; Member CCI WA) Mr Rod Astbury (CEO, WA Association of Mental Health) Prof Rhonda Marriott (Dean Murdoch University Health Sciences, Chair Nursing, Maternal and New Born Health, Aboriginal Health and Wellbeing Academy)
Perth North PHN Council
Chair: Dr Damien Zilm (WAPHA Director)
Country WA PHN Clinical Commissioning Committee (CCC)
Prof Geoff Riley (Chair Clinical Commissioning Committee CCC)
Chair: Prof Geoff Riley (GP former head Rural Clinical School)
Ms Gloria Sutherland (Community rep)
Dr Will Patterson (Port Kennedy GP)
Ms Nola Wolski (Community rep)
Ms Melissa Vernon (Area Health Services, AHS)
Ms Margaret Culbong (ATSI Health rep)
Dr Andrew Jamieson (WACHS Population Health Planner)
TBC (ATSI Health rep)
Dr Bret Hart (Population Health Planner)
Mr Wayne Salvage (Acting CEO AHS)
Mrs Denese Grifﬁn (ATSI rep)
Dr Karen Murphy (Medical Director AHS)
Country WA PHN Council
Dr Neale Fong (WACHS Board Chair) Ms Melissa Vernon Delegate of CEO WACHS) Dr Andrew Jamieson (WACHS ED Medical Services)
Mr Rod Carpio (Nursing rep)
Ms Vivienne Duggin (Rural Health West)
Ms Kathryn Fitzgerald (Allied Health rep)
Ms Linda Richardson (PHN GM)
Mrs Carole Bain (Silver Chain)
Mr Anthony Masi (Pharmacist rep)
Chair: Ms Anne Russell-Brown (WAPHA Director) Dr Mike Civil (GP, Chair of CCC) Mr Tony Addiscott, (Chair of Community Engagement Committee) Prof Bryant Stokes (Board Chair AHS)
Perth North CCC Chair is Dr Mike Civil; other doctors include Dr Belinda Wozencraft & Dr Allan Pelkowitz
Dr Stephen Langford (RFDS) Prof Sandra Thompson (WACRH) Ms Linda Richardson (PHN GM)
Perth South PHN Council Chair: Dr Marcus Tan (WAPHA Director) Dr Fraser Barrie (Co-Chair of CCC)
Regional Commissioning Committees In the Goldﬁelds, the chair is GP Dr Roy Morris; other doctors include Dr Clare Huppatz & Dr Lorin Monck. In the Great South, the chair is Dr Don Gunning; other doctors include Dr Mahesh Reddy, Dr Helen van Gessel, Dr Kristi Holloway & Dr Andrew Wenzel. In the Kimberly, the chair is Dr Sally Cornelius; other doctors include Dr Lauren Turner, Dr Kerr Wright & Prof Jeanette Ward. In the Midwest, the chair is Dr Stu Adamson; other doctors include Dr Nalini Rao, Dr Eberhard Mandishona & Dr Andrew Jamieson
Dr Gary Fernandez (Co-Chair of CCC) Mr Mitch Messer (Chair of Community Engagement Committee) Prof Dawn Bessarab (ATSI Health rep) Dr Robert McDonald (Board Chair AHS) Dr Robyn Lawrence (proxy Kate Gatti) (CEO AHS) Ms Geraldine Carter (Medical Director AHS) Ms Bernie Kenny (PHN GM)
In the Pilbara, the chair is Dr Martin Kumar; other doctors include Dr Phil Montgomery. In the South West, the chair is Dr Stephen Arthur; other doctors include Dr Michiel Mel, Dr Stephen Cohen & Dr John Pollard. In the Wheatbelt, the chair is Dr Bill Chapman; other doctors include Dr Olga Ward & Dr Tony Mylius
“Right now we can’t see beyond our current horizon. In the future it may be that private hospitals are interested in doing some work with PHNs and insurers will collaborate at that time. But there are no governance protocols in place at present that involve any private or proﬁt agencies.”
the WAPHA board as well as delegates from the relevant area health services, while each clinical committee is chaired by a local GP. The relationship between the PHNs and the area health services is mandated and the government has made both responsible for determining which KPIs each PHN will report on.
The structure is designed to support better connection and communication between the sectors and to ensure consumers are getting the right services at the right time and in the right place. It is simple yet revolutionary!
Connecting and breaking down silos is the focus of the PHNs and their structure relies heavily on links with the local area health services. This is particularly evident in the country PHN. WAPHA’s statewide bid was audacious and critics were sceptical of its ability to deliver, especially in the vast country PHN which covers Esperance in the south to Kununurra in the north. It was previously under the remit of three Medicare Locals. The Country PHN not only has a council and a peak Clinical Commissioning Committee (CCC) but it also links to the regional health services through seven regional commissioning committees. It may look like bureaucracy on steroids but it demonstrates how seriously WAPHA is taking the criticism that it will not be able to respond adequately to local health needs in the disparate social and geographical catchments of our vast state. Each PHN council has representatives of their clinical commissioning and consumer engagement committees and a member of
Procurement of services WAPHA has until July 1 to establish a competitive tender process for service delivery, though in some remote communities those services might be delivered by select tender to avoid service loss. “In the metropolitan areas we’d expect all contracts to go to an open market. We think there is a lot of interest from a suite of providers for services that MLs were providing as well as a raft of new ones. There is a lot of optimism.”
Perth South CCC Co-Chairs: Dr Fraser Barrie & Dr Gary Fernandez; other doctors include Dr Nick Waldron
costs of WAPHA, the three PHNs and seven ofﬁces in the country. The PHNs operate from the same Rivervale ofﬁce as WAPHA and each share support staff. However, each PHN has its own budget and it allocates resources to its local communities as determined by each PHN council, with the WAPHA board having the judiciary duty to sign off on those projects. Service delivery is already being evaluated by the Commonwealth and Learne said that WAPHA’s academic partner Curtin University would also have a role in evaluating tenders as part of the commissioning cycle to demonstrate to the Commonwealth how the WAPHA model works. Bold new world The goodwill is starting to have positive effects. WAPHA is data sharing data with WA Health, a breakthrough in the history of Commonwealth-funded programs and the State health service.
With funding coming its way from the mental health review and the primary care taskforce into chronic and complex diseases, that optimism might be well placed.
“That’s a great foundation,” Learne said. “If we work collaboratively, we can actually make an impact on these issues but it will take compromise and goodwill from stakeholders and that may mean giving up some things in order to make it work.”
By Jan Hallam
The Federal Government investment is $66m, of which $12m is allocated for the operational
FEBRUARY 2016 | 19
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In the Heart of Mandalay Electrophysiologist and cardiologist Dr Tim Gattorna writes of his time in Mandalay where he and a team of volunteers were helping local colleagues on the path to modernisation. Last year I was fortunate to have had the opportunity to visit Mandalay General Hospital (MGH) with Open Heart International. Our mission was to provide educational and procedural support for electrophysiological services to the local cardiology team, where the clinical demand is high. Open Heart International, an initiative of the Sydney Adventist Hospital (SAH), is a volunteer organisation that mobilises teams of medical, nursing and allied health professionals along with medical consumables, supplies and equipment to provide surgery in developing countries. It ﬁrst began in 1986 in response to the overwhelming need for surgery for rheumatic heart disease in Tonga. Mandalay was the last city of Burma to fall to the British in 1885, with the last Burmese King exiled to India to live out his life. Mandalay is considered the heart of Burmese Buddhism and traditional Burmese ways. Grind of poverty It was clear that the country is burdened by poverty and lack of infrastructure and recent ﬂooding has been devastating, causing great loss of life and livelihood. The middle class earns US$300 a month (nurses earn <US$70 a month). The wealthy are the military or business owners and the divide is wide. Mandalay General Hospital serves all of upper Myanmar and a population of 2.5 million. Healthcare is public and funding by the government has been very limited until recently. Private donations have signiﬁcantly contributed to the development of the hospital’s facilities. A new multilevel cardiac building was completed in 2014 on a strict donated budget of US$500,000 including a coronary care
Hard at work in the EP Lab
Dr Tim Gattorna (left); Dr Shaun Anderson and Monks (above)
unit and wards. However, the equipment still in use is well beyond what is considered acceptable by Australian hospital standards. The wards are large open rooms ﬁlled with beds, which spill into the corridors. Two of the cardiologists at MGH have undertaken EP fellowships in Singapore in 2011 and 2014 respectively, although, due to a lack of local equipment, have not, until recently, had the opportunity to perform procedures, resulting in deskilling and a growing patient wait list. The wait is over Our ﬁrst task was to review a list of 24 patients with supraventricular tachycardia awaiting ablation that had been collated and prioritised before our visit. These patients were highly symptomatic despite medications.
We were touched to hear that these patients had waited all year for the ‘experts from Australia’ to arrive and many were travelling several hundred kilometres to attend the hospital. Even more surprising was that, without realising it, we had already passed some of these patients and their families camped out on the hospital grounds on our way to the cath lab that very morning. Fortunately, technical issues such as equipment or power failure did not trouble us. Last year, one patient remained in darkness on the operating table for two hours until power was restored but she was undeterred. She had waited so long for the procedure she didn’t want to miss out! The case mix was interesting with a large proportion of the SVTs due re-entrant tachycardia via concealed accessory pathways (or three), with one fascicular ventricular tachycardia thrown in just to keep us on our toes. We also performed pacemaker implantations, including cardiac resynchronisation therapy (CRT), assisted at the pacemaker clinics, and provided the local techs with practical support. It was a rewarding experience and I felt proud to be there with my colleagues to help the people of Myanmar. I am conﬁdent the local electrophysiology team are appropriately trained and skilled to take on the challenges ahead. On their side they are determined, motivated and enthusiastic. I hope to be invited back next year to provide further education and support, and will be interested to see how they have progressed.
FEBRUARY 2016 | 21
Children on the Move Primary schools are taking the ‘Keep Active’ message seriously with campaigns to encourage students to walk or ride to school – and the kids are loving it! Two-wheeled devotees reckon that bicycles will save the world and, while that may be a slight overstatement, there’s no doubt that ﬁnding an active way to get to and from school will slow the rate of childhood obesity. And that’s got to be good for the health dollar. CEO of Bicycling WA Jeremey Murray is someone who ﬁrmly believes that two wheels are better than four. “When we go into schools Jeremey Murray about 95% of kids stick their hands up and say they’d like to ride to and from the classroom. We develop programs such as Ride2School within the local school community and map out safe routes with a ‘Ride with a Buddy’ message.” “Safety is a major concern and the biggest issue is the number of cars on the road. Of course one reason for that is that too many parents are driving their children to school. What we say to them, politely of course, is that if you’ve got time to drive your children to school you’ve got time to ‘ride’ them to school. The time factor’s pretty much the same with the added bonus that parents are getting some physical activity as well.”
22 | FEBRUARY 2016
“We’re all about encouraging young people to embrace an active form of transport to and from school. It’s not just bikes either, there’s walking, skating and scootering.” Footpath laws need changing One troublesome aspect of being on anything with wheels in Perth is the requirement that anyone riding on a footpath must be under 12 years of age. “If you follow that to the letter of the law, an adult accompanying a child would have to ride on the road alongside their son or daughter on the footpath and that’s ludicrous. We’re advocating strongly that this legislation should be changed. Perth’s not an overly cycle-friendly city yet but we’re getting there, and the state government has promised more money over the next few years.” “Research by the RAC suggests that every cycling dollar spent translates into a $3.50 saving to the health budget. It’s all about reducing physical inactivity, particularly given the spike in diabetes and heart disease.” “Mark Twain once said that ‘every time I see someone on a bicycle I think there’s hope for civilisation.’ We think cycling can save the world, and don’t forget Cadel Evans used to ride his bike to school!” Getting Community support It helps to be in a supportive catchment area and Ms Suzi Reardon, Year 2 teacher and Sustainability Coordinator at Wembley
Jodie and Imogen Wheeler
Primary School, happily concedes that it makes holding up the banner for active children a lot easier. “I’m fortunate to be at a school that’s so supportive of the Travel Smart ethos. We also get good support from the Town of Cambridge and we’re doubly lucky that most kids live within walking distance of the school.” “We had a ‘Walk Safely to School’ breakfast this term and all the kids dressed in bright clothes, the canteen ladies got up early and cooked eggs and baked beans. The children sat down and had breakfast with their parents and there was a nice community feel to it.” “We also had a ‘Walk to School Wednesday’, teachers tallied the participation rate in their classroom and it’s always amazing to see how many children get behind it - last week’s winner scored 100%! We had to change it to ‘Fuel Free Friday’ because some of the senior kids had early choir and they were grumbling that they couldn’t walk to school.”
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â€œOur slogan is â€˜Be Bright and Travel Right!â€™ and itâ€™s just one component in making a broader statement about sustainability and how to incorporate it into our lives.â€? The Safety House initiative has long since disappeared in Perth and thereâ€™s the occasional media-ďŹ‚urry about â€˜helicopter parentingâ€™ and the â€˜nanny stateâ€™. So, is safety a real concern? Safety vs independence â€œIt hasnâ€™t been much of an issue for us because most kids, particularly up to Year 3, arrive at school with a parent or an older sibling. The only problem weâ€™ve got is making sure children use the underpass rather than try to cross a busy road.â€? â€œWe push this message at assemblies, in the school newsletter and in the Wembley App. The positive feedback from parents regarding the Travel Smart initiative is wonderful!â€? A wet and drizzly day didnâ€™t stop eight-year-old Year 3 student Imogen Wheeler and her mother, Jodie from putting their best foot forward on a Fuel-Free Friday. â€œI walk to school almost every day even if itâ€™s raining. Most of the kids in my class do too and we have a competition to see how many walk, ride or scooter. Usually itâ€™s pretty close to everyone,â€? Imogen said. â€œMy brother, Hudson likes to walk on his own and we always use the underpass to get to school. The best thing about it is that I talk to Mummy and see my friends.â€? â€œWhen Hudson ďŹ rst started walking to school on his own Iâ€™d often pop in and check that heâ€™d made it safely but I havenâ€™t done that this year because I know heâ€™s okay,â€? said Jodie. â€œMy husband and I have been talking about getting him a small mobilephone just in case he needs it. Weâ€™re pretty lucky, there are lots of active programs at Wembley school that encourage children to be independent.â€?
By Mr Peter McClelland
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FEBRUARY 2016 | 23
How Lucky Am I? The personal experience of Dr Ainslie Waddell has shaped what HEĂĽDOESĂĽWITHĂĽSMOKERSĂĽANDĂĽEX SMOKERSĂĽINĂĽHISĂĽPRACTICE Recently, the local radiological group gave our practice a presentation on the new low dose CT scans for lung cancer screening in smokers and ex-smokers. About 25 year ago I stopped smoking, and before this my smoking past was chequered. My father smoked, not heavily, and my mother pretended to smoke but did not inhale. While quite young I tried smoking cane, which burnt a hole in my tongue. Chrysanthemum leaves, rolled up in toilet paper like a cigar, worked quite well, provided the moisture content was right. This continued into my teenage years. At University it was real cigarettes, and I was even known to have a cigarette at three quarter time when playing football for the University Mighty Green Machine.
days, I was drain free and home. Here, the physical issues faced were: sĂĽ 0AINĂĽCONTROLĂĽ ĂĽ0ALEXIAĂĽ32 ĂĽ4RAMADOL ĂĽ Panamax and anti-inďŹ‚ammatories. Even at three weeks post-operative, sneezing was not good and the costochondral junction and the skin over the right chest were still super sensitive. sĂĽ 3LEEPĂĽWASĂĽINTERRUPTEDĂĽBYĂĽRIBĂĽCAGEĂĽ discomfort. sĂĽ 0HYSICALĂĽEXHAUSTION ĂĽFEELINGĂĽGROSSĂĽ weakness after any activity, was not anticipated. It gradually improved by week three, at which time I was able to walk two kilometres without much problem. Emotionally, I knew what had to be done and resigned myself to that fact. I have always
had a positive attitude. After receiving the full pathology report of â€œall clearâ€? I consider myself very lucky, thanks to my own initiative and the low dose CT investigation. During recent consultations I have ordered nine other low dose CT Scans, with two other positive result. From my own experience and this result, I will continue to do this. I feel that discovery of a lesion before symptoms is good medicine and can give rise to better outcomes, myself included. ED: The whole issue is the subject of a recently published open access MJA editorial involving two WA respiratory physicians, Drs Annette McWilliams (FSH) and Fraser Brims (SCGH), (https://www. mja.com.au/search/site â€œLung cancer screening in Australia: progress or procrastination?â€?).
As a married man with a family, I continued to smoke, mainly in the car, at social events and when ďŹ shing of course. My wife and children implored me often to stop, the children leaving notes around the house - even on the fridge and the bathroom mirror, â€˜Please Dad stop smoking!!â€™ A couple of times I tried to stop but was not successful. By this time, I was smoking little cigars called Cafe Creams but they had a problem of spitting out little bits of tobacco, which burnt holes in my trousers. My wife was not impressed! During numerous ďŹ shing trips to the Mackerel Islands, I used Five Star â€˜roll your ownâ€™, enjoyed the trip and stopped again on coming home. Eventually, starting and stopping like this became too hard so the ďŹ lthy habit stopped.
Emotionally, I knew what had to be done and resigned myself to that fact. Back to the present-day talk from the local Radiology group. Given my past smoking, I decided to have a CT Scan that showed â€˜an indeterminate spiculated nodule in the right lower lobe, mean diameter >10mmâ€™. After a failed FNA, Prof Mark Edwards performed an excisional biopsy that conďŹ rmed adenocarcinoma on frozen section, so he went ahead with the removal of my right lower lobe. As I am allergic to morphine - clammy, sweaty and nausea - I was very apprehensive about the surgery. However, Fentanyl and those wonderful Indocid suppositories seemed to put me on a "high" post-operatively despite pain being about 4 or 5 out of 10. After four
24 | FEBRUARY 2016
Top left: Three weeks after his recent lobectomy, With one that didnâ€™t get away (circa 2003), Dr Ainslie Waddell working as a GP (circa 1999)
While doctors worry about the cancer-forming potential of too many CT scans, low dose CT screening of ex-smokers has been touted as a safe option. The consensus is towards improved early detection and outcomes for lung cancer in carefully selected groups of patients (see www.cdc.gov/ cancer/lung/pdf/guidelines.pdf ). Patient selection is age 55-77 years, â‰Ľ30 pack year smoking history and smoking cessation < 15 years. Ideally, screening should be performed by radiologists/thoracic
physicians skilled in low dose screening. One problem is that screening picks up lesions in about 25% of cases and most are false positives that require follow up imaging, sometimes biopsy, PET scans, etc to arrive at this conclusion. Along the way, they cause signiďŹ cant anxiety. These on-costs etc. need to be politically palatable â€“ affordability and cost-beneďŹ t analysis play an increasing part in working out if screening becomes a public health measure.
Saving and Spending in Retirement !SĂĽ!USTRALIAĂĽAGES ĂĽSUPERANNUATIONĂĽLAWSĂĽWILLĂĽCHANGEĂĽ4AXĂĽEXPERTĂĽA/Prof Helen Hodgson raises some important issues for all those of working age to consider. The superannuation system is notoriously complex â€“ not only are the rules confusing but it involves long-term planning and uncertainty. Under the current system there are three main sources of retirement income: the age pension, the compulsory superannuation guarantee charge and personal savings within and outside superannuation. Savings are encouraged by allowing tax concessions for income contributed to superannuation and income earned by a superannuation fund. There are further concessions available when a person retires such as exempt withdrawals from a superannuation fund for retirees over 60 years of age. Currently a person can contribute up to $30,000 pa ($35,000 if over 50) at the concessional tax rate that applies to superannuation contributions. The current political discussion over the future of the superannuation system is around the extent to which superannuation tax concessions favour those who have the ďŹ nancial resources to increase their voluntary savings in their superannuation funds. It is estimated that by the 2017-18 ďŹ nancial
year the cost of superannuation tax concessions will be about equal to the cost to the government of funding the age pension. The means test for the pension was tightened last year, limiting access to the part pension for retirees with assets over $823,000, excluding the family home. This has raised some concern as to how superannuation is needed at retirement.
[Superannuation] should be exhausted during retirement: there are other ways to provide for the next generation. The average balance for men retiring in 2012 was $197,000, and for women, $105,000. However, these balances are increasing as the rate of the superannuation guarantee increases. The superannuation guarantee commenced at 3% in 1992, and did not increase to 9% until 2002: a person who retired in 2012 has not contributed as much as a person who will retire in 2022.
So how much superannuation is enough? There is no magic formula. There are a range of factors including lifestyle, health, longevity and whether you own your home at retirement. While $1m is often mentioned, the Australian Institute of Superannuation Trustees says that the Australian Superannuation Funds of Australiaâ€™s (ASFA) comfortable retirement income standard of $58,300 for a couple can be achieved with $550,000 in retirement savings. $150,000 in savings will boost the age pension by 31%. Owning your own home is an important protection for retirees as it reduces living costs and is an asset that can be realised if the owner needs to enter residential care. The superannuation industry is also developing lifetime annuity products that will insure against longevity risk. Superannuation should be regarded as a retirement income product, not as savings. It should be exhausted during retirement: there are other ways to provide for the next generation. References on request ED: A/Prof Helen Hodgson is a taxation specialist at the Curtin Law School.
We take care of you â€Ś so you can take care of others Rural Health West has been recruiting GPs to country WA for over 25 years. If you want to practise interesting and challenging medicine, contact us today. T 08 6389 4500 E firstname.lastname@example.org W www.ruralhealthwest.com.au
FEBRUARY 2016 | 25
Action to Stop Abuse is Imperative The ﬁndings of the Senate committee inquiry into abuse of people with disability in residential settings were disturbing. Chair Senator Rachel Siewert calls for action. This inquiry, which received evidence from around Australia, conﬁrmed what many people have been saying for years: violence, abuse and neglect of people with disability is widespread and occurs around the country. Unfortunately, what is also clear is we have only scratched the surface of this issue. People with disability have been trying to get Governments to act for years, to no avail, and I'm concerned they will do this again despite the ﬁndings of our committee inquiry. Going on the evidence presented, a royal commission is necessary and this is our ﬁrst recommendation of 39. There were also overwhelming calls for a national complaints mechanism, for national workforce and workplace regulation and national worker registration, these issues and many more are
There is overwhelming evidence that [abuse] occurs right under our noses.
covered in our recommendations. The inquiry was harrowing and confronting, not least how people with disability were viewed as ‘less than’ in Australian culture.
others) and have difﬁculty in communicating with the judicial system. We need to improve these systemic barriers with supported decision making and legal capacity.
The committee received evidence from people who have been subject to violence and abuse, whistleblowers, family members, advocates and workers. People spoke of their hurt, humiliation and pain having suffered violence, abuse and neglect for years and this being swept under the carpet. Consistently victims felt that nobody was paying attention or many pretended it wasn't happening.
Families may not speak out through fear of being labelled as “difﬁcult” or losing their loved one’s placement. Institutions are reluctant to speak out through fear of bad publicity. In the past, whistleblowers have been sacked.
This abuse has occurred in all types of residential and institutional settings, including schools and there is overwhelming evidence that it is occurring every day under our noses. We know that people with disability experience more abuse than the general population, yet there are no deﬁnitive national statistics on prevalence. Nobody has been collecting this data. Those who try to report abuse often aren’t believed, most are too terriﬁed to report at all. The evidence shows people with disability struggle to be believed by the police (and
The committee has recommended that the Australian Bureau of Statistics includes people with disability in its surveys of reported violence, abuse and neglect. Our report is a snapshot of why abuse has been allowed to occur systemically on such a large scale so it is imperative an independent, national disability complaints mechanism be established to protect vulnerable people in these care settings. We as a community must do our best to end this shame which has caused such hurt and humiliation. I had hoped that in hearing the evidence of mistreatment, the Government would have acted. So far, it hasn’t. The New Year must bring some action.
Perth Cardio is moving to the heart of the new medical precinct in Midland. From February 2016, cardiology services will conveniently be available on site every day. So accessing world-class cardiology care, consultation and testing in the City of Swan will get a whole lot easier for your patients. For more details visit perthcardio.com.au LEADERS IN C ARDIOLOGY | ECHO | ECG | HOLTER MONITORING | STRESS ECHO | E XER CISE STRESS TESTING
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Reviewing Your MDO and Your Risk There are basically four Medical Defence Organisations (MDOs) in Australia vying for your membership. The decision of which MDO to join is critical – what’s important as a medical student or intern is different to the complex risks faced by, say, a doctor who owns and runs a private practice. The MDOs booklets, policy wording, product disclosure statements, category and ﬁnancial services guides total hundreds of pages, ﬁlled with insurance and legal jargon, exclusions, conditions and limitations. Comparing how MDOs promise to protect your assets and reputation is incredibly difﬁcult and time consuming. Superimposed are complex
By Chris Mariani insurance broker with Medical and General Risk Solutions
government support schemes and legislation that may be relevant, and the application of discretionary powers by MDOs as ‘mutuals’. To add to your complexity, medical indemnity is generally purchased direct with the MDO, whereas in most other professions the advice of an insurance broker is sought to help identify risks and select the best insurance. Gaining access to the right information is important. I recall a coffee mug in a surgery stating, ‘Don’t confuse my medical degree with your Google search’.
a contracted doctor working in his practice who went to the Fair Work Commission and alleged they were an employee. His MDO advised him ‘wages’ (the doctor’s words) were not covered by the policy. He should have used the words ‘I am in a dispute over the status of a contract’, which was covered by his policy. I took his case and within a few days, the MDO reimbursed the doctor’s legal fees. When deciding which MDO policy to choose, what are some of the important factors?
Having someone in your corner at claim time can be vital. I remember a doctor whose MDO had declined his claim over a dispute with
Legal/ accounting structure
Does my policy cover my practice entity (e.g. a service trust or company) and my employees, or do I require separate medical indemnity insurance for this? MDOs vary in whether these are covered under the doctor’s medical indemnity. For example, one MDO provides a free practice entity policy as part of membership, but the policy excludes nurses, allied health and other registered healthcare staff. Another covers a practice entity wholly owned by the doctor but does not cover any employees in the policy deﬁnitions, for which the doctor needs a practice entity policy.
Financial strength of MDO, experience, member beneﬁts
Read the MDOs latest annual/ﬁnancial reports. What are their net assets (MDOs are owned by the doctor members)? What beneﬁts and services do they provide?
How are claims managed?
Are there insights into how they have managed signiﬁcant claims to protect doctors? Do they have 24/7 medicolegal advice? What is the strength of their claims and legal teams? Will you get local claims service, and by whom?
Safety in numbers
In a multi-doctor practice, it is generally best to have all doctors and the practice entity insured with the same MDO. In the event of a claim involving multiple doctors and the practice entity, the MDO can often manage the claim with a single set of lawyers, which means greater efﬁciency and less downtime in brieﬁng multiple lawyers.
Starting in private practice?
Look beyond the premium quoted this year to ask what it will be in ﬁve years when you’re on the top billing band as a ‘mature risk’. Many MDOs have a ‘stepped’ premium model when starting out, so be aware of the ﬁnal price when comparing MDO costs.
What ‘bells and whistles’ cover is included?
Each MDO provides differing covers. Some policies will automatically cover limited overseas practice, legal fees for disputes with employees, employers and hospitals, Medicare audits, tax audits and other covers.
It’s not all about medical indemnity!
Running a private medical practice opens up complex risks. Many are not covered by medical indemnity. Most practices will require workers compensation, IT protection, management liability and business package insurances. The MDOs don’t currently offer these products.
The article provides general information and does not take into account your objectives, ﬁnancial situation or needs. Refer to the relevant Product Disclosure Statement before purchasing any insurance product. Medical and General Risk Solutions is a Corporate Authorised Representative of Insurance Advisernet Australia Pty Limited, AFSL 240549, ABN 15 003 886 687. Chris Mariani, Authorised Representative No 434578; email@example.com
såMr Tim Shackleton is the new CEO of Rural Health West replacing Ms Belinda Bailey who steps down after seven years. Tim was CEO of RFDS and most recently a private consultant specialising in rural health. s Former CEO of Healthway Mr David Malone has been appointed CEO of Australian Primary Health Care Nurses Association (APNA) and based in Melbourne. s The trustees of St John of God Health Care have appointed colorectal surgeon Dr Michael Levitt to the SJGHC Board. He replaces Dr Tony Baker, who has retired after 10 years. Dr Stuart Prosser has replaced
A/Prof David Watson as Director of Medical Services at SJG Mt Lawley Hospital. s Dr Penny Flett is retiring as CEO of Brightwater in March. The new CEO is Ms Jennifer Lawrence who has been with the organisation since 2003. s Mr Bradley Prentice is the new chair of Southern Cross Care. s Paediatric specialists Dr Martin De Bock, Dr Rishi Sury Kotecha and Dr Annette Lim and anaesthetist Dr Edmond O’Loughlin will share nearly $1m in grants from the Raine Foundation.
s Mr Brent Stewart has been appointed to the board of HBF. He was the founder of Market Equity. s Prof Steve Allsop, head of the National Drug Research Institute at Curtin University, received the Senior Scientist Award at the annual Scientiﬁc Alcohol and Drug Conference held in Perth late last year. s Orthopaedic surgeon Dr Michael Wren and radiologist Dr James Anderson were among those receiving Outstanding Service Awards at RPH.
FEBRUARY 2016 | 27
Perth’s premier rehabilitation care - all under one roof. As Western Australia’s only Australasian Faculty of Rehabilitation Medicine (AFRM) accredited private rehabilitation facility, our Specialist Rehabilitation Service is the ﬁrst choice in rehabilitation care. Our patient-centred approach provides care under one roof, with access to a range of health services including specialist rehabilitation consultants, rehabilitation nurses, physiotherapists, occupational therapists and social workers, along with a hydrotherapy pool. About the Specialist Rehabilitation Service: < Western Australia’s ﬁrst private rehabilitation service led by AFRM accredited physicians. < Single phone-call admission process. < Access to a team of medical, allied health and nursing staff. < A multi-disciplinary discharge report to inform post-rehabilitation care.
Our Specialists: Dr Ian Wilson MBChB, FAFRM Director of Rehabilitation
Dr Luca D’Orsogna MBBS, FAFRM Rehabilitation Physician
Dr Teck Yew MBChB, FRACP Physician/Aged Care Specialist
Dr Sean Maher MBBS, FRACP Physician/Aged Care Specialist
Your patient’s recovery is our priority and the team at St John of God Mt Lawley Hospital is committed to working with you to achieve the best outcome. For more information, contact: St John of God Mt Lawley Hospital Nurse Unit Manager, Specialist Rehabilitation Service: Mark Cook on 9370 9270 or firstname.lastname@example.org
At St John of God Mt Lawley hospital we are investing in a better tomorrow, today. 28 | FEBRUARY 2016
T: 08 9370 9222 F: 08 9272 1229 E: email@example.com www.sjog.org.au/mtlawley MEDICAL FORUM
How EDs Deal with Dangerous Patients
Prof Daniel Fatovich Emergency Medicine UWA RPH
violent patients, emerging from sedation, are sometimes triggered to re-escalate their violent behaviour, which places patients and staff at risk.
Emergency departments are a window on the world. We see the full spectrum of physical and psychiatric disorders, with a nuanced appreciation of trends over time. In my experience over 30 years, the problems arising from illicit drugs, alcohol and mental health problems have increased signiﬁcantly. Much of this is likely due to increased availability of both legal and illegal drugs, and a sense that there is a cultural norm of aggressive behaviour. Violent patients requiring sedation were rare in the 20th century but are now commonplace in the ED, sometimes daily. Much of this recent increase is directly caused by methamphetamine (“ice”) use. The most common scenario is for ice patients (typically a young male aged 25-35 yrs) to be brought to the ED by police, in a state of agitated delirium, with overt aggression, profound paranoia, psychosis and sometimes bizarre behaviour. We have also seen such behaviours from use of the synthetic cannabinoids (‘legal highs’) but with shorter episodes, compared to ice users. The essentials of our approach include: early identiﬁcation (this is easy), a coordinated team approach with our security staff, and sedation
Most sedated patients require a psychiatric review, which reﬂects the intense resources needed to manage these patients. It is disgraceful that patients with a drug-induced psychosis may spend days in the very inappropriate stimulant environment of an ED, awaiting an approved mental health bed. Sadly, we see repeat amphetamine-related presentations – almost half have previously attended the ED. (typically a benzodiazepine and droperidol). Our security staff are the most important team members, skilled in both verbal and physical approaches to obtaining control. They allow the clinical staff to safely access the patient and keep the situation safe for staff and other patients. There are, nevertheless, clinical impacts on other patients. While the violent patient is shouting and screaming, it is hard for uninvolved staff to undertake routine activities such as taking a history. Vulnerable patients (e.g. the elderly, children and those with mental health problems) experience distress and feel unsafe. Unfortunately, other
by Medical Director PROF JOHN YOVICH
Maintaining staff safety is absolutely essential to prevent signiﬁcant injuries to ED staff. A frequently expressed view is that no other industry would tolerate such a work environment. The fact that caring professionals continue to expose themselves in this way is a testament to their extraordinary commitment to patient care. However, other patients suffer as a result, because they have delayed access to care. The ﬁnal report of the National Ice Task Force highlights the well-established relationship between social determinants and problematic drug use, together with easy drug availability.
SPECIALISTS IN REPRODUCTIVE MEDICINE & GYNAECOLOGICAL SERVICES
PIVET MEDICAL CENTRE
Chinese delegation at PIVET ...sharing the technology: East & West China has a documented medical culture dating 5,000 years; but this differred from Western medicine until recently. The basic principles of traditional Chinese Medicine (TCM) centre on 3 themes: 1. Relative properties – the balance of Yin (inner, negative principles) and Yang (outer, positive principles). Sickness results from the loss of harmony between Yin and Yang whist recovery focuses on Yang functions to protect from outer harm; Yin providing the inner base to store and provide energy supplied by Yang.
The Chinese delegation from Ghuangzhou visiting PIVET Nov 15.
NOW AT 2 LOCATIONS PERTH & BUNBURY
2. Basic substance – TCM describes the movement of energised particles providing warmth and energy (properties of Yang) along with the lubricating state of blood and body ﬂuids (properties of Yin) being directed along Yin Luo channels which are utilised in Acupuncture. 3. Diagnosis – TCM is reliant on 4 modes of physical examination being observation, auscultation & olfaction, interrogation; and pulse taking & palpation.
Pioneering Professors John YOVICH and Guanglun ZHUANG. One of many cross-pollination visits between Perth and Guangzhou
WHO now categorises Infertility as the third-most serious disease worldwide after cancer and cardiovascular disease. China has recognised that the causes for infertility are complex and treatments require advanced strategies. The ﬁrst IVF infant born in mainland China occurred in 1988, a decade after Louise Brown in the UK and 6 years after our Jarrad Carter in Perth. With closer western afﬁliations, Taiwan succeeded in 1985 and Hong Kong in 1986. After a training period at the University of Sydney, Professor Guanglun ZHUANG established the Centre for Reproductive Medicine at Sun Yat-Sen University in Guangzhou, within Guangdong province. Sun Yat-Sen founded his university in 1924. He was a revolutionary who is now regarded as the founding father of the Republic of China.
For all appts/queries: T 9422 5400 F 9382 4576
FEBRUARY 2016 | 29
HeartsWest is pleased to announce some important new developments. DR PETER DIAS MBBS, MRCP, FRACP Consultant Cardiologist Specialist in Advanced Heart Failure and Cardiac Transplantation Specialist in Echocardiography Peter graduated with honours from Leeds University Medical School in 2004, also receiving a 1st class honours in Human Anatomy. He moved to Perth in 2008 and completed his general cardiology training and Advanced Heart Failure and Cardiac Transplant Fellowship through Royal Perth Hospital. *iÌiÀÃ >À` iÀÌwi` V V>À`}À>« ÞLÞÌ iƂiÀV>-ViÌÞv V V>À`}À>« Þ and a member of the Royal College of Physicians and a Fellow of the Royal Australasian College of Physicians. Peter is currently employed at Fiona Stanley Hospital as a consultant cardiologist in the state Advanced Heart Failure and Cardiac Transplant service. *iÌiÀ½Ãwi`ÃvÃ«iV>ÌÞVÕ`ii>ÀÌ>ÕÀi] >À`>V/À>Ã«>Ì>`iV >V>-Õ««ÀÌ] Echocardiography and general cardiology. Peter consults from our Armadale and Rockingham rooms.
DR WEN-LOONG YEOW MBBS, FRACP Consultant Cardiologist Coronary Interventionist Adult Structural and Valvular Interventionist Wen-Loong (or Wen) graduated from the University of Western Australia, he completed his cardiology training and two-year coronary interventional fellowship at Royal Perth Hospital in 2011. He then completed a two-year fellowship in adult structural and valvular interventions, with clinical and basic science research at Cedars-Sinai Medical Centre and the David Geffen School of Medicine at UCLA in Los Angeles. His research has been published in peer reviewed journals. He returned to Perth in 2014 and has joined Hearts West. He also has a locum appointment at Sir Charles Gairdner Hospital. In addition to interventional cardiology, he provides general cardiology support to the practice. Wen-Loong consults from our Armadale and West Leederville rooms.
Echocardiography. We are upgrading our echocardiography machines with Speckle Tracking Strain imaging, a new modality that allows detection of ventricular dysfunction before any reduction in function is detected by conventional means. It is particularly Useful for those with hypertrophic conditions and those who have had cardiotoxic pharmacotherapy. Stress echocardiography Service. Expansion of this service should allow a minimal wait for stress echo appointments for patients. Smartphone monitoring. We have access to AlivCor home monitoring that allows patients to make ECG recordings on a Smartphone during symptoms, sending them electronically to HeartsWest for review. Smartphone lease or purchase of a device that attaches to their Smartphone is available. This system is designed to diagnose infrequent arrhythmias not detected on Holter monitoring, without the need for implanting a monitoring device
Telephone 9391 1234 Fax 9391 1179 Email firstname.lastname@example.org www.heartswest.com.au 30 | FEBRUARY 2016
News & Views
Call for National Abortion Laws Australiaâ€™s patchwork of abortion laws creates unnecessary anxiety and expense according to two Queensland law academics. In a recent MJA editorial, Caroline M de Costa and Heather Douglas called for consistent abortion laws nationally so women could be assured of equal access to services. They suggest all states adopt the Victorian law, which decriminalised abortion seven years ago. There, a doctor can terminate a pregnancy at up to 24 weeks with the womanâ€™s consent, and after 24 weeks with the agreement of a second doctor. This change has not resulted in increased numbers of abortions, which have remained stable over many years (80,000 in Australia each year). Medicare funds non-invasive prenatal testing, such as US scans and foetal DNA, allowing earlier and safer termination of the pregnancy. The authors say that late abortion is restricted by health regulations in WA, SA and the NT and because in Queensland and New South Wales the law does not refer to fetal abnormality at all, there is abortion â€œtourismâ€? from other states to Victoria, and overseas. The editorial says â€œmifepristone is being used in accredited hospitals throughout Australia for second trimester abortions on the grounds
of fetal abnormality (and many private practitioners and clinics also use it for early medical abortion)â€?. However, they say access to the drug is very difďŹ cult for rural women. Victorian abortion law requires an objecting doctor to refer the woman to a health practitioner who is known to have no conscientious objections to abortion. With the growing number of older women conceiving, screening for foetal abnormality has increased, along with the desire for terminations. A/Prof Kirsten Black, spokesperson for RANZCOG, said a minority of women attending private abortion services were from lower socioeconomic groups, and that poorer women may have less access to abortion, reportedly suggesting that more abortions should be provided in public hospitals. In WA, the abortion law states that a woman can obtain an abortion, subject to counselling, up to 20 weeks. After 20 weeks, an abortion may only be performed if the fetus is likely to be born with severe medical problems â€“ which must be conďŹ rmed by two independently appointed doctors.
In 2014 there were 8366 abortions performed in WAâ€™s public hospitals. In 2015 up to October, 6769 took place at KEMH, Swan District, Bunbury, Bridgetown, Busselton, Kalgoorlie, Esperance, Port Hedland, Geraldton, Carnarvon, Broome, Derby, Kununurra and Albany public hospitals. Abortions were also reported at private clinics, private hospital day patient services and general practice (no ďŹ gures available). Abortions of pregnancies of 20 weeks gestation or more were performed at KEMH. The WA government has nominated Marie Stopes in Midland to perform procedures that will not be performed at the Midland Hospital because the administrators are Catholic. The government has invested $1.2m to upgrade the Marie Stopes facility to enable it to conduct medical and surgical terminations, contraception, vasectomy and tubal ligations. It will receive $500,000 in recurrent funding for three years with two one-year extensions available. Public patients or those disadvantaged will not be charged.
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Changing Trends in ENT By Dr George Sim, Paediatric ENT Surgeon, Murdoch ENT (e.g. ECG, echocardiogram) and treatment doses and duration, with propranolol the ﬁrst line treatment for infantile haemangiomas, including SGH. Implantable hearing devices (IHDs) Many patients with hearing aids (HA), even the newer ones, are poorly compliant in using them due to acoustic distortion, occlusion effect, discomfort and social stigma. Dr George Sim
Illustrated: A facial haemangioma. When subglotic, can be life threatening.
ENT technology and treatment of patients is constantly changing – take these recent innovations. Coblation Using a radiofrequency device, coblation enables a precise plasma ﬁeld to dissolve targeted tissues while maintaining the integrity of surrounding tissue – speciﬁc tissue ablation with minimal collateral damage to surrounding tissues It limits unnecessary prolonged exposure of tissues to high levels of power that increase the risk of thermal damage. Coblation functions at 40o-70oC, whereas electro cautery generates 400-600oC. Coblation can be used in adenotonsillectomy, obstructive sleep disorders (turbinate reduction, soft palate surgery, tongue channelling), sinus surgery and airway procedures.
Propranolol and infantile subglottic haemangioma (SGH) Infantile haemangioma is a benign soft-tissue tumour that affects up to 10% of newborns. Rapid proliferation is followed by a slower growth phase, before involution occurs around age ﬁve. SGH can cause severe airway obstruction in newborns during the proliferative phase, and carries a 50% mortality if left untreated. Treatments have included systemic corticosteroids, intralesional steroids, laser, tracheostomy and open surgical resection. In 2008, a landmark study reported on a child with a large infantile haemangioma who was treated with propranolol for an unrelated hypertrophic cardiomyopathy and exhibited rapid regression of the hemangioma within days. This novel use of propranolol has now revolutionised how we manage SGH. Protocols cover pre-treatment workup
IHDs are an option for patients with limited beneﬁt from traditional HAs but who are not yet candidates for cochlear implants. IHDs consist of bone-conduction devices (e.g. Bonebridge) or Osseo integrated devices (e.g. Soundbridge). The Vibrant Bonebridge transmits sounds by cranial bone conduction directly to the inner ear where they are perceived as natural sounds and achieve optimal transmission results. The Vibrant Soundbridge (VSB) is a middle ear implant which bypasses the tympanic membrane imparting vibrations directly to the ossicular chain thereby improving signal coupling. VSB consist of an externally worn audio processor that picks up sounds and ampliﬁes it to a level appropriate for the hearing loss. The ampliﬁed sound is then transmitted to the receiver coil of the implanted component. The implanted vibrating ossicular prosthesis has a ﬂoating mass transducer, which is ﬁxed to the incus and directly drives it via mechanical motion. Author competing interests nil relevant disclosures. Questions? Contact the author on 6332 6868
‘Social’ Egg Freezing, Hysterectomy Options, etc By Dr Cliff Neppe, Obstetrician & Gynaecologist, Joondalup The reproductive years Given the decline in fertility beyond age 35, should women consider “social” egg freezing if still nulliparous in their mid to late Dr Cliff Neppe 20s? After all, the average age of ﬁrst pregnancy is rising (around age 31 now).
reproductive future in there 20s. There is a current mismatch between when women choose to freeze their eggs (average age 36) and when they can use this technology to best effect (around age 26). Salpingectomy with hysterectomy for benign disease There is growing evidence that high-grade serous tumours of the ovary and peritoneal surface epithelium (the most common histologic sub-type of epithelial ovarian cancer) may originate in the fallopian tubes.
Human oocyte cryopreservation involves extracting, freezing and storing a woman’s eggs. Later, the eggs can be thawed, fertilised, and transferred to the uterus as an embryo.
There is no known beneﬁt for retaining fallopian tubes in the post-reproductive period, or after hysterectomy. Removal does not appear to increase surgical complications, or impact ovarian function.
A new ﬂash-freezing technique, vitriﬁcation, means that almost 90% of eggs survive the thawing (previously it was 20%). Thus, frozen eggs enjoy almost the same success rate as fresh eggs, when it comes to pregnancy resulting in a live birth.
The RANZCOG recommends we discuss with patients bilateral salpingectomy with hysterectomy for benign gynaecological disease. No data as yet quantiﬁes the overall risk-beneﬁt equation.
But in order to harness this technology to its fullest, women need to decide their
32 | FEBRUARY 2016
Consideration should also be given to bilateral salpingectomy for female sterilisation.
Hysterectomy options Postoperative changes in symptoms and sexual function are not inﬂuenced by the mode of hysterectomy. Gynaecologists increasingly prefer laparoscopic hysterectomy but should this be the standard? The choice of hysterectomy route depends on things like surgical indication, pelvic anatomy and vaginal access, patient preference, the surgeon’s competence and preference, and available support. Vaginal hysterectomy carries the lowest complication rate, is the most cosmetic and offers a short hospital stay. It is also the most cost effective. The limitation is adnexal pathology cannot be adequately visualised or addressed. Both vaginal and laparoscopic are preferred to the open route but are not always feasible. Supracervical hysterectomy is technically easier and potentially safer than total hysterectomy for benign disease but carries no other clinical advantage. Author competing interests – no relevant disclosures. Questions? Contact the author on 9301 0722
6 1 0 2 Innovations &
Against the Tide By Clin/Prof Mark Thomas, Renal Physician, RPH Acute kidney injury (AKI). Remote ischaemic preconditioning is protective against acute kidney injury during cardiac surgery – placing a Prof Mark Thomas tourniquet around the leg above systolic BP for three lots of ﬁve minutes, just prior to anaesthetic gives the kidneys an extra ﬁghting chance. Mother Nature's hormones are best it seems, as the effect is probably mediated by temporary release of endothelial relaxing factors that help minimise renal hypoperfusion (whereas many prior trials of pharmacological ﬂuids, inotropes and vasodilators have been disappointing). Chronic kidney disease (CKD). Trying to limit the triple injury of inﬂammation, ischaemia and ﬁbrosis inside your body’s organs is a daily challenge (best lubricated with a little more olive oil and wine, the ‘Mediterranean diet’). Diverging advice on BP targets. Liberalised international BP guidelines to <140 systolic that showed fewer CV events, were counter-
balanced by tightening to <120 with the US SPRINT trial ﬁndings, which had more survivors but more side-effects. This means, in effect, that each patient becomes their own control as we return to the time-honoured method of more individualised titration to the best tolerated antihypertensive dose, supported by self-monitoring patients who know when to reduce or omit their medication. Diabetic CKD has become a lot more fun. This has come with the emergence of non-obesogenic diabetic therapies (DPP4 inhibitors, GLP1 agonists, SGLT2 inhibitors). In contrast to the stubborn lack of beneﬁt (or even increased CV risk) seen with prior efforts at intensiﬁed diabetic control, the introduction of SGLT2 inhibitors (which inhibit reabsorption of sodium and glucose from the urine, and thus lower BP and body weight as well as glucose without risking hypoglycaemia) might even save lives (i.e. see emlagliﬂozin, Zinman et al, NEJM 2015). Dialysis and calciﬁed arteries. The two are closely linked, partially driven by too much phosphate and too much PTH. Expensive non-calcium phosphate binders such as sevelamer and lanthanum have been prescribed by nephrologists who may fail to stop their patients guzzling Coke and eating Maccas. Or they could recommend simple
magnesium tablets that do the same job for virtually no money. Cinacalcet (SensiparTM by Amgen) is a one-of-a-kind calcimimetic that provides medical PTH suppression by fooling the PTH gland's calcium receptor into switching off – but at even greater expense. For several years, nephrologists have been avoiding parathyroidectomies in dialysis patients with secondary hyperparathyroidism but with the average weekly price of "bone pills" rising from $13 to $60 per dialysis patient (with no net biochemical or survival beneﬁt), cinacalcet was delisted from the PBS in April 2015. Neck surgeons are sharpening the scalpels again! Local news The talented Prof Paolo Ferrari moved to NSW with the remaining Fremantle nephrology team shared between FSH and a leaner RPH. Previous ICU head until 2003, Dr Geoff Clarke AM, has published A History of the Intensive Care Unit - within the family of RPH for $25, complete with nephrology events. All proceeds to RPH Medical Research Foundation. Further reading www.nps.org.au/publications/ health-professional/nps-radar/2015/april-2015/briefitem-sensipar
Neonatal Care By Prof Karen Simmer, Director of NICU at KEMH & PMH and Prof of Newborn Medicine (UWA) The other is an inexpensive anti-inﬂammatory agent that will be given with antibiotictreatment in the hope of reducing white matter-brain injury associated with infection. This is a WA-led trial and very preterm infants will be recruited from NICUs in Australia, New Zealand, North America and Asia as large numbers are needed to prove this therapy will increase normal survival after preterm birth. Prof Karen Simmer
Prof Karen Simmer relates how critical thinking has changed what they do. Often in neonatal intensive care, less is more. Or simple inexpensive treatment can improve clinical outcomes. An example is the routine treatment with a single morning dose of caffeine for all preterm infants to increase respiratory drive and reduce the need for respiratory support. Another example is routine probiotics for the prevention of death and gut disease in preterm infants. This latter intervention was
slowly adopted only after 10,000 infants had been randomised in trials and some countries still are hesitant. In contrast, complex costly technology is sometimes introduced with little-to-no evidence to support a clinical beneﬁt and show no risk of harm. We are about to introduce two further simple treatments. The ﬁrst is topical coconut oil. This will be used initially in a small placebocontrolled pilot study. Data from trials in Asia suggest application with improve skin integrity and reduce bloodstream infection.
For healthy term infants in WA, we have changed growth charts to those appropriate for healthy breastfed infants. Previously, we had been using reference charts based on the growth of American infants, the majority of whom were formula-fed. Thus, we had been normalising some heavy infants and over-diagnosing failure-to-thrive in light ones. Breastfed infants weigh less than formula-fed infants after the ﬁrst few months of life and this is normal. Being overweight is not normal and the earlier it is identiﬁed, the better the chance of reducing the risk of later obesity.
FEBRUARY 2016 | 33
World Class PET-CT Services continue to be available to your patients at Oceanic. Oceanic Medical Imaging has amalgamated with Perth Radiological Clinic. At Hollywood a new joint venture company, Oceanic Molecular Pty Ltd has been created. Clin A/Prof Nat Lenzo and Dr Andrew Henderson are excited that the new joint venture company will allow ongoing and new innovation in molecular imaging by the skilled and dedicated team at Oceanic, with the addition of the facilities and expertise of PRC and their well respected sub-specialty radiologists. Your patients now have the security that innovation in PET-CT services will continue in Perth and you have the advantage of sub-specialty radiology opinions. Furthermore, Oceanic Molecular will be expanding their service to include new tracers and treatments.
Oceanic Molecular Hollywood Medical Centre, Suite 14 Ground Floor 85 Monash Avenue Nedlands WA 6009 Ph: 9386 7800 34www.perthradclinic.com.au | FEBRUARY 2016
MEDICALImaging FORUM Excellence in Molecular
6 1 0 2 Innovations & Bugs, Genes and the War on Sugar
By Ms Jo Beer, Dietitian and Diabetes Educator, Nedlands Increasingly, nutritional genomics will tailor dietary recommendations to a patient’s genome, although it must be remembered that most mutations (if relevant at all) confer only an increased risk of developing a disease. The War on Sugar
Ms Jo Beer
Diet and the gut microbiome Not long ago we thought that gut bacteria were just sitting there doing little but causing the occasional infection. Now they are so revered they are even transplanted. However, our Western diet may be damaging this valuable community leading to or exacerbating obesity, inﬂammatory bowel disease (IBD), chronic kidney disease and depression. For example, plant based diets promote beneﬁcial bacteria, whilst animalbased diets may increase the risk of IBD and colon cancer. Robynne Chutkan, gastroenterologist in Washington DC claims that Western lifestyles are starving our microbiome, depleting good bugs that keep us healthy whilst encouraging damaging bacteria. To counter this, there are moves to serve bacteria fodder they like (“prebiotics”) that produce short chain
fatty acids from ﬁbre and plant-based foods and to directly add good bacteria to the gut (“probiotics”). During 2016, we are likely to see more pre and probiotic fortiﬁed foods which is ﬁne in theory, but the precise strain of bacteria and amount remain unclear and this should not be done at the expense of following a healthy diet. DNA prescribed diets? Genome analysis is now readily available and cheap, leading to the identiﬁcation of genetic mutations or risk factors amenable to dietary intervention. For example, ACE gene mutations can identify individuals who should strictly limit sodium intake to avoid hypertension and higher levels of folate supplementation maybe needed for those with mutations in the MTHFR gene. Similarly, slow metabolisers of caffeine may need to restrict intake to reduce the development of hypertension and MI.
Fat has had something of a reprieve recently, and low carb products are becoming more popular than low fat foods thanks to the War on Sugar. The next stage in the campaign maybe to introduce a sugar tax, supported by Cancer Council Australia, Diabetes Australia and the National Heart Foundation of Australia. Similarly, Jamie Oliver is lobbying the UK government to add a 20% tax to sugar-sweetened drinks like sodas, sweetened juices and milks. ‘Natural’ sweeteners such as stevia and xylitol are going to become increasingly popular, but will not reduce the nation’s sweet tooth. Efforts must be maintained on limiting food and drink with added sweetness and promoting unprocessed foods, wholegrains and ﬁbre. Any tax must be backed by ongoing public education, especially for preventing and managing diabetes. Over the next few years, diabetics may welcome inhaled insulin which has recently been approved by the US FDA.
Exciting Times in Rheumatology By Dr Senq Lee, Paediatric Rheumatologist, Shenton Park Research into 'biologics' For over 20 years, rheumatology research has focused on inﬂammation at a cellular or molecular level, Dr Senq Lee leading to new medications broadly called "biologics" - medications that target inﬂammatory cytokines, reducing or stopping the inﬂammatory cascade. Further research is being conducted, including in other autoimmune diseases like SLE. Biologics offer patients with disease unresponsive to standard agents (NSAID’s, steroids and disease-modifying agents) another option for treatment to reduce morbidity and damage, improving long-term disease control. Long term steroid use and side effects can also be reduced.
Biologics are used as treatment in patients with juvenile idiopathic arthritis, juvenile dermatomyositis, rheumatoid arthritis, ankylosing spondylitis and systemic lupus erythematosus. (They are also used in nonrheumatologic autoimmune/inﬂammatory diseases, such as uveitis, psoriasis and inﬂammatory bowel disease.) In paediatrics, biologics are limited due to a lack of safety/efﬁcacy data in paediatric rheumatology diseases – more research is being conducted. The anti-TNF agents (etanercept, adalimumab, inﬂiximab) and interleukin receptor antagonists (tocilizumab) are used for children with refractory or severe juvenile idiopathic arthritis or systemic juvenile idiopathic arthritis. Adult rheumatology patients have more biologics available (e.g.certolizumab, golimumab, tofacitinib).
juvenile dermatomyositis) has reduced the need for uncomfortable tests such as muscle biopsy and/or EMG. MRIs are also very sensitive in detecting sub-clinical disease activity and damage, which if detected, may alter patient treatment earlier to minimise further damage. Musculoskeletal ultrasound is increasingly used to assist in diagnosis, assess for inﬂammation/synovitis and damage, and guide intra-articular corticosteroid injections. Many rheumatologists train in musculoskeletal ultrasound for these reasons; but there are barriers to its current use that include lack of time during the consult, inadequate MBS reimbursement, high purchase and maintenance costs, and cost of training.
Imaging modalities These have been increasingly useful in diagnosis, and assessment of disease activity and damage. MRI imaging for myositis (in
Author competing interests - no relevant disclosures. Questions? Contact the author on 9380 9484.
FEBRUARY 2016 | 35
Fertility, Gynaecology and Endometriosis Treatment Clinic
When your patient’s family plan isn’t going to plan... Fertility North can help. zCycle Tracking z Timed Intercourse z Artiﬁcial Insemination zOvulation Induction zIn-vitro Fertilisation (IVF) zIntra-cytoplasmic Sperm Injection (ICSO) (ICSI) zPregnancy Monitoring zDonor Services zSperm / Egg Freezing zOncology Fertility Preservation zEgg Freezing for Social Reasons zSemen Analysis
Dr Vince Chapple
Dr Jay Natalwala
Dr Santanu Baruah
Dr Gian Urbani
Dr Megan Byrnes
Fertility Specialist Qualiﬁcations
MB, BS (London) FRANZCOG MRepMed
MB, BCh (UK) DRCOG FRANZCOG MRepMed
MBBS, MRCOG (UK) CCT (UK), CGES FRANZCOG
MBCHB, MMEd(O&G) FRANZCOG MRepMed
BMedSci, MBBS FRANZCOG MRepMed
MBBS, DRACOG FRACGP
Dr Jane Chapple
Suite 30, Level 2, Joondalup Private Hospital, 60 Shenton Avenue, Joondalup WA 6027 Phone: (08) 9301 1075 Fax: (08) 9400 9962 Email: email@example.com
Fertility, Gynaecology and Endometriosis Treatment Clinic
6 1 0 2 Innovations &
New Solutions to Old Vascular Problems By Dr Stefan Ponosh, Vascular Surgeon, Nedlands
low complication rates. The complexity of venous pathology now treated endovenously is substantiative. Multidisciplinary Management Vascular patients are often elderly with complicated and high-risk co-morbidities. Shared care models are very effective, improving clinical outcomes and reducing costs and readmissions. Dr Stefan Ponosh
Vascular Surgery has become more focused on minimally invasive endovascular techniques and service delivery to improve outcomes for patients and the health system. Tibial endoarterial intervention Severe tibial calf arterial disease imparts signiﬁcant risks of ulceration, critical ischaemia and limb loss. Once primarily a disease of older smokers, the increase in younger diabetics has magniﬁed the burden. Advanced endovascular techniques have revolutionised management, making high-risk distal and pedal bypass rare and signiﬁcantly reducing the risk of major amputation. Percutaneous techniques under local anaesthesia allow the recanalisation of occluded tibial vessels that was previously impossible. This can now extend into the foot, re-establishing in line arterial ﬂow in many instances. In conjunction with focal
drug eluting stents and longer drug coated angioplasty techniques, recanalisations are increasingly robust and have reduced limb loss. Pedal endoarterial approaches in more complicated cases have further increased our success. Endovenous Intervention Chronic venous disease (CVD) and varicose vein disease (often seen as simply cosmetic) is a signiﬁcant burden to the health system (an estimated 2% of western health budgets). The impact of venous ulceration and other sinister sequelae of CVD cannot be underestimated. While open venous intervention remains a viable option, laser/radiofrequency ablation, alternate occlusive techniques, sclerotherapy and other endovenous techniques are minimally invasive and extremely effective. Using local anaesthetic and ultrasound guidance, even elderly and high risk patients can be treated with extremely
Examples are the Vasculogeriatrics Service at SCGH, where embedded physicians assist the vascular surgical service in a shared care model. Multidisciplinary Wound Services with close liaison between surgeons, podiatrists, infective disease physicians, wound care nurses, endocrinologists and domiciliary home nurses facilitate chronic wound management and dramatically improve outcomes. This multidisciplinary approach with increased primary health awareness and early referral has been shown to mitigate ulcer progression, promote prevention and ultimately save limbs.
Author competing interests – nil relevant disclosures. Questions? Contact the author on 0403239956.
Getting ‘Frequent Fliers’ to Engage By Dr Jim Goodbourn, Psychiatrist, Nedlands Keeping people out of hospital can save the community and improve the lives of patients involved.
Dialectical Behaviour Therapy (DBT) or Mentalisation Based Therapy (MBT) programs are evidence-based treatments for patients with emotional dysregulation – in Perth, demand far outweighs supply for such programs. However, this trend within psychiatry continues, as many GPs are aware.
One common presentation to GPs, EDs, and Dr Jim Goodbourn Mother-baby Units is the patient with emotional dysregulation – people who have difﬁculties with interpersonal relationships, risky and self-harming behaviour, aggression toward others, and often substance and alcohol problems. Many have an associated eating disorder. Their children and families are adversely affected.
Most such patients in our DBT-Skills day program are referred as inpatients, and despite ﬁve concurrent groups the waiting list keeps growing. Our research shows a halving of bed-occupancy by this group in the ﬁrst year, a cost saving for the community and a quality-of-life advantage for the patient.
This group presents a challenge because they do not easily engage with programs, or if they begin treatment, the drop-out rate is high. The net result is "frequent ﬂyer" patient that requires recurrent emergency admissions.
Why this success? The group program focusses ﬁrst on therapy-interfering behaviours, which is THE key intervention within DBT or MBT programs. And the engagement rate is excellent. Then, other concerns can be addressed: risky activity, alcohol, interpersonal problems etc. Patients leave when they have learned new skills sufﬁciently, perhaps into a more mainstream group process.
Health practitioners operate at many levels and know the dysregulated patient often needs both public and private services. Our experience suggests we should stop thinking about "borderline" patients and instead complete a quick but accurate assessment of the patient's capacity to engage with therapy. If this is poor, then they qualify for a program that addresses this engagement problem FIRST. Wait lists for suitable programs is crazily long. Failure to wisely use our shrinking resources is ultimately very costly to our community through emergency attendances and admissions. As practitioners, it is up to us to demand state-wide attention to this problem. ED. The author is a private psychiatrist with interests in teaching, supervision, directing group psychotherapy programs, and college politics – his comments are based on his limited experience.
FEBRUARY 2016 | 37
Lyme disease in Australia By Dr Astrid Arellano Infectious Diseases Physician Palmyra
COCHLEAR IMPLANT INNOVATIONS
Post Dip. Aud., B.Sc,
M.Aud.,M.Clin.Aud., BHSc (Physio)
Dr Vesna Maric
Cochlear implants (CI) have been at the edge of bionics innovation for 30 years, providing hearing to those with very severe hearing losses through direct stimulation of the auditory nerve. Here, we look at the latest developments in sound processing technology and implant design that continue to improve quality of life and communication for those with modern CI. THE IMPLANT. Internal, implantable structures of a CI system are becoming smaller and, together with surgical advances, build on a trend towards atraumatic surgery and increasing hearing preservation. Cochlear implantation no longer means losing all natural hearing; for many, it simply replaces the speech frequencies for which hearing aids are no }iÀÃÕvwViÌ°/ Ã >Ãi>`Ì>Õ«ÀiVi`iÌi`}ÀÜÌ in candidacy. Recipients with a combination of natural and CI hearing show best performance in understanding speech in noise, music appreciation and sound localisation. 7Ì ÀiV>``>ÌiÃ]Ì iÜLiiwÌÃv«>Ì>Ì from a young age and a growing likelihood for an MRI over a lifetime, MRI compatibility is of increasing importance. All the current models are compatible with a routine 1.5 Tesla MRI without the need for surgical magnet removal. In 2014, one company released a magnet that self-aligns within an MRI wi`]>Ü}Ã>viÌÞÕ«ÌÎ/iÃ>ÜÌ ÕÌÌ iii`vÀ>}iÌ removal. THE SOUND PROCESSOR. Sound processing in the externally ÜÀV«iÌ >Ã«ÀÛi`Ã}wV>ÌÞ>ÃVV i>À«>Ì manufacturers merged with hearing aid manufactures and borrowed innovations for better speech-in-noise listening, automatic responding to changing environments and connectivity to wireless devices. In addition to connecting their CI processor to a smartphone, listeners can stream to a compatible hearing aid in the opposite ear at the same time, >ÝÃ}Ì iLiiwÌÃvL>ÕÀ> i>À}vÀ>vÕÀ>}iv multimedia. Compared to other listeners, cochlear implant recipients still ÀiµÕÀiÃ}wV>ÌÞ } iÀÃ}>ÌÃiÀ>ÌÃÌ>V iÛiÌ i same understanding. To improve comfort and performance in noise, processors automatically detect, analyse and reduce Ã«iiV ÃÕ`ÃiÜ`]ÌÀ>vwVÀV>}}`Ã iÃ°/ iÞ combine multiple microphones and frequency analysis to zoom towards the dominant speech signal and away from potentially distracting speakers in a crowd.
51 COLIN STREET WEST PERTH WA 6005 P: 08 9321 7746 F: 08 9481 1917 W: www.medicalaudiology.com.au
38 | FEBRUARY 2016
Lyme disease is a multi-system tick-borne zoonosis caused by the spirochaete Borrelia burgdorferi. There is no objective evidence of Lyme disease endemic to Australia. Cases may occur in travellers to Lyme disease areas in the USA and Europe. Typical symptoms include fever, headache, fatigue, and a characteristic skin rash (erythema migrans, EM) in 60-80% of cases. The pink or red rash usually starts within ﬁve weeks of a bite, as a small red spot that gradually spreads in a much larger circle with a characteristic bullseye appearance. A small proportion of cases develop presumed blood-borne infection with a relapsing illness of fevers, joint aches and fatigue lasting over six months. Uncommonly, Lyme disease causes meningitis, mononeuritis or an erosive arthritis delayed by months or years. Infection is successfully treated within a few weeks using antibiotics, typically doxycycline or amoxicillin. In patients with vague and atypical symptomatology who may claim to have Lyme disease, there is often no supportive travel history, few positive examination ﬁndings, multiple negative investigations yet an anxious, frustrated person convinced they require treatment for Lyme disease. Test interpretation There are clear diagnostic algorithms and reputable, NATA-accredited, sensitive screening tests with high negative predictive value available in Australia. These conﬁdently rule out Borrelia infection. Two-tier serological assessment is reliable after the ﬁrst few weeks – screening EIA (PathWest) followed by conﬁrmatory immunoblotting for speciﬁc IgG bands (Sydney) – and avoids the cost and variable reliability of samples sent to Germany or the US. Positive or equivocal screening EIA tests require follow-up immunoblot testing as false positive tests occur with syphilis, leptospirosis, infectious mononucleaosis, and autoimmune conditions such as SLE and RA. Individuals with an EM lesion should be considered for skin biopsy and Borrelia burgdorferi PCR. Culture is usually negative. A negative screening Borrelia IgM/IgG test can be reassuring on the one hand but on the other, diagnoses such as multiple sclerosis, motor neuron disease, thyrotoxicosis, rheumatoid arthritis and DSM V diagnoses may need to be pursued. No conspiracy Some advocates believe Lyme disease or a Lyme-like illness (a vague condition supposedly caused by a Borrelia-like organism, transmitted by an undiscovered tick) is endemic in Australia and there has been a conspiracy by the medical profession to avoid making adequate treatments available. Many rely on The Lyme Disease Association of Australia website, which presents data as though evidence-based research but it is anecdotal and misleading and the treatment advice is dangerous. Individuals with longstanding vague symptomatology have deﬁnite morbidity that requires acknowledgement and proper management. However, the absence of objective evidence of Lyme disease with negative tests makes Borrelia infection very unlikely. Thorough clinical assessment is required to ensure signiﬁcant diagnoses are not overlooked. In some cases correct dietary advice, lifestyle changes, psychological support and acknowledgement of symptoms may be all that can be offered. Further Reading: First report of Lyme neuroborreliosis in a returned Australian traveller. Shradha Subedi et al. MJA 2015; 203 (1): 39-40. Author competing interests - no relevant disclosures. Questions? Contact the author on 9319 3811
Introducing our Brand
Disc Herniation Disc Bulge / Degeneration All Musculoskeletal Conditions Radio-Frequency Ablation Chronic Post Sx Pain
Pioneering Regenerative Interventional Radiology
Dr Arockia Doss MBBS (Ind) MRCP (UK) FRCR (Lon) FRANZCR Interventional Radiologist
Teleconsult Via Skype: imageguidedtherapyclinic Suite Suite 3, 3, 55 55 Hampden Hampden Road Road Nedlands Nedlands WA WA 6009 6009 PP 6389 6389 2776 2776 FF 6389 6389 2778 2778
Malignant melanoma surgery Areas of controversy in the management of malignant melanoma (MM) include methods of diagnosis, margins of wider excision and the role of sentinel lymph node biopsy (SLNB). The NHMRC guidelines are currently under review and remain the â€˜gold standardâ€™ for management. The WA Department of Healthâ€™s model of care for cutaneous malignant melanoma recommends referral of all melanomas with a Breslow thickness (BT) >1.0mm or metastatic lesions for discussion by a multidisciplinary team (MDT). The WA Melanoma Advisory Service is the only MDT in WA dedicated to melanoma management advice. Methods of diagnosis Most MMs are diagnosed in general practice. Clinical assessment using the â€˜ABCDEâ€™ criteria, with the aid of dermoscopy, where available, remains the best way to deďŹ ne suspicious lesions. A history of change in a pre-existing pigmented lesion or the occurrence of a new lesion with or without pigmentation in sun exposed individuals are the most suspicious symptoms. Excisional biopsy of the entire lesion with a 2mm margin is the standard of care for suspicious lesions. For equivocal lesions, serial photography aids assessment.
By Dr Mark Hanikeri Specialist Plastic Surgeon Subiaco
Shave biopsies and punch biopsies should be avoided as they may hamper subsequent assessment and may not be representative of the whole lesion. If the entire lesion cannot be excised, incisional biopsy or multiple punch biopsies of the â€œmost suspicious partâ€? should be performed or referral to a dermatologist or surgeon is appropriate. Excision of suspicious lesions with wide margins is inappropriate. Reconstruction using a ďŹ‚ap after excision of suspicious lesions is contraindicated. Excision margins Lesions conďŹ rmed to be MM on biopsy require excision with an appropriate margin. For in-situ lesions, a clinical margin of 0.5cm and for invasive disease, a clinical margin of 1cm is recommended. In some instances wider margins are considered reasonable. This includes poorly deďŹ ned in-situ lesions and thicker (>2.0mm BT) inďŹ ltrative, invasive lesions such as desmoplastic and neurotropic MM, especially on the limbs or trunk. In these instances, appropriate margins should be discussed with a melanoma specialist.
Sentinel lymph node biopsy Cases where the primary melanoma has a BT 1-4mm should have wider excision deferred until after discussion of SLNB with a surgeon experienced in the procedure. The MSLT1 trial results (NEJM Feb, 2014) demonstrate a survival and a disease-free survival advantage in patients with MM 1-4mm BT who have microscopic nodal involvement at the time of lymph node dissection, compared to those with macroscopic disease. Furthermore, staging offered by SLNB helps with treatment choice, including the potential for new adjuvant treatments that may one day be available for patients with early-stage melanoma that is predicted to recur and cause death. Trials to establish this role are underway. For this reason, SLNB may also assist patients with BT over 4mm or those with MM under 1mm BT with other â€œsinisterâ€? features (such as ulceration, mitotic activity, or lymphovascular invasion, especially in those under age 40).
Competing interest declaration: no relevant disclosures. Questions? Email the author at firstname.lastname@example.org
The science of IVF success At Hollywood Fertility Centre, we have been helping Western Australians start and grow their families for more than 15 years. Since 2006, our close association with world leading fertility group Genea has given us direct access to their pioneering technologies. +ROO\ZRRG)HUWLOLW\&HQWUHPHDQVKLJKVXFFHVVUDWHVXQGHUVWDQGLQJVWDÎ?DQGLQGLYLGXDOFDUH
Dr Simon Turner
Prof Lincoln Brett
Dr Julia Barton
Dr Bill Patton
Dr Michael Allen
MBBS, FRANZCOG, FRCOG
BMedSc, BSc (Hon), MBBS, FRANZCOG
MBBch, BAO, DCG, DRCOG, MRCOG, MRCPI, FACGO, FRCOG
MBBS (UWA), FRANZCOG
Visit www.hollywoodivf.com for referral forms and details of our treatments. It also includes information for your patients. Hollywood Fertility Centre Hollywood Private Hospital, Monash Avenue, Nedlands WA 6009 P (08) 9389 4200 W www.hollywoodivf.com
40 | FEBRUARY 2016
MRI services have expanded
Your patients can have a scan on one e of our brand new 1.5T or 3T MRI scanners with minimal wait time. Both scanners are wide bore, designed to maximise patient comfort and minimise claustrophobia. Envisionâ€™s friendly team of experienced technicians & sub-specialty radiologists will ensure your patient has quality images with efďŹ cient and accurate reports. Medicare rebates are available on eligible GP referred adult & paediatric scans.
Need a scan or report urgently?
Call us on 6382 3888 CT MRI X-RAY ULTRASOUND NUCMED DENTAL
178-190 Cambridge Street | Wembley 6382 3888 | envisionmi.com.au
SJG Murdoch Hospital More than 200 people headed lakeside at SJG Murdoch for its annual doctorsâ€™ Christmas party hosted by CEO Mr John Fogarty. General and laparoscopic surgeon Dr David Cooke was announced 2015 Doctor of the Year Award. 1
Gabrielle and Sophie Fogarty and Sally and Dr Michael Stanford
Dr Duncan and Priscilla McLellan and Dr David Cooke
Tracy Crompton and Dr Stephen Baker
Dr Graham Forward and Dr Don Coid
Dr Sanjay Sharma, Dr Nigel Barwood, Dr Beate Harrison and Dr Volker Mitteregger
Magda Rhodes, Geraldine and Dr Jacques Pretorius
Dr Meredith Borland, Dr Ian Rogers, Mr Colin Keogh and Prof Shirley Bowen
Mr John Fogarty and MLA Matt Taylor
42 | FEBRUARY 2016
Clinipath's annual function at Mosmans Restaurant was a perfect way to spend a summer evening.
Claudia Hahnel, Tanja Kailis, Dr Cary Kailis, Dr Alistair MacKendrick, Pamela Gabriels and Dr Peter Cummins
Dr Jack and Carol Oâ€™Connor and Dr Sue Martin
Dr Norman Lee and Dr CY Chin
Dr Simon and Monica French
Kim Asher, Paul Martin and Breana Smith
Dr John Edwards, Katarina Rakovska and Dr Anne Hales
Natalie Park, CEO Dr Gordon Harloe and Gayle van Oss
Siobhan Downer, Andrew Barclay, Dr Judy Cole and Dr Nigel Dormer
Steve Bertolini, Dr Indrani Saharay, Roz Epps, Jenny Heyden and Sheila Harloe
FEBRUARY 2016 | 43
Ramsay HealthCare Ramsay board members celebrated another big year for the group with doctors and staff of their WA hospitals at Winthrop Hall and the beautiful reďŹ‚ection pool in the grounds of UWA. 1
Ms Kim Chant, Sharon and Peter Mott, Hollywood CEO, and Dr Marg Sturdy, CEO Peel.
Dr Yuresh and Anushka Naidoo and Louise and Dr Cameron Burrows
Jackie Thomson, Dr Andrew Granger and Natalie and Dr Kenji So
Christine Cass-Ryall, Dr Rita Malik, Dr Steve Rodrigues and Dr Jon Armstrong
Minister for Health Dr Kim Hames, Ramsay CEO Mr Danny Sims, Mr Kevin Cass-Ryall and Mr Peter Evans
Dr Phil Childs, Dr Greg Witherow and Dr Hari Goonatillake
Mr Geoff Friebe, Dr Sarah Pickstock and Ramsay Chair Mr Michael Siddle
6 SKG Radiology
1 With city skyline as a backdrop, the team from SKG Radiology enjoyed a perfect night under the stars for its annual celebration for doctors and staff. Sonographer Diedre Coppen took out the Patients First Award and business analyst Maryann Maitland won the Team Player Award. 1
44 | FEBRUARY 2016
From left: Sophie Burke, Angelique Brynjulfsen, Sarah Chang and Kayla Temov at the SKG Christmas party.
The Mt Lawley team got arty at the annual doctors Christmas function held this year at Linton & Kay Art Gallery in Subiaco. Outgoing Medical Director A/Prof David Watson was farewelled at the function. 1
Dr Jerard and Tanya Ghossein
Dr John Taylor and Dr Ian Churchwood
Dr Luca and Petrina Crostella and Dr Simon and Aileen Edmunds
SJG Mt Lawley
KARRINYUP HEALTH PROFESSIONALS FOR SALE by Expressions of Interest 334 KARRINYUP ROAD, KARRINYUP, WA
Immediate admissions now available with 38 more private mental health beds to support the Perth community
MEDICAL SUITES - TITLES HAVE NOW ISSUED
Marian Centre is an established private mental health hospital in Subiaco. We are proud to have played a significant role in helping Western Australians suffering with mental illnesses since 2006. Now owned by Healthe Care Australia, we have undergone significant redevelopment works, boosting inpatient beds from 31 to 52, soon to be 69. Immediate admissions are now available. For direct access to our experienced Admissions and Assessment Mental Health Nurse, please call 1800 540 388. Medical 68m² to 433m² Available for Centre Zone strata areas immediate occpuation
Opposite Karrinyup Shopping Centre
Aaron Antonas 0434 659 818
A 187 Cambridge St, Wembley WA 6014 Admissions and Assessment 1800 540 388 P 08 9380 4999 F 08 9338 3179 E email@example.com mariancentre.com.au
FEBRUARY 2016 | 45
SJG Subiaco Hospital
The elegantly casual surroundings of Royal Freshwater Bay Yacht Club gave the St John of God Subiaco Hospitalâ€™s Medical Practitioners Christmas Soiree a relaxed atmosphere. CEO Dr Lachlan Henderson thanked doctors for their efforts at the hospital over the past year.
Dr Ben Carnley and Dr Dermot Collopy
Briony and Dr Mark Lee
Susan and Dr Digby Cullen, Dr Michael Gannon and Dr Mariam Bahemia
Dr Joe Pracilio and UND Dean Prof Shirley Bowen
Jenny Tomson, Dr Paul McRae, Dr Allan Pelkowitz and Dr David Borshoff
A/Prof Rosanna Capolingua and Mr Paul Boyatzis
A/Prof Shyan Vijayasekaran and Melanie Ward and Dr Jo Colvin
1 46 | FEBRUARY 2016
The crew from Hollywood Fertility got their Yee-Hah happening at their Christmas function complete with line-dancing, spurs and Stetsons.
Reto & Tinka Truninger, Dr Simon Turner & Dr Julia Barton
John Groppoli & Cailin Jordan
Entering Medical Forumâ€™s competitions is easy!
Simply visit XXXNFEJDBMIVCDPNBV and click on the â€˜Competitionsâ€™ link (below the magazine cover on the left).
Movie: Brooklyn Eilis Lacey (Saoirse Ronan) is a young Irish immigrant ďŹ nding her feet in 1950s Brooklyn. Lured by the promise of America, Eilis is torn between the thrills of the big city and the troubles of her homeland. The ďŹ lm is based on a book by Colm Toibin with screenplay by Nick Hornby. In cinemas, February 11
Movie: A Bigger Splash A psychological suspense drama with an all-star cast â€“ Tilda Swinton, Ralph Fiennes, Dakota Johnson and Matthias Schoenaerts â€“ delves into the murky waters of jealousy and deception. A glamorous coupleâ€™s romantic Italian getaway is shattered when an old friend and his daughter arrives. In cinemas, March 24
Movie: 45 Years Kate Mercer (Charlotte Rampling) is planning a party to celebrate her 45th wedding anniversary. One week before the celebration, her husband, Geoff (Tom Courtenay), hears news that the body of his ďŹ rst love has been discovered, frozen and preserved in the icy glaciers of the Swiss Alps. Berlin Film Festival gave this the gold gong. In cinemas, February 18
Musical Theatre: CATS The Jellicle Cats have had a makeover and are ready to prowl, re-invigorated, for their special night of the year. Andrew Lloyd Webberâ€™s classic CATS has been showing somewhere in the world for the past 35 years and audiences never tire of the fabulous music and the antics of the crazy cats. Crown Theatre, from April 16
Music: Bach's St John Passion An Easter must-hear is a Bach Passion. WASOâ€™s baroque players, the sublime St Georges Cathedral Consort and soloists Paul McMahon, Andrew Foote, Andrew Collis, Sara Macliver, Sally-Anne Russell and Richard Butler under the baton of principal conductor Asher Fisch bring this masterpiece to the stage.
COMP Movie: Trumbo Breaking Badâ€™s Bryan Cranston portrays Dalton Trumbo, a successful Hollywood screenwriter who was blacklisted in 1947 by the House Committee on Un-American Activities for refusing to name "suspicious" friends. He lost his livelihood and spent a year in jail for Contempt of Congress. But his great revenge was writing several scripts using a pseudonym, including the Oscar-winning Roman Holiday starring Gregory Peck and Audrey Hepburn. In cinemas, February 18
Doctors Dozen Winner Itâ€™s not every day that the Doctorâ€™s Dozen winner swings by to pick up his wine on the way to a windsurďŹ ng session. Dr Neil Banham is partial to Margaret River Reds and Yarra Valley Chardonnays and heâ€™s got his own wine cellar to keep them in perfect drinking condition. He emailed a week later to say the Xanadu dozen did not disappoint.
Perth Concert Hall, March 23
8JOOFST from the November issue Movie â€“ Hotel Transylvania 2: Dr Stephen Rodrigues, Dr Kate Concanen, Dr Dian Harun, Ms Andrea Piesse, Mr Ray Barnes, Dr Michael Allen, Dr Christina Wang, Dr Andrew Christophers, Dr Monica Keel, Dr Mathew Carter
Movie â€“ Freeheld: Dr Amir Tavasoli, Dr Donna Mak, Dr Wen Loong Yeow, Dr Hock Chua, Dr Amy Gates, Dr Astrid Valentine, Dr Jennifer Martins, Dr Alem Bajrovic, Dr Moira Westmore, Dr Sayanta Jana Movie â€“ Suffragette: Dr Carol McGrath, Dr Lawrence Chin, Dr Tony Connell, Dr Jenny Fay, Dr Elizabeth Sinclair, Dr David Storer, Dr Geoff Mullins, Dr Jeff La Valette, Dr Simon Turner, Dr Robert Weedon
t "HFJTN1BMMJBUJWF$BSF t 3FUIJOLJOH"HFE$BSF t #BUUMFGPS(1T)FBSUT.JOET t $MJOJDBMT4UBUJOT "UIMFUFT %JBCFUFT 8PVOET $FSFCSBM1BMTZ )FBSJOH-PTTNPSFy
Movie â€“ Trumbo: Delayed release November 2015 www.mforum.com.au
Jazz â€“ James Morrison & WASO: Dr Christine Pascott Choral â€“ Handelâ€™s Messiah: Dr Susan St Clair
FEBRUARY 2016 | 47
MY DAILY REGIMEN My doctor took one look at my gut and refused to believe that I work out. So I listed the exercises I do every day: jump to conclusions, climb the walls, drag my heels, push my luck, make mountains out of molehills, bend over backward, run around in circles, put my foot in my mouth, go over the edge, and beat around the bush.
WORDS JOINING OUR VOCABULARY IN 2016! Chairdrobe (n.): piling clothes on a chair in place of a closet or dresser. Epiphanot (n.): an idea that seems like an amazing insight to the conceiver but is in fact pointless, mundane, stupid, or incorrect. Internest (n.): the cocoon of blankets and pillows you gather around yourself while spending long periods of time on the Internet. Textpectation (n.): the anticipation felt when waiting for a response to a text. Unkeyboardinated (adj.): when you’re unable to type without repeatedlyy making mistakes.
v ry dogma ha Eve
DID YOU KNOW? Over a lifetime a woman eats about 20kg of lipstick. *** Physically it is impossible to sneeze with opened eyes. *** People talk at an average speed of 120 words per minute. *** Just like people, dogs and cats can be left-handed or right-handed. *** It’s physically impossible for a pig to look up at the sky. *** More than 50% of the world’s people have never made or received a telephone call. *** More than 75% of people will try to lick their elbow after reading this fact for the ﬁrst time. *** Women buy 85% of all Valentine's Day greeting cards.
s its day.
ess - Anthony Burg SOCIAL MEDIA I’ve given up social media for the New Year and am trying to make friends outside Facebook while applying the same principles. Every day I walk down the street and tell passersby what I’ve eaten, how I feel, what I did the night before, and what I will do tomorrow. Then I give them pictures of my family, my dog, and me gardening. I also listen to their conversations and tell them I love them. And it works. I already have three people following me—two police ofﬁcers and a psychiatrist.
MORE GAS, MORE MILES Sister Mary was truly a religious woman. Besides her church duties, she was also active in various hospitals visiting the sick and tending to their needs. So it was no surprise that one day, when she ran out of gas, the only container she could ﬁnd for the petrol was a bedpan. Sister Mary happily walked two blocks to the closest petrol station where she ﬁlled up the bedpan with petrol and trudged back to her car. Just as Sister Mary started tipping the petrol into the fuel tank, the trafﬁc light turned red and she had quite a large audience witnessing the spectacle. Just when she ﬁnished pouring in the last drops of petrol a big bruiser wound down his window and yelled, “I swear! If that car starts I’m becoming a religious man!”
48 | FEBRUARY 2016
at Old Kent River
Elegance of France It is a few years since I reviewed Old Kent River Wines and I was pleased to get the opportunity to try some of their interesting wine styles. To recap the history, the Old Kent River property at Rocky Gully was purchased by Mark and Debbie Noak in 1985 and they set about rehabilitating neglected areas of cleared bush. Plantings of Pinot Noir and Chardonnay was the ďŹ rst step and later Shiraz. I bought my ďŹ rst bottle of the Pinot Noir in 1998 and it had developed a cult following for the outstanding quality of the wine from such an unknown area at the time.
By Dr Martin Buck
1. 2008 Diamondtina Sparkling wines from the Great Southern are not common but the 2008 Diamondtina should put an end to any doubts about the suitability of the area to make great bubbles. This is a wine to try on your friends in a blind tasting and ask them from which part of Champagne does it originate? Made from 70% Pinot Noir and 30% Chardonnay and has spent six years on lees and bottle fermented in the traditional method. What a result! Aromas of toast, peach and honeysuckle leap out of the glass and the bead is ďŹ ne and long-lasting. There is crisp acid, aged yeast and peach ďŹ‚avours with a great ďŹ nish. A phenomenal sparkling wine that could easily be confused with a famous champagne house, very good value and I am ordering a case.
2. 2014 Sauvignon Blanc This wine is deďŹ nitely not the style that you usually will ďŹ nd in your local wine store. This is picked early so the resultant alcohol content is 12.5% and the ďŹ‚avours are more in the green apple spectrum with clean acid and just a little off dry. It is a refreshing wine with a big palate, a hint of gunďŹ‚int and some complex ďŹ‚avours. This is well suited to seafood and would be sensational with fresh Albany oysters. 3. 2014 Old Kent River Pinot Noir Now for the main event! A young Pinot Noir was provided for this tasting and it is a glimpse of how this wine will age and likely reach its peak in the next ďŹ ve years. Since 1985 much has been learned about the best clones and viticultural practice to produce sensational wines. There are some funky aromas in the glass with berries, oak and Bonox all thrown in together. It was a great vintage in 2014 with 14.5% alcohol indicating plenty of sunshine. Still a young wine in Burgundian terms but there is great palate weight, balanced, ďŹ ne tannins and a lengthy palate. This is another great Pinot Noir from Old Kent River and showcases the style from Great Southern. 4. 2010 Old Kent River Shiraz Lastly, this wine is a mature, cool-climate Shiraz, or Syrah, that reďŹ‚ects the silky styles from Hermitage. On the nose there are aged oak aromas and subtle berry fruits. The palate is well balanced with soft tannins and smouldering dark fruits. Some further ageing will be interesting but this is a wine that is ready to take out of the cellar. A classic cool climate, Hermitage-style Shiraz with class. Unfortunately my cruise through France has come to an end. It is a great collection of subtle, elegant wines that highlight how varied the Great Southern can be and the potential of the region.
WIN a Doctorâ€™s Dozen! Name Phone
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FEBRUARY 2016 | 49
Top 10 Showstoppers Perth will be welcoming a host of renowned international and local shows BETWEENĂĽ&EBRUARYĂĽANDĂĽ-AYĂĽ(ERESĂĽOURĂĽPICKĂĽOFĂĽTHEĂĽBUNCH
DANIEL ASSETTA (Rum Tum Tugger) Andrew Lloyd Webberâ€™s CATS is, somewhat soberly, 35 years old in May and in that time has become a musical theatre classic and a rite of passage for all theatregoers. However, last yearâ€™s London revival, which heads to Perth in April, has given the Jellicle cats a makeover by Lloyd Webber and director Trevor Nunn with new staging and some tweaking of the songs and a fresh exciting show is the result. The barometer of the changing times is the preening tom-cat Rum Tum Tugger. From the swaggering lionesque character of â€™90s, 22-year-old Australian performer Daniel Assetta is embarking on bringing a hip-hop, break-dancing, wisecracking jokester to the stage in the local production. â€œI saw the show in London and had to pinch myself that I would introduce Australia to this new characterisation. He is much more youthful with dreadlocks and an improvised cheekiness that includes some rapping and hip-hop dance breaks. Thereâ€™s nothing better than to be a cheeky rebel on stage,â€? Daniel said. â€œWe have played to audiences in Auckland and Sydney and everyone has responded positively to the new version and it has brought a whole new generation to its charms.â€? While Danielâ€™s own youthful exuberance bubbles up while speaking to Medical Forum, it belies his stage experience which began when he was 10 in the childrenâ€™s chorus of Opera Australia. He hadnâ€™t even heard of opera when his agent called to say the company was looking for boy sopranos. â€œI loved it and realised that I really enjoyed being on stage in front of an audience but my voice broke and I wasnâ€™t a boy soprano anymore! I was very fortunate to have that experience working with professionals and understanding that people actually make a living singing and dancing. It inspired me and performing at the Sydney Opera House is every performerâ€™s dream and I was doing it regularly for six years.â€? Daniel, though, conceded that ďŹ rst and foremost heâ€™s a dancer. Having scored a gig with Wicked! as a 19-year-old, he spent the next two years learning his trade. Being â€˜swingâ€™ or a performer who takes on multiple roles in a show, meant him juggling 10 characters a night. That said, his ďŹ rst character role as Rum Tum Tugger has proved even more challenging. â€œI didnâ€™t expect to be going straight into CATS from Wicked! It is a dream come true and having the responsibility of this role has been really challenging but exciting as I have been able to have input into a character that no one has seen before.â€?
Where: Crown Theatre When: April 16-May 8
1.CATS 50 | FEBRUARY FE EB BRU BR RUAR ARY 2016 20 2 016 16
You’ve read the book and seen the ﬁlm, now check out the stage play developed by Tom Wright. The mystery of the fate of the school girls remains but it takes on a whole new dimension in this Black Swan production.
6 PICNIC AT HANGING ROCK
WHERE: Heath Ledger Theatre WHEN: April 1-17 2 LA SOIREE SPIEGELTENT This was the red hot ticket of the Fringe Festival last year and it is 120 minutes of non-stop deliriously funny burlesque and cabaret. There are some new acts in the line-up and some welcome returns by the likes of the incomparable contortionist Captain Frodo (pictured) If you missed it in 2015, make sure you are ﬁrst in line this time round.
7 THE RIDERS
WHERE: Spiegeltent, Museum Gardens, Perth Cultural Centre
Tim Winton’s celebrated novel is transformed into a mystical and heartrending opera by WA-born composer Iain Grandage (liebrettist Alison Croggan) and brought to the stage by West Australian Opera led by artistic director Brad Cohen.
WHEN: January 22-March 6
WHERE: His Majesty’s Theatre WHEN: April 13-16
3 MEOW MEOW
8 BLACK SABBATH – THE END
Australia’s genre-bending ‘kamikaze cabaret’ diva Meow Meow brings her acclaimed mix of drag, chanson and performance art to the PIAF with her show Little Mermaid. WHERE: Octagon Theatre, UWA
Not many would have gambled on a ﬁve decade career for the granddaddies of Heavy Metal but here they are Ozzy Osbourne, Tony Iommi and Geezer Butler writing the ﬁnal chapter of the Black Sabbath story in Perth.
WHEN: February 24-28
WHERE: Perth Arena WHEN: April 15
4 GIVE ME A REASON TO LIVE
9 BEAUTY AND THE BEAST
Glaswegian choreographer and dancer Claire Cunningham has lived and worked with her crutches since she was 14 and diagnosed with severe osteoporosis. This solo piece for PIAF is to a haunting soundscape by Zoe Irvine.
WA Ballet brings this Australian premiere to Perth which tells a timeless story in an exciting contemporary way with choreography by David Nixon to a score of orchestral greats such as SaintSaens, Bizet, Debussy, Poulenc and Glazunov.
WHERE: PICA, Perth Cultural Centre
WHERE: His Majesty’s Theatre
WHEN: March 2-5
WHEN: May 13-28
5 CIRQUE ADRENALINE
10 GHOST THE MUSICAL
Circus on speed – that’s what punters can expect from this new production from the crew that brought The Illusionists and Le Noir to Perth. Big drawcard is the Sphere of Fear where motorcyclists do crazy things inside a round metal cage!
An all-time favourite date-night movie, Ghost has become a hugely successful musical and with Rob Mills (X-Factor, Grease) and Jemma Rix (Wicked) as the ill-fated lovers it will be a tearjerker.
WHERE: Crown Theatre
WHERE: Crown Theatre WHEN: From May 21
WHEN: From March 15
FEBRUARY 2016 | 51
medical forum FOR LEASE
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medical forum BENTLEY Rowethorpe Medical Centre is a nonprofit, friendly practice seeking a part time GP to provide visits to our onsite residential aged care facilities. Practicebased consultations are also available. t 'VMMZDPNQVUFSJTFE t /FXMZSFOPWBUFEQSFNJTFT t .PEFSOFRVJQNFOU t 0OTJUFQBUIPMPHZ t )PVSTUPTVJUZPV For enquiries, please contact Jackie on 6363 6315 or 0413 595 676
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General Practitioner FT/PT for privately owned womenâ€™s clinic located next to Rockingham General Hospital and in a DWS area DRANZCOG qualifications preferable Vibrant team-oriented group of GPâ€™s and Midwives Family friendly workplace focusing on high quality care Please contact Narelle Supanz on 0412 305 119 or via firstname.lastname@example.org
JOONDANNA We are seeking a VR GP to join our friendly team on a part-time or full-time basis. New, state of the art medical centre. Flexible hours and billing. Percentage negotiable. Fully-computerised. Nursing support for CDMP. Please call Wesley on 0414 287 537 for further details.
BANKSIA GROVE BERTRAM VR or Non VR GP required Part Time/ Full Time for our Two Bulk Billing Practices in the Suburb of Bertram - Bertram Family Medical Centre Fully Computerised with Best Practice, Nurse Support and Pathology. - Champion Medical Centre Fully Computerised with Best Practice, Nurse Support Onsite Dentist, Physiotherapy, Psychology and Pathology. Good Patient base, Busy Practices, Rates Negotiable, Privately Owned Contact Tricia on 9497 1900 for a Confidential Discussion or Email CV to: email@example.com
North of the River Family Practice is seeking a VR GP. Well-established team, accredited and fully computerised. Please Email: firstname.lastname@example.org
HAMILTON HILL A female GP required for a clinic in a DWS and AON area 5 minutes drive from Fremantle. %PDUPS(11SBDUJDF Part time or Full time doctor considered Fully computerised practice. Rates negotiable Contact Eric on 0469 177 034 or Send CV to email@example.com
MARCH 2016 - next deadline 12md Monday 15th February â€“ Tel 9203 5222 or firstname.lastname@example.org
MADELEY VR & Non VR General Medical Practitioners required for Highland Medical Madeley which is located in a District of Workplace Shortage. Highland Medical Madeley is a new non corporate practice with 2 female & 1 male General Practitioners. Sessions and leave negotiable, salary is compiled from billings rather than takings. 6QUPPGCJMMJOHTQBJE EFQFOEBOUPOFYQFSJFODF Please contact Jacky on 0488 500 153 or E-mail to email@example.com
SHOALWATER F/T or P/T VR GP required for our modern state of the art medical centre MPDBUFEJO4IPBMXBUFS %84 Offering modern surrounds and fully computerised clinical software. We are a friendly, privately owned and run centre. A full complement of nursing staff and administration team as well as onsite allied health, specialists and pathology. generous remuneration offered. Please phone Rebecca on 9527 2236 or Email CV to firstname.lastname@example.org
Are you looking for doctors for your medical practice? Australian Medical Visas is owned and run by 2 Practice Managers based in 8" XIPIBWFPWFSZFBSTFYQFSJFODF PGUIF6,BOE"VTUSBMJBOIFBMUIDBSF systems. We currently have a number of doctors who are looking for positions in Australia. We are able to assist practices with all paperwork involved including the NJHSBUJPOQSPDFTT JGSFRVJSFE Please visit our website www. australianmedicalvisas.com.au or contact Jacky on 0488 500 153 or Andrea on 0401 371 341.
AVELEY Aveley Medical Centre require a VR GP for both FT & PT. Well established practice. On site pathology psychologist and dietician. Fully accredited practice, computerised and with nurse support. WAGPET accreditation available as well. Excellent remuneration. Please Contact: 0400 814 091 WILLAGEE Full/part-time VR GP required for established busy practice with high prevalence of chronic disease. Fully accredited and computerised, this bulkbilling practice. IBTIJHIJODPNFQPUFOUJBM QFSDFOUCJMMJOHT (1PXOFEQSBDUJDF encourages development of special skills/interests with nursing support, on-site pathology. and neighbourhood pharmacy. DWS available for after-hours only. Enquiries welcome for confidential discussion to: email@example.com 0499 404 043 / 0421 529 568 PERTH VR GP Required t /FXNPEFSO t $PNQVUFSJTFEQSBDUJDF t /PODPSQPSBUFFOWJSPONFOU Mixed billing practice Great location opposite nib Stadium. Growth area with a growing clientele base. Please send your application by email to: firstname.lastname@example.org
GP Opportunities - WA Start the new year with a thriving practice. As a result of IPNâ€™s expanding network, there are currently a number of vacancies for Doctors South of the River. This exciting opportunity includes a ready made patient base and the potential to be rewarded with an attractive disbursement rate whilst enjoying the full suite of support that IPN offer.
Contact Craig Coombs s now his to take advantage of this special offer 0427 744 097 om.au email@example.com
With IPN, weâ€™re looking after you.
SOUTH PERTH VR GP required Part-time Position Well established South Perth/Como practice, situated very close to the city. On site Pathology and Physiotherapy. Fully accredited and computerised. Full time RN support. Friendly and supportive team. Contact by email: firstname.lastname@example.org or 0413 437 985
WEST PERTH BYFORD VR GP Female/ Male GP Required Full â€“ Time or Part -Time Under New Management Privately owned well established modern practice MPDBUFEJO#ZGPSE NJOTGSPN$#% DWS and area of need. Full admin, nurse and practice manager support. Onsite Pathology, Podiatrist, Dental and Pharmacy Fully computerised accredited Practice Excellent Remuneration Please email: email@example.com
GP required for our friendly, accredited and fully computerised general practice. This newly renovated, noncorporate practice serves a young, professional demographic as well as providing specialist sexual health services. Pathology, physiotherapy, psychology and dietician on site. This is an exciting opportunity for an enthusiastic practitioner to join our team; VR with experience in family planning and womenâ€™s health preferred. Contact Stephen on 0411 223 120 Email: firstname.lastname@example.org
Contact Jasmine, email@example.com to place your classified advert
MARCH 2016 - next deadline 12md Monday 15th February â€“ Tel 9203 5222 or firstname.lastname@example.org
Metro Area GP positions available VR & Non â€“ VR Drâ€™s are welcome to apply. Send applications to email@example.com
Looking for a Part Time/ Full time VR GP to join the UWA Medical Centre team. Flexible hours, fully computerised, full admin and nursing support. Patient base Students and Staff of the University. Bulk billing for students, private for staff. Please contact Dr Christine Pascott or Sharon Almeida Phone: 08 6488 2118 Email: firstname.lastname@example.org ; email@example.com
GPâ€™S PART/FULLTIME Brand new, Opening in April 2016
Are you a GP (DWS GP) working in Aged Care or looking to?
8FIFMQZPVXIJMFZPVGPDVTPODBSJOHGPSPUIFST *NQSPWFZPVSwork-life balanceBOEincome XIJMFPQUJNJ[JOH healthcareGPSZPVSQBUJFOUT )"8-BJNTUPDSFBUFFĹĽDJFOUTZTUFNTBOETVQQPSUGPS(1TQSPWJEJOH IFBMUIDBSFUP3FTJEFOUTBU3FHJTUFSFE"HFE$BSF'BDJMJUJFT 3"$'T 0VS3FHJTUFSFE/VSTF 3/ WJTJUT3FTJEFOUTTPPOBGUFSBENJTTJPOBOE QSPDFTTFTEBUBJOUP.FEJDBM%JSFDUPSUPBTTJTUUIF(1JODPNQJMJOHIFBMUI QSPĹŁMFT5IF3/HFOFSBUFT$PNQSFIFOTJWF.FEJDBM"TTFTTNFOUTBOE BMMUIFPUIFSSFMFWBOUQBQFSXPSLUPTVQQPSUQBUJFOUDBSF JODMVEJOH BDDPNQBOZJOHZPVPOZPVSSPVOET
Mundaring GP super Clinic VR GPs wanted to join a friendly team Â‡opening in April 2016
HAWL provides a unique solution in Aged Care. Increased income now, & income growth for the future.
Â‡DWS and AON and 70 % offered.
)"8-TVQQPSUTZPVSOFFEGPSĹ¤FYJCJMJUZBSPVOEXPSLDPNNJUNFOUT DPOĹŁEFOUZPVDBOTVCTUBOUJBMMZJODSFBTFZPVSJODPNF8FTUSVDUVSFZPVS EJBSZUPJODMVEF$PNQSFIFOTJWF.FEJDBM"TTFTTNFOUT $BTF$POGFSFODJOH BOE4UBOEBSE$POTVMUT)"8-IBT3FTJEFOUTJO3"$'TJO2ME8"
Â‡State-of-the-art Medical Centre
contact Dr Kiran Puttappa
You deserve a system that works for you.
0401 815 587
We encourage enquiries from DWS GPâ€™s too. ConďŹ dential enquiries can be directed to: Caroline Claydon Phone: 1300 798 198 Email: firstname.lastname@example.org
Apollo Health is seeking local Drâ€™s with an interest in : - Skin cancer - General family medicine - Walk in /Urgent care For our practices in Armadale, Cockburn and Joondalup FRACGP required, Relocation incentives available
If you would like to join our dynamic team please contact ofďŹ email@example.com
GENERAL PRACTITIONERS REQUIRED Belvidere Health Centre (39 Belvidere Street, Belmont) Looking for something different? Are you seeking a ďŹ‚exible working environment? Our clinic offers the following opportunities to GPsâ€™ wanting to contract their services: Ĺ” Ĺ” Ĺ” Ĺ” Ĺ” Ĺ”
(FOFSPVTSBUFT 'MFYJCMFXPSLJOHIPVST $MJOJDBMOVSTJOHTVQQPSU 'VMMZDPNQVUFSJTFETZTUFNT 7BSJFEDMJFOUCBTF 0OTJUF*SPO*OGVTJPOUIFSBQZ
%BZTDVSSFOUMZBWBJMBCMF.POEBZT 5IVSTEBZTBOE'SJEBZT For further information please contact Rod Redmond at (08) 9458 0505 or firstname.lastname@example.org
medical forum Leaders in cardiology
Medical Specialist Acquired Brain Injury
STRESS TEST SUPERVISING PHYSICIAN
,OCATION %AST 6ICTORIA 0ARK Part Time
CASUAL / PART TIME
"RIGHTWATER /ATS 3TREET IS LOOKING FOR A PART TIME -EDICAL 3PECIALIST TO JOIN ITS INTERDISCIPLINARY 2EHABILITATION TEAM /ATS 3TREET IS A STATE OF THE ART PURPOSE BUILT REHABILITATION FACILITY FOR PEOPLE n YEARS WHO HAVE EXPERIENCED A MODERATE TO SEVERE BRAIN INJURY 7HILST SUPPORTING INDIVIDUALS ACROSS THE FULL BRAIN INJURY SPECTRUM THE PROGRAM HAS A STRONG FOCUS ON COGNITIVE REHABILITATION 4HE TEAM IS COMPRISED OF ALLIED HEALTH PROFESSIONALS NURSES AND DISABILITY SUPPORT WORKERS WITH THE SESSIONAL MEDICAL SPECIALIST SESSIONS PER WEEK REQUIRED TO ENSURE MEDICAL GOVERNANCE OF THE CLIENTS 4HE ROLE ALSO PROVIDES AS REQUIRED MEDICAL OVERSIGHT OF A TRANSITIONAL PROGRAM FOR PEOPLE WITH COMPLEX DISABILITY AT -ARANGAROO !S A MEDICAL SPECIALIST YOU MAY HAVE A BACKGROUND IN REHABILITATION GERIATRICS OR NEUROLOGY AND HAVE HAD EXTENSIVE EXPERIENCE WITHIN THE ACUTE HOSPITAL SETTING 2EMUNERATION WILL BE IN LINE WITH !-! GUIDELINES AND WORKING DAYS AND HOURS ARE NEGOTIABLE &OR FURTHER INFORMATION PLEASE CONTACT 4IM ,O ON
Perth Cardiovascular Institute is one of the fastest growing private cardiac services in Australia, with a focus on providing outstanding patient care with an ethical, thoughtful and sustainable approach. Perth Cardio has invested in the best medical technology, high skilled staff and we value culture, teamwork and innovation and we are currently seeking an enthusiastic individual to join our team.
In the role you will: â€˘
The ideal candidate will: â€˘
HOW TO APPLY: Send an application with a cover letter, resume and referee details to email@example.com
Supervise patients undergoing Exercise Stress Tests and Stress Echocardiograms Be supported by a strong team of cardiac technicians, sonographers and cardiologists Be responsible for taking a lead in patient care in emergency situations Be able to undertake training to further your skills and knowledge in diagnostic testing Receive a salary that is negotiable and experience based
Have current advanced life support skills or be willing to undertake training Have interest in cardiology Be able to clearly explain procedures to obtain consent and reduce patient anxiety Have strong communication skills to document findings and interact with cardiologists
A unique opportunity exists for Doctors (individuals or groups) wishing to acquire their own practice or partner with an industry leader. s .EW SUBSTANTIAL STATE OF THE ART MEDICAL CENTRE DUE FOR COMPLETION MID s $73 LOCATION WITH RAPID POPULATION GROWTH LESS THAN MINUTES FROM CENTRAL 0ERTH s 4URNKEY OPERATION AS A STAND ALONE OR IN PARTNERSHIP
Ongoing business mentoring, management, legal and accounting support available. s -INIMAL STARTUP COSTS s 4O BE ELIGIBLE YOU SHOULD HAVE THE &2!#'0 AND !USTRALIAN RESIDENCY OR CITIZENSHIP
To ďŹ nd out more and for a conďŹ dential discussion contact Paul Rowe, Managing Director, 4HE "USINESS 3QUAD s 0HONE %MAIL PAUL THEBUSINESSSQUADCOMAU MARCH 2016 - next deadline 12md Monday 15th February â€“ Tel 9203 5222 or firstname.lastname@example.org
medical forum Produced right here in Western Australia! Full Colour Personalised Practice Newsletter -RLQRYHUVDWLVÂżHG PHGLFDOSUDFWLFHVDFURVV $XVWUDOLDZKRSURYLGHHealth NewsDVDYDOXDEOHSDWLHQW VHUYLFHLQWKHLUSUDFWLFH ,WDVVLVWVZLWKDFFUHGLWDWLRQDQG ZHGRDOOWKHZRUNIRU\RX9HU\ UHDVRQDEO\SULFHGDQGDFree Trial OfferIRUWKRVHVWDUWLQJRXW6LPSO\ SKRQH-HQQ\ on 9203 5599.
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Sessional Rooms available Full practice management Sessional Rooms are available at the St John of God Murdoch Medical Clinic. * full-time/part-time/sessional * medical systems and secretarial support * adjacent to Fiona Stanley Hospital More information phone: 9366 1802 or email: email@example.com
With a reputation built on quality of service, Optima Press has the resources, the people and the commitment to provide every client with the finest printing and value for money. 9 Carbon Court, Osborne Park 6017 } Tel 9445 8380
HEALTH WATCH CLINICS MELVILLE / JANDAKOT / COTTESLOE General Practice )FBMUI8BUDI$MJOJDTJTEPDUPSPXOFEBOEOPODPSQPSBUF 5IFSFJTBOFNQIBTJTPOHPPENFEJDJOFBOEOPUIJHI UISPVHIQVUHFOFSBMQSBDUJDF We require FT/PT male or female VR GP for our clinics.
See: www.healthwatchclinics.com.au Enquiries to: firstname.lastname@example.org or (08) 9383 3435
Venosan Diabetic Socks
The Magic of Silver for Sensitive Feet No Compression Silver Ion Therapy
ARE YOU LOOKING TO BUY A MEDICAL PRACTICE? As WAâ€™s only specialised medical business broker we have helped many buyers ďŹ nd medical practices that match their experience. You wonâ€™t have to go through the onerous process of trying to ďŹ nd someone interested in selling.
Contains the antimicrobial silver yarn ShieldexÂŽ which enhances a balanced foot climate.
Youâ€™ll get a comprehensive package on each practice containing information that you and your advisers need to make a decision.
Tested and proven in controlling over twelve types of bacterial and fungal infections common on the feet and legs.
Weâ€™ll take care of all the bits and pieces and youâ€™ll beneďŹ t from our experience to ensure a smooth transition.
Silver yarn - is permanent and cannot be washed out of the socks.
Keeps feet cooler in the summer and warmer in the winter
Comfort for The Patient t
Soft-Spun Cotton - Ultra soft cotton
Fully cushioned foot and fully cushioned sock
Comfortable for arthritic patients
Your WA Consultant â€“ Jenny Heyden Tel 9203 5544 or Mob 0403 350 810
To ďŹ nd a practice that meets your needs, call:
Brad Potter on 0411 185 006 Suite 27, 782 - 784 Canning Highway, Applecross WA 6153 Ph: 9315 2599 www.thehealthlinc.com.au
Do you need a logo or website? Contact Thinking Hats today and we can help! email@example.com