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July 2017

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EDITORIAL

Are Doctors Made of Steel? Exploring the issue of post traumatic stress disorder (PTSD) among first responder emergency services presented a perplexing dilemma. While wading through myriad reports that have sprung sadly into life from suicide clusters in the ambulance and police services, it became obvious that while doctors helped gather expert evidence for these reports, little has been done to support the mental health of doctors working in first responder positions. We spoke to local psychiatrist Dr Mathew Samuel, who works on PTSD with serving military personnel, veterans, police, ambulance paramedics and fire fighters. The irony, he said, was while doctors looked after the mental health of all these people, they were very poor at looking after their own. Talking to doctors reluctant to talk about their mental health is hard enough, talking to them about PTSD and not even kryptonite can scratch the surface of their superhero exteriors. The stories that come through loud and clear in these reviews is there are no right and wrong people for the job of first responders, though a sense of dedication and desire for community service are pretty important.

“I can admit freely, the people who most stigmatise mental health are health professionals. We are our own worst enemies. We use pejorative terms that often don’t acknowledge the fact that people who have mental issues are genuine. We see this all the time with diagnoses of PTSD and eating disorders, to name just two conditions.”

Doctors can be ensnared in this culture of silence. They can be unnerved yet are expected to treat conditions such as anxiety, depression, alcohol and substance abuse and sleep disorders – and even experience some of these themselves. Yet they feel they can’t seek help. This is not only cruel, it is unethical and a waste of a good doctor who is sorely needed by the community.

These reports have exposed how work environments need

MEDICAL FORUM

The community’s perceptions of mental health is changing, have doctors’? Dr Samuel, who deals with mental health stigma every day of his working life, has an interesting take on this.

“Doctors experience these issues, of course we do. My days as a registrar, the attitude was ‘it’s your job and you’ll just get over it’. Our seniors’ attitude was ‘we went through it, so you have to go through it’. That’s exactly the same culture as the army and it doesn’t leave any room for PTSD, unfortunately, and that is where we are failing.”

It’s probably more about understanding the inevitable pressures of these jobs and the different impacts they have at different times. Some people appear to deal with them with apparent ease, some struggle and need support to get back on the horse and a small minority will be crushed by issues unique to them in time and place.

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With all we’ve heard about the destructive cultures such as bullying and sexual harassment that exist in medicine, there’s still a lot the profession can learn from St John Ambulance, WA Police and the Department of Fire and Emergency Services. The issue of PTSD isn’t going to go away and it needs vigilance – by workers taking responsibility for their own health and organisations that support them.

So how can a doctor put their hand up in an environment like this and say, ‘I’m struggling’.

Nor is it simply a case of ‘if you can’t stand the heat, get out of the kitchen’, a line heard repeatedly in this investigation.

PUBLISHERS Ms Jenny Heyden - Director Dr Rob McEvoy - Director

both openness about the risks to physical and mental health for frontline workers and strategies to mitigate them so these people can continue to deliver essential services and remain relatively intact.

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

Clinical Services Directory Editor Ms Jenny Heyden (0403 350 810) jen@mforum.com.au Journalist Mr Peter McClelland journalist@mforum.com.au

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

JULY 2017 | 1


CONTENTS JULY 2017

48

16 FEATURES 16 Close-Up: Dr Ken Jones 20 A Shed for All Seasons 25 PTSD and First Responders 48 The Life Aquatic: Dr Gordon Hay

& Dr Sally Garnett

NEWS & VIEWS 1 Editorial: Are Doctors Made of Steel?

4

Jan Hallam Letters to the Editor In Defence of Antibiotics Prof John Yovich Antibiotics Response Dr Owen Robinson Make Credentialing Simple! Dr Stuart Burton Declare War on Waste Dr Belinda McManus Waste Response Mr Jim Dodds Super Not Just for Retirees Dr Kane Della Vedova Typos – Check the Source Ms Penny Boon After Hours and Consumers Ms Pip Brennan Men Sought for Trial Dr Serene Lim

25

20

6 6 8 14 15 23 50

Waste Under Scrutiny Curious Conversation: Dr Jens Ritter After Hours Comment Have You Heard? Beneath the Drapes 60 Years of Raine Foundation Practice Mangement: How Secure is My IT Mr Jerome Chiew 51 App Review: HANDOC Dr Clare Matthews

Lifestyle 44 Funny Side 51 Beer Winner: Dr Jade Jagoe-Banks 52 Theatre: 1984 53 Beer Review: Coopers

Dr Sergio Starkstein & Dr Bradleigh Hayhow

54 Competitions

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clinicals

5

Prostate Specific Antigen Dr Johan Conradie

33

Medicines and Poisons Legislation Mr Neil Keen

35

Prostate ‘Stapling’ for BPH Dr David Sofield

37

PSA Puzzle: Test or Not to Test? Dr Andrew Tan

39

Too Many PSA Tests? Prof Tim Welborn

39

PSA and Effects of Exercising Dr Sandra Mejak

41

Signs for Men on TRT Prof Bu Yeap

43

How to Raise Alcohol Issues Dr Richard O’Regan

43

Alcohol-Related Liver Disease Dr Briohny Smith

45

Managing Thyroid Nodules Dr Dean Lisewski

46

External Circular Fixators Dr Simon Wall

guest columns

12

Risk it All…Pay the Price? Dr Phil Chapman

28

Gambling and Young Minds Ms Melissa Stoneham

Thursday, September 14 7:15 – 8:50am | Royal Perth Yacht Club

29

Death by a Thousand Paper Cuts Dr Arusha Miocevich

31

Specialist or Generalist? Dr Tim Fiori

Keep this breakfast free! See www.doctorsdrum.com.au for panellists and to reserve a seat

INDEPENDENT ADVISORY PANEL for Medical Forum John Alvarez (Cardiothoracic Surgeon), Peter Bray (Vascular Surgeon), Chris Etherton-Beer (Geriatrician & Clinical Pharmacologist), Joe Cardaci (Nuclear & General Medicine), Alistair Vickery (General Practitioner: Academic), Philip Green (General Practitioner: Rural), Mark Hands (Cardiologist), Pip Brennan (Consumer Advocate), Olga Ward (General Practitioner: Procedural), Piers Yates (Orthopaedic Surgeon), Stephan Millett (Ethicist), Kenji So (Gastroenterologist) Astrid Arellano (Infectious Disease Physician) MEDICAL FORUM JULY 2017 | 3


LETTERS To THE EDITOR In defence of antibiotics Dear Editor, I am perplexed about the editorial in the Medical Journal of Australia (17 April 2017) concerning antimicrobial resistance (AMR) and the lopsided viewpoint it presented. In particular it implies that controlling AMR in Australia requires, among other strategies, addressing the “unrestrained use of antibiotics”. As a 72-year-old gynaecologist enjoying good health I thank three aspects for my blessed life: 1.

2.

3.

As a child of the 1940s and ’50s, whenever I was too unwell to attend school, my mother took me to one of our local GPs in Midland Junction who, upon seeing my red throat and noting tender neck glands, gave me a penicillin needle “in the bum” and prescribed some oral penicillin. As an RMO of the early 1970s, I faced 25% pelvic infection rates posthysterectomy; particularly vaginal hysterectomy, hence I eagerly embraced the new concept of prophylactic antibiotics, providing a more relaxed medical career than my mentors (and totally avoiding mortalities as well as major morbidities). To this day, I cover every gynaecological and fertility-related invasive operation (including male andrological surgeries) with prophylactic antibiotics; using penicillin or the related ß-lactam cephalosporins.

I am concerned by the ‘heavy teaching’ of medical students and vulnerable young medical practitioners who pass their examinations by indicating they only prescribe antibiotics when there is proven microbial infection, unresponsive to an observational period. As a Medical Director I face numerous accreditation processes in two Australian states each year (covering laboratory, dayhospital and clinical assisted reproductive technology services) and have to justify my use of antibiotics in a process known as AMS – antibiotic microbial stewardship. So far I have been allowed to continue this practice as I have been able to present

SYNDICATION AND REPRODUCTION Contributors should be aware the publishers assert the right to syndicate material appearing in Medical Forum on the MedicalHub.com.au website. Contributors who wish to reproduce any material as it appears in Medical Forum must contact the publishers for copyright permission. DISCLAIMER Medical Forum is published by HealthBooks as an independent publication for the medical profession in Western Australia.

4 | JULY 2017

personal horror stories from the 1970s and ’80s explaining my pro-antibiotic bias. I certainly do not support the low-value intervention promoted in the recent edition of MJA, particularly when it relates to young people and pregnant women. Newer medical graduates have been ‘born into’ a blissful period of reduced septicaemia, unstimulated to develop my depth of passion in defence of a pro-antibiotic approach. Is this why I face stories of young people losing limbs or dying from those dreadful scourges, Group A streptococcus (Strep pyogenes), Pneumococcus pneumonia and Meningococcus (Neisseria meningitides)? As I understand it, these organisms have mostly remained quite sensitive to penicillin or the related cephalosporins and the real problem of antibiotic resistance is more associated with chronic infections – aged care, prolonged hospitalisation and debilitation. The current young doctors may have been oversold the idea they should withhold antibiotics until there is a proven need. Previously healthy young people will continue to lose limbs and even die from this widely promoted policy of delay. Adj/Prof John Yovich, West Leederville ........................................................................

RESPONSE This letter is a good demonstration of the complexity of managing the antimicrobial resistance problem. As mentioned by Dr John Yovich, antibiotics have revolutionised the outcome of infections and, together with immunisation and infections control, antibiotics are the single medical intervention which has reduced crude mortality rates over the years. However, what is also clear is the association between the use of antimicrobials and the rise in antimicrobial resistance. Today, resistance to antibiotics is unfortunately common not only within our hospitals but also in the community. Although in Australia we are fortunate to still have therapeutic options – unlike the case of septic shock due to a K. pneumoniae reported by Chen et al in the US – it is well documented that infections due to resistant organisms have a worse outcome, increase cost and length

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of stay compared to similar infections due to susceptible pathogens. The Australian Government has released its first National Antimicrobial Resistance Strategy 2015-2019 and one of its key features is the implementation of effective antimicrobial stewardship (AMS) to reduce inappropriate antimicrobial use, improve patient’s outcome and reduce adverse consequences including resistance, toxicity and unnecessary costs. The number of publications supporting AMS has significantly increased in the past five years, from 50 in 2009 to over 500 in 2016. For example, at a community level, a national campaign to reduce unnecessary prescriptions was associated with a 36% reduction in outpatient antibiotic use and a significant reduction in penicillin resistance in Streptococcus pneumoniae. In the healthcare setting, a meta-analysis showed that AMS reduced antimicrobial resistance by 34%. Similarly, AMS was associated with a reduction in infection due to resistant organisms such as MRSA, ESBL Klebsiella spp or carbapenem-resistant Pseudomonas aeruginosa. Furthermore, AMS has been associated with reduction in Clostridium difficile infection, mortality, length of hospital stay and cost. Importantly, many publications have demonstrated that the measures implemented to reduce antimicrobial use did not cause harm or have unintended consequences. While it is well recognised that in the severely infected patient such as those in septic shock, early appropriate antimicrobial therapy improves lives, systematic antibiotics for a red throat or a cough, prolonged antimicrobial prophylaxis after surgery are things of the past. AMS is now part of the accreditation standards in all medium to large hospitals and is being implemented in most other healthcare settings. It must continue if we do not want to go back to a pre-antibiotic era. References on request

Dr Owen Robinson, Infectious Diseases Consultant, RPH & FSH ........................................................................

continued on Page 6

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Prostate Specific Antigen Prostate cancer is one of the most common cancers diagnosed in Australia. It is estimated that just over 16,000 new cases will be diagnosed this year (23 % of all new cancers). Even though the five-year survival rate is greater than 95%, prostate cancer mortality (12.7 % of all cancer deaths) is expected to be the third highest after lung and colorectal cancer this year. (Prostate cancer statistics | Prostate Cancer, 2017) Serum prostate-specific antigen (PSA) is an effective marker of prostate cancer; its value as a screening tool is less certain. As with any tumour marker, sensitivity nor specificity are not 100% implying that a negative result does not rule out malignancy and a positive result does not confirm diagnosis. Additionally, it is not able to reliably discriminate between benign prostatic pathology, low-grade malignancy and highgrade malignancy. In the setting of malignancy, it may not distinguish between localised and metastatic disease. Various factors other than prostate cancer may cause abnormal levels of PSA, which may impact on patient care and should be considered when interpreting PSA results (see Table 1). One of the most important factors seldom considered is the differences seen among PSA methods performed on different analysers. A major reason is the lack of standardisation amongst the various manufacturers of PSA reagents. There are numerous assays for prostate-specific antigen detection with well-documented variability in measurement. Take Home Points • Prostate cancer is one of the most common cancers diagnosed today.

Despite international efforts to standardise the assays across manufacturers, mainly through creating a common reference material, this has not eliminated betweenassay differences. Whilst there have been improvements, results from various assays remain non-comparable primarily due to use of different antibodies and calibrators. This applies to many other analytes and underpins why serial testing should always be done using the same assay to minimise the effect of result differences on patient monitoring.

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Notwithstanding the variability seen between manufacturers, random variation will always form part of serial testing results. Both biological and analytical variability play a significant role when interpreting serial results. Attempts to improve specificity that may be helpful include: • Age-specific reference range intervals and • free PSA to total PSA ratio A less used marker that seems to hold some promise of improved accuracy in predicting prostate cancer risk, compared to other markers is known as phi (Prostate Health Index). phi combines free-PSA, total PSA and truncated proPSA (p2PSA) into one index. Truncated proPSA (p2PSA) forms part of the free PSA fraction found in the circulation, p2PSA is found in a higher proportion of free PSA in patients with prostate cancer. The utility of this marker has not been fully characterised.

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• Interpret using age specific ranges • Appropriate use of free to total-PSA ratio are indicated for PSA levels above age-related- median to <10 ug/L • The usefulness of PHI is still to be confirmed.

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2) lies at or above the age-related, methodspecific 97.5% reference limit, but below a value of 10 μg/L – limited to 4 tests per 12 months (66660). References available on request.

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JULY 2017 | 5


LETTERS To THE EDITOR continued from Page 4

Waste under scrutiny

Declare war on waste Dear Editor, On the subject of waste in the health system I think there is one area that is being overlooked and yet would account for a great deal of cost, not to mention environmental pollution. I am speaking from my experience working as a GP anaesthetist in Perth's hospitals since 1991. Thus Armadale-Kelmscott, Peel, Rockingham, Swan, Bentley, Kalamunda and Osborne Park. There is an increasingly ENORMOUS amount of non-biodegradable waste collected from every operating theatre on a daily basis. Just think for a moment of how many operating theatres there are across the state working each day! From my observations: 1.

Single use tourniquets for each patient.

2.

Kimberley Clark paper/plastic mix drapes freshly opened for each operation. So many go unused and are immediately discarded because there are often far too many in the pack for the requirements of the operation. (The paper is probably sourced from the Amazon rainforest).

3.

Cotton Hucks towels thrown out not having been used but no longer sterile.

4.

Single use scissors.

5.

Single use disposable plastic slide sheets for transferring patients on and off the operating table.

6.

Disposable instruments.

After Dr Belinda McManus contacted us (see War on Waste in the Letters to the Editor), we sought some clarification from the Department of Health as to the status of the Sustainable Health Review mentioned in the published response by the Director of the Environmental Health Directorate. (See Have You Heard?, P14) The review was flagged by the then Opposition Health spokesman Roger Cook as part of the 2017 election health commitment earlier in the year. It is now taking shape. Digging around, we also found a report into Consumable Stock Management in Hospitals prepared by the Auditor General in February 2016. Its preliminary audit found no evidence that the procurement, storage, delivery or quantities of hospital consumable stock were mismanaged. The auditors visited Royal Perth Hospital, Bunbury Regional Hospital and the State Distribution Centre (SDC) and analysed relevant data. It found the electronic imprest system worked efficiently in stock control. The imprest system measured the desired amount of each consumable item, in each imprest storeroom, in each ward, in each hospital. When stock reached a lower than desired amount, an order was automatically generated. Stock is managed in all metropolitan hospitals by the Health Corporate Network (HCN). As an illustration of the scale – RPH has 116 imprest stores. The HCN also runs the SDC where around $6.5m worth of consumables are held on any given day. This equates to about four weeks of stock supply for all metro hospitals. Product selection This is where it gets a bit unwieldy but the AG’s team was satisfied with the process. “A robust assessment of the quality, value, safety and function” of a product is undertaken before an item is added to the imprest stores. The assessment is done by a committee of senior nurses and clinicians. Products considered faulty or substandard once in use go through an evaluation process. However, the report did identify a significant shortcoming: hospitals don’t monitor actual use. Once an item leaves the imprest store, no hospital is able to determine if it was used, discarded or still remains within the confines of the hospital. “Therefore actual use and consequently waste of consumables is not known,” the report said. “The volume of consumables used in each hospital is substantial and methods for directly tracking use may not be cost effective. Senior staff in Health expressed a desire to measure actual use and waste, but as yet, no appropriate direct methods have been identified.” “Senior staff also believe improvements may be made by indirectly monitoring waste as Health moves to an activity based funding model…It requires extensive knowledge of the exact costs of providing care to a patient, including the cost of consumables.” It recommends the Department investigate such an accounting method.

continued on Page 8

CURIOUS CONVERSATIONS

Cool Hand Jens Vascular surgeon Dr Jens Ritter recalls an inspirational ‘moment’ in a career that still captures his imagination. I chose vascular surgery because… as a young student I thought they were the coolest guys in town! Even when all hell broke loose they remained calm and they could fix almost anything. I’m still fascinated by its incredible versatility. We operate, quite literally, in every region of the body. When I’m not working I like to… spend lots of time with my family. I love hanging out with them particularly as my son is still young enough to think it’s not completely ‘uncool’. One of my best moments in medicine was… my first renal transplant. To see the kidney come to life when the clamps were

6 | JULY 2017

released, knowing that it was a moment that would change the life of the patient forever, was truly uplifting. If I had 10 minutes with the new Health Minister, Roger Cook I’d say… that the health-care system is much better than some people would have you believe. I’d also remind him that the public system will always be loss-making because we’re dealing with large numbers of extremely sick patients. However, these are the people where we make the biggest difference and we need to remember that. When I retire I’m going to… travel. We used to do a lot of that, and I love exploring other countries and different cultures. I can’t wait to do more of it! MEDICAL FORUM


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LETTERS To THE EDITOR continued from Page 6 7.

Plastic disposable Guedel Oral Airways with a, wait for it, USE BY DATE. (The government accreditors must love that one! Keeps the taxpayer-funded accreditors employed, I suppose.)

These are just some of the things but the list and the volume of waste is much greater. I do think an audit of this waste across all hospitals would be extremely worthwhile. One has to wonder whether Infection Control have shares in the corporations that produce all this costly waste! Dr Belinda McManus, GP ED: Dr McManus emailed this letter to the Minister for Health Roger Cook and received a reply from the Director of the Environmental Health Directorate. We publish the response here.

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

RESPONSE Dear Dr McManus, Thank you for your email correspondence dated 10 May 2017 to Hon Roger Cook. The Minister has asked that I respond to you on his behalf. Non-biodegradable waste is an issue of concern to Department of Health and in particular, by the respective hospitals themselves. The costs of handling and disposal of such waste has been the subject of reviews by the individual hospitals. The hospitals currently have contracts in place to recycle specific products (particularly with items used in operating theatres) and are implementing recycling programs in co-operation with their waste contractors to reduce the amount of waste that is being disposed. For example, Sir Charles Gairdner Hospital recycles bed screen and curtains, polypropylene wash bowls (PP) and oxygen masks (PVC), IV bags (PVC) (but not tubing) providing they were not contaminated with biohazard material. Hospitals are also looking at practices to reduce waste being generated and new technologies that enable a reduction in waste being disposed. The matters you have raise will be forwarded to our Sustainable Health Review for consideration. Jim Dodds, Director, Environmental Health Directorate .....................................

Make credentialing simple! Dear Editor, I write in response to Dr Tony Robins’ response and in complete agreement with Dr Phil Green (Raw Deal for GPs, May). Tony completely misses the point. I am a regular locum provider and would certainly NOT wish to avoid the rigours of agencies scrutinising my qualifications.

8 | JULY 2017

What really sticks in one’s craw is the fact we, as locums, have to do this for every health agency in Australia. I am accredited as a GP Anaesthetist at Armadale Hospital. However, if I wish to work as a locum in Esperance I have to go through exactly the same accreditation process AGAIN for WACHS. Why can’t AHPRA assess our capabilities and have all the necessary pieces of paper and references on file and then the relevant health agencies throughout Australia pay a fee to access that data if we wish to work under their jurisdiction. Sounds pretty simple to me! Oh, yes, but there it is. Simple and Government bureaucracy seem to be an oxymoron. Dr Stuart C. Burton, GP, Kelscott ........................................................................

After Hours and consumers Dear Editor, It sounds too good to be true. No waiting, no going to the GP surgery, and someone coming to you in the comfort of your home, after hours, and bulk billing you. What is not to like? I remember getting a fridge magnet advertising this wondrous service and despite thinking it was probably too good to be true, I

put it on my fridge for future reference. The future came about a year later with another of my chronic migraine headaches, and no migraine medication to hand. I was actually able to find the fridge magnet immediately, a miracle in itself, and rang the number. I discovered after the doctor arrived that I wouldn’t be able to get hold of my regular prescription but was given painkillers to assist. Sadly, those painkillers were ones I didn’t usually take and caused my mild nausea to become more acute. Some hours after he left, I made my way reluctantly to an emergency department for a shot of anti-emetic and pain killers. Having carefully scoured the After-Hours: Urgent or Free For All? (June edition) and unpacking the many acronyms and factions that are behind this issue, there seems to be two models: •

Traditional – GP working for a GP, providing care that can’t wait until morning

Business-based – after-hours GP model of advertising directly to consumers and being a little creative about the MBS number.

So understandably, Australia has woken up from the after-hours GP dream with a $250-million hangover and concerns about both safety and value for money. It would appear that neither model has been continued on Page 10

After-Hours Comment The Medicare Benefits Schedule Review Taskforce into urgent after hours primary care services delivered its preliminary report for consultation and is recommending changes to the four urgent after-hours item numbers (597-600) only. In the June issue we spoke to the WA Deputising Medical Service about its decision join a breakaway group with three other deputising services from the peak body, the National Association for Medical Deputising Services. At the heart of the discontent was not so much the use of urgent item numbers, though there is certainly consternation about what constitutes ‘urgent’, but the intense marketing focus on the consumer by some after-hours service providers as an alternative to a daytime GP. This distinction is understandably blurred in consumer-land where an after-hours service that is bulk billed and comes to you is pretty irresistible. The distinction is sharply defined in the minds of Government which has to pay dearly for the convenience and for daytime GPs who have all the costs of providing a bricks and mortar service and the prospect of patients defecting not for any other reason than perceived convenience. Since the report’s release on June 7, there has been a plethora of argument on both sides of the after-hours service divide, some which show evidence that after-hours services have, contrary to earlier reports, contributed to a decline in ED presentations, depending on how and when you look at the numbers. Certainly, no one wants to return to the dark days of the 1990s where it was almost impossible to get any doctor to make a home visit after hours. However, that’s a long stretch from consumers calling doctors in for prescription repeats and sick notes when time is money even if it is frustratingly wasted time for a doctor who has a list as long as his arm. Changes to the criteria of urgent after hours are needed, so those people whose only other redress is the emergency department are seen appropriately by an after-hours GP. If another model of primary care is needed for those consumers who want regular GP services after hours, then that conversation should start outside the precinct of urgent after hours.

Jan Hallam MEDICAL FORUM


Launching of the UWA Medical School appeal in Winthrop Hall.

“The school arose out of the dreams of a few, and these dreams were translated into reality by the donations of ordinary citizens. The school belongs to the public of Western Australia.” The late Neville Stanley, a founding professor of the UWA Medical School and father of UWA medicine graduate Professor Fiona Stanley.

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In 1955, a capital fundraising appeal was launched to raise £400,000 to establish the UWA Medical School. As the State’s first medical teaching facility, it gave local students the opportunity to pursue a career in medicine close to home.

uwa.edu.au/med60 MEDICAL FORUM

The fundraising appeal was a monumental task considering the State’s modest population. However, West Australians from all walks of life embraced the cause and the necessary funds were raised within the year. On average, each person in Western Australia generously donated 18 shillings. In today’s terms, that’s more than $250 per person.

The UWA Medical School welcomed its first students in 1957, and ever since has produced a growing number of world-class graduates who make an incredible impact on the quality and availability of healthcare in the community. For 60 years of stories, to share ANNIVERSARY 1957 – 2017 MEDICAL SCHOOL your memories and for information on upcoming celebrations visit uwa.edu.au/med60

JULY 2017 | 9


LETTERS To THE EDITOR continued from Page 8 created with feedback from consumers. Clearly, we consumers are very keen on avoiding emergency departments, being able to attend GP appointments without having to take time off work, and we love being able to wait at home rather than in a GP’s waiting room. Whether any of this is affordable is another thing but we would urge that any review of the After-Hours GP service needs to include patient feedback first and foremost. Home GP visits where patients can get scripts and referrals would clearly meet the needs of patients with a disability, parents with small children and no car etc. We must never forget that the current alternative, a trip to the Emergency Department for something that could be dealt with in primacy care is always going to be very expensive. Ms Pip Brennan, ED, Health Consumers Council of WA ........................................................................

Super not just for retirees Dear Editor, I write in response to the articles on changes to superannuation tax rules in the new budget (Help to Negotiate the Super Circus, June). While the importance of understanding these changes is paramount, the discussion sparked with colleagues on this matter highlighted a much larger issue – the disturbingly low economic IQ in our medical community.

I am an intern, just starting off in the salaried world, but I have quite a different mindset when it comes to money compared to most people, especially doctors. Most of my interest came from tutoring economics during university, which drove me to become quite heavily read in finance topics and encouraged me to attend various seminars on money and how it works. Only after several years did I begin to have clear financial goals, a detailed investment strategy, and a baseline of tax break comprehension. Superannuation is an excellent government scheme which helps people finance their lives when they retire. For many it’s a realisation that they only ever knew how to make money one way – by working. This epiphany occurs at different times for most, but it is often recognised too late to make a significant difference to one's financial outlook in retirement. The answer that most juniors need to begin to wrestle with early is – how to make your money make money, and what is passive income. But the answer is a question! It sure is. There are so many paths to choose and each one suits people in different ways. My feeling is that very few of my colleagues feel sufficiently equipped for this endeavour, and are busy enough trying to decide whether or not to get a credit card. Having the highest paid jobs in the country does not guarantee our long-term security, but enables us to achieve strong financial goals instead. Superannuation will have our back, but we juniors need more. Who should we turn to for help, and what should we focus on? Dr Kane Della Vedova, intern, RPH ........................................................................

Typos – check the source Dear Editor, As a Medical Secretary I take umbrage at your inference that the so-called "typos" are that of the Medical Secretary. I certainly agree that the errors are there, and that they are highly amusing, but I suggest that most of them are the error of the Medical Practitioner dictating and the Typist has blithely followed her Boss's line of dictation and not corrected the obvious bad grammar and sentence construction. PS: Having said that, I do love that section of your magazine and, as I make my own Christmas crackers, your jokes are often inserted into many of them! Ms Penny Boon, Practice Manager, Nedlands ED: More cracker jokes, Penny, on P50 ........................................................................

We welcome your letters and leads for stories. Please keep them short. Email: editor@mforum.com.au (include full address and phone number) by the 10th of each month. Letters, especially those over 300 words, may be edited for legal issues, space or clarity. You can also leave a message, completely anonymous if you like, at www.medicalhub.com.au.

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JULY 2017 | 11


Letters to the Editor

INCISIONS

Risk It All... Pay the Price? Adrenaline junkies will empathise with Dr Phil Chapman and his neardeath experience but mostly with his questioning, ‘where from here?’. was thrown around like a rag-doll for what felt like an eternity. I made it to the surface, gulped a breath or two and then another wave crashed on top of me. And then five more! It was, for all intent and purposes, a neardeath experience. No endorphins, no mental clarity just severe pain in my head and neck. A subsequent x-ray revealed no fractures so I took a week off work and tried to re-align my brain. I was lucky, but another mountainbiking colleague had an even closer shave. He broke his neck, there was no neurological fall out but he was stuck flat on his back postsurgery for over a month.

Dr Phil Chapman taking the risks in the big waves.

That word, adrenaline! For those of us who’ve spent a decade or more achieving professional qualifications culminating in a highly rewarding career, chasing the adrenaline rush can turn out to be a double-edged sword. It both fascinates and motivates many of us in the medical fraternity, sometimes with painful and costly results. We’re a cohort with a disproportionate number of individuals who seem quite happy to ‘risk it all’ doing ‘extreme’ things. A lot of us, quite literally, put our lives on the line chasing down those elusive and intensely pleasant endorphins! And that’s despite the fact that we often see people on a daily basis who are paying the price for going to the edge, and sometimes beyond. So, what’s behind all this? What drives us? Many of us are confident, high achievers, and with that comes a sense of near invincibility

– and that ‘natural high’ is pretty addictive, too. A post-endorphin ‘buzz’, and the mental clarity that goes with it, can last for days. The world of the rock climber, the mountain biker, the elite cyclist, the marathon runner and the big-wave surfer is a very different one compared with the humdrum routine of normal life.

And yet we still continue to chase the endorphin ‘rush’ like a bunch of crazed lemmings! Should we know better? We’re all getting older, we’ve got families and a wellpaid professional occupation so why put all that on the line? They’re questions I struggle to answer.

But there can be a price to pay! I was reminded of this recently when, after just signing-up to the ‘50 Club’, I found myself dropping down the face of a very large wave no longer attached to my surfboard. This was a different kind of ‘rush’, one full of fear!

The routine overprotected, oversanitised, almost completely risk-free lifestyle that most of us lead might have something to do with it. That can get pretty boring so perhaps it’s little wonder some of us ‘push the envelope’ and step well outside the comfort zone.

It didn’t last long, only a few seconds, and I had no time to prepare for the impact. Hitting the water at the base of the wave felt like slamming into a concrete wall. I was almost knocked unconscious but I could still feel the severe jab of pain in my hyperflexed neck. Tonnes of water landed on top of me and I

I guess there comes a moment when you realise that your reflexes just aren’t up to the mark anymore and your body can’t tolerate the beatings, the exhaustion and the pain. Perhaps it’s then we have to admit gracious defeat and embrace something else. Music, art, literature, anyone?

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JULY 2017 | 13


HAVE YOU HEARD?

Health and sustainability In the Letters pages we published a GP anaethetist’s dismay at the unnecessary waste in the public system. The Health Minister Roger Cook said that her concerns would be referred to the Sustainable Health Review, which was an election promise and, just before we went to press, was announced as a goer. The panel will be chaired by Robyn Kruk, a former NSW Director General of Health who is well versed in government reform. The terms of reference include: • A review of WA health system to put patients first, embrace innovation and technology, and improve financial sustainability; • Expressions of Interest for Reference Groups are open and it will consult widely with consumers and carers, front-line staff, health leaders and others; • The final report is due by March 2018. The Health Minister’s statement said the review would rein in expenditure, which has apparently tripled to $9b in a decade. Other members of the panel include the Director General of the Department of Health, the Under Treasurer; an employee nominee, and a nominee of the Minister for Health. Roger Cook was at pains to stress that this wasn’t a toe-cutting affair but an attempt to flatten the cost trajectory to sustainably deliver future health services.

Medihotel checks in Five bidders have been shortlisted to build Labor’s first Medihotel next door to Fiona Stanley Hospital. The successful tenderer will be announced soon. LandCorp received 11 submissions for the new facility. The Medihotels were an election promise and designed to support recuperating patients and allow family members to stay with patients, while freeing up hospital beds. Lands Minister Rita Saffioti said that over a 10 to 15-year period, the Murdoch Health and Knowledge Precinct would deliver 1200 residences, about 175,000sq m of

14 | JULY 2017

floor space including commercial, health, research, residential, and short-stay or hotel accommodation.

SIHI funded till 2019 There was consternation in the ranks about the pending expiry of the Southern Inland Health Initiative which has rejuvenated general practice medical services for people living in the South West and Southern Gascoyne regions, particularly the neglected Wheatbelt. The Labor Government announced last month that it would continue to fund the medical workforce incentives until June 2019. The Royalties for Regions funding was due to run out on June 30, 2017, but the Government announced it would provide a baseline commitment of $33m a year for GP incentives. The Commonwealth also contributes funds through the PHN. There are now 133 GPs in the SIHI region, 36 more than before the incentive scheme was in place.

Bowel screening uptake slows We are not a poo nation it seems. The pick-up rate for the swabbing of faeces and sending a sample off is in the minority – two in five eligible people are participating in the Australian Government’s National Bowel Cancer Screening Program (NBCSP), which began in 2006, targeting 50 to 74-year-olds. Yet Australia continues to have among the highest rates of bowel cancer in the world representing 8.6% of all cancer related deaths (second only to lung cancer). If detected at the earliest stage, the five-year survival rate for bowel cancer is 93%, we are told. Men are more likely to be diagnosed with, and die, from bowel cancer, and men are less likely than women to participate in bowel cancer screening. Modifiable lifestyle risk factors include overweight and obesity, lack of physical activity, inadequate dietary fibre, high intake of some foods such as processed meat, high alcohol consumption and smoking. Other risk factors include a personal history of bowel polyps and family history of bowel cancer.

Moody blues Still with the poo talk, at the recent congress of Royal Australian College of Physicians, A/Prof Patrick Charles explored some of the emerging observations of people who had undergone faecal transplants. Faecal transplants have become increasingly popular for the treatment of multiple conditions including chronic fatigue, irritable bowel syndrome, Parkinson’s and autism. Patrick says there is also anecdotal evidence of recipients mimicking the mood and other characteristics of their donor such as changes to body shape (either weight gain or loss) and depression. He said while human DNA usually only varies between 0.1-0.5% per cent the mixture of microbiome varies as much as 80%. “As the health sector continues to experiment with faecal transplants for various conditions, careful selection and screening of the donor has to remain a focus,” he said. Food for thought that may make you look sideways next time you ride a bus or take a train.

Welfare and boutique hospitals Also at the RACP congress, physicians who do addiction medicine think the testing of welfare recipients for illicit drugs is both impractical and ineffective. Research and experience shows this is likely to fail because forcing addicts into treatment is an ineffective way of combating illicit drug use. It is a health care issue for which there should be adequate funding of treatment and support services. These moves might catch votes but the worry is that people looking for help will end up standing in a longer queue. Another interesting opinion was voiced at the congress from Brisbane doctor A/Prof Ian Scott who said big budget mega hospitals (his words were Taj Mahals like the new Adelaide hospital at a cost of $2.1b and we could probably add FSH) were set to become a thing of the past, with smaller hospitals focusing on one or just a few specialties (for example, a cardiovascular hospital) or a demographic (aged care) set to become more commonplace. The downsizing and specialisation of hospitals will be more cost effective and provide better levels of health care for patients, he said.

Best for Baby, Best for Dad

Promoting organ donation

Men’s Health Week may have come and gone but the love lingers on the St John of God Health Care Facebook page with 254 pictures of children and the significant men in their lives. The photo comp was part of SJGHC’s Healthy Men, Healthy Minds competition as a way of raising awareness of perinatal mental health. Helen McAllister, director of SJG Raphael Services said one in 10 men experienced anxiety or depression when they welcomed a new baby or when their partner was pregnant. “Men don’t access the same support services as women do during pregnancy so there is less opportunity for men to speak about their concerns or seek further help and we suspect that the real number of men who experience perinatal anxiety or depression is much higher,” she said. Seeing a GP was the first step to get in touch with services that can help.

The sad truth is that road traffic accidents provide most of the live organ donors. And with 90% of immediate family of those registered to donate going through with it, plus the opt-in system we have in Australia, the federal government has recently awarded $430,000 in Community Awareness Grants to encourage more people to join the Australian Organ Donor Register. They want prospective donors to discuss their donation decision with family and friends, while they are with it, because it is the relatives who obstruct by objecting (10% of the time). The funds will help finance 16 national and local community projects. For the first five months of this year, 211 organ donors and their families saved and transformed the lives of 582 people but about 1400 Australians are on the wait-list for a transplant. The register can be accessed at www.donatelife.gov.au.

MEDICAL FORUM


• WA Chief Scientist Prof Peter Klinken was made a Companion of the Order of Australia (AC) at in the national Queen’s Birthday Honours. • Dr Omar Khorshid is the new president of AMA WA. Dr Mark Duncan Smith and Dr David McCoubrie are the new vicepresidents. • For WA GP and Curtin academic Prof Moyez Jiwa has been appointed Chair of a new Editorial Board to guide Australian Family Physician (AFP) for two years.

Back in their cage Despite vocal opposition from some in the medical profession, including AMA WA, the Labor Government has reversed the former Government’s ban on Mixed Martial Arts bouts in cages. The cage is back and there is an equally loud voice to say it makes the sport much safer. In 2013, Dr Paddy Golden, who has been a ringside doctor for MMA bouts, spoke to Medical Forum about his concerns how unsafe it would be for fighters to compete without a cage. That year the

New oversight of OTA After the upheavels over the past couple of years within the organ and tissue donation bureaucracy, the Federal Government has announced new oversight with the establishment of the Australian Organ and

Barnett Government banned the ‘cage’ or Octagon against the safety advice of WA’s Combat Sports Commission. The Sports Minister Mick Murray said while MMA was not “everyone’s cup of tea”, he wanted to make it as safe as possible. “It makes no sense to continue with a ban that is only good for putting athletes at risk. MMA is already legal and taking place across Perth at a grassroots level, but athletes and promoters have been left frustrated that they can’t use the standard safety equipment for their sport.”

Tissue Donation and Transplantation Board with WA’s Dr Mal Washer as chair. The board, said Minister Ken Wyatt’s statement, would “govern the Australian Organ and Tissue Donation and Transplantation Authority (OTA)”. Its creation was a recommendation of last year’s review by Ernst and Young.

• The Western Australian Health Translation Network (WAHTN) had been accredited as an Advanced Health Research and Translation Centre by the National Health and Medical Research Council (NHRMC). Accreditation is expected to improve access to national level funding and networks. • Fiona Beermier is the new CEO of Ngala. She was previously CEO of disability service provider Intelife. She replaces Mr Ashley Reid who has become CEO of Cancer Council WA. • Nadine Magill is the new WA manager of the Prostate Cancer Foundation of Australia. She replaces Cate Harman who was with the foundation for more than 10 years. • The State Government has allocated $310,000 for the Regional Men's Health Initiative to address issues of mental health and wellbeing, and suicide in men in regional and remote farming communities. It will also spend developing a State Men's Health and Wellbeing Policy to complement WA Women's Health Strategy and WA Aboriginal Men's Health Strategy.

BY THE NUMBERS

124,600+ The number of weight loss surgery-related procedures billed to Medicare (2014-15) The total costs for the Medicare-billed procedures were about $62.8m – $25.7m was paid by Medicare and out-of-pocket costs for patients and/or health insurers were about $37.1m • There were 22,700 weight loss surgery separations in 2014-15 in Australia. 79% were a primary procedure, the remainder were adjustments, revisions, removals (eg of devices) • There were 9.7 separations per 10,000 population. WA had the highest rate of 17.3 • In WA 66.5% men were overweight or obese (24.4% were obese); 54.6% if WA women were overweight or obese (24.2% were obese). WA had the nation’s second lowest obesity percentage with 24.6%. The highest was Tasmania with 32.3%.

• Australia had the seventh highest proportion of obesity in populations 15+ years. The US had the highest and Korea had the lowest.

• 487 weight loss surgery separations look place in WA public hospitals compared to 4020 in private hospitals. • There were 333 open (or approach not specified) weight loss surgery separations in WA; 4144 laparoscopic procedures and 30 endoscopic procedures.

• Sleeve Gastrectomy was the most performed weight loss surgery with 12,349 from a total of 17,313 procedures. Source: Impact of overweight and obesity as a risk factor for chronic conditions, AIHW

MEDICAL FORUM

JULY 2017 | 15


Close-Up

Dr Ken Jones – Building Dreams In his 60 odd years, there’s never been a moment when Dr Ken Jones has stood still – be it in business or in his family life. Ken Jones’ life story is full of surprises. Most will remember his heady days with Foundation Health about the year 2000 when the company was locking horns with Revesco, Primary Health Care, Mayne Nickless and Westpoint Corp to acquire general practices and amalgamate them into bigger medical centres. What may not be known is that Ken had also entered the battle for his premature son, born at 28 weeks in August 2001. The striving for his family and his model of the ideal practice continues today. Just over 50 years ago he migrated to Perth from the UK with his working-class parents. He was 16 and raring for adventure. After completing his electrician apprenticeship, he headed to Port Hedland and Dampier for five years to seek his fortune. Working on the construction of power stations and large iron ore facilities paid well. Creating the nest egg “I spent two years up there as a single man, went to England on holidays, then went back up north for three years with my first wife. We made enough money to buy two houses, one in Shenton Park and one in Leederville, and that gave us a good nest egg for the future. I didn’t have a mortgage throughout medicine!” he said. A downturn in the construction trades in the 1970s enticed Ken to seek a “recession-proof occupation”. He crammed Years 11 and 12 into a single year at Leederville Technical College to gain a TAE score high enough for medicine. “An impressive result for a work hardened tradesman, 13 years out of school, competing with some of the brightest academic minds in the state,” he said proudly. In 1979, he entered medicine at UWA and describes the

next six years as “probably the best years of this part of my life. Being a medical student was a thrill and a rare privilege.” He was enthralled by the whole scene – campus life, the hospitals, the students, the academic staff and the patients. He started medicine aged 29 years with five other “oldies” and he recalls a nurse, farmer and mechanic among them. “We’d hang out as a group during our six years in medicine. It was brilliant from a social point of view and a real privilege to go back and learn as a mature ager.” He’d made quite a lot of money in the North West as an electrician. But to fund his way through his higher education he worked Friday and Saturday nights at the Sunday Times and the Western Mail, loading trucks and collating papers. He did this for seven years and also worked some of his holidays as an electrician. He could not stand still. He spent a few years renovating houses and remembers putting proceeds into a deposit that earned 21.5%! In his final year of medicine his daughter from his first marriage was born. Loving good medicine He graduated in 1986, aged 36. Then followed three years at Fremantle Hospital, one year in general practice under the Family Medicine Program, then a year at KEMH and Wanneroo hospital doing obstetrics and gynaecology. “Working on the hospital wards and in casualty was a dream come true. It was so good getting into other people’s lives, watching the specialists go into the operations, it was fantastic and the best years of my life.” In 1989, his GP job at Whitfords Avenue Medical Centre under Dr Steve Jarvis established in his mind the model for general practice. “This was the first substantial multidisciplinary medical centre in Perth. Steve knew the business well and I learned the medical centre model from him. After working a year there, I moved to a similar facility in Thornlie for another year.” At the age of 41, Ken established the Belridge Medical Centre in Beldon. “For the first year it was hard going. Interest rates were 16-17% on a $1million loan,” he recalled, adding he was pleased when a chance encounter with a Commonwealth Bank Manager as a patient led to lower interest rates and more relaxing times. “It was the usual formula – bulk billing, 12 hours/7

16 | JULY 2017

days, pathology, radiology, chemist and physiotherapy onsite – an instant success; eight busy doctors within 18 months.” “I had a lot of keen young GPs. It was different in those days [1991], you put an ad in Saturday’s West and GPs would work the shifts you gave them and take 50%. Not anymore!” He opened his second medical centre in Joondalup in 1994. Then divorce came and with it, the dividing of resources – Ken kept the medical centres. The Foundation experience “During the 1990s, there developed a professional disapproval of medical practice owners and GPs who worked in large bulkbilling medical centres. We were reproached for offering ‘5-minute medicine’, ‘never seeing the same patient twice’ and ‘ripping off Medicare’. The views of our College and the AMA were not encouraging.” He describes these organisations as “very conservative” and he took umbrage at the bad publicity. “I found this very offensive at the time and it was probably one of the drivers for me – I’m going to show that it can be done properly. I worked long hours, offered numerous minor surgical procedures, provided home and nursing home visits and delivered babies for 10 years. On top of that, I offered afterhours access and comprehensive onsite services. So the attitude of some of my peers and certainly my professional associations disappointed me.” Looking for a new challenge, Ken developed an ‘amalgamation’ model. “I’d identify willing GPs within a defined catchment; purchase their businesses; contract their services; relocate them into new facilities. I did not endorse building new facilities within a catchment unless I could fill these with existing catchment GPs. Mine was not a GP competitive model.” He stopped practising in 1999, set up office close to the city and engaged a PA. They spent the year analysing almost every metropolitan general practice location in Australia. They looked at things like amalgamation potential, suitable relocation sites, possibility of co-locating chemists, lease-break costs, etc. (Remember, Google launched in September 1998, so it was copious notes.) “During that phase, I bought and placed options on a number of medical businesses in Perth including Karrinyup, Spearwood, Kingsway, Madeley, Cottesloe, Rockingham and Bicton.”

continued on Page 18 MEDICAL FORUM


EST 1972

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Close-Up

Dr Ken Jones ... in the 1970s as a young electrician, with son Preston

continued from Page 16

Dr Ken Jones – Building Dreams In late 1999, an association with Michael Boyd, who was a shareholder of Sonic Healthcare, yielded a decision to list Foundation Healthcare on the ASX. They floated in January 2000. Early milestones included: • Raising over $150m for acquisitions and business development. • Purchasing Clinipath in February 2000. • Completing purchase of about 30 businesses in WA in early 2000. • Purchasing medical centre group businesses in NSW, Victoria and Queensland in July 2000. • Relocating administration centre to Sydney in August 2000. • By May 2001, Foundation had 1000 GPs (6% of Australian GPs). • By late 2001, there were contracts to buy a large radiology practice and several large specialist groups. • Reported profit of $21m for FY 2000/2001, and capitalised at about $400million by EOFY. • Formed supply relationships with Lifecare physiotherapy and dentistry, Sonic healthcare, Sigma pharmaceuticals in 2001. “It was busy, busy, busy – 18 months of rapid acquisitions and plans. I had big ideas. I thought Foundation would own 20% of general practice. I saw medicine from two points of view, from patient care and as a business. Creating a business from all the raw material that was around Australia was something that was good for doctors and patients.” Business and dreams “The business for me was a dream. My philosophy was being applied, that is, bringing family doctors into a really nice facility where they provided continuity of services and paramedical services. It was good model for patient and doctor in regards to long-term interest and income.” “Today, many doctors are working in medical centres. It’s amazing how quickly it has happened.” Some critics might say he paid too much for some practices and didn’t factor in that, once sold, contracted principals of some practices put their feet up. This made it more difficult to find staff to provide services on a seven-day basis, although Ken had no argument about the better lifestyle focus.

18 | JULY 2017

Ken married Tracey in the 1990s and life took off – fast! “It all seemed to happen as a whirlwind in the third quarter of 2001. Tracey’s pregnancy went sour, I had to fly with her to Perth from Sydney and she delivered an unwell child at 28 weeks. She needed support.” “My focus shifted from passion for business to supporting my family. I recommended that a new managing director be appointed and that I take on the role of integration and consolidation of our existing general practice business.”

to complete the plan. By the end of 2002, Sonic effectively owned the business. Sonic appointed a new MD and the company’s GP leadership proved attractive, the former business model was restored and IPN is again the largest medical centre operator in Australia. They seem to have respect for GPs.” The human touch shows Ken virtually took a year off to spend with his family in early 2000s. Not one to adopt a quiet life, Ken said he unsuccessfully ‘retired’ twice.

“So I had some conversations with Michael Boyd and it was a key turning point for Foundation Health – these things take time, we ran a little behind and the market sensed that, and then I essentially withdrew and was replaced by Ralph Shreeve.”

He bought a retail clothing chain, expanded the business for two years, lost a lot of money and “learned it is prudent to stick to what you know.” Another venture was building up a substantial property portfolio, then the GFC hit and he was highly geared, so took some punishment.

Parting of the ways

He re-entered general practice in 2009.

“He said he would change the model – Foundation would not continue to endorse large medical centres but would basically treat GPs as referrers of radiology and pathology, which was entirely different to the model that was successful with the market and GPs.”

“I still believe in the importance of maintaining a strong doctor/patient relationship. I have delivered 1000 babies. I see many families – some four generations – who have been loyal for 25 years. I am busy irrespective of the season. Large medical centres, if operated properly, are good for patient care.”

He said soon after Ralph announced his changes to the market and cancelled Foundation’s building program, the Foundation share price dropped.

It is his relationship with patients that he thinks of when asked, ‘What gives you most pleasure?’

“The banks started to look at lending ratios. The rest is history.” “I had lost control of the Board. Clinipath, which was a great acquisition for us because it gave us a great cash flow, ended up going to Sonic, which I and the chief financial controller Richard Atkins opposed strongly.” “Michael Boyd’s father Dennis Boyd was the operator of Lifecare dentistry and physiotherapy which was floated about a year before and was a flop. Michael and Dennis wanted Foundation to take on Lifecare to provide services in the medical centres and to own it. But we didn’t want that. There were arguments on the board until I left because I stopped turning up to management meetings.” “Lifecare came into Foundation and then for 3-4 years Ralph Shreeve ran things from Sydney on a tight budget. The business was shrinking – then Sonic came in and took Foundation out and installed a new manager. I’m not bitter. I’m disappointed I wasn’t there

“Patients are like old friends. Ninety per cent of a consult can be chatter where people dump their emotional stuff on you. I’ve seen two cases today: one lady whose husband died last night and another whose brother hung himself last week. While this might seem macabre, I get some satisfaction in giving them a target to drop their anger on and run through their most private thoughts. That’s why I say being a GP is a very special thing – people will tell you everything.” “It’s about being a decent doctor – if I get a new patient and spend time with them and make them feel special you will have them for life if you keep doing that. If you are into quick medicine and getting them out so you can get the next one in, then the goodwill won’t stay with you. Goodwill has to be earned.” “I’m best busy and will probably work for another 10 years. I love general practice and should never have left it. I was once an $80 million man. But money isn’t everything.”

By Dr Rob McEvoy

MEDICAL FORUM


You have more important things on your mind than your retirement plan.

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JULY 2017 | 19


Feature

A Shed for All Seasons Men’s Sheds are the service group for a new era where men’s physical and mental health are paramount.

Mike Wiggins

It’s a lot more fun than sitting around in life’s ‘departure lounge’ and being part of a Men’s Shed has the added benefit of boosting the physical and mental wellbeing of older men. And they’re popping up everywhere, says WA Development Officer Mike Wiggin.

“They’ve certainly come a long way since the first one opened in Tongola, Victoria, in July 1998. One thing that hasn’t changed much is the fact that a lot of wives and partners come in to pick up the membership forms. They’re well aware that their men need to be part of the community and develop strong, supportive social networks.” “We’ve got around 150 active Sheds in WA and new ones are opening on a regular basis. And the range of activities is amazing, everything from woodwork and metalwork to building wheelchairs and repairing computers. There’s a 93-year-old who recently got his PhD in Sociology, a man with a lot of skills and expertise in all sorts of areas.” One of the notable features of the Men’s Shed movement is its strong commitment to community involvement. “Every Shed is driven from the bottom up by the members themselves. And each Shed is an independent, not-for-profit entity that makes its own rules and regulations. That degree of individuality is important because you need to have a close relationship with local councils, particularly as the broader activities involve schools, P & C associations and sporting groups.” Social service agenda “One good example is the Fremantle Shed, which has an impressive track-record

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in Youth Diversion programs involving a close collaboration with stakeholders in the juvenile justice sector.” “We receive funding from the State Government to the tune of $150,000 a year, which means we have to operate community programs using an ‘outcomes based’ model and provide detailed information backed up with education support.” “There’s a board with six elected members and three independent appointees so we’ve got a good mix of skills and expertise. And that’s a big help with the interface between the Shed and local councils.” When it comes to funding, Mike is quick to acknowledge the contributions from both Lotterywest and Department of Veteran Affairs (DVA). “It’s not entirely surprising that DVA has been strong supporter of the Sheds. We all know that some military personnel really struggle to reintegrate back into society and suffer from mental health issues. If a Shed has certain number of returned servicemen or servicewomen it becomes eligible for a grant from DVA. And we couldn’t do without Lotterywest. They’ve contributed around $7.5m over the last three years.” Mike also points out that there are some tangible differences between the city and the bush. And this time the latter isn’t a poor relation! Bushies lead the way “It’s quite common that a Shed in the country can get up and running in one year, whereas it’s more like two years in a major city. Once a decision has been made to build one, the networks in the bush obviously have a strong practical component and before you know it they’re up and running.”

The rise of Men’s Sheds has seen a decline in other service groups such as Rotary and Lions clubs. “They’ve done a great job for a long time but the numbers are shrinking right across Australia,” Mike said. “They ask a lot of their members in terms of time and energy and that model is nearing the end of its useful life. The way Sheds operate is very different. You turn up when you want, you stay as long as you want and then you go home again.” A common factor in every Shed is the presence of sophisticated, and potentially harmful, machinery. “Every member has an obligation to make sure that the working space is a safe one. We’re not a commercial venture and we’re not scrutinised in the same way but all Sheds are subject to WA Association guidelines. All Sheds have their own individually tailored training programs and that’s complemented by a system of ‘colour-coded’ dots on name badges.” According to Mike, the real benefits occur when the machines are switched off. “At 10am and 3pm, we all ‘down tools’, put on the kettle and have a cup of tea. And, when some men find out that they’re not the first one to be struggling with prostate problems or Parkinson’s, that’s when the real health and wellness kicks in.”

By Peter McClelland

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MEDICAL FORUM


PHILANTHROPY

The Raine Foundation 60 Years On The Raine Foundation has been at the heart of some of WA’s most important medical research projects for the past 60 years. It needs help to continue. Many people equate the Raine Study with the Raine Foundation but they are wrong, sort of. When Professors Lou Landau, Con Michael, John Newnham and Fiona Stanley launched this study in 1990, recruiting 2900 mothers and their newborn to a longitudinal research cohort, the study took on the name of the 1957 benefactor, Mary Raine. The Raine Medical Research Foundation awarded $650,000, which kick-started their study. Today, 150 or so international researchers investigate this cohort. The foundation still partly funds the Raine Study, among the $1.3m on average awarded for medical research every year since inception. The fact that the UWA Medical School is celebrating its 60th birthday this year, and so is the Foundation, may be no coincidence. In February 1957, Joe Raine died of a stroke, and Mary six months later signed over her property empire to UWA, believing that medical research could prevent deaths such as her husband suffered. The Raine properties, which included many properties in Raine Square, including the Wentworth Hotel, and the flagship Windsor Hotel in South Perth, were eventually sold off by UWA (the last, the Windsor in 1998). The long relationship with the biggest private bequest to UWA for medical research had started in 1957, the same year the medical school was established.

Mary Raine

Raine Honour Role (Incomplete) The Raine Medical Statistics Unit Busselton Population Study Raine Centres of Excellence The Raine Study

In money terms, Mary Raine’s gift was almost twice that raised by UWA’s public appeal for donations to establish the medical school. She died in 1960. Since its inception, the Raine Foundation has distributed more than $50 million from its Raine Capital Fund in support of about 500 researchers in Western Australia.

Medical Student Vacation Scholarships

Rising costs, the negative impact of the GFC, and current low interest rates means the money distributed to medical research by the Raine Foundation has not gone up significantly since 1990 – for example, the Foundation can afford to award ‘priming’ grants to only five research scientists (about half of those funded 30 years ago).

Raine and Heart Foundation Postdoctoral Fellowship

The Raine Medical Research Foundation needs to embark on a fund-raising campaign to ensure they offer a place to the best and brightest young minds in Western Australia. “If our young scientists are unable to secure support for their salaries and research, they will inevitably leave the profession or the State which will have a far-reaching impact – not only on medical advances and health outcomes, but also on the WA economy,” says Lyn Ellis, Director of the Raine Medical Research Foundation since 1990. See www.rainefoundation.org.au.

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Peking Union Medical School/UWA Student Exchange Program Raine Major Research Grants Raine and Cancer Foundations Research Fellowship Award

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Raine/Department of Health Clinical Research Grant Raine/SGIO Postdoctoral Scholarships Raine Distinguished Visiting Professorships (incl. RVP Program) Raine International Visiting Research Fellowships Raine/Faculty of Medicine, Dentistry and Health Science MBBS/PhD Scholarships Raine Bachelor of Medical Science Scholarships Department of Health/Raine Clinician Research Fellowship Program Raine Priming Grants

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JULY 2017 | 23


24 | JULY 2017

MEDICAL FORUM


PTSD FEATURE

First Responders and PTSD Our emergency service workers are often put into physical and mental danger in the course of their working day and it is costing lives. Over the past five years in WA, a new focus and commitment has been given to the identification and treatment of post-traumatic stress disorder (PTSD) among the state’s emergency services – or first responders. Action has been partly spurred by a spate of suicides and union agitation which sparked independent reports and parliamentary inquiries. The spotlight fell sharply on St John Ambulance after five suicides of paramedics and volunteers over 16 months. Reports from the Chief Psychiatrist, Dr Nathan Gibson (November 2015), Phoenix Australia (Centre for Posttraumatic Mental Health, February 2016) and an Independent Oversight Panel (August 2016) explored everything from management culture to wellness and health training programs. Dr Gibson in his findings said the five suicides in WA among the 6000 SJA paramedics and volunteers represented “a significant human tragedy for families, friends and colleagues alike and is a matter for public concern.” In his reviewers’ interviews with families and colleagues, he identified as significant sources of stress in the lives of the five: • Their first responder roles • Workplace factors • Organisational factors • Social factors • Individual factors “What emerges is a complex interplay between work and non-work factors where their combination and relative importance is unique for each individual.” Impact of cumulative stress The reviewers found “little evidence that exposure to ‘critical incidents’ in their role as first responders was a key factor” in the deaths of the five, though concerns were raised about “cumulative stress and the challenges associated with the changing nature of the job in having to deal with abusive and aggressive patients and those affected by alcohol and drugs.” Most of the five were receiving mental health treatment and when management was made aware of their struggles, support was offered. “A majority … made use of the SJA funded external counselling service. Others sought treatment independently from SJA from external providers.” The Independent Oversight Panel, which comprised Dr Neale Fong, Mr Ian Taylor and Adelaide PTSD expert Prof Alexander MacFarlane, did an extensive literature review and made 27 recommendations that encompassed the need for a more detailed understanding of the unique psychological needs of the ambulance workforce, development of more effective career

MEDICAL FORUM

transition pathways, an integrated wellbeing and support strategy and mental health screening. Prof MacFarlane who spoke about his PTSD research at a psychiatry masterclass in Perth earlier this year, has done a lot of work in the area of cumulative burden of trauma exposure. The panel wrote in the report that this cumulative burden was “an important risk factor that could be better anticipated and managed by St John in relation to the predictable rates of psychological injury and the related risk of suicide in ambulance officers.” Reluctance to own PTSD However, an ironic twist is the reluctance of first responders to acknowledge the mental health risks of their job. In submissions received and at hearings conducted by the panel, participants were “generally silent on the connection between the nature the role… and mental health problems.” The report said: “… this was not surprising, as previous studies have shown that frontline workers accept these exposures as part of their work but tend to underestimate the associated risk and effects. What the workforce does not anticipate is the impact of organisational stresses which they contend can exacerbate unnecessarily the consequences of the traumatic stresses in the workplace.” SJA was asked to respond to this story but its publication coincided with the CEO being away and an official response was unable to be given. That said, Medical Forum understands from other media reports that the organisation has instigated widespread changes.

In March 2016, there was a WA Parliamentary Standing Committee looking into WA Police and a subsequent report was presented, How do they Manage? Police officers who gave evidence said they felt they were not valued once they revealed a serious medical issue. The report said: “This raises questions about the culture within the police service, as well as the provisions in place to compensate officers. WA is the only state which does not have a workers’ compensation scheme for police officers and it is rare to be awarded an ex gratia payment. Medically retired officers often struggle financially.” Grey zone of workers comp The authors of the parliamentary committee’s inquiry drew on the WA Police Union’s Project Recompense report and a previous committee’s report: The Toll of Trauma on Western Australian Emergency Staff and Volunteers. George Tilbury, president of the Police Union, told Medical Forum mental health issues had been a concern to the union for many years. “The Project Recompense builds a case to advocate for a fair and sustainable process to compensate our members without the need for ad hoc ex-gratia payment applications. WAPU has been so overwhelmed with requests for assistance with ex-gratia applications that it was deemed necessary to undertake research into not only members’ experiences of work related physical or psychological trauma and the agency’s response but also the forms of compensation available.”

By Jan Hallam

JULY 2017 | 25


PTSD FEATURE

PTSD: The Road to Recovery PTSD can be treated and outcomes are positive. That’s the message first responders – and doctors – need to hear, says psychiatrist Dr Mathew Samuel. Hollywood Clinic has the government contract to deliver mental health services for serving military personal and veterans, so it has extensive experience in the treatment of PTSD through its Trauma and Recovery program led by psychiatrist Dr Mathew Samuel. Mathew said that there were a growing number of first responder emergency workers – police, ambulance paramedics and firefighters – who were being treated for trauma-related illness.

Dr Mathew Samuel

He said there were three vital first steps in treatment for PTSD:

• Assessment – “This is the first and most crucial. People must be assessed appropriately and urgently. Both a medical and psychiatric assessment is extremely important”. • Medication – “A lot of people suffer from sleep disturbance, hyper-arousal, flashbacks, nightmares and increasing anxiety. They have increasing difficulty getting on with their job and getting on with their lives.” • Therapy – “Individual therapy managed by a psychologist trained in trauma is important. Not all psychologists are trained in trauma and if not properly managed this therapy can do more harm than good.” And group therapy – “Sharing experiences with people who have had similar experiences can be beneficial. People realise it’s not just happening to them. Often people think a weakness in their personality has given them PTSD and don’t realise that others face similar challenges.” A 10-week program is seen to be the most effective though Mathew said a four-week program had been developed for first responders.

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Ripple effect on families “The program delivers psychological education, relaxation techniques and we also have a chance to meet with the family because PTSD has a huge ripple effect with anxiety and flashbacks often played out on family members,” he said. “We have learnt a lot from military veterans and found that these modalities, if appropriately given, produce improvement. We can either get people back to work or help them move on to a new phase and we can help the families to resettle as well.” Mathew said there was no quick fix and the journey to good mental health from a diagnosis of PTSD required a lot of support and, critically, follow-up with groups called back at three, six and nine months.

any treatment for PTSD we want to make sure their alcohol use or drug dependence is addressed or the treatment will fail.” Mathew said that emergency workers are a relatively new cohort on the Trauma and Recovery program. “We have been only looking at this for the past 10-12 months, so that is less than 50 patients and that’s not enough for a data analysis. Phoenix Australia undertook an analysis of the 10-week program for military personnel and veterans and found positive results particularly at the three, six and ninemonth follow-ups.” Mathew has given evidence at both the standing committee and the SJA Independent Oversight Panel and believes the reports have had a positive impact within the organisations.

“People are allocated a psychologist or if they have seen another psychologist before coming to the clinic we work with that person. We also recommend regular follow-ups with GPs or a psychiatrist if they are taking medication for PTSD. The important thing is continuity. When they leave the treatment plan they need to have something to fall back on if they have a crisis.”

“We have met with health and welfare people at these organisations to stress how important it was that people with PTSD get appropriate and immediate help. There is a stigma for a lot of these first responders to seek help. For many, the places they have to go for treatment are places they take their patients in crisis. They feel that other people need help more than them.”

Mathew said he and his team had just received ethics approval to access data to see how their military patients’ fared five years after initial treatment.

“So it is important they are given discreet but real help and I think there has been a definite improvement in the understanding by the police and the ambulance services to get help for those people.”

“We know they do well in the in first 6-12 months but nobody has really looked at the long-term outcomes. A recent article in MJA suggests that people with PTSD have a higher chance of having other medical conditions. We want to know if their quality of life is the same or has changed. “ Mathew said the risk substance abuse was high in this cohort. First address substance abuse

“The trauma field is quite a confronting field of practice. People are in crisis and there is a lot of expectation on clinicians and a fair amount of bureaucracy as well. But there is also great reward in helping people get back on the horse and resume their lives. I hope more psychiatrists and GPs want to become involved in delivering treatment to first responders. We have to play our part too.”

“Often their first response to the way they feel is to use alcohol, marijuana or sleeping drugs to numb their flashbacks or hyper-vigilance, which is why that medical assessment at the start of treatment is so critical. Before they are ready for

MEDICAL FORUM


PTSD FEATURE

Training Early Dr Petra Skeffington is a researcher and academic at Murdoch University and a clinical psychologist in the field of trauma. She believes more needs to be done to support the high-risk group of first responders.

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Petra works with Department of Fire and Emergency Services recruits on a mental agility and psychological strength training program, which she developed. “We look at the aetiology of how PTSD develops and how individuals might learn skills to derail its development,” she said. “One of the key factors across high-risk and male-dominated professions is the number of barriers to treatment seeking. Dr Petra Skeffington One of the core themes underpinning the training I do is normalising mental health, normalising the appropriate reactions and expected reactions we might have following any crisis or intense situation.” “A lot of first responders have good knowledge identifying their physical injuries and know when they need professional support. It’s drawing those parallels so they can recognise when some other distress, which is not a physical injury, is occurring – to recognise it as a problem and identify if they need external support.” There will always been populations in the community who will be at higher risk of mental health problems because of the nature of their work but the majority of first responders have developed their own coping strategies, Petra says. Training at the recruit level can help people develop those strategies from the start of their career. “So it’s not even a resilience or prevention plan but a wellbeing plan so these workers can be their best selves,” she said. Some in the community might think that these jobs are well known to be stressful, high risk and challenging, so if a person can’t cope with those pressures, they find another occupation.

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“While I understand that logic, we don’t always know what will trigger a reaction in us. My experience working with these populations, and in my private practice, when there are large scale disasters, we can expect people to have an adverse reaction,” she said.

 District Medical Officer (GP / Emergency Medicine)

“But how we function and react to what’s going on in our lives is fluid. So things that might be OK in one part of your career may not be fine at another point. The most obvious example is attending accidents, anything involving children, which for many people can be OK for the most part until they have their own children. Or they attend an incident which may involve a child the same age as their child. These may not necessarily be massive crisis or trauma events but they hit a soft spot and that soft spot moves because we change over time. I don’t think we have good predictive power to be able to tell how we will react.”

 Medical Administration

Petra said as mental health was being talked about more freely and becoming a part of our regular vernacular, there was a danger that the term ‘trauma’ was being misused. “People who have some distressing event will say, ‘I was so traumatised by this, I have PTSD now’. We see this in other spheres such as Obsessive Compulsive Disorder. What we have is the language to say these things but it massively diminishes what it is actually like for people who have these disorders,” she said. “It can create an impression that for someone who has severe PTSD that they should be able to ‘get over it’ or move on because we can’t appreciate what they are experiencing when we are gauging it by people who have the language but not the disorder.”

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JULY 2017 | 27


GUEST COLUMN

Gambling on Young Minds Professional sport and online gambling can be potentially destructive bedfellows suggests the Director of the Public Health Advocacy Institute, Melissa Stoneham. Online Gambling is everywhere! Whether you’re watching sport, playing online games, using social media or just taking a stroll through the city it’s hard to miss. And anyone with a smartphone or tablet can gamble anytime – day or night – even if they're underage. This sort of access, particularly to those under the age of 18 years, should be of serious concern to the public health sector. And so should the enticement tactics used by online sports betting agencies. Teenagers are up to four times more likely to develop a gambling problem compared with adults, and one in five adults with a gambling problem started before they turned 18 and indigenous young people are particularly vulnerable. A recent Australian study looked at the exposure of young people to the promotion of online gambling and the use of social media platforms such as YouTube, Twitter and Facebook. Seven major wagering brands were selected, representing sponsorship relationships with different football teams and codes.

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It’s a refreshing sign that some AFL players have begun to speak out regarding the onslaught of gambling advertising YouTube was the most influential platform in attracting young people to online gambling. These audio-visual clips use humour, sexual innuendo and, predictably enough, lots of celebrities! Twitter is also used extensively in the sportsbetting area, most notably in ‘real time’ with prompts to place bets while actually viewing the event. The absence of Responsible Gambling messages and the prevalence of Refund Betting on Twitter is of real concern. The promotion of a no risk/no lose scenario – if you lose $150 we’ll give you a $100 refund – is not something to be encouraged. On Facebook it was found that the use of

cartoons, often portraying team mascots, is designed to engage younger fans with online content. It’s a refreshing sign that some AFL players have begun to speak out regarding the onslaught of gambling advertising and are now calling for tougher restrictions. Western Bulldogs captain Easton Wood recently called gambling a ‘sinister and dangerous activity’ and highlighted the fact that it occurs ‘every time their footy heroes ‘pull on their boots’. Such comments from within the sports themselves increase public awareness of online gambling with the added ‘clout’ of stars of the game adding their actual voice. The online saturation of the gambling promotion message normalises gambling. It would appear that young people are increasingly associating gambling as an integral part of the sporting experience. The last thing we want is fans, irrespective of their age-group, talking about the odds of their team winning, rather than will their team win. It’s time to act! References on request

28/3/17 8:52 am

MEDICAL FORUM


GUEST COLUMN

Death by a Thousand Paper Cuts Dr Arusha Miocevich is a RMO at Royal Perth Hospital with a cautionary tale about generational change and the practice of medicine. It’s not an uncommon occurrence to hear it proclaimed that ‘junior doctors are not the same breed’ as they once were. Overtime? Protected working hours? Parttime work? A medico Jedi Master had no need of these things back in the good old days, apparently. Nothing makes a junior doctor roll their eyes more than hearing the words, ‘back in my day’. And, to be fair, I guess senior doctors are pretty sick of us whining about how much paperwork we have to do. Well, we all have to get used to it because for the first time in history we have four generations stuck with one another in a patchwork system that’s struggling to keep up. With the advent of a more intense medicolegal environment, an increasingly ageing population and an exponential improvement in information technology, the role of the junior doctor is shifting to more administrative and clerical roles. And that simply does not translate into particularly challenging or stimulating medicine. It’s often slow, painful and frustrating. It’s a bit like a paper-cut, at first irritating and

Yet when I look at my colleagues from university, I still see compassionate, intelligent individuals buried somewhere underneath the paperwork.

distracting but if you get enough of them it feels like the practice of clinical medicine has morphed into death by a thousand cuts. There’s no doubt that issues such as unrostered and unpaid overtime, reduced training exposure and the pressure to join increasingly competitive and expensive training programs has led to a perfect prescription for poor workplace mental health. New doctors are now a mixed demographic of undergraduate, post-graduate, local and international students most of whom are not the beneficiaries of a free education. And they pop out of the system with large debts!

So what do all of us, we four generations of doctors, actually have in common? Surely it has to be our ‘calling’, the love for our craft, and compassion for our fellow human beings. The required dedication, combined with the fortitude to push through tough times during our medical training, is about something more than money or prestige. And a lot of us have been pretty dedicated already! We’ve raised funds for PMH, volunteered with Dr Yes to tell young people about the risks of substance abuse and working late into the night assembling birthing kits. Yet when I look at my colleagues from university, I still see compassionate, intelligent individuals buried somewhere underneath the paperwork. It’s wonderful that there’s an increasing recognition of mental health issues such as burnout and suicide amongst doctors. Young medical professionals are being asked to run a vastly different gauntlet compared with their predecessors. Surely there must be a way of streamlining the clerical workload? But, most importantly, we need to champion things that really count – clinical teaching, genuine curiosity and compassion for others.

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GUEST COLUMN

Specialist or Generalist One of the faces behind neurotechnology ‘start-up’ Humm.tech, Dr Tim Fiori, suggests to young doctors to look beyond conventional career choices. When I started life as a medical student a senior consultant told us all that we would ‘struggle to specialise’. The logic being that his generation was going to both live longer and work longer before hanging up their stethoscopes. So, according to him, we'd all have trouble getting into our ‘dream specialties’ due to a scarcity of positions plus being forced to compete with a deluge of new medical students. I recall brushing off the comment by asking a recurring question, ‘so what kind of doctor do I want to be?’. Stumbling through our degrees and internships, we largely remained protected against the market forces of health care. Some of us were on scholarships and all of us, we thought, could rest assured that we’d be employed once we graduated. But when we made the transition to hospital residents a degree of panic began to set in. It became increasingly clear that we would have to compete for a limited number of positions and doing so could require a lot of ‘on-call’ hours and registrar positions with no real light at the end of the tunnel.

Specialist or Generalist? Surely it’s not a binary choice? More and more junior doctors are using medical degrees as ‘passports’ into new and exciting ventures… This is not a new problem, nor is it unique to the medical profession. The difference being, arguably, in the structure of our career progression and our expectation of doing just that – progressing! Many of us entered medicine aspiring to join the ranks of a niche specialty. Subsequently, just as many of us are now looking at the practicality of achieving such a goal. Postgraduate degrees, research publications and overseas experience are just some of the increasing requirements before being considered for specialist training. Many of us are now facing a dilemma – Specialist or Generalist?

But I think it can be viewed a little differently. Surely it’s not a binary choice? More and more junior doctors are using medical degrees as ‘passports’ into new and exciting ventures, whether that’s entrepreneurial projects such as personalised medicine and developing medical devices or pursuing roles in advocacy and public health. A medical degree is a rare privilege, and has the added bonus of allowing us to fund a project or a vision while work flexibly as a locum. We are so lucky to be able to take creative risks in exploring our passions! I think we finish our degrees far more prepared to make such choices than we realise. I’ve followed just such a trajectory by commercialising my research interests in neurotechnology while still working as an RMO. It’s been a steep learning curve but it’s given me the chance to develop a wider set of experiences useful in both clinical and nonclinical settings. A deviation into the unknown can be an exciting thing and open up all sorts of career opportunities. So, ‘Specialist’ or ‘Generalist’? We live in exciting times and I think we’ve got a lot more choices than that!

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MEDICAL FORUM


CLINICAL UPDATE

Medicines and poisons legislation In WA, the Poisons Sale Act of 1879 sought to restrict the sale of a small number of dangerous poisons, covering 15 substances including arsenic, strychnine, cyanide, chloroform, belladonna and opium. In 1910, it was superseded by the Pharmacy and Poisons Act, which not only expanded the list of substances but also registered pharmacies. In 1964, an updated Poisons Act classified poisons according to broad risk categories and started to shape the contemporary prescriber and dispenser relationship. On 30 January this year, the Medicines and Poisons Act 2014 and the Medicines and Poisons Regulations 2016 came into effect, replacing the ageing Poisons Act. It continues to regulate the manufacture, sale and use of medicines and poisons. In practice, it provides the legal framework that underpins the medicines supply chain and the basis for prescribing and dispensing of medicines. The modernised legislation is simpler, easier to understand and more flexible. Key concerns addressed are those of national consistency and less red tape. For most practitioners, there will be limited day-to-

By Mr Neil Keen Chief Pharmacist Dept of Health

day impact, however it provides for greater flexibility in handling medicines, designed to make the most of the current and future health workforce. Major changes to the Act include an overhaul of licences and permits. The Act extends powers to collect and share information on Schedule 8 medicines, important for plans to introduce real-time reporting. The Act permits the notification of doctor shoppers and provides the ability to restrict supply to them. The most obvious changes are within the Regulations. One major difference is the addition of health practitioner groups to work with medicines, including paramedics and Aboriginal health practitioners. For the most part, the requirements for writing a prescription have not changed. A key reform has been to remove the requirement to handwrite details on computer generated prescriptions for Schedule 8 medicines, although pharmacists may be required to confirm authenticity in some cases. The Regulations also pave the way for secure electronic prescriptions and permit more choice in medication chart use in aged care facilities.

by Medical Director Prof John Yovich

Prescribing is easier but with this comes greater responsibility.

ED

Under the previous legislation, the long-term prescribing of Schedule 8 medicines required authorisation by the Department of Health. In many cases, this is no longer required, so long as practitioners comply with a published Code. Authorisation will still be necessary for anyone notified as drug dependent and for certain high risk drugs, doses or formulations. The Department will continue to monitor these prescriptions and engage with prescribers on matters of concern. An important initiative has been to codify a framework for Structured Administration and Supply Arrangements. These are colloquially referred to as “standing orders”, but until now were not legally recognised in WA. The Department of Health’s guidance will assist health practitioners on all aspects of the new legislation and can be accessed at www.health.wa.gov.au/pharmacy.

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Immunoprotection – DFB126 is the major component of sperm surface glycocalyx Capacitation - removal of decapacitation factors by adenylate cyclase and tyrosine kinase Hyper-activated Motility - whip-like motility assists zona binding, penetration Oocyte-induced sperm activation - CRISP and Catsper opening K/Ca channels Cumulus dispersal - hyaluronidase released from the acrosomal cap disperses coronal cells Acrosome reaction - acrosomal cap dissolves enabling zona-binding, protease released Zona binding - zona proteins 1 to 4, ZP3 - species specific binding, protease dissolves zona Activating factor - spermolemma binds to oolemma and releases fertilin Sperm-induced oocyte activation - PLCζ, PAWP and PIP2, release of second polar body Cortical granule release - prevents any further sperm entry to oocyte ICSI bypasses all the above but most large data-sets show no increase in any fetal abnormalities above IVF (Hansen 2013) which itself shows only a small rise above natural conception; bearing in mind ~100,000 filtered & washed sperm are placed with the oocyte at IVF.

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JULY 2017 | 33


34 | JULY 2017

MEDICAL FORUM


CLINICAL UPDATE

Prostate ‘stapling’ for symptomatic BPH

By Dr David Sofield Urological Surgeon Palmyra

Nearly six million men in Australia are affected by benign prostatic hyperplasia (BPH); troublesome symptoms include nocturia, frequency and urgency, which can cause loss of productivity, depression and decreased quality of life. Complications include infection and urinary retention.

The growing number of men with prostatism may look to this method for symptom relief.

ED

Medication is often the first-line therapy for BPH, but relief can be inadequate and temporary. Side effects of medications can include sexual dysfunction, dizziness and headaches, prompting many patients to discontinue therapy. For these patients, the alternative is transurethral resection (TURP) in its various forms, which in turn has potential side effects including retrograde ejaculation (100%), erectile dysfunction (15%), bleeding and urinary incontinence (1-2%). Typically, hospital stay is 24-48 hours and full recovery takes up to six weeks. About prostate ‘stapling’ The FDA-approved UroLift® System is a novel, minimally invasive technology for treating lower urinary tract symptoms due to benign prostatic hyperplasia (BPH). Developed in collaboration with Australian urologists, the UroLift® permanent implants, delivered during a minimally-invasive transurethral outpatient procedure, relieve prostate obstruction and open the urethra directly without cutting, heating, or removing prostate tissue. Many patients can be treated as day cases with no indwelling catheter. Post operative symptoms – most commonly urgency and mild dysuria – typically resolve in 3-5 days. Clinical data from a pivotal 206-patient randomised controlled study showed that patients with enlarged prostate receiving UroLift® implants reported rapid and durable symptomatic and urinary flow rate improvement without compromising

Prostatic cross sectional view

MEDICAL FORUM

Cystoscopic prostatic urethral view showing protruding lateral lobes obstructing urethral channel

sexual function. Patients also experienced a significant improvement in quality of life. In this study, the most common adverse events included hematuria, dysuria, micturition urgency, pelvic pain, and urge incontinence. Most symptoms were mild to moderate in severity and resolved within two to four weeks after the procedure. Five year data from the L.I.F.T Study, presented at The American Urological Association conference (May 2017), showed in summary: • Preservation of sexual function; • A highly tolerable, minimally invasive procedural experience; • Rapid reduction of symptoms after the procedure; • Sustained effect, with IPSS (International

Needle deployed through compressed prostate lobe into peri-prostatic space

Patient’s right implant fully deployed with left implant partially completed

Cystoscopic prostatic urethral view showing lateral lobes retracted by Urolift® implants with urethral channel formed

Prostate Symptom Score) and Qmax (peak urinary flow rate) remaining 36% and 44% improved from baseline, respectively; • Quality of life (QoL) score improvement of 50% over five years; • Durable treatment, with only a 2-3% retreatment rate per year. Indications for ‘stapling’ The UroLift® System is available in Australia and other countries; costs are fully rebated by all major health funds; and this treatment is a new option that sits between medication and transurethral resection. It is particularly suitable for younger, sexually active men with moderate symptoms of BPH and also has a role in the medically unfit patient, including those on anticoagulant therapy. References on request

Four UroLift® implants deployed retracting lateral prostatic lobes creating an unobstructed urethral channel

JULY 2017 | 35


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MEDICAL FORUM


CLINICAL UPDATE

PSA puzzle – to test or not to test? The US preventive services task force (USPSTF) recently changed their recommendation on prostate cancer screening from discouraging men from being screened at all ages to recommending men aged 55-69 discuss the benefits and harms of PSA testing with their doctor and make an informed decision. Why? The answer lies in changes in how we diagnose prostate cancer and how low grade prostate cancer is managed. Early detection of prostate cancer in men aged 55-69 is likely to lead to a reduction in the incidence of metastatic disease in these men and prostate cancer mortality.

By Dr Andrew Tan Urologist Nedlands

Prostate cancer screening has been controversial. New diagnostic approaches are making the process easier to navigate for doctors and patients.

ED

Prostate cancer accounts for over 20,000 cancer diagnoses and over 3000 deaths annually in Australia. However, most men diagnosed with prostate cancer will not die of the disease because in many cases it is a slowly progressive disease. The treatment for prostate cancer, in particular advanced prostate cancer has changed over the last few years. There are now many options to slow the progression of incurable metastatic prostate cancer – all come at a cost however, both side effects to the patient and financial cost to the health system (expensive new drugs taken over many years). Definitive treatment and cure of prostate cancer may decrease the financial burden of metastatic disease. Changes in diagnostic methods One of the main criticisms of PSA screening was that it resulted in too many men being referred for unnecessary prostate biopsies. These were most commonly done transrectally with core needle biopsy and whilst generally safe, a sepsis rate of around 2% was reported. Steps to decrease the sepsis rate include the use of fluoroquinolones, preparing the rectum with betadine and identifying men at risk of harbouring multi-resistant bacteria (usually recent travel to South-East Asia). Two of the biggest advances in more accurate and safer diagnosis were the use of multiparametric prostate MRI and transperineal prostate biopsy. MRI has led to a decrease in prostate biopsies because of improved accuracy in determining who needs one and where the biopsy should be targeted. While it is not 100% accurate and must be interpreted in

An ultrasound guided transperineal route for prostate biopsy.

the context of PSA levels and clinical findings, most urologists agree MRI has improved both the accuracy of diagnosis and treatment planning. Transperineal prostate biopsy uses a grid template to take more biopsies of the prostate and is able to accurately target areas of abnormality seen on MRI. Because the needle passes through the skin there is a very low risk of infection – some large volume centres report a zero sepsis rate (compared with transrectal biopsy. Transperineal biopsy requires a GA and takes longer). Active surveillance vs active treatment For men with low volume and low grade (Gleason score 6) cancer and low PSA, active surveillance with regular PSA check, prostate examination and re-biopsy has been proven to have an excellent rate of safety over many years. Patients who show evidence of stage or grade progression are switched to active therapy. This is very reassuring to patients – the knowledge that low grade disease can be safely watched. The side effect profiles of active treatment for clinically localised disease for both surgery and radiotherapy are continuing to improve. Robotic surgery allows faster recovery and less blood loss. Radiation is continuing to evolve with dose fractionation and image guided therapy. References available on request

MRI prostate showing two lesions in the prostate

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Author competing interests: nil relevant disclosures. Questions? Contact the author andrew@perthurologyclinic.com.au

JULY 2017 | 37


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MEDICAL FORUM


Clinical Opinion

Too many PSA tests? Prostate cancer screening is known to increase cancer detection. But there is no evidence that routine digital rectal examination, nor regular PSA screening, improves longevity. Also several US and Canadian guidelines from 2012-2016 firmly recommend against PSA screening at any age. Large randomised trials of PSA screening show a reduction in mortality rates of less than 1 case per thousand over 10 years. This is despite knowledge that prostate cancer is the most commonly diagnosed cancer in Australian men. In 2017 the risk of being diagnosed with prostate cancer by the age of 85 is 1 in 7, but the 5- year survival rate is 95%.

By Prof Tim Welborn Endocrinologist

This is because most prostate cancers are slow growing and non-aggressive. Symptoms develop late in the course of the condition, and they parallel those of benign prostatic hyperplasia.

suggestion is to implement shared decision making with male patients aged 55 to 75 years. A full discussion of benefits and harms should precede any mutual decision to proceed with a PSA test.

The over-diagnosis of indolent non-lethal prostate cancer and its zealous treatment with radical prostatectomy and/or DXRT has an immediate and high morbidity rate. The complications include total impotence, urinary incontinence, and radiation proctitis. Fortunately our urologists are alert to these issues and most collaborate with a policy of ‘watchful waiting’.

The patient must be alerted that a positive test could lead to watchful waiting rather than any intervention.

Recent enlightened advice from US urologists and physician groups have modified the ‘no screening at any age’ approach. The

Exceptions include high-risk patients with a strong family history of prostate cancer or those with a known BRCA mutation. But above the age of 75, PSA screening is only advised with caution and only in very healthy individuals. Reference: Prostate Cancer Screening – a Perspective on the Current State of the Evidence. Paul F Pinsky et al. NEJM 2017; 376: 1285-1289.

Research

Exercise effects when measuring PSA?

Bailis, and Hanks, 2013) showed an average increase of 9.5% in total PSA in healthy male cyclists, when measured straight after cycling. Other studies also confirm an increase with cycling (Safford 1996, Oremek 1996, Kindermann 2011, Frymann 2006, Rana 1994).

Research has concluded that cycling for exercise can increase prostate specific antigen (PSA) in the short term. The mechanism is unknown but has been postulated to involve both mechanical stimulation of the perineum and increased blood flow. Should abstinence from cycling, or even other forms of exercise, be therefore advised when doing this test?

So if prolonged cycling increases PSA in men of screening age, what about other exercise? The evidence suggests other exercise can increase PSA but the relationship is not as clear-cut. When other exercise has caused an increase, it has been less than with cycling, and is more likely in older men, in those who already have cancer, and with more intense and/or longer exercise.

The PSA in context The controversies surrounding the PSA test are beyond the scope of this article. PSA is produced by both malignant and benign prostate cells, and PSA levels are known to increase in benign prostatic hyperplasia, prostatitis and prostate cancer. The probability of cancer occurring given an elevated PSA is 1 in 3, although prostate cancer can still be present with a normal PSA. Procedures that increase PSA include radical prostatectomy, ultrasound-guided needle biopsy, and transurethral resection of the prostate – the increase in PSA is far greater than 100%, and the PSA can remain elevated for days to weeks. Non-invasive manipulations, such as ejaculation, digital rectal examination (DRE), and cystoscopy also increase PSA but to a lesser degree, and for shorter periods of time than surgical manipulations. It is also recognised that free PSA (fPSA) has been

MEDICAL FORUM

By Dr Sandra Mejak Sport and Exercise Medicine Physician Karrinyup

What should a practitioner advise? shown to be eliminated within 2-33h, whereas total PSA takes 2-3 days, and that if PSA is elevated, the lower the fPSA:tPSA ratio, the higher the likelihood of cancer. Cycling and PSA The evidence of cycling causing an increase in PSA has been mixed, though many of the studies that did not show an increase had methodological deficiencies in either the age of men tested (too young), or distance cycled (too short). More recent studies have confirmed that cycling increases PSA. My own paper (Mejak,

• One possible approach is to repeat an elevated single random PSA test after 48 hrs abstinence from cycling (and probably ejaculation and DRE). If it remains elevated, treat the elevated result with the usual further investigation or monitoring. [The alternative is to advise every patient undertaking a PSA test to avoid cycling (and probably ejaculation and DRE) for 48 hrs beforehand, but this method is harder to control and document accurately.] • Avoidance of all exercise for 48 hrs before PSA testing may have merit, when compliance and accurate documentation are not problematic.

JULY 2017 | 39


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Clinical Update

Things to watch out for in men on TRT Testosterone replacement therapy (TRT) is for men with pathological hypogonadism due to diseases of the hypothalamus, pituitary gland or testes. A clinical diagnosis of androgen deficiency is confirmed on biochemical testing. In men with pathological hypogonadism, TRT is expected to improve symptoms and signs of androgen deficiency, which may be non-specific (e.g. decreased libido, lethargy, fatigue, decreased energy or endurance, and low mood) or organ-specific (e.g. reduced muscle mass and strength, increased fat mass, and osteopenia or osteoporosis). Efficacy of TRT is gauged by the clinical response, often complemented by serum testosterone concentrations. Potential contraindications and risks are assessed prior to starting treatment and safety of treatment monitored, particularly Hb and PSA.

By Prof Bu Yeap Endocrinologist FSH and School of Medicine UWA

For daily transdermal formulations this can be measured after 1 week (gel) or 2 weeks (liquid or cream), either prior to (gel or cream) or following (liquid) a morning application. For men on long acting depot IM testosterone undecanoate, test before the following injection (trough level). The aim is to maintain pre-dose or trough levels in the lower part of the reference range for eugonadal men. Testosterone absorption can vary thus personalisation of TRT via dose titration (dose and/or frequency) may be needed. Assessing efficacy Men with pathological hypogonadism who are given TRT often report improvement in libido and sexual activity, improvements in lethargy

There is much we know and much we don’t know about HRT in men. As usual, the risk-benefit analysis by the well-informed GP yields best results.

ED

of LH, impaired testicular responses to LH or reduced sex hormone-binding globulin concentrations). In this setting, losing excess weight often increases endogenous testosterone so this is the recommended approach. Androgen abuse through the use of high doses of androgenic anabolic steroids in the absence of a medical indication has been associated with harm.

Pre-TRT risk assessment Contraindications to TRT include prostate or breast cancer, undiagnosed prostate problems with or without elevated PSA, severe lower urinary tract symptoms, untreated polycythaemia, untreated severe obstructive sleep apnoea, and unstable or inadequately treated cardiac disease. TRT impairs spermatogenesis so men wanting fertility should have this addressed before treatment. A recent Position Statement by the Endocrine Society of Australia (ESA) says there is no convincing evidence that men with pathological hypogonadism treated appropriately with TRT had any increased risk of malignant prostate disease. Nevertheless, when there is a substantive risk of preexisting prostate disease, digital rectal examination and a prostate-specific antigen (PSA) test should be performed before TRT. Older frail men with pre-existing cardiovascular disease should be optimally managed beforehand. In short, in men where these are of concern, cardiovascular disease and prostate cancer risks should be assessed before TRT. Biochemical monitoring whilst on TRT Monitor FBC for any increase in Hb or haematocrit – the ESA recommends assessment 3 months after initiation of TRT and then annually. Polycythaemia induced by TRT should prompt evaluation for hypoxic conditions e.g. smoking, sleep apnoea or respiratory disease. Any polycythaemia can usually be managed with reduction of TRT dose (and/or frequency) but may rarely require venesection. Routine PSA during TRT screens for prostate cancer. Testosterone levels can guide TRT adequacy. MEDICAL FORUM

and fatigue, having more energy, and may notice increased muscle mass and strength. Periodic evaluation of bone density can be informative as often this is lower in men with pathological hypogonadism and improves on TRT. Partners of men receiving TRT can provide important insights into the impact of treatment. Caveats to TRT The ESA Position Statement noted that there is limited data from high quality RCTs to justify testosterone therapy in older men, usually with chronic disease, who have low circulating testosterone in the absence of hypothalamic, pituitary or testicular disease. (This conclusion is unchanged following the publication of the T Trials sub-studies.) The cardiovascular effects of exogenous testosterone in middle-aged or older men without pathological hypogonadism remain unclear and further research is needed in this area. Obesity is not an approved indication for testosterone treatment. Obese insulinresistant men often have lower testosterone levels (due to reduced pituitary secretion

Key references (others available on request) Yeap BB, Grossmann M, McLachlan RI, et al. Endocrine Society of Australia position statement on male hypogonadism (parts 1& 2): assessment and indications for therapy, and treatment and therapeutic considerations. MJA: 2016; 205: 173178, and 228-231, respectively. ED. The author is recruiting patients to TEX. (The effects of testosterone and exercise on fitness, physical activity and vascular health in men.) Testosterone and exercise training together improve limb muscle strength and performance more than either alone. What about the effects on fitness and health of blood vessels? Heart attacks or strokes become increasingly common as men grow older – is this related to lower levels of testosterone? Recruitment is men aged 50-70 years with a waist circumference of 95 cm or more (about 37 inches) without known cardiovascular disease, uncontrolled high blood pressure or cholesterol, renal failure, prostate cancer or other major medical illness. Contact 6151 1138 or email: shuen-chyn.soh@uwa. edu.au Competing Interests: author disclosures. BBY has received speaker honoraria and/or conference support from Bayer, Lilly, Besins, has been a member of an Advisory Board for Lilly and Besins, and has received research support from Bayer, Weight Watchers, Lilly and Lawley Pharmaceuticals.

JULY 2017 | 41


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MEDICAL FORUM


CLINICAL UPDATE

How to raise alcohol issues in men Overuse of alcohol is common, accounting for 3.3% of Australia’s disease burden (1.6% for women and 4.9% for males). Screening for high alcohol intake, and if relevant, followed by brief counselling on alcohol use may reduce consumption, health impacts and medical care resource use.

By Dr Richard O’Regan Addiction Medicine Specialist Joondalup

Prepare you questions and responses Asking about alcohol and other substance use in a non-judgmental fashion gets results.

Men usually present to a GP only when they are ill and in need of immediate treatment, rather than for checkups. Reasons include the societal masculine image of being selfreliant. Discussing alcohol intake needs to be opportunistically raised whenever men present.

The sterotypical image of a homeless individual with an enlarged nose and ruddy complexion drinking cheap alcohol from a paper bag is far from reality. Like individuals suffering methamphetamine, heroin, cannabis, benzodiazepine or prescription opioid addiction, most appear “normal” during a consultation. The majority will not raise their substance use with a medical practitioner due to shame, guilt, or previous negative judgement.

Doctors quantify intake often using a standard drink/unit (10 grams) of alcohol but patients respond in terms of bottles of wine, stubbies of beer, or as a proportion of a bottle of spirits. Having a standard drink table handy assists in rapidly determining the number of standard drinks being consumed, guiding the intervention level required. One thing can lead to another

It may be as simple as “How often do you have an drink containing alcohol?” followed by “When you have a drink, about how much do you drink?” Many with problematic alcohol use are aware they drink too much and so asking, “Do you ever feel you should reduce your alcohol intake?” raises the overconsumption issue while simultaneously assessing their readiness for change.

Effects of alcohol are dose-related Alcohol related liver disease (ALD) is a common consequence of excessive alcohol consumption. The spectrum of ALD often mirrors the total consumption of alcohol. Mild abnormalities in LFTs and hepatic steatosis are frequently observed in those with heavy or binge-style alcohol use. As alcohol frequency, volume and dependence increases to extremely heavy alcohol use, alcoholic hepatitis, cirrhosis and hepatocellular carcinoma (HCC) become more frequent. Cessation of alcohol consumption may reverse alcoholic steatosis and hepatitis and prevent progression of cirrhosis. MEDICAL FORUM

Alcohol use identified as high risk or dependent use can lead to a discussion of options for managing use. For further information or support in managing patients with alcohol related problems contact your local Community Alcohol and Drug Service www.mhc.wa.gov. au/getting-help/community-alcohol-anddrug-services. Further reading: www.mhc.wa.gov.au/ media/1934/heres-to-your-health2017web.pdf

The ‘AUDIT C’ is a brief 3-question screen that reliably identifies hightened risk and /

Alcohol related liver disease Trends in alcohol use suggest that less Australians are drinking alcohol on a daily basis. However, the number of Australians drinking at a potentially harmful level remains stable with an estimated one in five adults.

ED

or problem use: a score of four or more in men suggests elevated alcohol use risk. An alternative is the CAGE questionnaire. Both are simple, brief, and reliable at identifying alcohol consumption that warrants further discussion.

Be the opportunist doctor

Discomfort in raising alcohol consumption diminishes with practice and we know routine enquiry improves the detection rate of patients consuming alcohol at hazardous or dependent levels. So only asking about alcohol intake in those who appear to be heavy drinkers results in missing many conversations that could change lives.

Alcohol overindulgence requires an opportunist approach in men. It is often hidden. Doctors are in the hot seat.

Not all individuals who drink at hazardous levels develop ALD. The risk of alcohol related cirrhosis increases in men who drink 60-80g and women who drink more than 20g/alcohol per day over 10 years with between 6 and 41% developing cirrhosis. In those who drink more than 30g/alcohol per day the risk of developing any form of ALD is 23.6 times more than non-drinkers (and cirrhosis 13.7 times more likely to develop). Sex, race and co-existent risk factors for liver disease also influence the development of ALD. Individuals consuming less than 20g of ethanol per day do not develop ALD. Diagnosis may be difficult Diagnosis of ALD can be difficult with patients frequently underestimating or denying alcohol intake and physicians lacking reliable clinical screening tools and reliable diagnostic tests. Elevations in GGT, MCV and an AST/ALT ratio greater than two are highly suggestive

By Dr Briohny Smith Hepatologist South Perth

With 20% of Australians consuming harmful levels of alcohol, this is a hard nut to crack for society, and tests our clinical skills.

ED

of alcohol abuse. Carbohydrate deficient transferrin has been useful in detecting heavy alcohol use though sensitivity and specificity is poor. Imaging and histopathology is useful to stage ALD though this can rarely differentiate ALD from other causes of liver disease. The exception is alcoholic hepatitis which has characteristic histopathological findings. Alcohol cessation is the only treatment for ALD. It is important to identify those with continued on Page 46

JULY 2017 | 43


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Before: 59-year-old man; 20 years of pain, heaviness, night cramps, itch. After: six days post VenasealTM & ultrasound-guided phlebectomy. Symptom free.

Before: 37-year-old woman with ‘Hidden varicose veins, severe itch from venous eczema, After: EVLA GSV & SSV & UGFS in single treatment. 14 days later – symptom free.

Dr Luke Matar (MBBS, FRANZCR, FACP) Contact us: E: admin@veinclinicperth.com.au P: 9200 3450 F: 9200 3451 www.veinclinicperth.com.au


CLINICAL UPDATE

Managing the thyroid nodule

By Dr Dean Lisewski Endocrine & General Surgeon Murdoch

are largely accepted here and determine who should have fine needle aspiration cytology (FNAC). For instance, ATA High and Intermediate suspicion nodules should have FNA at ≥1 cm; ATA Low suspicion should have FNA ≥1.5 cm; and ATA Very Low suspicion should have FNAC ≥2 cm. ATA Benign (pure cyst) or nodules <1 cm probably do not need FNAC.

Thyroid nodules can be a source of anxiety for patients and doctors. Managing the thyroid nodule has changed little, but imaging and cytopathology have become much more sophisticated. The prevalence of palpable thyroid nodules is 5% in women and 1% in men. With the ease of access to high-resolution ultrasound scans, 19%-68% of randomly selected people have a thyroid nodule and importantly, 7-15% of nodules will be thyroid cancer, ranking this cancer 3rd amongst females (12%) and 4th amongst males (7%) within the 15-39 age group (2014 WA Cancer Registry).

Cytological stratification The Bethesda system of nodule classification is common. (See table) Bethesda III and IV nodules represent indeterminate group- follicular lesions, some of which will be follicular cancers. It is not

possible to diagnose Follicular Cancer on cytology alone as vascular and capsular invasion are diagnostic hallmarks. Other tests for working up a nodule include TFT and TPO. If thyrotoxicosis is present adding fT3, tF4, TSHR Ab, and a thyroid scan will help. For patients who are potentially in need of thyroid surgery, adding PTH and Calcium to exclude concomitant primary hyperparathyroidism is beneficial as two birds can be got with one stone.

Author competing interests – nil relevant disclosures. Questions? Contact the author on 9310 7878.

Surgical indications are known cancer or suspicion thereof, compressive goitre or retrosternal goitre, or thyrotoxicosis. Clinical assessment with ultrasound and cytopathology determines whether to recommend surgery or medical management. Assessment is multimodal (clinical/ sonography/cytology) Clinical presentation can be asymptomatic e.g. incidental nodule on imaging. Symptomatic presentations include neck mass, hoarseness, airway difficulty, chronic cough, dysphagia, persistent sore throat, Pemberton’s sign (facial engorgement on raising upper limbs) or venous neck distension. Most thyroid cancers occur sporadically, however enquiry into risk factors (including radiation exposure or family history of thyroid cancer) is useful. Red flags for referral to a surgeon include stridor associated with a goitre, nodules in patients with risk factors for thyroid cancer, unexplained hoarseness, rapid and painless enlargement over weeks, cervical lymphadenopathy, or tethering or fixity of a neck mass. The American Thyroid Association (ATA) guidelines for managing thyroid nodules

Class

Description

Risk of Cancer

Clinical Notes

BI

Non-Diagnostic

?

Insufficient cellular material for diagnosis - repeat FNAC. There is probably no benefit in performing more than two needle biopsies.

BII

Benign

0%

Observe or refer for surgery if >4cm or symptomatic.

BIII

Indeterminate follicular

5-15%

Atypia of Uncertain Significance or Follicular Lesion of Uncertain Significance (AUS/FLUS). Large nodules or those with suspicious sonographic features benefit from diagnostic hemi thyroidectomy or surveillance US. Growth >25% diameter at 6 months indicates further intervention, such as FNAC or surgery.

BIV

Atypical follicular

20-25%

Follicular Neoplasm - Offer a diagnostic hemi thyroidectomy if fit for surgery.

BV

Suspicious of malignancy

90%+

BRAF immunohistochemistry (IHC) recommended because if present the lesion is malignant for which total thyroidectomy is offered. If BRAF negative a diagnostic hemi thyroidectomy with on-table frozen section is used.

BVI

Malignant

100%

Total thyroidectomy with some benefitting from lymphadenectomy.

MEDICAL FORUM

JULY 2017 | 45


CLINICAL UPDATE

A brief guide: circular external fixators A circular external fixator is a special device that treats complex fractures and limb deformity through the use of pins and thin wires under tension that hold the bone within a frame made up of rings joined together with threaded rods (see below). Circular frames were developed in the Soviet Union in the 1960s by Professor Gavriil Ilizarov (whereas the standard external fixator has straight rods connecting pins along only one side of the limb).

By Dr Simon Wall Orthopaedic Surgeon

They might look like they’re from outer space but early weight-bearing is one advantage, as is self-care.

ED

When are they used? These frames are useful in a number of scenarios, when they have particular advantages over nails or plates. Examples include: • acute complex fractures with severe soft tissue injury. • to address non-unions that have not healed with traditional methods. • infection, where implanted metalware is contraindicated. • to permit correction of complex limb deformities, either in childhood and more commonly in post-traumatic mal-union. They are perhaps most controversially known for their use in limb lengthening, although this technology is much more frequently used to regenerate new bone to replace bone loss, rather than to overcome short stature. Circular external fixators can be used anywhere on the body, including the upper limbs and the head and neck but are most commonly used on the lower limbs, especially around the knee, tibia and ankle. Advantages and disadvantages Advantages • In most circumstances, immediate weight bearing is possible, a major advantage over other forms of internal and external fixation. • A valuable alternative to screws, nails or plates where infection or soft tissue coverage may be an issue. • The biomechanics of the frames also allow a fracture to be compressed dynamically to facilitate healing, or even to be distracted, to regenerate new bone.

Left to right; Most patients tolerate the frames well, which allow early full weight bearing, Circular external fixator on the tibia, anterior view

• Most patients, or carers are able to ‘lookafter’ their own frame, including pin-site care, tightening components and adjusting as specified. Disadvantages • The frames are cumbersome, and require alterations to clothing. • They can be psychologically difficult to tolerate, despite patients being counselled by the surgeon beforehand. • Commonly need to be worn between

continued from Page 43

Alcohol related liver disease alcohol-dependence as they will likely benefit from additional support and strategies to maintain abstinence. Baclofen, disulfarim and naltrexone have all been used to assist in maintaining abstinence. Though liver disease is a contraindication to disulfarim and naltrexone, these medications are likely to be safe and useful in experienced centres. A subset of those with severe alcoholic hepatitis may benefit from corticosteroids

46 | JULY 2017

in a specialized unit. Those with cirrhosis require HCC surveillance and management of complications including variceal bleeding, ascites and encephalopathy.

Author competing interests: nil relevant disclosures. Questions contact the author on 6381 0343

3 months and a year (because gradual deformity correction or difficult fractures take more time to heal). What problems may occur? Pin sites may be sore and become infected, requiring a short course of antibiotics. Patients may have increased pain at the fracture site, especially after any frame adjustments or increased activity, necessitating increased analgesia and/or activity modification.

Key Points • Alcohol is a frequent cause of liver disease. • Elevated GGT, MCV and AST:ALT>2 are highly suggestive of ALD • Alcohol abstinence may reverse steatosis and hepatitis • Cirrhosis is not generally reversible but progression may be halted by abstinence • Pharmacological therapies are likely to be safe and useful in assisting with alcohol abstinence

MEDICAL FORUM


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WEMBLEY Suite 10, First Floor 178 Cambridge Street Wembley WA 6104 www.workspine.com.au JULY 2017 | 47


Travel

The Life Aquatic Dr Gordon Hay and wife Dr Sally Garnett took their medical degrees out for a sail for a couple of years and had a time of their lives.

There’s something about life on the ocean waves that captures the imagination. In 2008 Dr Gordon Hay and his wife Dr Sally Garnett made that dream a reality by stepping off dry land and onto the deck of their 43-foot sailing catamaran, Morning of the Earth. “It was all about exploring other places, travelling to some pretty out of the way destinations, meeting new people and doing lots of diving, fishing and surfing,” said Gordon. “There was a real sense of discovery, it was an amazing trip and we did it in our own kind of way – very different from hopping on an aircraft or ferry! I’d love to do it again.” “We bought the boat in St Lucia in the Caribbean, sailed around there for about six months and did some locums and a fellowship. Then we sailed to Trinidad and lived there before coming through the Panama Canal, crossing the Pacific and finally making landfall in Coffs Harbour, NSW.” Working, holiday, perfect “After working on the north coast for a while we sailed up to Darwin, more doctoring in the Top End and then back to Perth. It was an amazing trip, and I was able to do part of my orthopaedic training along the way. I had fellowships in Switzerland and Auckland, with lots of locum positions.” The two intrepid mariners didn’t have the fun all to themselves. Dr Gordon Hay and Dr Sally Garnett on their voyage around the Pacific.

48 | JULY 2017

“We were joined on quite a few occasions by family members and friends. In fact, one couple joined us on the Panama to French Polynesia trip, which included an 18-day sailing leg to the Galapagos Islands. We stayed there for five weeks and it was incredible!” MEDICAL FORUM


Travel

“We had lots of exciting wildlife encounters, particularly with the seals. One morning we woke to six draped across the transom and one even came inside the cabin and made himself at home.”

“Although, despite all that, my one regret is that we didn’t spend longer at sea. I’d happily spend another year out there in the Pacific. There’s a lot of ocean out there, and thousands of beautiful islands.”

“There were plenty of other interesting moments, too. We were swamped by a big wave in Tahiti that broke the steering gear and pushed us towards a reef but we were able to manoeuvre back into the safety of a lagoon and do some running repairs.”

Although Gordon had plenty of sea miles under his belt, stepping onto a cruising catamaran was something a little different.

“The fishing was amazing, really big tuna that were then grabbed by sharks. In Tonga and the Tuamoto Islands we were swimming around with hammerhead sharks. That was pretty spectacular.” Keeping it ship-shape Gordon makes the point that, despite all the exotic flora and fauna, there is a more mundane and domestic aspect to off-shore cruising. “There’s a fair bit of work involved in maintaining the boat. You need to keep all the systems running and there’s always something breaking down, from hydraulics to engines and the 12-volt DC power. It’s a major challenge, and it keeps you busy. I’m a pretty handy sort of person, I can turn my hand to most things but it’s a steep learning curve sometimes.” “The catamaran was eight years-old when we bought it, and that’s about the time in a boat’s life when you start to have equipment issues. Fixing those sorts of things can be a bit tricky, particularly in a foreign port.” MEDICAL FORUM

“I had sailed the Atlantic aboard the tall ship, Young Endeavour, but she had a naval staff crew so it was quite different to being at the helm of our own boat. I have to be honest and say I conned my wife into thinking that I had a bit more sailing experience than I actually had. She didn’t take long to realise that fact!” “Thankfully, Sally proved to be a highly capable co-skipper.” Mod-cons make it easy “The navigation part of it isn’t too difficult these days, mainly due to the fact that we have easy access to GPS and chart plotters. In the good old days you had to use a sextant and we did have two on-board although getting a bearing and doing the mathematics can be a bit of a challenge.” “It was sad to see the boat go when we sold it, but we just weren’t using it. Our lifestyle has changed now. We’ve got two children – a five year-old and one at 18 months. It was better to have someone else enjoying the sailing than see it rotting away in a marina. The upkeep is expensive and we weren’t even using it on the weekend.”

great out of Busselton. It’s so different in the Caribbean, where you can go for a three-hour sail and end up in another country.” So, would they do it all again? “We’d love to do another trip, maybe next time with our children. Once they get to about 10-12 years-old and can swim, look after themselves a bit and sail the boat it would be a wonderful experience.” “But life’s great at the moment. We live in Yallingup, which is a lovely place. My wife and I both surf and we have a lot of fun as a family. I’m a lucky man.”

By Peter McClelland

“And really, the cruising grounds aren’t all that

JULY 2017 | 49


Practice Management

How secure is my IT? By Mr Jerome Chiew, www.critical-it.com.au The WannaCry ransomware virus that made the news recently is a timely reminder that businesses cannot take security for granted. The only reason why this incident made the news around the globe was because of high profile institutions such as England's NHS being severely affected. The virus exploited a known security hole that Microsoft patched in March 17. The root cause is failing to install updates and patches as they become available.

you may have in place. If you're relying on Microsoft's built in anti-threat engine, Windows Defender, you'd be providing yourself with a false sense of security (see www.itnews.com.au). 2.

There are tips you can use to minimise the risk of infection or your system being compromised. 1.

Deploy a good antivirus with heuristics for detecting and removing threats. The independent antivirus testing website evaluates and ranks business protection software in areas of protection, performance and usability. www.av-test. org/en/antivirus/business-windowsclient/windows-10/ A good antivirus helps catch any malware that's hitched a ride on a USB flash drive or CD/DVD and stops malware from executing if it makes it through the internet and email filters

3.

Access levels, permissions and passwords are your weakest link. Ensure that all user accounts have the lowest permissions possible, allowing just enough access to complete tasks. Most threats run under the infected user’s credentials, so the less permissions a user has, the less damage done. Passwords should be changed frequently, be complex and long. User accounts should have an automatic lockout after five incorrect attempts at logging in. Use at least two words sprinkled with numbers and symbols to ensure it can't be too easily guessed. Install a UTM device https://en.wikipedia. org/wiki/Unified_threat_management to filter your Internet connection and incoming emails. This will weed out most of the attempts to insert malware when browsing websites and eliminate malicious attachments in emails.

4.

Educate staff on how to create easy to remember complex passwords, ensure they vet contractors wanting physical access to systems and cross-check phone/electronic requests for sensitive business information. Show them how to verify authenticity of emails and to always ask if in doubt.

5.

Ensure all systems are patched and updated. If you're running software that the vendor no longer supports, upgrade or replace immediately. Microsoft release updates for all of their supported software, not just Windows, at least once a month. Ensure that you also update other software like Adobe Acrobat Reader regularly, not just Windows alone. https://its.ny.gov/ security-advisory/multiple-vulnerabilitiesadobe-acrobat-and-adobe-readercould-allow-code-execution

This also includes ensuring that firmware in devices like Internet modems and printers are patched and updated. http://www.zdnet. com/article/flaws-in-popular-printers-can-lethackers-easily-steal-printed-documents/

From the moment I picked your book up until I laid it down I was convulsed with laughter. Someday I intend reading it

- Groucho Marx (1895-1977)

The Christmas Cracker Collection Inspired by our correspondent this month (see Letters to the Editor) we went hunting for some groan aloud cracker jokes. When we were in the hospital I got my wife a blanket. What was awesome was they were kept in this machine that was specifically made to heat blankets. I laid the blanket over my wife and said “do you think they keep these at womb tempteratures” An Englishman, a Frenchman a Spaniard and a German are all standing watching a street performer do some excellent juggling. The fuggler notices that the four gentlemen have a very poor view, so he stands up on a large

50 | JULY 2017

wooden box and calls out, “Can you all see me now?” Yes Oui Si Ja Why are blonde jokes so short? So men can remember them.

I thought Oxygen was dating Magnesium – OMG

Four Puns in One A motorcycle gang made up of ancient bisexual Norse monarchs: the Bikings Signs of the Times

How many ears does Captain Kirk have? Three... a left ear, a right ear and a final front ear.

Ban Pre-shredded Cheese: Let’s make America grate again

So Oxygen went on a date with Potassium – it went OK

Can we just admit we may have taken this ‘Anyone can grow up to be president’ thing just a bit too far…?

Acutally Oxygen first asked Nitrogen Out, but Nitrogen was all like ‘NO’ I though Oxygen had that double bond with the Hydrogen twins, looks like someone’s a HO

AutoCorrect has become my worst enema The best part about getting vaccinated isn’t the lollipop. It’s the part where you don’t get sick and die.

NaBrO MEDICAL FORUM


APP REVIEW

HANDOC Clinical Usefulness

Ease of Use

Review by Dr Clare Matthews Liaison GP, Osborne Park Hospital It’s purpose This App has been developed by a group of seven hand surgeons from the Western Australian Plastic Surgery Centre. The App, first released in March 2017, is not intended for patients and is designed principally to facilitate specialist advice and allow referrals of privately insured people by medicallytrained people such as ED doctors and nurses, occupational GPs, onsite medics and injury management advisers. The text offers emergency first aid and succinct clinical management of the more common acute presentations. There are good quality anatomy images prepared by surgeons for easy reference and as a refresher for primary care providers who might see hand injuries infrequently. It advises on useful information to include in a referral and how to contact the service 24/7 via telephone or email. There is also the option to sign up for regular clinical newsletters. Details Free. Requires iOS 7.0 or for iPhone, iPad, iPod touch users and installs onto android devices as well. It requires 37.4M and does not require Wi-Fi, and only requires an internet connection if sending images to the on-call specialist. There are no in-App purchases. Interestingly it is designated for over 12s since it refers to medical treatment! As at the beginning of May the App had been downloaded 300 times, the newsletter had been subscribed to via the App 75 times. Overview This is a slick App that looks and handles well; it is easy to navigate offering great anatomical images of all of the structures of the hand and wrist (individually swipeable, not layered). There is succinct and useful first aid and management advice for acute hand injuries.

It offers a 1300HANDOC number and email for 24/7 contact with an on-call specialist. The designers are at pains to point out that this App still promotes a direct call to HANDOC as the optimal clinical approach “and there is always a specialist hand surgeon ready to provide triage and medical advice”. It allows a referral direct from your device, attaching photos of the injury to your email for which the usual internet connection is required. (N.B. One would need to be cautious about the lack of security of the email information if it identifies the patient.)

Summary: Pluses: Sleek appearance and great anatomical pictures - useful for me, I can never remember where the TFCC attaches! It’s also a powerful advertising method for this group of plastic surgeons in Perth. I canvassed the many remote and rural doctors on the Facebook site GPDU and many felt that it was a useful tool. The App works on any smartphone, Apple or android. Minuses: We need to be cognisant as referrers that there are other hand specialists in Perth seeing privately insured patients.

Beer

Winner

MEDICAL FORUM

Joondalup GP Dr Jade Jagoe-Banks was the latest recipient of a carton of Doctor’s Dozen Gage Roads Beer. She looked wistfully at the usual prize of a dozen bottles of wine but even that wouldn’t have helped her much – Jade’s pregnant and expecting their first child in August. Free beer and a baby – Jade’s husband is a lucky man!

JULY 2017 | 51


Theatre

Back to the Future of 1984 1984 is a play for our times, and even more so when you factor in Donald Trump’s ‘alternative facts’. George Orwell’s classic novel is a confronting read and this is a piece of theatre production, which comes to His Majesty’s theatre from August 4, has some equally disturbing moments. Actress Ursula Mills spoke to Medical Forum about the show. “I play Julia who’s a pretty shadowy character. You never really know which side she’s on and, in this production, that’s exacerbated by the fact that at certain times she’s portrayed as a projection of Winston’s imagination.” “The two main characters are continually circling each other under the gaze of an oppressive regime while the play builds towards the inevitable climax of Room 101. Everyone who’s read the book knows about that awful place where the characters are confronted by their most terrible fears. And Winston, perhaps like most of us, cries out ‘Do it to someone else!’.” “It’s a confronting scene and we’ve actually had people leave the theatre. In fact, I think the record stands at 22 who walked out of a London production.” “The show is quite faithful to the book and we’re certainly trying to recreate the impact of Orwell’s writing. We mustn’t forget that ‘Nineteen Eighty-Four’ was published in 1949, a pretty turbulent time with the looming, overarching shadow of the Cold War.”

52 | JULY 2017

Audiences will be seeing the book unfold on stage, says Ursula. Both the actors and theatre-goers know it’s not ‘real’ but the overall effect is a powerful one. “Yes, it is ‘theatre’ and we all know that but it’s also meant to be a viscerally ‘real’ experience. As an actor I’ve done plays that have stayed with me, disturbing roles that really sink into your mind and that’s not entirely surprising, I guess.” “To give a really meaningful performance you have to draw on parts of your own personality that you hope will connect with the character you’re portraying. What’s up there on the stage is meant to be honest and truthful, and part of that comes from an actor’s psyche.” “And, I have to say, playing Julia does leave a certain amount of detritus. But that’s OK, too. You don’t pop out of drama school as a fully formed actor and these demanding roles are important in the development of an actor’s career.” The play was first performed in London in 2013 and, in four short years, a lot has happened. And not all of it’s been good. “We live in pretty uncertain times, everything from terrorism to the revelations of Edward Snowdon. Apparently when Trump was elected, Orwell’s book hit the best-seller lists all over again!” “We’re all becoming very used to living under the gaze of ‘soft surveillance’, and we’re

Ursula Mills

actually pretty complicit in that acceptance. Every time we swipe a card we reveal what we’re doing, where we’re going and even what we’re eating! The fact that we’re more aware of it is a good thing, but it’s interesting that most of us seem happy enough to give away our personal information quite willingly.” “Sure, there’s a level of resistance by Winston and Julia and that’s a lingering tension played out on stage. And one of the things I like, if ‘like’ is the right word, is that Julia is a survivor. But I think, essentially, that this story is deeply tragic. Both people, when faced with the most awful expression of terror, end up betraying each other and that’s heartbreaking.” “This play is a cautionary tale. People will get different things out of what’s presented on stage, and perhaps some might feel that we have to think more deeply about our very own ‘Big Brother’. “Maybe all of us should start looking at our smart phones in a different way?

By Peter McClelland MEDICAL FORUM


Food & Beer

Coopers: Tall, Dark, Handsome First an acknowledgement of bias: one of us was raised in Adelaide and baptised in the holy waters of the Coopers Leabrook brewery. The other is not biased (except perhaps in his exposure to most of the beers in Belgium) thus giving rise to one of our most divergent tastings yet…

Dr Sergio Starkstein & Dr Bradleigh Hayhow

T he Beers Best Extra Stout (6.3%) The Best Extra Stout is presented as a top-fermented beer, with maturation in the bottle which enhances the flavour of the finest barley malt, and with aromatic hops. This Stout has a rich, almost opaque colour, with a nose typical of a good stout. Taste was pleasant, creamy, with a smooth ending, and reminded us of coffee grounds and dark chocolate. We found this Stout gentle to the palate and more drinkable than Guinness. One of Australia’s best stouts. Score: 8/10 Mild Ale (3.5%) First, we have to admit that one of us is against the mid-strength category (is that still a beer?). The Mild Ale is cloudy with some body, but not enough taste to make it worthwhile. Perhaps its market is those thirsty people looking for a beverage that looks like a full-strength beer, but won’t lead to embarrassment in public. At the very least, it is better than a mid-strength lager. Score: 3/10 Sparkling Ale (5.8%) The Sparking Ale is presented as having a distinctive balance of malt, hops and fruity characters. Sparkling it is, with high carbonation a distinctive feature.

Unfortunately, the head didn’t hold and the aroma was uninviting. Tasted like a mild Indian Pale Ale, with sweet notes. Not a bad entry point for ales. Score: 6/10 Premium Lager (4.8%) This beer is presented as having a “refreshing flavour, with a good balance of malt and hop characters”. It is certainly a lager, but does little to distinguish itself from other common brands. It is a refreshing beer with a clean finish, but no hops were detected. Score: 4/10 Original Pale Ale (4.5%) The Pale Ale is described as “fruity and with floral characters balanced with a crisp bitterness.” This ale has a good foamy head and a nice, cloudy, amber colour. Good nose and tasting of hops. Score: 6/10 Dark Ale (4.5%) The Dark Ale is described as “starting fresh and creamy, finishing with a lingering coffee flavour.” This beer has a good threading of head on glass. It is malty, fruity with a slight taste of molasses. There’s still a little room for improvement in this promising younger cousin to the Best Extra Stout. Score: 7/10

The Verdict Coopers offers a good range of beers for regular drinking and we’re big fans of top fermentation. We were most impressed by the dark offerings, but would never pit them against the splendid Belgian Ales. We did not have an opportunity to taste the Extra Strong Vintage Ale, which would at least have competed on alcohol content. Coopers faces a challenge in balancing its strong and iconic brewing tradition with a global demand for innovation and improvement – but its footings are sound.

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MEDICAL FORUM

JULY 2017 | 53


COMPETITIONS

FEATURE

COMP

Entering Medical Forum's competitions is easy! Simply visit www.medicalhub.com.au and click on the ‘Competitions’ link to enter. Movie: The Trip to Spain Director Michael Winterbottom wrangles, yet again, the impressive thought wilful talents of comedians Steve Coogan and Rob Brydon on another trip, this time to Spain with lashings of witty banter, gorgeous Spanish scenery and delicious food. In cinemas, August 3

Music: Simone Young: 20 Years With WASO When Simone Young first stood in front of the WASO 20 years ago, she was a seasoned conductor of particularly opera throughout Europe and Australia. In the interceding years, Young has become a giant of the podium taking on the might of Wagner and Brahms with her signature art and determination. In the past five years along, her discography includes the works of Bruckner, Mahler, Brahms and the entire Ring Cycle of Wagner. Young started her pathfinding conducting career at the tender age of 24 at the Sydney Opera House in a production of The Mikado and has taken the opera world by the horns ever since, though she is saying yes to more symphonic and concert works these days. Young’s anniversary concert with WASO features elegance in the shape of the Hayden Symphony No.99, something bold in Brahms Academic Festival Overture, and something completely new with the world premiere of Australian composer Andrew Schultz’s Maali. This last piece draws on the solo talents of the orchestra’s wind principal players – Peter Facer (oboe), Allan Meyer (clarinet), Jane Kircher-Lindner (bassoon) and David Evans (horn). Perth Concert Hall, August 4 and 5, 7.30pm

In cinemas, August 17

Movie: Valerian and the City of A Thousand Planets From the director of The Fifth Element comes Valerian with an intriguing cast of Cara Delevingne, Dane DeHaan, Clive Owen, Ethan Hawke and Rihanna joining forces to bring this comic book series to life. Visually spectacular and artistically exciting. In cinemas, August 10

Theatre: 1984

Women’s Health

His Majesty’s Theatre, August 4-14

• Keeping Abreast • Treating Anorexia Nervosa • Risks vs Rewards of Medicine • Clinicals: HRT, Hyperhidrosis, Breast & Bone Density

M AY 2 0 1 7

Movie – 20th Century Women: Dr Twain Russell, Mrs Hillary McWilliam, Dr June Sim, Dr Ranjan Shrestha, Dr Alison Stanning, Dr Henrietta Bryan, Dr Alarna Boothroyd, Dr Diana Fakes, Ms Claire Armanasco, Dr Simon Machlin

Stephen King’s The Dark Tower hits the big screen with the last Knight Warrior, Roland Deschain (Idris Elba), locked in battle for the safety of the universe with the Man in Black (Matthew McConaughey). Hitech Good v Evil with ripping effects.

A revival for our times! George Orwell’s classic Cold War dystopic novel hits the stage with a powerful cast delivering a powerful performance. Set on an April day in 1984. Comrade 6079, Winston Smith, thinks a thought, starts a diary, and falls in love. But Big Brother is always watching.

M E DIC AL FO RU M $12 .50

Winners from May

Movie: The Dark Tower

Movie – The Shack: Dr Craig Schwab, Dr Angeline Teo, Dr John Van Bockxmeer, Mr Maxwell Weedon, Dr Esther Eu, Dr Beverly Teh, Dr Michael Armstrong, Dr Amir Tavasoli, Dr Trixie Dutton, Dr Michael Bray May 2017

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Movie – Hounds of Love: Dr Helen Mead, Dr Colin Stewart, Dr Donna Mak, Dr Max Traub, Dr Rob Hendry, Dr Michelle Luy, Dr John Williams, Dr Katherine Ng, Dr Orna Gabbay, Dr Lyn Minsker

Theatre: Bell Shakespeare’s Merchant of Venice Money makes the world go around. Portia has it. Bassanio wants it. Shylock lends it. Antonio owes it. Welcome to Shakespeare’s world of justice and prejudice. Mitchell Butel plays Shylock, one of the most fascinating characters in the history of theatre. Heath Ledger Theatre, August 9 -12

Music – WASO Swing on This: Dr Dian Harun Theatre – Endgame: Dr Annette Finn Theatre – Enoch Arden: Dr Matthew Oud

54 | JULY 2017

MEDICAL FORUM


You can never stop

MedicalForumWA 0717 Public Edition  
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