Medical Forum WA 07/13

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Men’s Health t Combat Sports t Boys’ Toys t Allan Fels t Sperm Donation t Prostate Clinicals & more...

July 2013 Major Sponsors

Perth Pathology

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Major Sponsors

CONTENTS FEATURES

E-POLL & EVENTS

11 Spotlight: Mental

15 Gender Benders

Health Commissioner Prof Allan Fels

34 Conference Corner

16 Ophthalmologist

CLINICAL FOCUS

Dr Angus Turner 18 Combat Sports: Taking

the Gloves Off 21 Trailblazer: Dr Graeme

Fitzclarence

NEWS & VIEWS

11

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39 Case Report: Atypical

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26 Protecting an

28 Breaking Up: a Health

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41 PSA Screening, in

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37 Common Eye Injury

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22 Talk About a Revolution

27 Sperm Donors Are Still

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Weekend

41 Medicolegal Q&A:

Abdomen

Healing in Burn Injury

14 Pilbara Remote

32 The Blokes Book

30 Some Things in the

36 Quest for Scarless

Feelings Too

25 Beneath the Drapes

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12 Have You Heard?

24 Practice Tip

Neoplasms of the GI Tract

Hearts: Ventricular Septal Defect

9 Editorial: Men Have

24 Veterans Show Way

3 Neuroendocrine

34 Congenital ‘Holey’

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Perth Pathology

50 Kitchen Confidential

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52 Arts: Stomp 53 Arts: St Petersburg

Ballet 54 Competitions

1

PUBLISHERS Ms Jenny Heyden - Director Dr Rob McEvoy - Director

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

ISSN: 1837–2783 ADVERTISING Mr Glenn Bradbury advertising@mforum.com.au (0403 282 510) EDITORIAL TEAM Managing Editor Ms Jan Hallam editor@mforum.com.au (0430 322 066) Medical Editor Dr Rob McEvoy (0411 380 937) rob@mforum.com.au Clinical Services Directory Editor Ms Jenny Heyden (0403 350 810) jen@mforum.com.au Journalist Mr Peter McClelland journalist@mforum.com.au EDITORIAL ADVISORY PANEL Dr John Alvarez Dr Scott Blackwell Ms Michele Kosky Dr Joe Kosterich Dr Alistair Vickery Dr Olga Ward SYNDICATION AND REPRODUCTION Contributors should be aware the publishers assert the right to syndicate material appearing in Medical Forum on the MedicalHub.com.au website. Contributors who wish to reproduce any material as it appears in Medical Forum must contact the publishers for copyright permission. DISCLAIMER Medical Forum is published by HealthBooks as an independent publication for the medical profession in Western Australia. The support of all advertisers, sponsors and contributors is welcome. Neither the publisher nor any of its servants will have any liability for the information or advice contained in Medical Forum . The statements or opinions expressed in the magazine reflect the views of the authors. Readers should independently verify information or advice. Publication of an advertisement or clinical column does not imply endorsement by the publisher or its contributors for the promoted product, service or treatment. Advertisers are responsible for ensuring that advertisements comply with Commonwealth, State and Territory laws. It is the responsibility of the advertiser to ensure that advertisements comply with the Trades Practices Act 1974 as amended. All advertisements are accepted for publication on condition that the advertiser indemnifies the publisher and its servants against all actions, suits, claims, loss and or damages resulting from anything published on behalf of the advertiser. EDITORIAL POLICY This publication protects and maintains its editorial independence from all sponsors or advertisers. GRAPHIC DESIGN 2 Thinking Hats

Letters to the Editor

Thoughts on ETS at Northam Dear Editor, RE: Rural ETS, A Teleheath Notion (June). Initially, I felt great relief with the arrival of ETS in Northam. We were busy. At the time, we were rostered for 24-hour shifts; 12 hours on duty, 12 hours on call (usually on-site and working for a minimum 14-18 hours). For a variety of reasons, presentations were on the increase (with this work now covered by at least three doctors) and we were also taking more phone calls from peripheral hospitals suffering from a shrinking pool of GPs across the Wheatbelt. Once ETS started and removed the bulk of our phone calls, we could concentrate on the physical presentations in Northam casualty across busy periods. It certainly made a difference, despite not being a 24-hour service. Patients presenting to the peripheral sites were being managed more efficiently and effectively by the ETS team, who actually had time to listen to the nurses’ assessments! I suspect patients began to realise if they presented during ETS operating hours they would be 'seen' by both a nurse and doctor. I'm sure both of these factors led to less phone calls to us during non-ETS hours. It was a welcome relief. For the Northam ED with a duty doctor present, ETS was touted as a valuable resource but, as reported, initial uptake was slow. I think this was natural and related to familiarity. Reform leaders initially intended to make discussion with ETS mandatory, prior to transfer of all patients from Northam to Perth, but after further thought it remained the suggested approach. Having someone else arrange liaison with the receiving hospital and transfer was very valuable in freeing us up to focus more on managing the patients still in the department. An ETS bombshell came prior to the hospital’s well publicised clinical incident review. The word ‘mandatory’ returned, without discussion; the doctor in Northam must discuss with ETS ATS1 & 2 cases, abnormal ECGs, 'sick' and febrile children <6 months, and re-presentations. Cases that had been managed competently for years, now mandated discussion. But if we didn’t know an ECG was abnormal, how could we discuss? Furthermore, ETS was never meant to be a 24-hour service, which meant that towards the end of a busy day, when ETS has gone home, when I am tiring and my competence is waning, I am OK to cope alone and manage these patients?! These new stipulations put a lot of GPs working in rural areas off-side and may have contributed to the ongoing, unusually low uptake of the ETS by GPs. Following the hospital review, the structure of the Northam ED medical workforce changed considerably and I think has resulted in a further reduction in the use of ETS here, both due to a lack of familiarity from the now mostly locum workforce and the frequent availability of an on-site FACEM. Ironically, there is probably now the physical workforce day-to-day to resume taking phone calls from peripheral sites but let's not upset a well-established service now! For peripheral hospitals I can see ETS has brought a fresh ray of hope. These hospitals were surely at risk of becoming redundant as patients were coming to Northam having bypassed the local hospital at their own discretion, or after being told to by ambulance or nursing staff. Attracting nursing staff to work in

the face of little medical support was surely tenuous. I think the value of ETS to these hospitals is well documented and we should continue to hear the good stories as a result. Long live Royalties for Regions and the WA mining boom! Dr Matt Archer, GP Anaesthetist at Northam & Merredin, living in York.

I am not a cost to the system Dear Editor, I have recently read many articles featuring government ministers and various health bureaucrats talking about GPs ‘double dipping’ by claiming rebates for consultations undertaken at the time of doing GP management plans. I can’t believe their cheek! A patient travels maybe 50km each way to see me in a rural clinic. Or for that matter an urban clinic. They spend half an hour with our practice nurse getting the basics of their care plan fleshed out. I then spend another half hour checking that over and typing letters to allied health professionals, containing as per the template all the relevant information that’s been expanded into the GP management plan. Then the patient, who by this stage is very bored with all the paper spewing out of the printer to just get their toenails done or their back seen to, asks for repeat scripts, two referrals, a full skin check and wants to know about the new lump in their breast that they just noticed last week. As far as the patient is concerned, an hour wasted on a physio referral is not good time management for them and they want their money’s worth. Sure, I could ask them to drive the 100km again tomorrow and the next day to sort it out, but then they would need to get an appointment too! After all these years of BEACH studies, is it not abundantly clear to those in government that we deal with at least six things most visits? With all the ridiculous tick-a-box templates and mandatory requirements for a stingy five assorted visits to allied health attached to the GPMP, it’s a wonder any of us do them at all, except as a favour to our pensioners who can’t afford the allied health any other way. Why does some Medicare bureaucrat always assume we are trying to rort the system? All I want is that my patients get a fair rebate for the services provided, and at some stage someone to trust me that I have provided the services for which I have billed. It doesn’t seem to be rocket science. I get the feeling that we are never considered to be a service provider, we are simply a system cost. And I really object to that! Dr Olga Ward, Medical Adviser, Rural Health Wes Continued on P4

We want to hear what you think. Send in your letters by July 10 to editor@mforum.com.au medicalforum

By Dr Michael Armstrong FRCPA, Histopathology and Cytopathology

Perth Pathology (Perth Medical Laboratories Pty Ltd APA) 152 High Street Fremantle WA 6160 26 Leura St, Nedlands WA 6009 Ph 9433 5696 Fax 9433 5472

www.perthpathology.com.au

Dr Mike Armstrong trained locally at UWA and Perth teaching hospitals. He has a special interest in GI and skin pathology and cytopathology. Mike has been with Perth Pathology since early 2007.

Collection centres throughout the Perth metropolitan area including: Fremantle (Main Lab); Perth CBD, Atwell, Bedford, Belmont, Bentley, East Perth, Ellenbrook, Hilton, Joondalup, Kardinya, Kinross, Maddington, Malaga, Palmyra, South Lake, South Perth, Southern River, West Leederville

Neuroendocrine Neoplasms of the GI Tract Current concepts and a brief focus on rectal neuroendocrinetumours Neuroendocrine neoplasms are derived from neuroendocrine cells. They are uncommon, accounting IRU RI *, WUDFW WXPRXUV DQG DUH PRVW FRPPRQO\ IRXQG LQ WKH LOHXP DSSHQGL[ DQG UHFWXP

invasion are being treated by endoscopic resection and follow up.

The term “carcinoidâ€? has lost favour in FXUUHQW FODVVLĂ€FDWLRQ VFKHPHV DQG LWV XVH LV QR longer recommended. The term is a source of confusion, mainly because it implies benign behaviour, which is often not the case. The new :+2 FODVVLĂ€FDWLRQ QRZ XVHV WKH WHUP Neuroendocrine Tumour (NET).

*However, recent studies have shown that even 1(7V FP VL]H GR PHWDVWDVLVH RQH VWXG\ VKRZLQJ XS WR RI SDWHQWV ZLWK UHJLRQDO nodal metastases). This raises the question whether new treatment/management strategies are required. Endoscopic ultrasound may play an important role in the evaluation of these lesions.

1(7 LV GHĂ€QHG DV D ZHOO GLIIHUHQWLDWHG neuroendocrine neoplasm composed of cells with features similar to those of normal gut endocrine cells, expressing general markers of neuroendocrine differentiation with mild to moderate nuclear atypia and a low number of PLWRVHV SHU KSI Below is an outline of the latest WHO FODVVLĂ€FDWLRQ IRU QHXURHQGRFULQH WXPRXUV RI WKH GLJHVWLYH V\VWHP 1(7 * 1HXURHQGRFULQH WXPRXU JUDGH

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NEC (Neuroendocrine carcinoma – large cell or small cell type) MANEC (Mixed adeno-neuroendocrine carcinoma) Hyperplastic and pre-neoplastic lesions Grading is based on morphology and assessment of cell proliferation by mitotic counts and Ki-67 index (which is an RNA antigenic marker of cell proliferation). * PLWRWLF FRXQW SHU KSI DQG RU .L LQGH[ ” * PLWRWLF FRXQW SHU KSI DQG RU .L LQGH[ * PLWRWLF FRXQW ! SHU KSI DQG RU .L LQGH[ !

are asymptomatic, found incidentally on rectal examination or endoscopy. The other half present with symptoms including rectal bleeding, pain and constipation. Carcinoid syndrome is rare. Rectal NET is usually a solitary submucosal nodule with overlying intact mucosa, situated ² FP DERYH WKH GHQWDWH OLQH DUH FP DUH FP DQG DUH ! FP LQ VL]H KDYH UHJLRQDO O\PSK QRGH metastases at the time of initial presentation. Five-year survival is dependent on the stage RI GLVHDVH ZLWK DOLYH DW \HDUV IRU ORFDOLVHG GLVHDVH IDOOLQJ WR IRU WKRVH ZLWK UHJLRQDO QRGDO PHWDVWDVHV DQG IRU those with distant disease. 3URJQRVLV LV GHSHQGHQW RQ ‡ 6WDJH OHVLRQ FRQĂ€QHG WR PXFRVD VXEPXFRVD vs invasion of muscularis propria, lymph node status, distant spread of disease). ‡ 6L]H WKRVH ! FP KDYH KLJKHU UDWHV RI metastatic disease),

Perth Pathology

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General Pathologist / Managing Partner: Dr Wayne Smit 0410-488736

‡ Angiolymphatic invasion.

Histology / Cytology: Dr Michael Armstrong Dr Tony Barham Dr Tom Grieve

*HQHUDOO\ UHFWDO 1(7V OHVV WKDQ FP LQ VL]H and limited to the mucosa and submucosa do not metastasise. (*see comments below). The management aim for GI tract NETs is complete surgical removal with clear margins. 5HFWDO 1(7V FP VL]H ZLWK QR O\PSKDWLF

It is important to appreciate that NETs have malignant potential, which varies according to anatomical site. Small intestinal and colonic NETs are less indolent than those of stomach, appendix and rectum.

0417-094799 0416-577619 0409-849448

Infectious Diseases (Microbiology): Dr Laurens Manning 0400-783194 Haematology: Dr Rebecca Howman

0417-935873

Laboratory Director: Paul Schneider

0417-931850

Providing phone advice to clinicians and a comprehensive range of medical pathology investigations, including: ˆ ,MWXSPSK] 7OMR +- IXG ˆ ']XSPSK] MRGP 4ETW ERH *2%W ˆ ,EIQEXSPSK] ]IW [I HS PEF GSRXVSPPIH -26W ˆ & MSGLIQMWXV] MRGPYHMRK LSVQSRIW ERH QEVOIVW ˆ 1MGVSFMSPSK] ERH 7IVSPSK]

A brief word on rectal NETs Rectal NETs are rare, with an DQQXDO LQFLGHQFH RI ² SHU DQG DQ DYHUDJH DJH of 56 years at presentation. Half Q Tumour nests in the rectal submucosa and mucosa.

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Our concepts of neuroendocrine lesions are VWLOO HYROYLQJ +RSHIXOO\ ZLWK EHWWHU GHÀQHG FODVVLÀFDWLRQ V\VWHPV DQG PRUH XQLIRUP reporting and data collection, further inroads into our understanding of these lesions can be made. It is clear that more research will allow us to better understand the behaviour of these OHVLRQV DQG ÀQH WXQH PDQDJHPHQW

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Letters to the Editor Continued from P2

Pain sucks for injured workers Dear Editor, Mr Chris White, CEO, WorkCover WA (WA compo compares favourably, June 2013) rightly calls for factual information to support any suggestions as to how the scheme he administers could be improved. In so doing, he has sidestepped the call for reform of the system made by pain specialists Drs John Salmon and Stephanie Davies (Management of WA’s work injured needs reform, May 2013). Does WorkCover have a case to answer or are these experienced pain specialists making a big fuss about nothing? Well, let’s look at some facts. In the WorkCover WA Guides for the Evaluation of Permanent Impairment (3rd edition, 2010), we read that because there is currently no validated measurement tool for the assessment of pain, WA has followed the NSW WorkCover Guides by excluding Chapter 18 (The Assessment of Pain) of the AMA(US) Guides V. Without providing any factual evidence to bolster its position, WorkCover WA claims that pain has already been factored into the impairment ratings for demonstrable work-related conditions. If that were indeed the case, extrapolating from this administrative decision, one might reasonably expect to find that the Guides being used in WA (and NSW) rely upon the use of validated measuring tools to determine the extent of bodily impairment. But that is not the case: there are hardly any studies that would validate the assessment of

physical impairment currently being used by WorkCover. [Davies, 2008] This is doubly detrimental to the injured worker with ongoing pain and apparently little or no assessable impairment. Contrast this to the attempt to resolve the vexed question of psychiatric impairment. Here, not only does WorkCover WA use ‘impairment’ as a surrogate term for ‘disability,” but also Approved Medical Specialists (AMS) are mandated to use the Psychiatric Impairment Rating Scale (PIRS), which was constructed by an expert group of NSW psychiatrists. The PIRS comprises six subscales, each of which is said to delineate and evaluate discrete areas of functional impairment: self-care and personal hygiene; social and recreational activities; travel; social functioning (relationships); concentration; and employability. Data on the reliability and validity of the PIRS has yet to be published by NSW WorkCover, although it did fund such a study in 2003. [Davies, 2008] Could it be that the results were inconclusive (or even worse than that)? Furthermore, the final calculation of impairment rating using the PIRS is skewed towards the lower scores, thus reducing the overall amount of compensation paid. [Davies, 2008] But at least workers with psychiatric impairment/disability are afforded a mechanism of sorts for assessing their entitlements. Why are workers with chronic and disabling pain being denied the same opportunity? Given that each of the original PIRS subscales applies equally to the assessment of painrelated impairment/disability, WorkCover

Star

Joke A very old, wizened man in robes went to his GP and sat wearily at his desk. “What seems to be the problem?" asks the GP. "Well doctor, I hope that you can help me," the old man replies. "I am a man of religion, and I spend my days walking everywhere and preaching the word. My faith prevents me from wearing footwear of any kind and now my feet look like this." The man puts his feet on the desk. The GP winces, noting both feet are covered in very hard calluses. "I see," says the GP. "Is there anything else?" "Well," the man responds, "my faith will only allow me to eat curded yam, and I fear I am growing weak.." He pulls up his robe and the 4

GP winces again. The man has the body of a thyrotoxic greyhound. "I see," the GP replies once more. "Is there anything else?" "Well, the curded yam has another unwanted side effect." And with that he breathes out in the stunned GP's face. The GP winces again, and almost passes out from the foul odour. "So tell me doctor," asks the old man, "what do you think is wrong with me?" The GP collects himself and says, "I am afraid you have Mary Poppins Syndrome." "Mary Poppins Syndrome?" exclaims the old man. "What is that!" “It means," the GP replies, "you're a supercallused fragile mystic plagued by halitosis"

could easily formulate a Pain Impairment Rating Scale. This would rectify the glaring anomaly and ensure both equity and consistency in AMS assessment. As an additional benefit, it would remove the stigma of chronic pain that appears to have become part of the workers’ compensation culture in WA. This benefit would spin off into the world of third party insurance where, according to Drs Salmon and Davies, insurers currently seem to be following WorkCover’s lead and are denying injured workers early access to evidence-based assessment and pain management that, ironically, would likely improve return to work outcomes. Mr White refers to the balancing act to ensure that the requirements and interests of participants in the scheme are being met. The recommendations made by Drs Salmon and Davies should be seen in this light and not swept under the carpet, yet again. Dr John Quintner. Consultant Physician in Rheumatology and Pain Medicine Davies GR. The psychiatric impairment rating scale: is it a valid measure? Australian Psychologist 2008; 43: 205-212.

Equitable share of resources a right Dear Editor, In response to “Give a Little Bit…” (June edition), my involvement in founding a Not-for-Profit has raised myriad questions for me about “aid”, giving, donors and basic human rights. Researching this process, I was impressed by the number of fantastic Australians who have initiated development programs around the globe. They shared their advice and expertise freely. The work that we now support in India started 40 years ago. Training health workers, focusing on mothers and providing education support has resulted in massive, sustainable and intergenerational change. Working in remote Australia I see the devastating effects of intermittent funding, endless “new ideas”, short-term commitments driven by political interests and a lack of cultural and historical understanding. When short-term funding ends and eager plans evaporate, the questions focus too readily on the community rather than unrealistic planning. Sustainable change takes time and requires reliable funding and local knowledge. Australians have a generous spirit but there is still more to do. Parents and teachers can model the value of sharing, businesses can support employee donations, large corporations can share their profits and governments can ease restrictive tax deductibility policies. Continued on P6 medicalforum

medicalforum

5

Letters to the Editor Continued from P4 Donor education has a role in the effective use of money raised. While accountability is essential it must be balanced against the burden of excessive reporting requirements. Many organisations spend precious resources on expensive appeals and meeting the needs of the donor. While we all like something in return, perhaps it could be the knowledge of the positive change for those in need rather than a prize, an event, a tax deduction or an overdetailed report. Then more would reach where it is needed and our “giving� would have greater effect. Many of us live in comfortable abundance through the good fortune of our birth, our health, our education and the work of previous generations. We have more than we need and indeed more than is our fair share. As long as there is an inequitable distribution of resources and the rich live as though they have more rights than those who are poor, basic human rights will remain out of reach for many. An equitable share of both resources and opportunities is a human right rather than a favour to be bestowed. Dr Jennie Connaughton, CINI Australia

Working together, head to toe

Significant technical advances in endovascular surgery over the last five years especially in the management of ‘below knee’ tibial occlusive disease, as seen in diabetes has had significant benefits. This has led to dramatic improvements in limb salvage. Recanalisation of even occluded vessels is now feasible. Using minimally invasive devices and novel techniques such as drug-coated balloons and stents, transpedal approaches, and specialised low profile endovascular equipment has led to high success rates. Revascularisation in combination with aggressive control of infection is often required. Awareness of risk, early referral, and a multidisciplinary approach are key to saving toes, feet and limbs.

Dear Editor, RE: Embracing Life, Diabetes and All and Speak to the Feet, June edition. From a vascular surgeon’s perspective, diabetes poses an ever increasing management challenge, with multiple factors such as macro and microvascular disease, polymicrobial infection, neuropathic sensory loss and mechanical foot deformity. The increasing incidence of diabetes amongst younger patients is contributing to the burden of chronic limb ischaemia facing tertiary vascular services. Many diabetics fear losing a limb. Fortunately, in a contemporary setting this is rare, especially with aggressive management. The key is a combination of effective diabetic control, multidisciplinary tissue loss management (vascular, wound care, podiatry, microbiology), and aggressive vascular intervention when required. In many instances, the most significant hurdle is a lack of awareness of the risk. Counselling patients to meticulously care for their feet and seek regular preventative podiatric review is essential. Allied to this is the awareness amongst primary care physicians that early referral to tertiary multidisciplinary foot ulcer services or to vascular surgeons with an interest in ulcer management can significantly improve outcomes and save limbs.

Mr Stefan Ponosh, Vascular & Endovascular Surgeon

Quiet givers Dear Editor, There are two extremes in health philanthropy (‘Give a little bit‌’ June) – the high end and the quiet end. The high end acquires great wealth and gives some of it away. Many become well known. The quiet end go the extra mile and do it at a 50% discount. These givers are called GPs. Their philanthropy goes unnoticed since few of the recipients understand Medicare. E/Prof Max Kamien, City Beach

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Practice Management

Make Yourself Right at Home... This insight into the life in a busy general practice is written anonymously but speaks for the many!

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elcome to our practice. The following are some suggestions of how to make things most pleasant for our staff.

As you have already figured out, your scheduled appointment time is just a suggestion. Feel free to ignore it and do as you please. If you are not going to show up, please do not call. We like the suspense of trying to figure out what you are going to do. Sometimes we run bets on it. So as you can see, calling and informing us of your intentions would just take the fun out of our day. Verbal abuse is always appreciated. If possible, wait till the waiting room is full. Please be creative in your profanity, we all like to expand our vocabulary. Bring as many small children as possible. Three or more is preferred. If you don't have that many, borrow from your neighbours (look for the most poorly behaved). Make sure they all have juice and crayons because we love to clean. Also, we encourage them to jump on the furniture, play rough, and go through the drawers.

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Do not bring any prior records as we request. Calling other clinics gives us time to catch up with old friends. Please feel free to stay on your cell phone. Handless headsets are preferred because it really makes it challenging to figure out if you are talking to us or the person on the phone. Make sure to call back later and ask us questions about all the things we were trying to explain. Be sure to insist we follow your neighbour's recommendations – especially about anaesthesia and operations. Our schooling and training really don't teach us much, so we appreciate the guidance. Give medications as you see fit. Instruction labels are only put on because the label printer is cool. We understand that when your pain doesn't resolve it is our fault not yours. Ignore the 'employees only' signs. Just wander around as you please. If you think that you have an infection of any kind please wait a minimum of three days before being seen. Also, be sure to exhaust all treatments available over the

counter before calling for an appointment. Oh, and 10 minutes before closing on a Friday is the perfect time to call and tell us you're in trouble. Always complain about the bill. We know our prices are too high. In general, we tend to be greedy and don't care. Please be sure to let us know of all illnesses you THINK you may have because you looked it up online. Then be sure to dictate to us how you should be cared for. We look forward to caring for you. If you have any suggestions as to what we can do to make life easier for you and more difficult for us, please do not hesitate to let us know. O

RING

BELLS? We’d like to hear from you. Scan the QR code and leave a message on our website or email editor@mforum.com.au

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Editorial

Men Have Feelings Too Men don’t clog up GP waiting rooms, but tend to be over-represented at EDs on a Friday and Saturday night. Are men the worst or best patients? There isn’t a lot of excitement out there about men’s health, except for some disease-specific areas. Using stereotypes, you could be forgiven for thinking that men are defined by their libido, their mental health, their earning capacity and not much else. Where does this come from and should we be frowning?

They keep a raft of marketing people employed with the task of enticing men out of their cubby-holes to think preventive health. Blokey Pit-stop health checks and Merv Hughes enticing men to look at their tackle are the results. It’s a hard ask for marketing because men refuse to define themselves in terms of their illness.

Depending on their age, of course, the sexuality of men is a major driver for their health and social prowess. Even young newly-married men like to fantasise about playing the field, energies they divert to nurturing when offspring arrive. Older men are walking prostates and erectile dysfunction if the lay press and the Internet are anything to go by.

Males appear to be victims of their Y chromosomes. Testosterone has a way of rearing its ugly head. Wars are not fought by women (who are encouraged to rub it on to get a slice of the action). Men with testosterone to burn make up most of our sporting heroes, most of them admired for being competitive winners, not pussy team players. Although the media might be blamed for making instant celebrities out of these people, the quest for high performance is a predominant male trait.

A subversive theory is that for our cashstrapped health system, men are the perfect patient group. Believing they are bullet proof, they present late with health problems and have a low-key fix-it approach to putting things right. Then it’s back to work!

The high performance male is evident in the young male doctor or patient, where both are better equipped for more demanding of good outcomes. Meanwhile, community violence increases and presents

itself to EDs and elsewhere as road and biffo trauma. The big picture is that national health is favourably influenced by male role models. This doesn’t mean we should all get excited when Arnold Schwarzenegger visits Perth! People like Bill Gates (brain power and persistence) and Nelson Mandela (no compromise on principles) are important too. The myths of heroes on white horses and Aussie mates looking out for the underdog must not be replaced by recent memories of flawed men, whether wayward priests or corrupt stockbrokers.Men are what they do. How we commend successful males is very important to men’s health. O Any thoughts on men’s health? Scan the QR Code to be directed to the website or email editor@mforum.acom.au.

smithcoffey

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Spotlight

Making Mental Health a Priority As an economist and carer, Prof Allan Fels is well placed to bring a balanced view to his role as chairman of the National Mental Health Commission. on reflection, given the statistics on life expectancy we have no choice but to address these issues. That should form part of every consultation with a GP.”

As a carer to his daughter Isabella, the Chairman of the National Mental Health Commission (NMHC), Prof Allan Fels is well aware of the practical ramifications of policy decisions made within tight budgetary constraints. Given the finite nature of the health dollar, he stresses the importance of medical practitioners taking a broad approach to the mentally ill. “I went to school in Perth [now John XXIII] and it was a classic Jesuit education. There was a strong sense of the need for public service and most of my life I’ve worked in sectors with a focus on areas of community interest. My background in economics is rather unusual because mental health is usually the province of psychologists or psychiatrists. I think the Commission will overcome the culture shock and they’re beginning to understand my strange terminology.” One of the principal aims of the NMHC is to ensure that mental illness receives the same priority and focus as any other part of the health system. Currently, 6% of the national health budget is allocated to mental health. Patrick McGorry, Professor of Youth Mental Health at Melbourne University, has stated emphatically that the sector is being underfunded by 50%. “I agree that mental health doesn’t receive the priority it should from either government or the community. There is an acute shortage of resources and that’s not going to change in a hurry. Admittedly, there are some ways the money could be better spent.” “It’s extremely important that we’re as open as possible about mental health issues. That’s why I went on the ABC program, Australian Story so that my daughter’s journey with schizophrenia could be told publicly. It’s only by continuing to talk about mental illness that we gain a better understanding and then stigma and discrimination will be broken down.” “There has been some improvement in this area but there’s still a considerable distance to go.” The link between mental illness and homelessness is undeniably strong and Allan reinforces the importance of housing support and the need for the agencies involved to work cohesively. “Unless there is increased stability in housing the statistics on mental illness will

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In relation to Men’s Health, the numbers don’t bear close scrutiny when it comes to the mentally ill. And, if you’re looking at young men as a subset, they’re even worse. “There’s no doubt that many men are reluctant to seek medical help, particularly in relation to mental health. The statistics aren’t impressive. Between the ages of 12-25, there’s about $3.27b in lost productivity every year.”

Q Allan Fels

There are a large number of mentally ill patients who like to smoke and I’ve been extremely tolerant of that because it’s a form of relief for them. But, on reflection, given the statistics on life expectancy we have no choice but to address these issues.. only improve slowly, particularly for young people. And this must be addressed from a whole of life perspective that embraces not just accommodation but also medical issues, counselling and employment. This area is even more notorious than other parts of the health sector in that it’s divided into countless autonomous groups that aren’t always efficient in their interaction with one another.” “Fragmentation is a problem, particularly when working with government agencies that usually prefer to work in a more concentrated way.” Allan underscores the point that GPs are a crucial point of first contact and it’s vital that they address both the physical and the mental needs of patients. “It’s important that GPs take a broad interest in the physical health of these patients. I’ve had to rethink this aspect myself. There are a large number of mentally ill patients who like to smoke and I’ve been extremely tolerant of that because it’s a form of relief for them. But,

“One aspect that’s relevant for medical practitioners is what’s called the ‘overshadowing effect’. There’s some evidence that when an individual with a mental illness sees a doctor and talks about side issues, physical problems included, that those areas are clouded by the banner of mental illness.” There is a strong correlation between Aboriginal people and higher comparative rates of mental illness, particularly in WA, this is reflected in a disproportionate number of indigenous people incarcerated in our prison system. “Prof Pat Dudgeon from the School of Indigenous Studies at UWA is a commissioner on the NMHC and she brings a strong background to our discussions. On all measures the mental health outcomes for Aboriginal people are worse compared with the remainder of the population. This area needs high priority and that’s why we devoted a special section to Indigenous issues in our first report.” The WA Minister for Mental Health, Helen Morton, recently reiterated the importance of allowing family members and carers to be fully involved in the treatment and recovery journey. Prof Fels couldn’t agree more. And, as far as the Commission is concerned, there are two carers, including Allan, on the NMHC. “Family members have a huge contribution to make. They’re the ones with the best knowledge of that person and a lifelong commitment to their welfare. We must make sure that privacy laws don’t obstruct this too much and we also have to train health workers to become more adept at working with families.” O

By Mr Peter McClelland

11

Have You Heard? medicine practitioners, optometrists, podiatrists and nurse practitioner clinics. With Dr Marcus Tan as CEO, and the injection of funds from Seven West Media and Telstra, it appears Health Engine has moved from primarily listing medical practitioners.

Big Guns gun for polio Where to now, Superclinics? We were told that putting GP clinics alongside EDs was going to save millions (by cost shifting to the Commonwealth?) and relieve overburdened EDs. Not really, according to a study published in the MJA last month that looked at 2009-11 ED attendances at Freo Hospital, Charlies and RPH. Researchers say the AIHW figures were flawed as they considered urgency status (ED triage scale) instead of complexity, as judged by them. As a consequence, estimated GP-type attendances dropped from 25% to 11%. They concluded that After-hours GP clinics, superclinics and polyclinics fill service gaps but have minimal effects on ED attendances. The AIHW has since announced that it is reviewing its research methodologies, including consultation with some of the researchers who contributed to the MJA article.

Test may reduce overdose Risk profiling through genetic testing is highlighted by a press release Medical

Forum received for DNAdose testing out of Melbourne under clinical geneticist A/Prof Les Sheffield. He suggested the test could reduce drug overdose deaths in Victoria, which outnumber road accident deaths. GenesFX markets the test for genetic markers for ultrarapid metabolisers of codeine derivatives (<10% of the population), or of antidepressants (enzyme CYP2D6), or slow metabolisers of tranquillisers (20% of the population) who are prone to overdose. It costs $270 each test and Healthscope Advanced Pathology is involved.

All in together Web marketing of practices is hotting up with a report that IPN is unhappy with Primary Health Care’s marketing of its 1800 Bulk Bill website, which lists this group’s bulk billing practices, based on a location search. And if you type “Primary Care Practices in Perth CBD” into Health Engine you now get a collection of physiotherapists, GPs afterhours, chiropractors, Chinese

The Australian Government responded to lobbying from Global Poverty Project’s Australian Director, Samah Hadid and pitched in $80m for worldwide polio eradication. Microsoft billionaire and philanthropist Bill Gates was close by. The Polio Eradication and Endgame Strategic Plan 2013-2018 also had Canadian and UK Governments contributing, and The Bill Gates Foundation was chipping in a US$1.8 billion, with US$5.5 billion calculated to end this disease worldwide by vaccinating in hard-to-reach areas. Akram Azimi, the 2013 Young Australian of the Year [who appeared in Medical Forum in June], is an ambassador for the campaign run by 25-year-old West Australian Michael Sheldrick, who holds a UWA arts and law degree and has food, education and other vaccines as part of the package.

Snapshot of rural GPs November 2012 census figures have yielded some interesting trend data from the Rural Health West report Minimum Data Set Report and Workforce Analysis Update 2012. It looks at the GP workforce in RA 2 to RA

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risk of gestational diabetes is increasing. This risk is better predicted using a series of cardiometabolic risk factors in pregnancy, including body mass index (BMI), blood pressure, lipids, glucose, insulin and highdensity lipoprotein (HDL) – better than blood sugars or BMI. They’ve derived a formula to help clinicians identify women who should be targeted for post-pregnancy intervention. 5 in WA. An additional 39 FIFO doctors (equal GP/registrar split) made up the largest workforce increase. Average age of the overall GPs was 48.4 years, with doctors aged 55-64 making up 23% of the workforce (64% male). Only 8.5% of the doctors lived in RA 5 (Very Remote) locations. There was a 14% turnover of the workforce in a year, with most moving to Perth (39.5%), interstate (14%) and overseas (9.3%). There were nine additional doctors in the 65+ age group in 2012. Amongst 202 proceduralists, a third was overseas trained. The number of IMGs working in the bush is the lowest since 2007 but they still accounted for 51.8% of the rural and remote medical workforce in WA. There were a record 86 GP registrars in the rural workforce – 19 more than 2011 and they are getting older. Their average age had increased from 32 years in 2002 to 36.5 years in 2012.

Gestational diabetes risk UWA researchers say that while obesity in the obstetric population is increasing, the

Eye test for Alzheimer’s trialled Prof Ralph Martins [McCusker Alzheimer’s Research Foundation] and Prof Yogi Kanagasingam [CSIRO] are leading a local team trialling an eye test with 1000 volunteers which may become a screening tool for Alzheimer’s disease. The goal of the trial is to see if the NeuroVision eye test can detect amyloid proteins earlier. If the eye tests correlate with what is occurring in the brains, then a screening tool for Alzheimer’s will be developed.

Driving kids to drink A line of kids clothing for four-year-olds sporting the logos for the Jim Beam Racing Kids Team, liquor ads outside schools and sporting commentators slipping in booze promos are among the “Top 10 alcohol advertising shockers of 2012-13” according to the first annual report of the Alcohol Advertising Review Board led by Prof Fiona Stanley and Prof Mike Daube. Both said that the findings showed that self-regulation of alcohol advertising was

failing, irresponsible alcohol promotions were common, young people were heavily exposed to alcohol advertising, and there is an urgent need for regulation on alcohol promotion.

New disclosure guidelines Australian Commission on Safety and Quality in Health Care has put its new Open Disclosure Framework up on its website with the major changes being a move away from open disclosure as an exercise in risk management to one of ethical practice, patient rights, professional obligation and quality improvement. There is a greater emphasis of involving patient, family and carer in open disclosure and more support for staff involved in adverse events. Read the full framework at www.safetyandquality.gov.au/search/ open+disclosure+framework. O

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Rural Training

Young Doctors’ Outback Adventures

Q Sponsored doctors in Karajini National Park and at Mt Whaleback, right.

S

ix young doctors got up close and personal with the concepts of rural and remote at a special tour sponsored by Kimberley Pilbara Medicare Local, WAGPET and Pilbara Regional Advisory Committee (RAC). The six sponsored registrars, Dr Shannon King (PGPPP, from Shelly), Dr Chung Jian Tan (a Hopsital PGY 4 from Perth), Dr Leonard Timoney (a hospital PGY 2, from Swanbourne), Dr Jenny Donnelly (GP Registrar, from Beaconsfield), Dr Andrea

Van Rijn, (GP Registrar, from Albany) and Dr Kate Rieben (a hospital PGY 2, from Fremantle), were on the Pilbara Rural and Remote Weekend. There they discovered the realities of the resources industry at BHP Billiton’s Mt Whaleback and some of the issues faced by medical staff at the Puntukurnu Aboriginal Medical Service and Parnapajinya community clinic. And all this was topped off by participation in Rural Health West’s annual Rural and Remote Retrieval

Conference at the Karijini Eco Retreat. “The weekend aims to showcase the Pilbara to registrars and medical students with a view to attracting talent to the region. It also provides them with the opportunity to meet local health professionals working in the region,” CEO of KPML Chris Picket said. O

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E-Poll

Gender Benders?

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ast edition, when 142 GPs responded to our E-poll we asked their gender to see if our questions yielded gender differences in responses (see www.medicalhub.com.au/wa-news/doctor-polls). For the record, 57 female GPs responded, as did 82 males, while three did not disclose gender. We can now report significant gender differences on only two questions. Here they are, along with our attempt to explain the differences! O

Q

Do you agree with the RACGP idea that patients with specified health problems in need of chronic care are registered with a particular general practice to receive that care? #PUI

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15

Feature

A Man With ‘Long-Way’ Vision When a near-blind indigenous man told Dr Angus Turner that he could see a long way, it gave the young ophthalmologist profound insight into his own life and practice. It’s perfectly understandable how an enthusiastic dissection of an ox eye in a Year 10 science class might capture the imagination of a 15-year-old school boy and inspire a life in ophthalmology. A dramatic squirt here, a gross splurt there sum up a perfect day at school. But what a young Angus Turner did next was a little more unusual. The year was 1992, a time when teenagers’ imaginations were fired by the relatively new phenomenon of the World Wide Web. The curious incidence of the ox eye at the Guildford Grammar School science lab quickly moved to the computer lab and in just a click of a mouse, Angus was sending an email to the professor of ophthalmology at Oxford University.

the outdoors, right from school. I’ve always jumped on any possibility for a bush trip.” “People in the bush are pragmatic and friendly and they seem to be able to see the bigger picture. And ophthalmology is very rewarding. There are a number of treatments and options that really make a big difference quickly.” But with the bush work, comes the challenge – and reward – of working

“To be honest, I was searching the Oxford website because I loved rowing and was on the page for the famous Oxford-Cambridge boat race. I just followed the links to ophthalmology. The professor had just set up his webpage and the first email to trickle through was from a 15-year-old boy with an interest in eyes in Perth, Australia, asking him if he had any work!” “He wrote back and said it was a lovely idea but I probably should go to medical school first. As it turned out, I did both. After completing my internship at ‘Charlies’ in 2001 I was incredibly fortunate to be awarded a Rhodes Scholarship, so I knocked on the professor’s door 10 years later. It was such a privilege to work with this amazing community of scholars.” Every turn of his career has been an adventure for ophthalmologist Dr Angus Turner. After five years in Melbourne, where he completed his training, he returned to WA to the Lions Eye Institute in 2011 and has spent the best part of the past three years running clinics in the bush. Several days after Medical Forum spoke to him, he was set to depart on a seven-week road trip starting at Kalgoorlie, through the Goldfields, Pilbara and Kimberley winding up in Kununurra visiting communities and towns along the way with a team that included registrars, optometrists, orthoptists, nurses and liaison workers. He can hardly contain his excitement. “Normally I fly in and fly out on bush trips. It’s going to be a nice change to go more slowly and appreciate the vast land and people and communities rather than just barging in for a few hours. I’ve always loved 16

Q Dr Angus Turner hits the dirt roads on a series of bush clinics.

culturally. The first step on his cultural awareness journey was as a second year medical student wandering around the Goldfields with indigenous pastor Geoffrey Stokes, who took Angus on a 10-day bush adventure. It was Geoffrey who posed to Angus one of his biggest professional conundrums. “He told me not to look an Aboriginal person in the eye; to just be comfortable sitting side by side and staring off in the distance. But that is the direct opposite of what I have to do, and if there are hundreds of patients, I’ve got five minutes. Telehealth has the same problem. I have to ask ‘can I shine this light into your eye’. It can be a real problem.”

“I have had patients who – and I love this expression – ‘I can see a looong way’ and they wave their hands out into the distance. ‘And I can see the stars’. And when I check my objective measure on the chart they can’t see a thing and may be legally blind. But that patient is expressing their longp way vision and I have to respect that and try not to put my expectations on that person or that community, because it’s not really going to work.” “It is a great privilege to work in these communities but I have to keep the broader picture in mind that people have family, cultural issues and other health conditions that may be more devastating. Their sight is just one part of the picture.” “So it can be tricky to turn up as a visitor into a community with our own idea of patient flow and our own way of doing things and expect everyone to come running. If there is no trust or community acceptance, that visit will be a flop. Engaging with the local community, the Aboriginal health workers, the drivers who collect patients from all over, the clinic staff – everyone in the team is so important.” “I’m a great advocate for the work of optometrists who have a whole network of visits into smaller communities that specialists don’t do. They are a key in identifying cases that we can do something about, and they also support the service by explaining what is happening and following up.” Team work, when it comes down to it, is what Angus Turner relishes ever since he was a school boy. Rowing in the winning eight in the 1993 Head of the

“In some communities and for some people, their vision is a lower priority than it is for me. Some patients may not want to come to clinic because there are more complex and important things going on in their lives.” medicalforum

Q Dr Angus Turner demonstrating an iphone adapter to Dr John Stace in Derby.

River gave him an appreciation of the power of individuals working together but organisation is the key. He’s brought that aesthetic to his medical practice. “One of the challenges of field work is organisation and I love that aspect too. There are up to 50 people involved in this seven-week trip, more if you count each hospital stop. One of the hardest things is to communicate well to everyone in the team to ensure that no one is left out of the loop, while at the same time concentrating on a very small eye ball in front of you.” “That’s where the importance of team work really comes in. It’s about building a team spirit so that the service can be sustainable. I am so grateful to have people around – here at the Lions Eye Institute and in the remote clinics. Everyone just rolls up their sleeves and get on with it and though the days are busy there is a wonderful feeling of getting some great work done.” Angus says that he is just a part of a continuum of work in indigenous eye

So it can be tricky to turn up as a visitor into a community with our own idea of patient flow and our own way of doing things and expect everyone to come running. If there is no trust or community acceptance, that visit will be a flop. health that was started by the greats of ophthalmology, people such as Father Frank Flynn, Prof Ida Mann, who undertook the first survey of trachoma in the 1950s and ‘60s, Professors Fred Hollows, Hugh Taylor and WA ophthalmologists Drs Phil House and Peter Graham. “They have all been an inspiration to me. Phil House, who has been going to the Pilbara for 21 years, took me under his wing when I was a fourth year med student and has helped me throughout my career.” Like his heroes, Angus also looks beyond Australia’s borders to lend a hand. “I grew up in rural South Africa into a family of five generations of country doctors. It must be something genetic! We left for WA when I was nine but I’ve been working in South Africa recently for three months and I’ll be returning for a couple of months at the end of the year because there’s something really great working in developing countries.” “We have first world standards of eye care which we’re trying to make accessible for

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remote communities in Australia. That is one challenge. But continents like Asia and Africa have to deal with much greater need at different levels of equipment and expertise. That challenge is something that keeps us down to earth.” For Angus, the challenges of the future lie in building on the work of ophthalmologists before him. He wants to make more city doctors aware of the bush services, hence a new website – outbackvision.com.au – has been launched. And telehealth is opening exciting horizons. “I really enjoy the potential of telehealth because our diagnosis is based on images and the capacity for imaging the eye is extraordinary with the technology in our pockets. The potential of images with diagnostic ability being sent from anywhere is huge.” “But there are barriers. I’d like optometrists included in telehealth and considered part of the eye team and I’m lobbying for that at the government level. GPs in the country are just so busy with such short time available to obtain good images of the eye. Other challenges relate to indigenous people not feeling comfortable in a video conference setting.” On a personal level, the 36-year-old says there’s a whole life adventure yet to unravel with travel and work in far flung places on the horizon. “And I’m excited about that.” O

By Ms Jan Hallam

17

Feature

Taking the Gloves Off Combat sport elicits a lot of passion for and against. Medical Forum looks at at the pros and cons. From pulling on the boxing gloves in Northern Ireland, to playing professional nal rugby in Sweden and windsurfing in WA o Dr Paddy Golden is one ED medico who doesn’t like to stand still. Paddy’s had a long involvement with sports medicine and he thinks that combat sport (CS) is getting some bad press that it doesn’t deserve. Perception, argues Paddy, is a long way from reality. “Some people have jokingly suggested that an ED on a Saturday night is a bit like combat sport. It’s not, because CS is so well controlled. Everyone knows the requirements, from the competitors to the referee and the physician in attendance. It’s an absolutely honest and transparent activity.” The sport has rigorous safety-based requirements, some of which commence well before the event. There is a precontest medical examination, a check of biannual infectious disease serology and annual certificate of fitness, medical attendance and treatment (if required) at the event and a post-contest medical examination. In some sports there is also random drug testing. “We have international and interstate competitors coming to WA and we check their accreditation and serology from HIV to Hepatitis B and C. If there’s a doubt about any aspect of their fitness they aren’t allowed to compete. In fact, I wouldn’t have let the Danny Green/Paul Briggs contest go ahead and I said so in evidence to the Combat Sports Commission (CSC). Briggs wasn’t fit to fight – he was weakened from recent weight loss, his eyesight was compromised and his balance wasn’t good.” “I’ve stopped guys from fighting because they’ve failed medicals at the weigh-in. It’s disappointing for them and their opponent.” Paddy has a long history of involvement in sport, including pulling on the boxing gloves as a youngster. He grew up in the West Indies, did his medical training in Scotland and both his parents are doctors. “I did some competitive boxing in Northern Ireland but rugby took over from that with a stint playing professionally in Sweden. I came to Perth in 1998 and that was very much a climatic decision. I’m not that keen on the cold.” 18

Q ED physician Dr Paddy Golden says combat sport gets bad press it doesn’t deserve

“Sports Medicine Australia contacted me and I did medical supervision at triathlons and the City to Surf. I still work with the Associates Rugby Club and I have a real passion for combat sports. I get paid a nominal fee but I’d do it for nothing.” “I’m the principal adviser to the CSC but, notwithstanding that, I think that for any member of the medical profession the priority is the health and safety of the individual. It’s not ethical to isolate one group and say, ‘I’m not going to support you because I don’t agree with the choices you’ve made.’ Where do you stop? Do we refuse to see people in EDs because they smoke?” “The AMA is quite happy for members to treat smokers, drug addicts and alcoholics, but it’s a different story for anyone involved in combat sports. It has withdrawn its support from the CSC and that’s definitely

had a negative impact. Boxing WA is finding it harder to get doctors. It’s legally required for a doctor to be in attendance and there have been occasions when it’s been impossible to find one.” “Perception doesn’t match reality. In amateur boxing they use head-guards, larger gloves and it’s highly regulated.” “I’d like people to gain a better understanding of these sports. Decisions are being made on the basis of a distorted perception and, in many cases, it’s a distinctly limited view. I’ve heard people say that ‘the sport’s barbaric’ and they don’t want to be seen to support it, but there’s a certain hysteria to all this. Good medicine is evidence-based but the people who are against CS only look at the risks and don’t see the benefits.” Paddy believes there are many positives of participating in these sports, both for the medicalforum

individual and in a broader philosophical sense. [The CSC is the controlling body for boxing, Muay Thai, Mixed Martial Arts (MMA), Kickboxing and Shooto contests.] “You only need to talk with the trainers to know that some of the guys they’ve been working with need guidance and control in their lives and it’s important for them to see there are consequences for their actions. There’s a great deal of mutual respect in the ring. It’s an activity that instils some fine personal qualities and a good philosophy for life.” Paddy is concerned that some people are making decisions based on limited perceptions. When he speaks with other doctors regarding CS, it elicits a range of reactions. “The doctors who’ve seen it for themselves are uniformly positive and most of the ones who haven’t don’t express much of an opinion. There’s no doubt that there are people who regard the sport as pretty unpleasant and don’t want to be seen supporting it. In some cases, when you mention CS, there’s this lingering perception of two men entering an arena and only one man leaves.” This is particularly so whenever the term, ‘cage fighting’ is bandied about. This has no relevance whatsoever to CS, argues Paddy, however it may well have influenced a recent legislative decision affecting MMA events. The sport, as a whole, is administered under the Combat Sports Act 1987 and from March 1, a ban on ‘fenced enclosures’ in MMA events has come into effect. “This is yet another distorted perception of CS. MMA is a three-dimensional sport and the ‘fenced enclosure’ is nothing like a ‘cage’. It’s the medical aspect I’m concerned about, specifically the competitors and the people sitting at ringside when ejections

Injury is just a punch away Dr David Holthouse is a Wembley neurosurgeon who’s concerned about the cumulative effects of combat sports but is also aware of the value of sensible legislative controls. “I’m not completely against these sports but the research is pretty clear on the potential risk of long-term problems. Technically, there are no safe parameters when you’re stepping into a ring and facing the medicalforum

occur. The square, roped area used for boxing isn’t suitable for just that reason. It’s interesting to note that the CSC actually supports the use of fenced enclosures for MMA, but they have no choice but to abide by this decision.” “I wrote to the WA Minister of Sport and Recreation, Terry Waldron, [see the Minister’s response to Medical Forum] and expressed my concerns and, in particular, the fact that the more dangerous ejections occur rapidly with no opportunity to reposition competitors in the centre of the ring. I’ve had support from the Association of Ringside Physicians in the USA, with Dr Joe Estwanik citing past incidences of serious injury due to ejection through roped enclosures.” Paddy hopes the medical fraternity look beyond the common perceptions of CS and make an informed, evidence-based judgement.

It’s important to focus on the reality of CS. There are boundaries that need to be drawn, but to withdraw medical support from something that fosters a healthy lifestyle is a blinkered approach.

“It’s important to focus on the reality of CS. There are boundaries that need to be drawn, but to withdraw medical support from something that fosters a healthy lifestyle is a blinkered approach. I’d argue that until you understand something fully you shouldn’t pass judgement on it. Come along and see for yourself.” t $POUJOVFE PO 1 possibility of being knocked unconscious. Any fight can go badly and an individual is only ever one punch away from a brain injury.” “There isn’t a neurosurgeon anywhere who’d dispute that.” “I’d like to see some controls in place where, after any sort of head trauma, there’s a period of compulsory suspension and perhaps there should be a baseline MRI so that a competitor can be monitored over a period of time.” “I would never openly support combat sport but it’s legal and, if it were banned, people would find avenues to keep doing it. Repeated head trauma is not a good thing and some individuals will definitely end up with long-term problems. If I were asked to tick a box that resulted in these sports not continuing then I probably would.”

Minister Defends Enclosure Ban The WA Minister for Sport and Recreation, Terry Waldron, acknowledges both the value and diversity of Combat Sports (CS) and is a strong supporter of continuing medical supervision. However, he has given the ‘thumbs down’ to the use of a fenced enclosure. “Combat Sport is a legitimate industry and a popular pastime that promotes health and fitness, as well as being an entertainment spectacle. Quite aside from the health and social dividends that participation in sport delivers, combat sports in general have an enhanced focus on individual qualities such as discipline and respect.” “I sought advice from the Department of Sport and Recreation, the Combat Sports Commission (CSC) and the industry itself before making a decision to ban the fenced enclosure for MMA. The CSC will continue to monitor MMA contests to ensure the safety of all participants, officials and spectators.” The Minister agrees that an integral part of the effective monitoring of this sector involves the full participation of the medical fraternity. “The medical supervision of combat sports events is very important and the CSC takes this matter seriously. Following amendments to the Combat Sports Act 1987, which came into force on March 1, 2013, the medical supervision of both amateur and professional contests is now legislated and required by law.” “I’m disappointed that the AMA has withdrawn its association with the CSC and the broader combat sports industry. While I respect the views of some within the AMA I don’t understand their reasoning in withdrawing a direct association, and therefore influence, within the industry.” “However, we’ve made the necessary amendments to the Act whereby the Minister can now appoint a medical practitioner to the CSC. There’s a database of doctors who are available to attend combat sports events and promoters use this list to provide medical supervision at contests.” ED: AMA WA withdrew from the its position on the Professional Combat Sports Commission in 2011. The then president Dr David Mountain said at the time it was inappropriate for the association to remain part of the commission because AMA WA opposed the sport of boxing as research showed there was a number of damaging health effects associated with it. O

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Old Dog, New Tricks

Q Dr Graeme Fitzclarence at work. Below: with sons and wife, Dr Cherelle Fitzclarence.

It may have been the long way round to medicine, but for GP registrar Dr Graeme Fitzclarence, the journey has made him a better doctor. Dr Graeme Fitzclarence has come a long way since his boyhood days on a farm near Bencubbin in the WA Wheatbelt. How’s this for a quirky CV? Panel beater, spray painter, mustering pilot and stockman in the Pilbara, paramedic in the Northern Territory and throw in a heart transplant along the way. And all this before he became a medical student. Graeme was nearly 40 when he began his studies at UWA’s medical school. Eight years later he’s in South Australia as part of his rural GP training and he recently applied to WAGPET for an anaesthetist traineeship. His early years as a mature-age student brought some interesting insights into the world of medicine along with a few light-hearted moments. “I was the oldest male but not the oldest student. There were two women who were even older than me! I always felt respected by my fellow students but that wasn’t always the case with some of my professional colleagues. There were a few registrars in the hospitals who caused a few problems and that led to some difficulties on occasions. I’ve certainly been in situations where I’ve been older than the consultants.” “For some of my younger female colleagues I was something of a father figure. There was an amusing evening in Kalgoorlie when a few of the local guys were becoming overly-attentive with a couple of the young female graduates. Both of them asked me if I’d mind pretending to be engaged to them. One would’ve been okay, but two was stretching it a bit.” Being a mature-age student is not uncommon these days but Graeme’s premedicine background is unconventional to say the least. medicalforum

“I was heading towards being a farmer and then my parents decided to sell the farm. So I enrolled in a pre-trade Year 12 automotive engineering course and then transferred to Newcastle, NSW, where I continued my trade training and also did my private pilot’s licence. I ended up working on cattle stations in the Pilbara combining aerial stock mustering and jackerooing. And then a friend of mine who was flying a helicopter fell out of the sky right beside me and was killed. I lost my nerve.” “So we went back to the east coast, I built up a panel-beating and spray-painting business and supported my wife, Cherelle through medical school in Newcastle. [Dr Cherelle Fitzclarence is Deputy Director Prison Health Services, WA. See Medical Forum March 2013].” Once again, life had another twist in store. “I had my own smash repair and sandblasting company but I was working too hard and breathing in a lot of nasty isocyanates. At the age of 26 cardiomyopathy brought my life as a tradesman to a screaming halt. A cardiologist said to me, ‘you’d better go home and get your affairs in order because you’ll be dead in 12 months.’ We sold up everything we had, travelled around Australia and when we got back I still hadn’t died. In fact, I felt a lot better.” “Cherelle applied for a job in the NT and, in a round-about way that’s what led to medicine. After I had my heart transplant in 2000, I couldn’t go back to breathing in toxic fumes so I did a nursing degree at the NT University and did a lot of paramedical work offshore and on mine-sites.” “And then I thought, why not medicine? I did the interviews, the AMSAT and walked into UWA at the ripe old age of 39.”

Bringing both maturity and life-experience to the world of medicine is a good thing, says Graeme. “My background and, in particular, my illness has shaped me both as a person and as a doctor. It’s provided me with empathy and wisdom that I wouldn’t otherwise have had. I can vividly remember gathering our children around before my heart transplant to tell them I was going into hospital and the outcome was a little uncertain.” “I’ve just finished speaking with a patient who’s staring down the barrel of a kidney transplant. She was in real turmoil and I was able to draw upon my own experience to make it easier for her.” “I also think that coming to medicine as an older person can give you an enhanced understanding of the profession. When Cherelle was training we had three young children and, at the time, I had no idea how hard it must’ve been. Medicine does take a toll on families, there’s no doubt about that. I reckon one of the most important skills a doctor can develop is the art of selfpreservation.” And the future for Graeme Fitzclarence? “There was a 20 year warranty on the heart transplant, and that was 13 years ago. At the time it seemed a lot but right now it doesn’t seem like anywhere near enough and I’m very aware of that. But, with new drugs and improved monitoring, a lot of transplants are pushing well past the 20 year mark.” O

By Mr Peter McClelland 21

Men’s Health

Talk About a Revolution For people like Dean Dyer and Rob Reekie the time has come for the community to take the issues of men’s health seriously for all our sakes. A men’s revolution may seem an odd concept in a world where many would say was run by men. However, Dean Dyer from the Men’s Advisory Network says that the state of men’s health and wellbeing is serious and calls for some creative thinking to save lives. “Here’s a snapshop: 48% of men have a mental health issue; 17% of men don’t use their Medicare Card; 90% of violent acts are perpetrated by men and 70% of the victims are men; 80% of the homeless are men; 90% of the prison population is men – then there’s road trauma, suicide and relationship failure. Just being male is a risk factor,” he said. “Men are raised in a culture where they are constantly being told to ‘man up’, ‘stand strong’, ‘suppress emotions’, ‘don’t cry’, ‘be wary of other men not on your team’ and it’s leading to ill health and for some early death.” “At M.A.N. we are working to straddle those statistics by helping men and boys and also lobbying for a change of male culture; to stop men seeking solace in booze and drugs or knocking themselves off.” Dean is talking with politicians about the establishment of a Minister for Men’s Interests and on May 22, MLC Nick Goiran made an impassioned speech in the Legislative Council for the proposal to be considered seriously.

Q M.A.N.'s Dean Dyer

“The pattern that is emerging is one of an absence of real men. By “real men”, what I mean is men who are a source of safety and protection; I mean men who have integrity and who are willing to accept responsibility. I mean men who are going to step up and engage with their children, teach their sons boundaries of respect, and affirm their daughters. It is for this reason that I am convinced that we should introduce a minister for men’s interests into the governance model of Western Australia,” he said. 22

Q Rob Reekie and Mates volunteers at a stall in Busselton.

It is the credo to which Rob Reekie has devoted the past 10 years of his life. Rob was founder of the men’s support group Mates in Busselton. It is a much applauded and rewarded group that offers men in the district 24-hour crisis care and counselling and began from a well of deep understanding of the problems men faced.

and counselling services so that cycle of violence can be broken.”

Rob, by his own admission, was an angry man and it deeply affected his relationship with his partner and family. He enrolled in an anger management program in Brisbane before heading to Busselton to reconcile with his wife, so he knew that he had to take these lessons on board. While it didn’t work out for him and his wife, it did start a new life for Rob who has offered a lifeline to thousands of men since October 2003.

Rob said that about 90% of inquiries came from women.

“I started Mates firstly so I could keep reinforcing what I was learning and secondly because there was nothing here in the town for other men. So I trained and became a counsellor and with a team of volunteers we now offer emergency counselling and crisis care 24 hours a day, seven days a week.” “Mates has set up an emergency house, so men have somewhere to go when they call time out. They can have a chat and a bed, which is healthier than them heading to the pub. Police from the five towns around us have access to the house, which has been a big move. If they attend a ‘domestic’, the male can be removed to a safe environment. He discovers immediately the consequences of his actions and it gives us at Mates a chance to build a rapport.” “Mates also has an office in the court where we help advise about restraining orders as well as information about our anger management

“We also have good relationships with doctors in the community. Mates saw more than 1500 people in the anger management program and over a week, we have between 40 and 50 men coming in for programs, counselling, or just volunteering around the place.”

“They can see after 10 years that we’re not a group that cracks jokes and runs the other half down. We give out good information and they see results. We encourage the guys to go home and show the partners what they are learning to try and get back on the same page.” “The message we putting out is it’s time for men to stand up and become role models and to be very aware of what we are teaching our children. There is a movement going on and we hope we are leading it. It is about guys standing up and taking responsibility.” “It’s time we lost the Aussie larrikin. The drinking and drug culture here is ridiculous – it’s crazy what’s going on. Wrong messages are given at home. But we don’t sugar-coat ours. We say to some of the guys, ‘are you teaching your son to end up in crisis care?’ ‘Are you teaching your daughters that it’s OK for their partners to hit them’. ‘You are setting your kids up to fail’.” ED: Men’s Advisory Network, 33 Moore St, EAST PERTH. Tel: 9218 8044 www.man.org.au Mates Support Group: 39 Barlee St, Busselton, Tel: 9752 3217 O

By Ms Jan Hallam medicalforum

Continued from P18

Taking the Gloves Off Adam Metcalf runs a CS training academy and is one of the leading referees in Perth. He stresses the distinct differences across the broad rubric of CS and the specific ramifications affecting competitor safety. “One area that concerns people is the cumulative effect of repeated strikes to the head. Within the different forms of MMA there are varied levels of impact before an opponent is on the canvas and out of the contest. One of the essential differences between boxing and martial arts is that the latter uses a smaller glove and the choice to submit lies with the competitor. In boxing, and some other disciplines, the contestant’s corner decides to ‘throw in the towel’ so that relies on someone else’s interpretation of the situation.” “It’s absolutely mandatory for a doctor to be in attendance because the primary concern is always the safety of the competitors. The doctor has the right to stop the contest at any time.” Adam has noticed a decline in the number of doctors who are willing to supervise CS events. He also has first-hand experience regarding the merits of a fenced enclosure.

Medical Assessment Panels: Recruitment of Doctors and Specialists From time to time, WorkCover WA requires the services of medical professionals to serve on Medical Assessment Panels. $ SDQHO PD\ EH FDOOHG ZKHQ WKHUH LV D FRQÀLFW RI medical opinion about the nature or extent of an injury or a worker’s capacity for work, and one of the parties wishes the proceedings to continue. Three medical practitioners are chosen by WorkCover WA’s Director of Conciliation from a list of medical SURIHVVLRQDOV ZKR KDYH LGHQWL¿HG WKHPVHOYHV DV ZLOOLQJ and eligible to participate in workers’ compensation Medical Assessment Panels. At least one medical SUDFWLWLRQHU ZLOO EH D VSHFLDOLVW LQ WKH UHOHYDQW ¿HOG Medical practitioners who have treated or examined the worker are not eligible to sit on the panel. WorkCover WA are currently interested in recruiting GRFWRUV VSHFL¿FDOO\ IURP WKH VSHFLDOWLHV OLVWHG EHORZ

Q Trainer Adam Metcalf

“Since the AMA withdrew their involvement from the CSC we have found it more difficult to find medical supervision. I’m luckier than most because I have several doctors who train with me at the gym. They understand the sport and they want to see it properly monitored.” “There’s a certain stigma attached to an enclosed arena and I think, for some people, there’s a misplaced association with dog and cockfighting. I’ve stopped fights because competitors were in danger of toppling onto the judges table. One of the arguments against a fenced enclosure is that it’s more difficult for a doctor to get into the arena. We did an experiment, timed the whole thing and it took 7-8 seconds longer for a person to struggle through the ropes and lend assistance.” “MMA events are highly controlled. I’d love the AMA to come and watch one of our events and see it from a doctor’s perspective. I’m sure they’d get a more positive perception of the sport when they listen to competitors talking about their training and preparation.”

ED: Combat Sports Commission WA www.dsr.wa.gov.au/combat-sports O

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By Mr Peter McClelland medicalforum

23

Men’s Health

Veterans Show the Way Men returning home from war have, from a place of great anguish and turmoil, created a model of care that is helping everyone. The Veterans and Veterans Family Counselling Service (VVCS) takes a whole-of-life approach to tackling the issues that trouble the physical and mental health of veterans and their families and it stands as a remarkable testament to a group of Vietnam veterans who said ‘enough is enough’. As they returned in 1972 to a society they felt had rejected them, Vietnam veterans gave each other support and it wasn’t long before they realised they shared more than just their wartime experiences. There were physical symptoms of a war waged in the tropics with chemicals and symptoms of mental anguish such as anxiety, hyperarousal and anger. Then the lobbying of government began, which led firstly to the classification of PTSD as a result of combat in 1980 and by 1982, with funding from the Department of Veterans Affairs, the Vietnam Veterans Counselling Service was established. Back then it was staffed with professional counsellors supporting volunteers and now, 30 years on, it has evolved into a fully professional service with 15 centres across Australia. The director of the WA service, Mr Glen Menezes, said the veteran community was still at the heart of VVCS and Vietnam veterans were still the largest users of the service across Australia. “The Redgum song Only 19 is exactly what Vietnam veterans were experiencing. The rashes that come and go, the nightmares, the flashbacks, the jumpiness with backfiring cars, helicopters, relationship issues and inability to get on with their civilian lives – all the symptons that have been categorised under the four clusters of PTSD.� “Partners were driving a lot of it – which is typical of most men’s health. They were saying ‘if you don’t get help, I’m walking out the door and taking the kids with me’. In fact a lot of them did do that and this breakdown of their psychosocial life led them to seeking some help.� “GPs are probably the first people to see these symptoms and working strategically with GPs has become a core part of our work.� The VVCS and the DVA are working with Medicare locals especially in areas where there are known clusters of veterans to support and encourage GPs to identify who is a veteran and their family members so they can be directed to a raft of health services. “This identification is the biggest issue we need to approach. We did a project in 2008 with the WA GP Network (Pathways to Care) to identify veterans and their families and the cluster of symptoms that they are likely 24

Q Director of the Veterans and Veterans Families Counselling Serviced

to present with. A veteran is not going to walk into a surgery with PTSD, or anxiety, stamped on their forehead.� “Families of veterans have their own cluster of symptoms that are different from other families. We know that children of Vietnam veterans have significant adjustment issues as a result of growing up with a veteran parent and we’re finding that similar anecdotal evidence from families who have been involved in more recent conflicts.� “But it is also broader than that. Research is showing that people living with someone with a mental health illness can also have similar symptoms. The VVCS provides services for families as well and last year saw about 1200 clients. About 40% are veterans, about 25% partners, 25% children and other family members make up the remainder.� “The VVCS is an uncapped and free service for veterans. There are 72 contracted counsellors across the state as well as at the head office in Applecross. For parts of the state that we can’t reach, we use Teleheath which is being used well and effectively. The service does not have a time limit, with

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Glen adding that some of the children of Vietnam veterans are approaching 50 and the service will continue until it is no longer needed. “We have sent more people to warzones in Timor, Afghanistan and Iraq than we did to Vietnam. However, we have learnt the lessons from Vietnam about how to work collaboratively with veterans so there is broad support across the board.� Glen said that more veterans were coming forward and he attributes the education of high ranking officials in the ADF as the breakthrough but added that with the increasing number of women in the forces, DVA services are not male services. “Support from such high ranks helps destigmatise mental health, so we’re getting people from all walks of life and ages putting their hand up saying I need help.� “In broader government terms there’s a realisation that mental health support is a force multiplier with benefits for the entire community.� y O

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By Ms Jan Hallam

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BENEATH the Drapes X Dr Daniel Heredia has replaced Dr Margaret Sturdy as Director of Medical Services at Hollywood Hospital and Dr Sturdy has taken up the position of CEO/DMS at Peel Health Campus, which is now operated by Ramsay Health Care. X Mr David Malone has been re-appointed Executive Director of Healthway for a further five years. X The University of Notre Dame will establish the Churack Chair of Chronic Pain Education and Research after a private donation of $1m from Geoff and Moira Churack. The head of the department is expected to be selected later in the year. X Western Australian Metropolitan Hospitals and Country Health Services 2014 junior doctor intake is now open. Positions for Resident Medical Officer, Registrar, Senior Registrar and Fellows are advertised on www.jobs.wa.gov.au. Applications close on Friday, July 12 at 11.45am. www.pmcwa.health.wa.gov.au/rmo/positions. cfm X Dr Nik Zeps has been appointed national research coordinator for SJOG Health Care. He will oversee the cancer biobank and the translational research program in the pathology division. X Aged Care provider St Ives Group, which was bought last year by RAC WA, has appointed RAC vice-president, Mr Tony Evans, Hawaiian Group CEO, Mr Russell Gibbs, and Southern Cross Care executive, Ms Wendy Silver, to its board. X CEO of WA-based Youth Focus, Ms Jenny Allen, has signed with NSW Black Dog Institute. Ms Allen said the move would improve the delivery of mental health care services in WA. X Rural Health West has been awarded two contracts from the Federal Government to deliver programs to boost participation by health professionals in outreach health services in rural and remote areas and for Indigenous chronic disease programs. X In Government tender news, the WA Country Health Service will be looking to redevelop the Sub-Acute Care and Day Therapy Care facilities at the South West Health Campus, And the Department of Fire and Emergency Services will be on the hunt for critical care paramedics for its rescue helicopter. X GP registrar Dr John van Bockxmeer, who featured in Medical Forum in September, has won the Young Leader Award at the 2013 HESTA Primary Health Care Awards for his work with indigenous and refugee communities. X Mr John Fogarty has been appointed as Executive Director Perth Southern Hospitals and CEO of St John of God Murdoch. Mr Fogarty is currently Chief Operating Officer at Mercy Health in Melbourne. He will join SJGHC on September 9. X Anaethetist Dr Richard Riley, Booragoon GP Dr Natalie Sumich and paediatric registrar Dr Clark Maul have been appointed to the President’s Medical Liaison Committee in Perth for MDA National.

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Guest Column

Protecting an Endangered Species Dr Will Thornton says rural GPs need serious support before they become a thing of the past.

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s a semi-urban GP who enjoys working rurally, I think I have gained an objective view of rural medicine issues – initially via locum stints and now through sessions in the Wheatbelt. Changes in models of rural care have increased patient and community expectations of general practice. As demands on shrinking general and procedural GP services increase, demands for specialist services also increase. Technology such as eHealth, TeleHealth and ETS helps with supply but it is by no means solving the service shortage. There is a growing number and complexity of patients in rural areas needing both chronic and appropriate acute primary care. As a result, these patients are being inappropriately diverted to rural ED settings. This complicates the issues of hospital and RFDS transfers, rural hospital inpatient care and delayed access to primary care. All add to the cost of health provision. The current solution involves increasing

the level of ED staffing with FACEM-led ETS access to city services, which has some benefits but it needs to integrate with the existing primary care service providers. The usual solution to the shortage of GP service is to import it – and obviously overseas trained doctors (I am one too!) play a vital role. But for a sustained long-term solution, local graduates need training in rural medicine. WAGPET, our regional training provider, is excellent but no longer are all their Registrars required to complete a rural term, and the assessment for entry reflects this. Yet country hospitals and general practice in the Wheatbelt offer amazing educational opportunities. Workforce provision is challenging; but local networks often have fiscal interests that outweigh the practical need of the community for continuity of care by a regular provider. University courses are under fiscal pressure to reduce/rationalise the rural component of their courses, often pressured by the bureaucrats but also by content-driven and assessment-pressured students. So, how to retain existing services and attract the new?

What may work: t DPOUJOVF UP GVOE SVSBM USBJOJOH JODFOUJWFT (such as the Rural Incentive Program) t GVOE ASFTQJUF GPS MPDBM SVSBM (1T t EP OPU SFMZ PO QFSDFOUBHF CJMMJOH remuneration for rural GPs. What won’t work: t SFEVDJOH UBYBCMF USBJOJOH BMMPXBODFT t EJWFSUJOH QSJNBSZ DBSF QSFTFOUBUJPOT JOUP specialist-led services. Retention is paramount and that involves looking after GPs who have served their community, 24/7, for years. Rather than ignoring burn-out, we need to look at providing some respite (a model embraced by one Wheatbelt shire, where the local GP gets a five-day weekend every six weeks), on-call cover such as ETS, assistance with ongoing education, finances and sessional cover. Why don’t Country Health Services provide performance reviews such as those encompassed in revalidation, rather than vilification and medical board referral? Without these issues being addressed, the rare rural GP will be a thing of the past. O

Interested in becoming an Ap Approved ed Medical Specialist in the workers workers’ compensation com ion system? syste Train with a world-renowned expert in Permanent Impairment and Occupational Medicine WorkCover WA is pleased to announce ce that international internat expert ert in occupational medicine, Professor Mohammed mmed Ranavaya, Ranavaya will be in Perth on 27 and 28 July to conduct training and workshops hops in the AMA AM Guides 5th Edition. This is a rare opportunity for medical professionals essionals in WA to train with a recognised authority in the use of the AMA guides. Day 1 of the program will review the concepts and methodologyy of AMA 5, including relevant case studies. The morning of Day 2 will consist of chapters 5–13 of AMA 5, along with discussions on the central and peripheral nervous system, mental health and behavioural disorders. The second part of Day 2 will entail an examination that will qualify medical SUDFWLWLRQHUV WR JDLQ DFFUHGLWDWLRQ DV D &HUWL¿HG ,QGHSHQGHQW 0HGLFDO ([DPLQHU &,0( )RU IXUWKHU LQIRUPDWLRQ DQG UHJLVWUDWLRQ IRUPV SOHDVH YLVLW WKH $PHULFDQ %RDUG RI ,QGHSHQGHQW 0HGLFDO ([DPLQHUV ZHEVLWH DW www.abime.org.

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$SSURYHG 0HGLFDO 6SHFLDOLVWV $06 $SSURYHG 0HGLFDO 6SHFLDOLVWV $06 play an important role in the Western Weste Australian workers’ compensation compensatio system ystem by conducting impairment impa assessments sessmen that determine whether injured workers are eligible to access ured wor FHUWDLQ EHQH¿WV RU SXUVXH D FRPPRQ FHUWDLQ EHQ law claim for damages. Training in the use of the American Tra Medical Association Guides to the (YDOXDWLRQ RI 3HUPDQHQW ,PSDLUPHQW ¿IWK HGLWLRQ $0$ LV WKH ¿UVW VWHS towards gaining your accreditation as an AMS. All medical practitioners are welcome to apply. WorkCover WA is particularly interested in applications from specialists practicing in areas of occupational and environmental medicine, orthopaedic surgery and plastic surgery and/or who are located in regional areas.

medicalforum

Guest Column

Sperm Donors Are Still Needed Since 2004, the low rate of sperm donation has become worrying for infertile couples and their doctors says Dr Angela Cooney.

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ne in 20 men has sperm production abnormalities and roughly half of all subfertility can be attributed to a male factor. IVF can be successful, especially using Intracytoplasmic Sperm Injection (ICSI), even where there are extremely low sperm counts or if sperm can be obtained through testicular biopsy.

But what about when there’s no sperm at all? Klinefelter's Syndrome is the most common chromosomal anomaly (an incidence of one in 500 men) and most of these will have complete azoospermia. Others may find themselves without sperm post-cancer treatment where chemotherapy or testicular removal has been necessary. And then there are situations where, not only are there no sperm, but no man either. Lesbian couples have been using informally donated sperm from friends or relatives for decades. But some same-sex female couples may not have an appropriate informal donor available. Or they may prefer the ethical and legal simplicity of a formal

donor arrangement where there is no fear of an informal donor demanding parental rights. Some single women find themselves in the difficult position of wanting a pregnancy without being in a relationship and knowing that every passing month brings them closer to childlessness. There will always be a need for sperm donors – but where are they? It wasn’t all that long ago that hundreds of male university students earned a bit of beer money by donating sperm. But the supply of donors has dried up (pun intended) to the point that there are now 18 month waitinglists for donor sperm in most of WA's reproductive technology services. The likely cause of this is the awareness of the rights of a donor-conceived child to access information regarding their genetic origin. Back in the early days of sperm banking and donation, nobody much cared about the offspring and certainly none of the spotty baby doctors ever imagined they would meet the end-result of five minutes wrestling with a jar and a porno magazine. But all that changed in 2004. A child born in WA after that date as the result of gamete

donation on reaching the age of 16 and after discussion with an accredited counsellor can gain access to identifying information about the donor. Consequently, any person wishing to donate gametes now needs to sign a consent form stating that they are prepared for a donor-conceived child to contact them in the future. The most common source of donor sperm is men who have had a child or children with reproductive technology assistance, and still have sperm in storage they no longer need. But there are legal limits to their altruism because a single donor in WA can only be used for the creation of up to five pregnancies. Increasingly, sperm is being imported from overseas though the same requirements of consent regarding identifying information must still be met. Does the general public believe that IVF can do everything now, and that there’s no more need for sperm donation? Or is this part of a more sweeping social inertia that also gives Australia one of the lowest organ donation rates in the developed world? O ED: Dr Cooney is a member of the Reproductive Technology Council.

Why I Donated My Sperm A young professional, who is married with one child, agreed to write about why he decided to become a sperm donor.

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he only person I’ve talked to about donating my sperm has been my wife and she’s very supportive. My parents are conservative and highly religious so I probably won’t discuss it with them but I’d have no problems telling my friends and siblings.

jump through all the hoops, including counselling, and then you have to wait six months before you’re allowed to donate. No wonder there’s a shortage of donors!

One of the main reasons I decided to become a sperm donor was because some friends of mine were having trouble conceiving and, more specifically, they had real difficulties finding suitable donor sperm. I saw this as a very simple way to help people who were having difficulties starting a family.”

I’m perfectly happy with the current laws allowing the release of information identifying donors. And I’m comfortable meeting any resulting children – potentially there could be five of them – and answer any questions they may have. It’s been made very clear that I’ll have no legal obligation to them and I would see them as no different from any other member of the public, apart from a genetic similarity.

What surprised me was how complicated the process is in Australia. There’s obviously a need for proper counselling and donors need to be made aware of the potential consequences, but the six month cooling-off period is a little strange. You medicalforum

And after all that, you can donate sperm and then withdraw consent and have it destroyed.

I’m fascinated by genetics. And I can really understand a person being curious about a biological parent. As to whether I will always wonder if there

is another ‘me’ out there, the fertility clinic is required to tell you how many children result from a donation. And I will ask at some point. The actual mechanics of the procedure haven’t changed much over the years. It used to be a glass jar and now it’s plastic. I imagine the magazine selection might be a little better than previous years. O www.donatedontwaste.com.au Reproductive Technology Council www.rtc.org.au 27

Guest Column

Breaking up – hard on your health Healthy relationships means healthy people and clinical psychologist Prof David Indermaur says it’s time for serious investment in this part of life.

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he question of how and why being in a relationship is associated with so many health benefits for men is now attracting serious research interest with this connection now widely accepted as a key predictor of health and longevity. Conversely, relationship distress is strongly linked to health problems both for adults and their children. The basic message is that relationship health is fundamental to physical and mental health (especially for men).

One implication of this is that it’s worthwhile investing in relationships. This often means re-investing in an existing relationship rather than breaking up in the hope of finding a better one. One of the big relationship myths is that the ideal partner is out there waiting for you. Any ‘user guide’ for relationships would warn that the falling-in-love stage is almost always followed by the power battle stage, which is the biggest test. If a couple can successfully traverse this minefield, the ‘gold’ of deeper love and harmony can be claimed. At this point both parties have a sense the relationship is their choice and in their best interests. Medical practitioners can help their patients by pointing to the evidence on the health-relationship connection. This may be a revelation for some or for others a confirmation of what they already know. Importantly (especially for men) it may

serve as the wake-up call: a reminder and an inducement to improve their current relationship or get out of a destructive one. In all cases, it is important to followup consciousness-raising with helpful information or advice, perhaps from a psychologist who can talk through the issues and link with further resources. Working towards a healthy relationship is healing and helpful in many ways. There is both a science and an art to good relating. There is also much evidence that, for those suffering a range of physical and psychological maladies, the presence of a supporting partner can be of great benefit. Including the partner in various treatment plans can greatly assist the effectiveness of treatment. Men spend thousands on their ‘toys’ but often neglect investing in their most beneficial and meaningful asset – their relationship.

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Encouraging men to see their relationship as a vehicle that can take them much farther than they imagined, might be helpful. Probably the biggest obstacle in our society is the archaic cultural belief that relationships are not to be enjoyed but endured. Such a belief robs us of the great benefits that come from good relating. In the worst cases, one partner’s self-esteem becomes so cruelled as to be invisible. Unfortunately, research many years ago established how the subjugated party in an abusive relationship is essentially trained to be helpless (‘learned helplessness’). Medical practitioners are often the only professionals in a position to be able to reach out to those suffering in this way and help them re-establish a belief in themselves and to take action to reduce the harm. The key for men is to establish a sense of responsibility and pride in the quality of their relationship. Old cultural beliefs that see men as a tragic-heroic figure, contained by females (mothers, wives) that have separate value structures, maintain the man in the position of the eternal child. By aligning healthy relationships with a healthy masculinity – one where the man feels powerful enough to take some responsibility for improving the relationship would obviously be a step in the right direction. The new generation of men are much more alive to these possibilities. These quick pointers might help a man with suspected relationship issues: t $IBMMFOHF UIF CFMJFG UIBU JG UIF relationship is not working it must be because he has chosen the wrong woman. t $IBMMFOHF UIF CFMJFG UIBU HPPE relationships happen spontaneously and if effort is required, the relationship is fatally flawed. t 6TF BQQSPQSJBUF NFUBQIPST o F H UIF relationship is like a car – it carries you both, it needs regular servicing and maintenance and it has to work for both of you. t 4VHHFTU TPNF UIJOHT GPS UIF NBO UP EP UP energise the relationship – e.g. doing things that actually ‘work for her’, whether this means gifts, acknowledgements, quality time or physical affection. t 4FFLJOH QSPGFTTJPOBM IFMQ JT OPU B TJHO PG weakness – psychologists or counsellors are non-judgmental relationship consultants. They are service providers and when carefully chosen can be a useful ally to relationship growth. O Competing interests: none declared. David is an Associate of the Hart Centre, which has a network of relationship therapists throughout Australia

medicalforum

Guest Column

Balancing Act of Dr Dad Being a good doctor and father doesn’t have to be mutually exclusive, as Prof Bruce Robinson, who set up The Fathering Project in 2002, points out.

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It is possible to make your work a ‘friend’ within a family environment. In my book, Fathering from the Fast Lane I talk about ways to make this happen. An example? Take one of your children to a conference – it’s brilliantly successful.

t was both unforgettable and very sad, and it happened one evening when I was dining at a restaurant. It was a clear reminder of just how easy it can be for men to be wonderful doctors but less than wonderful parents. I began talking with a woman across the table who, as it turned out, was the daughter of a doctor. He turned out to be someone I’d known from my medical student days. In fact, he’d been one of my earliest role models.

I remembered him as a kind and compassionate man who was loved by everyone. We all thought of him as a bit of a saint, someone who’d be a fantastic person to have as a father. Just as I finished enthusing about his fine qualities and how we always had time for others, his daughter became quite angry. She said, ‘well he never had time for us!’ She went on to tell me how he put all his energy into his medical practice, neglected the emotional needs of his own children which led them to resent his work as a doctor. I’m sure this man didn’t set out with the intention of working too hard and neglecting his children. I think he made three common mistakes that we, as ‘medical fathers’ are often prone to make. Too much work – basically, he didn’t know when or how to stop! It’s easy to slip into two seemingly contradictory traps with medicine: a feeling of powerlessness amidst all that complexity and ascribing far greater importance to it than it actually warrants.

Being a good father makes a difference! Children of ‘absent’ fathers – emotionally and geographically – are more likely to perform poorly both at school and in their personal lives. That’s one reason we established the Fathering Project at UWA – to remind fathers that they’re vitally important to their own children. They also have a role to play as ‘father figures’ to other young people and to pass on things that work well to other men. So many times I’ve heard doctors say, when they’re reflecting on their early years in medicine, ‘I’m supposed to be intelligent, so how did I ever let that happen to me?’ Too much energy – work took just about all he had! Consequently, there wasn’t much left when he got back home. He relied on his wife to meet the needs of the children, and that’s something I’ve struggled with as well. It’s absolutely vital to get home at the end of the day with a bit of ‘petrol in the tank’. Interestingly, doctors who engage with their children become more productive, more optimistic and much more likely to rise to the professional challenges inherent in medicine. Work versus Family – in the end, his work as a doctor was seen by his children as the ‘enemy’ in relation to being a good father.

www.thefatheringproject.org. O

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Gastroenterology

Some Things in the Abdomen Medical Forum looks at some of the important issues occupying the minds of a selection of WA’s gut specialists. They are all busy! Laparoscopes and Inguinal Hernias Dr Chris Couch focuses on bariatric surgery, hernia repair and gallbladder surgery. As a surgeon, he has seen many changes in hernia repair over the years, particularly inguinal hernia surgery. Patches and laparoscopic repair have been the biggest. He said patches have become lighter, materials less reactive, and tailor-made versions wrap around the spermatic cord. Laparoscopically, he only uses staples to apply patches about 5% of the time, having compared 500 cases with and without staples and has found hernia recurrence rates about the same, that is 2%. Without staples, nerve damage is virtually unknown. Laparoscopic patching, changing people’s attitudes, and the relatively frequent occurrence of contralateral inguinal hernias have all changed what’s offered. First, the laparoscopic dissecting balloon opens up the preperitoneal space across the midline, so applying a patch to the contralateral side really only adds 10-15 minutes to total surgery time. Second, bilateral surgery adds little to the patient’s inconvenience – pain etc. Third, prior laparoscopic surgery makes repeat access to the preperitoneal space very difficult, making open surgery the chosen option for later contralateral hernia repair (with all its attendant disadvantages for the patient). For these three reasons, he finds himself offering young fit men who do manual work bilateral laparoscopic repair if they decline ultrasound, believing many will be back for surgery on the other side if he doesn’t. Otherwise, he carefully examines the contralateral groin and, if negative, doublechecks with ultrasound using an experienced operator he trusts. Often, subclinical hernias are found, bearing in mind that about 30% of patients have a lifetime risk of developing a second hernia.

Hepatitis, Now and Then Dr Sam Galhenage is a gastroenterologist with a special interest in viral hepatitis and advanced liver disease. “The main thing is substantially improved cure rates with hepatitis C, from 40-50% to abut 75% for genotype 1 patients. And 30

in the next three or four years we are going to move away from more toxic interferon-based therapies to combinations of medications with 90% cure rates,” he said. Hepatitis C treatment costs about $80,000 per patient at present and the new protease inhibitors will be more expensive, However, the details of government funding has not been worked out yet. Sam wonders if those with the most advanced liver disease will qualify. “But a 90% cure rate offers a significant degree of cost benefit because of the morbidity associated with chronic liver disease. We are fighting a losing battle to reduce the number of injecting drug users and we need to pool more resources into safe injecting practices and treat these people for hepatitis C while they are being rehabilitated for their drug use. George O’Neil’s naltrexone clinic in Subiaco is the only facility doing this.” He said it had taken about four years to get the drugs listed on the PBS, but that happened in April last year. At the moment, injecting drug use precludes treatment in public clinics but it’s a subjective call and there are psychosocial issues and more to take into account. Sam estimates about 30-40,000 people in WA have hepatitis C. He said trips to SE Asia really only risk hepatitis B, which could be prevented by vaccination, although migrants from China and India had higher rates of this

infection (8% of the Chinese population). He sees this as a future cost burden. When it comes to FIFO workers and younger people, alcoholic liver disease is his main concern, so community attitudes to alcohol are important. He predicts growing demand in his field and a lack of hepatologists to help out.

Colorectal Cancer Survival Dr Cameron Platell, colorectal surgeon, talked about his research into adjunct treatments over the last five or six years. “We are looking at predicting how cancers respond to chemotherapy and radiotherapy, in particular rectal cancers. We’ve looked at the immune and inflammatory responses to cancer and how that influences survival.” Amongst various immune markers, they have noticed that T suppressor cells can be stimulated by the cancers. “Taking into account all the other prognostic factors, these cells just stand out like sore thumbs in terms of their predictive response medicalforum

for outcomes. We’ve had that published in the Journal of Clinical Oncology and it’s had about 250 citations now.� “We probably over-treat a large number of patients. If you could predict those who are not going to respond at all, those patients should be targeted with other adjunct treatments. For example, if you could pick a patient who was going to have no response to radiotherapy, why would you subject them to six weeks of treatment with all the attendant side effects and complications?� They are currently researching that area and the immune response seems to be a strong predictor of responsiveness. On the other hand, defining the genetic signatures of cancers has not offered ways to individualise treatments, as was hoped. “Our work has highlighted a group of patients with stage 2 bowel cancers who do appallingly as regards survival outcomes, so we just give these patients chemotherapy. Tumour behaviour predicts the poor outcome – one of the most important markers is extramural vascular invasion, visible to pathologists, with the tumour invading out through blood vessels instead of going to the lymphatics.� He said they now have the paradox where stage 2 or 3 colon cancers have equal survival outcomes. He suggested we are probably treating stage 3 patients really well and undertreating stage 2 patients.

The Bugs That Inhabit Us Dr Oliver Waters, astroenterologist and general physician at the Centre for Inflammatory Bowel Disease (Fremantle Hospital), has a particular interest in how the bowel microbiome – the bugs that inhabit us – influences bowel disease and other things. “The gut microbiome appears to harvest energy and nutrients that we couldn’t otherwise and it also modulates the immune system. Emerging data from areas such as allergy, asthma and atopy shows that the microbiome may be key.� The hygiene theory around rising atopy and autoimmunity in the Western world came into view, for which he said the seminal paper was by a Japanese group in 2009. They used probiotics in neonate germ-free mice to ameloriate an allergic response to antigen, whereas adult mice did not benefit. He said science was trying to explain observations like these. “In inflammatory bowel disease, the genes in our population that have been associated with Crohns disease and ulcerative colitis haven’t change in 100 years, so something else has changed. Patients with IBD have a reduced biodiversity in their microbiome.� Is this chicken or egg? Studies from Australia and Scandinavia have shown that taking antibiotics (particularly against anaerobes) in childhood increases the risk of developing IBD in the future. Microbiome differences have been noted in people who are obese, and those with increased cardiovascular disease or diabetes. “It’s pointing perhaps to a dysbiosis of the microbiome, a narrowing of the biodiversity, which triggers someone into having a problem. If you look at gut flora, you have about 100 trillion bacteria, all anaerobes that are hard to culture – about 80 of the 5000 bacterial species. The big transition has been they can now do rapid DNA sequencing, the 16s ribosomal DNA which is specific to bacteria, and they can tell proportions of each, all backed up with massive computing power.� New technologies have generated vast amounts of data. Oliver says probiotic use, using the microbiome to predict autoimmune disease, and exploring inheritance patterns (e.g. twins have better microbiome concordance than spouses) are emerging interests. However, the more they learn the more complicated it gets, making ‘ah-ha’ moments more difficult to attain. “The ultimate probiotic is a faecal transplant, and they are running trials of this in ulcerative colitis. The latest case studies of 10 children had three in remission at the end of four weeks. How efficacious it will be in the long term is another question.� And faecal transplants have proven efficacy in people with intractable Cl difficile gut infections. The problem is standardising things for clinical trials. Continued on P32 medicalforum

PIVET MEDICAL CENTRE Specialists in Reproductive Medicine & Gynaecological Services

Fertility News

by Medical Director Dr John Yovich

Vitamin D... relevant for fertility Vitamin D has known relevance to bone health and calcium homeostasis. My memory from medical student days is of rickets due to low Vitamin D but also unusual features and symptoms in children from hyperCholesterol molecule calcaemia, following H[FHVV IRUWLÀFDWLRQ RI milk in the post WW-II period. In recent years, it has become concerning that Vitamin D status in the population is falling, causing a focus on various body systems where Sunlight disorders might be ascribed. In the area Vitamin D molecule>The body’s main source of the seco-steroid Vitamin D3 – cholecalciferol of reproduction, with open B ring - is derived from the B 9LWDPLQ ' GHÀFLHQF\ spectrum of UV rays from the sun acting on cholesterol (a sterol) in pale areas of skin. is reported with Images courtesy Google public arena. infertility as well as PCO and endometriosis, and with diminished semen parameters. Pregnancy-induced disorders such as hypertension and gestational diabetes are also claimed but controlled prospective studies have not yet been reported. 2I LQWHUHVW WR 3,9(7 LV WKH ÀQGLQJ WKDW VHPHQ SURÀOHV DPRQJ PHQ LQ VXEIHUWLOH UHODWLRQVKLSV DUH DEQRUPDO LQ a D VLPLODU ÀJXUH WR 9LWDPLQ ' LQVXIÀFLHQF\ 2Q WKH FRQWUDU\ RXU VLVWHU FOLQLF LQ &DLUQV VKRZV 9LWDPLQ ' GHÀFLHQF\ LV UDUH EHLQJ YLUWXDOO\ ]HUR DW the 50nm/l cut-off and only 6% at 75 nm/l, matching a recent report in ANZJOG from Cairns Base Hospital (Bendall et al, 2012). This may correlate with our observation that sperm motility and morphology appears better among the males of far North Queensland compared to our Western Australian males who come mainly from the southern half. We plan formal studies to check a vitamin D correlation but we already advise WA men ‌ to take their shirt off and expose untanned skin to the sun for 20 minutes twice-a-week!

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Continued from P31

Supporting young men with Androgenetic Alopecia Rising awareness and social acceptance is prompting more men in their teens and early 20’s to seek advice for Androgenetic Alopecia. Nedlands based, immediate past president of International Society of Hair Restoration Surgery, Dr. Jennifer Martinick says hair loss can be devastating for young men. Psychological effects, feelings of loss of youth, identity and sexuality can lead to depression or suicidality. These men are vulnerable, often misinformed and try ineffective, unscientific /expensive ‘snake oils’ to regrow hair, leaving them disappointed/out-of-pocket. General practitioners should be sensitive, supportive, reassure and advise about clinically approved medical /surgical treatments. Quick Facts: 1 70% of men suffer Androgenetic Alopecia 2 Onset: puberty to fifties 3 Family History: not always positive 4 Polygenic inheritance 5 5alpha reductase increases DHT production ,miniaturising terminal follicles 6 Gradual Loss, usually following a classical pattern with retained occipital fringe CONSULTATION CRITERIA 1. Exclude other causes of hair loss Patchy loss? Consider Alopecia areata, Cicatricial alopecias, Trichotillomania, Syphilitic Alopecia, Tinea Capitis Diffuse loss? Consider Telogen Effluvium, medication side effect, dietary deficiencies, systemic disease Consider scalp biopsy or Dermatology referral. 2. Support and empathy It is normal for men to be concerned with body image; there is no shame getting help. Have them express their feelings and assess for depressive symptoms; consider counseling. 3. Educate patient Hair loss continues throughout life. Medical treatments are effective short /medium term. Surgical hair transplantation is the only permanent treatment. 4. TGA Approved Treatments Minoxidil 5% topically daily. Minoxidil up-regulates VEGF, retaining and regrowing hair. Finasteride 1mg daily Finasteride, a 5 alpha reductase inhibitor, blocks over 70% DHT. It regrows terminal hairs in the vertex and midscalp. Recent claims of persistent sexual dysfunction after cessation of Finasteride have caused controversy. Clinical trials covering nearly 13 million total patient years have shown no definitive link. Lasercomb 655 nanometre wavelength stimulates mitochondrial activity 2mm into the skin. Research suggests a decrease in cell apoptosis. Note: all other commonly advertised medications/remedies do not have TGA approval and lack evidence for efficacy or safety Surgical hair transplantation Modern hair transplantation provides permanent and natural results. Patients interested in surgery or those who have failed with medical treatment can be referred to a hair loss physician who can assess them for suitability for surgery. Further information: www.ishrs.org or Dr. Jennifer Martinick 9386 1104. Author of the article is Dr Sara Kotai MBBS Hons.

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Things in the abdomen Obesity Surgery trends Dr Harsha Chandraratna, who does obesity surgery, has mirrored the US trend of moving from gastric banding to gastric sleeve surgery. “Surgery is not a quick fix for obesity. If you don’t change your lifestyle habits and have an operation, within 3-5 years your weight will come back up. We see that frequently and there are programs now for people to ‘maintain their sleeves’ or health weight loss.” “People like the reversible idea with banding but the truth is if you take it out you put your weight back on. There’s an electrical vagus nerve stimulator coming onto the market, which only gets you 10-20% weight loss and you have to wear a pacemaker and laparoscopically put hooks onto the vagus nerve. We think other things do the job better.” He mentioned the endoscopic sleeve, where a metre-long stent is placed in the pyloris and food is barely absorbed – it can only stay in for up to six months, producing temporary results, much like the gastric balloon. He says bariatric surgeons have been lucky in Australia in that there is no restriction on what surgery gets refunded and no prerequisite programs mandated by health funds, like in the US. “We like to think we can make an unbiased decision on the right surgery but patients go to surgeons who do what they want, or what their friend had.” It is the patient push for long-term results and discontent with dietary restrictions that has moved him from banding to sleeve surgery. However, he acknowledges the greater risk profile from this more major surgery, particularly the risk of a post-operative leak, which can then lead to laparotomy and repair, prolonged hospitalisation and perhaps death. O

By Dr Rob b McEvoy

A Bloke’s Bible The Men’s Advisory Network’s The Blokes’ Bookk is the perfect si size and a perfect companion to help men keep tabs on their physical and mental wellbeing. Now coming up to its first anniversary, the booklet, which is both a resource, with references to just about every health and social service a bloke would ever need, and a health checklist has been a huge success. Issues such as diet and exercise, relationships, fatherhood, alcohol and drugs, emergency help, accommodation, finances and legal matters are all dealt with in a friendly but straightforward way. And most importantly is a guide to a vast array of community and government services. The Department of Health provided $30,000 to MAN to produce the booklet and a 20-panel pocket directory of WA services for men. The book is available from MAN, Tel 9218 8044 or online at www.man.org.au O medicalforum

DIE – From darkness to light : Advances in Sonography Aids Diagnosis of Deep Infiltrating Endometriosis Endometriosis is one of the most challenging gynaecological disorders, affecting 10% of premenopausal women. Symptoms of endometriosis include dysmenorrhea, dyspareunia, dyschezia and infertility. One possible reason for major delay and misdiagnosis of this condition is the suboptimal primary assessment of patients with pelvic pain and suspected endometriosis.

By Dr Anjana Thottungal MBBS, MD, MRCOG, FRANZCOG, DDU

Deep infiltrating endometriosis (DIE) is defined by the presence of endometrial implants, fibrosis and muscular hyperplasia below the peritoneum. The exact incidence of DIE is unknown, but it appears to be increasingly diagnosed. Commonly, it involves the uterosacral ligaments, the rectosigmoid colon, the vagina and the bladder. Intestinal endometriosis is one of the most severe forms of DIE. Adequate primary assessment of patients with suspected DIE is particularly important as it not only reduces diagnostic delay but also enables clinicians to plan appropriate surgical treatment options, especially in cases of advanced and extensive disease. With a focus on the preoperative evaluation for DIE, several studies have evaluated the diagnostic value of magnetic resonance imaging (MRI). However, MRI is time consuming and expensive. Recent evidence strongly suggests that transvaginal sonography (TVS) has an important role in detecting DIE of the pelvis, not only involving the ovaries but also the vagina, the rectovaginal septum, the uterosacral ligaments (USL), the bladder or the rectal wall. Higher diagnostic accuracy of TVS has led to the suggestion that TVS should be used as the first line of diagnostic imaging in suspected DIE. Accurate preoperative diagnosis of intestinal endometriosis is also essential for informing women about the specific risks of surgery (e.g. colorectal resection). Rectosigmoid junction is the site of nearly twothirds of cases of intestinal endometriosis and is easily evaluated on TVS. Rectosigmoid endometriosis is almost always associated with USL involvement. Studies have shown that a simple rectal enema (Fleet enema) one hour before TVS permitted easy identification of the different bowel layers. Sonographic demonstration of utero-rectal adhesions, reflected by a negative uterine sliding sign, is an easy method for predicting the presence of DIE involving the rectum. Following are the sonographic changes of pelvic structures associated with DIE: t 6UFSPTBDSBM MJHBNFOUT SFHVMBS JSSFHVMBS IZQPFDIPJD OPEVMBS structure or hypoechogenic linear thickening with regular/ irregular margins near the cervical insertion (Fig. 1). t 7BHJOB UIJDLFOJOH BOE PS UIF QSFTFODF PG B IZQPFDIPHFOJD DZTUT or non- cystic nodularity within the posterior vaginal wall (Fig. 2). t 3FDUPWBHJOBM 37 TFQUVN IZQPFDIPHFOJD OPEVMBSJUZ PS DZTUJD NBTT in the area between the rectum and the posterior vaginal wall from the level of introitus to the lower border of the posterior lip of the cervix (Fig. 3). t #MBEEFS IZQPFDIPHFOJD OPEVMBSJUZ XJUI XJUIPVU DZTUJD GFBUVSFT within the posterior wall of the urinary bladder. t 10% 1PVDI PG %PVHMBT DPNQMFUF PCMJUFSBUJPO XIFO

medicalforum

Q Figure 1-Uterosacral nodule seen near the cervical insertion

Q Figure 2-Hypoechoic cystic lesion in the vagina

Q Figure 3-Hypoechoic lesion with cystic areas on the RV septum

Q Figure 4-solid irregular nodule in the intestinal loop adherent to posterior wall of the uterus.

the uterus and adnexae and rectosigmoid colon are fixed to each other with disappearance of the peritoneal structure. Obliteration is considered to be ‘incomplete’ when peritoneal limits are partially identified with the presence or absence of suspended or lateralised fluid collection.

Q Figure 5-Mid-sagittal view of the pelvis on Sonovaginography.

t 3FDUPTJHNPJE DPMPO SFHVMBS JSSFHVMBS IZQPFDIPHFOJD mass distorting and replacing the normal appearance of the muscle layer of the rectal wall. t #PXFM MPOH OPEVMBS QSFEPNJOBOUMZ TPMJE IZQPFDIPHFOJD MFTJPO involving the intestinal wall (Fig. 4). It has been found that sonovaginography is a reliable and simple method for the assessment of rectovaginal endometriosis and provides information on location, extension and infiltration of the lesions, which are important factors in selecting the kind of surgery. Sonovaginography involves introducing sterile gel into the vagina that creates an acoustic window between the transvaginal probe and surrounding structures of the vagina (Fig. 5). An accurate mapping of the disease extension helps to define the multidisciplinary surgical team needed to manage the patient. References on request. Q

A MercyCare Service Advertising Feature Thirlmere Road, Mount Lawley WA 6050 T: 08 9370 9222 F: 08 9272 1229 E: hospital@mercycare.com.au W: www.mercycare.com.au/hospital 33

CLINICAL UPDATE

Congenital “holey” hearts: Ventricular septal defect

By Dr Luigi D’Orsogna, Paediatric Cardiologist. Western Cardiology. Tel 9346 9300

V

entricular septal defect (VSD) is the commonest congenital heart disease of childhood (55% of cardiac defects in WA). Single or multiple defects of the interventricular septum can be simply classified as membranous or muscular, and they can be isolated or associated with other defects like coarctation of the aorta or more complex malformations such as Tetralogy of Fallot. The pathophysiology and clinical manifestation of a VSD after birth is dependent on its size, the pulmonary vascular resistance (PVR) and the differential pressure between right and left ventricles.

Pathophysiology Immediately after birth the PVR is high, hence there will be little flow across the VSD, which will be clinically “silent”. As the PVR diminishes over the ensuing days, flow increases across the defect. Small defects are not associated with symptoms but a typical pansystolic murmur at the lower left sternal border is audible; smaller defects tend to produce louder murmurs as greater turbulence is created by the larger pressure difference between ventricles. Conversely, excessive pulmonary blood flow from a large defect increases pulmonary artery pressure, which in turn raises the right ventricle pressure and diminishes the pressure difference across the VSD, thereby making the murmur less prominent.

Q Fig2: with AmplatzerTM VSD occlusive device in situ.

However, the newborn or young infant manifests symptoms and signs of excessive pulmonary blood flow: dyspnea and tachypnea that cause difficulty with feeding, tachycardia and hyperdynamic praecordial activity with or without a thrill, and an accentuated second heart sound with the pansystolic murmur. There may be an ejection systolic murmur at the left upper sternal border (excessive flow across the pulmonary valve) and a mid-diastolic murmur at the apex (increased flow across the mitral valve). If congestive cardiac failure develops, hepatomegaly is the best indicator at this age.

Investigation and treatment Q Fig 1: 2 -dimensional echocardiogram (apical 4 chamber view) showing a large mid-muscular VSD (arrow).

Echocardiography is most accurate and informative. A small VSD requires no treatment as the defect may diminish or even close spontaneously; most small muscular

VSDs close before school age and even moderate or large defects diminish enough in infancy so that no treatment will be needed. However, if the infant with moderate or large VSD shows signs of not thriving or develops heart failure, then surgery will be required early, usually before six months of age. An asymptomatic moderate to large VSD requires elective closure later in infancy or early childhood to avoid the long-term complications of either pulmonary hypertension or volume overloaded left heart. Surgery is now relatively low risk with mortality <1%. Transcatheter VSD device closure has limited application as it can only be used safely with muscular defects in older infants; perimembranous defects are close to the cardiac valves and the conduction system, thereby risking their damage from an occlusive device. Infective endocarditis prophylaxis is not required for VSD unless there has been previous endocarditis (but it is required for six months after cardiac surgery/device closure). Declaration: Western Cardiology has contributed to the production costs of this clinical update. No author competing interests.

Conference Corner Dates: Venue: Website:

Date: Venue: Website:

Dates Venue: Website:

Dates: Venue: Website:

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Rural Health West Aboriginal Health Conference July 6-7 Pan Pacific, Perth www.ruralhealthwest.com.au or www.ruralhealthwest.com.au WA ANZCA Winter Scientific Meeting July 20 University Club, UWA www.anzca.edu.au/events General Practitioner Conference & Exhibition July 20-21 Perth Convention Exhibition Centre www.gpce.com.au/en/visit/perth/ Rural Health West Remote Coastal Emergency Medicine Conference September 6-8 Gnaraloo Station www.ruralhealthwest.com.au

GPET Convention 2013 Dates: September 11-12 Venue: Crown Perth Website: www.agpt.com.au/NewEvents/ GPETConvention2 2013 Rural and Remote Mental Health Conference Dates: September 17-19 Venue: Bridgeley Community Centre, Northam Website: www.wacountry.health.wa.gov.au National Environmental Health Conference Dates: September 24-26 Venue: Parmelia Hilton Website: www.eh.org.au/events WA ANZCA Meeting Bunker Bay Dates: October 11-13 Website: www.anzca.edu.au/events

Rural Health West Fremantle Conference Date: October 19 Venue: Fremantle Website: www.ruralhealthwest.com.au WA Transcultural Mental Health and Australasian Refugee Health Conference 2013 Dates: October 31-November 1 Venue: Duxton Hotel, Perth Website: www.transrefugee2013.com.au Australasian Injury Prevention & Safety Promotion Conference Dates: November 11-13 Venue: The Esplanade Hotel, Fremantle Website: www.injuryprevention2013.com.au

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CLINICAL UPDATE

Quest for scarless healing in burn injury

By Winthrop Prof Fiona Wood, Director of the Burns Service WA & UWA Burn Injury Research Unit

T

he burn-injured patient has complex evolving pathophysiology that impacts on all body systems. Improving burn healing requires both a broad understanding and a subspecialist focus on treatment. Debilitating scarring limits the life of survivors so a vision of scarless healing aims to improve outcomes for life. It has led to the exploration of regeneration.

Focus both wide and narrow The 2005 MJA-published future vision of clinical care, points to a number of disciplines: “Assessment is key to understanding the extent of injury. Debridement is focused on tissue salvage. Reconstruction balances repair with regeneration. t *OWFTUJHBUJPO PG NVMUJNPEBMJUZ NVMUJ scale characterisation, including confocal microscopy and synchrotron technology will quantify assessment. t %FCSJEFNFOU VTJOH BVUPMZUJD JOGMBNNBUPSZ control techniques with image guided physical methods will ensure the vital tissue frameworks are retained. t 5JTTVF HVJEFE SFHFOFSBUJPO BGGPSEFE CZ self-assembly nano-particles will provide the framework to guide cells to express the appropriate phenotype in reconstruction. To solve the clinical problem a multidisciplinary scientific approach is needed to ensure the quality of the scar is worth the pain of survival.� Currently, many of these highlighted technologies are available and innovative research can move them towards safe implementation if they are matched with clinical observations, those that result from close working relationships between research and service delivery. The clinical research framework brings together basic science, population health and clinical research. We know that every intervention from the time of injury impacts on the scar worn for life: first aid and pre-hospital care; disaster response; wound and scar assessment; oedema management focused on tissue salvage; cell-based therapies to guide healing, in particular the impact of the nano chemistry and architecture; rehabilitation that begins at the time of injury and is measured by function for life; the influences of genetics and epigenetics; the neurological and psychological response to injury; and population data linkage that reports on the lifelong impact of burn injury. Incorporating innovation into practice requires education that includes telehealth, and is subject to audit.

Many options to explore In burns, the repair of injured skin is essential to protect underlying tissues and re-establish an intact barrier with all related functions. Whether this can be achieved using conservative or surgical methods depends on the extent of injury in terms of 36

surface area and depth. Frequently, to ensure survival, rapid wound cover is essential and for many years, split thickness skin graft (SSG) has been considered the gold standard. A SSG, taken from a non-injured site, creates an additional wound and retains the characteristics of the site of origin. The result is always a scar. Therefore, fundamental to the quest for scarless healing is the exploration of techniques of tissue salvage and therapy that make up a new gold standard. Traditionally, the fundamental requirements for skin healing were considered to be: t " TPVSDF PG DFMMT DBQBCMF PG differentiation into the tissue lost, and t "O BSDIJUFDUVSBM GSBNFXPSL GPS cells to migrate into and express the appropriate phenotype. However, just as complex tissues have self-organised into the adult body, there are parallels with tissue repair after burns. Although the drivers to self-organisation are not fully understood, they require: Q Burns telehealth flyer t % TQBUJBM JOGPSNBUJPO PG UJTTVF damage and the relationship to the t $BO UIF $/4 % JOGPSNBUJPO IPVTFE JO intact surrounding tissues, and the homunculus be used to drive t " GFFECBDL NFDIBOJTN UP HVJEF TFMG regenerative nerve repair within the skin? organisation. t 8JMM TIBQF SFDPHOJUJPO BU UIF DFMMVMBS BOE In our quest for scarless healing within the tissue level facilitate a regenerative healing framework of this working hypothesis, key pattern? pieces of the jigsaw have been uncovered. t 8JMM SFHFOFSBUJPO PG OPSNBM &$. We now know that the skin at a contralateral structure be associated with normal site, which has not been injured, has long phenotypic expression of skin cells? term changes of the nerve fibres within t 8JMM UJTTVF SFHFOFSBUJPO CF BTTPDJBUFE XJUI the skin construct. We postulate that the or even dependent upon systemic recovery changes are related to alterations in the CNS of the immune system? homunculus. Acute changes related to neural plasticity become established long-term, as Although we are living in a time where seen in phantom limb syndromes. science and technology are advancing exponentially, harnessing this knowledge to Burn injury is related to an aggressive and clinical practice is a challenge. Meanwhile, prolonged inflammatory response that maybe our greatest challenge is translating results in the development of a scar with what we know now into routine practice, an abnormal extracellular matrix (ECM). such as the impact of first aid education in The ongoing abnormal ECM (in shape and the community on the scar someone will chemistry) is permitted by the immune wear for life (see image). system for which we now ask: t %PFT UIF QFSNJTTJWF JNNVOF TZTUFN lead to an increased lifetime risk related to an alteration in the immune response e.g. cancer? Conversely, will a recovered immune system mitigate against this risk?

Declaration: Author competing interests: No relevant disclosures.

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CLINICAL UPDATE

Common eye injury refresher I

t is important to recognise the signs and symptoms of severe, sight-threatening injuries and conditions. The history of the presenting complaint will point you in the right direction, for example, chemical injury or mechanism of injury (blunt or sharp). Here, we are reminded of some simple techniques to determine the severity of an eye injury using basic instruments and techniques – focusing on three signs that will hone your ophthalmic diagnostic skills.

Eye complaints and injuries account for up to 3% of all emergency department visits. The bulk of these visits are due to trauma and include mild injuries such as corneal abrasions through to sight-threatening injuries, which include penetrating eye injuries, severe chemical injuries and retinal detachments.

an irregular, flower-shaped pattern (Figure 2) then you must consider iritis – the cause of this distorted pupil is posterior synechiae, that is, adhesions of the iris to the lens during inflammation. A fixed dilated pupil would point you towards possible acute angle closure glaucoma.

Pain relief

Red Reflex

Use topical anaesthetic drops (such as amethocaine, tetracaine or oxybupivacaine) as a screening tool. Does the pain subside with simple topical anaesthetic drops? If the answer is yes, then the pathology is superficial and would include flash burns, corneal abrasion, corneal ulcer, chemical injury or corneal laceration. If the pain does not subside with the topical anaesthetic then you must consider more serious, posterior eye pathologies such as iritis, acute glaucoma or orbital pathologies.

Using a direct ophthalmoscope, look for the red reflex in the injured eye. If the red reflex is dull then consider vitreous and/ or retinal pathologies. The most common causes of a decreased reflex post trauma would be a vitreous haemorrhage and/ or a retinal detachment. Simple techniques in detecting severity of eye conditions in ED or GP practice can hasten the treatment and triage of patients.

By Dr Michael Wertheim, Ophthalmologist

Q Figure 1: Penetrating eye injury

Pupil What is the pupil shape? If the pupil is a teardrop shape (Figure 1) then you must consider a penetrating eye injury – the cause of the teardrop shaped pupil is the iris prolapsing out of a full thickness laceration. If the pupil has

Declaration: Perth Eye Centre P/L, managing the Eye Surgery Foundation, supports this clinical update through an independent educational grant to Medical Forum. Author – no competing interests.

Q Figure 2: Iritis with posterior synechiae.

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CLINICAL UPDATE

Case Report: Atypical thyroid nodule

by Dr Simon Ryan, Endocrine Surgeon, Hollywood Medical Centre. Tel 9386 3070

A

FNA (fine needle aspiration) of a woman’s thyroid nodule is reported as “atypical” with the pathologist’s conclusion “raising the possibility of follicular neoplasm”. At this point she is referred to me. Ms RH, aged 50, had a solitary and symptomatic (compression) left sided thyroid nodule of 4cm maximum dimension. This occurred against a background of longstanding hypothyroidism and thyroxine replacement for over a decade.

I explain to the patient that nodules with this type of FNA finding usually require a histological – rather than cytological – specimen. Atypical follicular-type aspirates can arise from benign nodules such as hyperplastic nodules and follicular adenomas but also from follicular thyroid carcinomas. These entities are presently best distinguished by a histological specimen (i.e. operative), which allows close inspection of the nodule capsule to determine whether there has been a breach of this capsule by tumour cells. A breach defines malignancy in follicular thyroid lesions. A nodule with capsular disruption (follicular carcinoma) can often require further surgical and adjuvant treatment, while benign lesions usually require I offered this no further patient a total treatment. thyroidectomy given Many patients that she was already come to thyroid hypothyroid and surgeons in taking thyroxine and this situation in this way would fearful they have avoid a completion a confirmed thyroidectomy in the cancer, however event of a follicular only about 20% thyroid carcinoma of nodules with Q Ultrasound of a large left-sided thyroid nodule (in a different being diagnosed on atypical follicular patient). a hemi thyroidectomy aspirates are specimen. follicular carcinomas.

After surgery, the nodule was confirmed to be benign histologically – a hyperplastic (colloid) nodule. However, within this specimen was a second lesion, a 2.3 mm papillary thyroid carcinoma (PTC). While another source of alarm for patients, PTCs less than 10mm – so-called microcarcinomas – are found in up to 30% of thyroidectomy specimens in autopsy studies. They nearly uniformly have benign behaviour and do not warrant further treatment, even if found within a hemithyroidectomy specimen. Ms RH is now well, on a stable dose of thyroxine, with normal parathyroid function and unremarkable voice. The learning points from my perspective are: t BUZQJDBM UIZSPJE OPEVMF BTQJSBUFT suggestive of follicular neoplasm usually lead to a surgical biopsy for capsular assessment, however the majority of these nodules are benign. t QBQJMMBSZ NJDSPDBSDJOPNBT BSF DPNNPO in thyroidectomy specimens where the original operation was for benign indications such as multinodular goitre and Graves' disease; this patient should be reassured regarding the minimal clinical significance of these lesions and lasting treatment via thyroidectomy.

Referring Doctor’s Perspective This woman drew my attention to her neck, having noticed a swelling over the left thyroid gland that had been bothersome for about two weeks, that is, a mild globus sensation while swallowing and pressure in her neck. She had a palpably enlarged non-tender left thyroid nodule and no palpable regional lymph nodes. I referred her to a Perth radiologist for thyroid ultrasound and, if indicated, guided FNA of the nodule. This was done.

Histology of the aspirate was atypical and raised the possibility of follicular neoplasm for which she was referred immediately to the thyroid surgeon. For me, as a GP who has not thought long and hard about it, I do not have unanswered questions after reading the broad explanation in Dr Ryan's letter. I believe specialist correspondence should enrich our knowledge of the relevant subject. This experience will not change the way I

Dr Sam Irekpolo, Jurien Bay General Practice. Tel 96521484 manage similar thyroid patients in future but it will improve my patient counselling prior to referral. I can see that teaching FNA (fine needle aspiration) to GPs would be useful in some cases where distance might be a constraint.

Declaration: This Case Report is supported by an independent educational grant to Medical Forum from Hollywood Private Hospital.

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CLINICAL UPDATE

Risks in (not) diagnosing prostate cancer

By Clinical A/Prof Justin Vivian, Urologist. Tel 9382 4999

V

arious colleges and government agencies seem to provide mixed messages on prostate cancer detection. When it comes to biopsies, small changes in methods have the potential to decrease negative biopsies and improve safety.

Screening recommendations and use varies

MRI (which costs patients $500-700).

The American Urological Association has Prostate biopsy just downgraded recommendations for Prostate biopsy is done with prostate cancer screening to align more a transrectal ultrasound with the more conservative U.S. Preventive probe to image the gland Services Task Force (USPSTF), which says (TRUS/PB). The biopsy the harms outweigh the benefits for prostate needle passes through cancer screening. This policy change has to either the rectal mucosa be seen in the light of the Urologists in the (transrectal) or the skin USA being very aggressive on prostate cancer (transperineal). The risk of screening for many years. At the same time, infectious complications Prof Bruce Armstong (Director of Australian following TRUS/PB has Agency for Health and Welfare), who has increased up to fourlong opposed prostate cancer screening, fold and up to 10% of changed his mind and now believes benefits patients admitted with are likely. post biopsy septicemia require ICU admission The European prostate screening study group from Goteborg (Sweden) had the most compelling evidence for a benefit from prostate cancer screening with similar numbers needed to treat as breast and colon cancer screening trials. Interestingly Australia, like Sweden, has one of the world’s highest incidences and mortality rates of prostate cancer. There are no studies of prostate cancer screening in an Australian population. This uncertainty leads to disparate practices regarding PSA testing amongst Australian doctors – not acting on an elevated result is risky. The Goteburg study used a PSA cutoff of 3.2 ng/ ml to suggest biopsy. PSAs Q Prostate cancer MRIs. above this level should at least prompt discussion of (with rare fatalities). This increasing risk is the risk of prostate cancer with the patient. largely due to the increasing prevalence of New parameters such as free to total ratio fluoroquinolone resistance. Predictive risk and proPSA can be added to PSA in online factors include frequent antibiotics usage, calculators to refine an individual’s risk of a frequent travel to SE Asia (livestock antibiotic biopsy diagnosing cancer (http://deb.uthscsa. feeding), diabetes, and increased number of edu/URORiskCalc/Pages/calcs.jsp). proPSA biopsies taken. is available via Clinipath as a PHI-prostate One effective strategy to reduce infectious health index test that is not MBS-rebateable. complications was pioneered locally at MRI use Hollywood Hospital with the use of betadine Currently, MRI use in diagnosis of prostate rectal suppositories at the time of biopsy. cancer involves targeting an abnormal A randomised trial has just been published area, and reducing the number of biopsies from Canada demonstrating a significant risk required. The negative predictive value of reduction with this technique. MRI’s is such that it will not replace biopsy In areas of high fluoroquinolone resistance, yet but it can give useful information faecal cultures can identify antibiotic regarding staging and reassure patients in the resistance and prompt adjusted prophylaxis setting of a negative biopsy with a rising PSA. in individual cases, while the same strategy Unfortunately there is no rebate for prostate 40

can be used in individuals at risk (immune suppressed, frequent travelers, or prolonged antibiotic users). Avoiding the contaminated rectum and performing transperineal biopsies is another solution. Reported sepsis rates of 0.2% following transperineal biopsy compare favourably to the 2.8% for transrectal biopsy (with similar prostate cancer detection rates). The drop in septic complications following transperineal biopsy is more significant as these patients had more biopsies (14) than the transrectal group (10). References Sanders et al, ANZ J Surg 83(2013) 246-248, Infectionrelated hospital admissions after transrectal biopsy of the prostate. Tsivian et al, Urology 2013 May 19. pii: S00904295(13)00372-5. doi: 10.1016/j.urology.2013.01.071. Lawrentschuk Nathan, ANZ J Surg (2013) 197-198, The role of magnetic resonance imaging in prostate cancer Barentsz JO et al, ESUR prostate MR guidelines Hugosson J, Carlsson S, Aus G, et al. Mortality results from the Göteborg randomised population-based prostatecancer screening trial. Lancet Oncol 2010; 11: 725-732. Andriole GL, Crawford ED, Grubb RL 3rd, et al. Prostate cancer screening in the randomized Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial: mortality results after 13 years of follow-up. J Natl Cancer Inst 2012; 104: 125-132. Schröder FH, Hugosson J, Roobol MJ, et al. Prostate-cancer mortality at 11 years of follow-up. N Engl J Med 2012; 366: 981-990 Declaration: The author treats prostate cancer; no competing interests identified.

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Medicolegal

CLINICAL UPDATE

PSA screening, in context

Stray Tests

Dr Robert Davies, Urologist, West Australian Urologic Research Organisation. Tel 9381 8945

Q

P

SA has become an acronym that provokes strong responses. Essentially, men who are not suitable for consideration of curative intent treatment should not be screened. Men whose screening is positive need appropriate referral so the patient is not faced with a situation where delay has culminated in incurable disease. This may have profound medicolegal consequences for the referring Doctor.

PSA’s strengths and weaknesses PSA screening needs to be considered in context, like any other test. With regard to prostate cancer it has a sensitivity (~21% for detecting any cancer at a PSA cut-off of 4ng/ mL), a specificity (~91% for a PSA cut-off of 4.0 ng/mL), a positive predictive value (~30% for a PSA >4ng/mL) and a negative predictive value (~85% for a PSA ≤4 ng/mL). While prostate cancer can be diagnosed at any level of PSA, concluding that “PSA testing can’t detect prostate cancer� (as the discoverer of PSA Richard Ablin stated in an oft quoted 2010 op-ed in the New York Times) is to throw the baby out with the bath-water. Despite its limitations, it remains overwhelmingly the best prostate cancer tumour marker that we have.

US & Australian recommendations PSA screening for cancer is contentious. The American Urological Association (AUA) has just issued revised guidelines that should be considered alongside the Urological Society of Australia and New Zealand (USANZ) recommendations: t %P OPU TDSFFO NFO VOEFS BHF t "DDPSEJOH UP UIF "6" DPOTJEFS SPVUJOF screening between ages 40-54 only in those at higher risk (e.g. positive family history or African-American race), and according to patient-doctor wishes. t " CBTFMJOF 14" BU B ZPVOHFS BHF JT B significant predictor of later prostate cancer and disease-specific outcomes. USANZ recommend men interested in their prostate health have a single PSA test and digital rectal examination (DRE) at or beyond age 40, to help estimate prostate cancer risk over the next 10-20 years. In these circumstances PSA is considered as providing prostate cancer risk stratification rather than true screening. If the result is less than the age specific median, the intensity of surveillance may be reduced but those with PSA levels above should be more carefully monitored. t 5IF HSFBUFTU CFOFGJU PG TDSFFOJOH JT in men aged 55-69; both the AUA and USANZ recommends doctor-patient shared decision-making based on a man's values and preferences. t 5IF "6" TBZT SPVUJOF TDSFFOJOH FWFSZ UXP years (or less often) may be preferred over annual screening, to preserve most benefits reduced by false positives; rescreening intervals can be individualised according to a baseline PSA level. medicalforum

t 5IF "6" EPFT OPU SFDPNNFOE SPVUJOF PSA screening over age 70 or in any man with <10-15 year life expectancy (although some over age 70 and in excellent health may benefit). In short, PSA screening should be confined to men who are most likely to benefit from early diagnosis and treatment.

Act on screening results PSAs appropriately performed in a man suitable for curative intent treatment, should be acted on. Whilst repeating an isolated elevated PSA after a few months is a reasonable first course of action, watching serial PSAs gradually progress from minimally to exceedingly elevated over several years is akin to allowing a patient to gradually exsanguinate whilst dutifully measuring a rising pulse and falling blood pressure. Since the risk of extra prostatic spread increases continuously as PSA rises, early referral can mean the difference between detection of localised (curable) versus locally advanced or metastatic (incurable) disease. The proportion of organ-confined cancers drops to <50% for PSA values >10ng/mL.

Q Performing high dose rate prostatic brachytherapy at SCGH.

Rectal examination PSA has not replaced digital rectal examination (DRE) – both should be performed as part of screening, as in combination, the positive predictive value doubles when the PSA is in the 4-10ng/mL range. Furthermore, the risk of missing a significant high grade cancer by omitting the DRE has been estimated at 17% in one major study. Author competing interests: No relevant disclosures.

“Three patients have recently asked me to order tests for them, after non-medicos requested this. One Ms Morag Smith, wanted an antenatal Avant’s Senior Solicitor, answers screen and had no intention of attending the question for Medical Forum. any medico or midwife for pregnancy care. One suggested we do a PSA, which I disagreed with. The other wanted a re-test of her thyroid, which her naturopath said was warranted and cheaper under Medicare. Where do I stand, in a medicolegal sense?�

A

Patients who insist on seeing a non-medical person for follow up and treatment should be informed of the risks of obtaining treatment from someone who is not a doctor. The discussion should involve taking steps to ascertain the patient’s understanding of their condition and reasons for, and the nature of, treatment. If, despite counselling, the patient continues to refuse to see you for follow up, you may want to consider whether to end the doctor-patient relationship due to the patient’s failure to follow your advice and recommendations. Details of the discussion should be documented in the patient’s file. You should only agree to a test or investigation requested by a non-medical third party if you believe it is clinically indicated. Should you agree to conduct a test or investigation, you still need to take a history and examine the patient to confirm that the test is clinically indicated. In addition, you still owe a duty to the patient to inform them of any finding that requires follow up. This duty applies even if the patient states they do not intend returning to see you to discuss the results. If a patient requests a test or investigation and you do not agree that the test/ investigation is required, it is not advisable to comply with the patient’s request. Medicare pays for clinically-relevant services. This means services that are generally accepted by your peers as being necessary for the appropriate treatment of the patient. If you order a test that is not clinically relevant, you risk a possible review by the Department of Human Services. It is also possible that you could face disciplinary proceedings. Finally, you can always contact your MDO for advice on managing situations such as this. O 41

Genetics

It’s in the Genes. Or Is It? We all hear about the value of genetic testing. Genetic pathologist Dr James Harraway provides some insights on where genetic testing sits in the scheme of things. Dr James Harraway, on the Genetics Advisory Committee of the Royal College of Pathologists of Australasia (RCPA), is one of about a dozen genetic pathologists nationally. RCPA has recently reported that the 39 labs that do DNA or RNA testing in Australia have been trying to cope with a 27% increase in test volume and a 5% increase in the type of genetic tests per year. “Genetic pathology is a relatively new subspecialty. It’s a small field that is hopefully growing, with a small number [seven, nationally] going through training now,” he highlighted, adding that consultant positions were limited. Genetic testing, while black and white in some cases, has focussed doctors on a growing number of interpretive tests, where good advice on the possible meaning of test results can be as important as the test itself. In fact, formal genetic counselling and informed consent is a prerequisite before doing some genetic tests. This explains the emerging role of clinical geneticists and the decisions James grapples with regularly in his lab.

42

“For a lot of single gene inherited disorders that might be late onset or severe, there is a requirement that informed consent be obtained by a specialist in this area, a clinical geneticist in most cases, to discuss implications for the patient and family members. This is for things like Huntington’s chorea or breast or ovarian cancers – BRCA1 or BRCA2 mutations. Additional post-test counselling is important as results can be complex or ambiguous – for example the ‘variants of uncertain clinical significance’ that are sometimes found.” “Most days we will receive a test request from say, a GP or surgeon, because a patient mentions a family history and the doctor writes the disorder on the request form. Often the patient isn’t as informed about the test ramifications as they should be. Occasionally, colleagues are really clued up on it, but laboratory accreditation by NATA stipulates for some complex tests – level 2 tests – the patient must have written informed consent, and the test has to come from a specialist in the area” he explained. If circumstances indicate, he would ring the doctor to discuss some of the complexities and potential referral to a specialist.

Q Genetic Pathologist Dr James Harraway

Genetic tests are now so subspecialised, only one or two labs across Australia may test for a specific inherited disorder. Some rare disease tests are sent overseas. This is why James has regular contact with WA clinicians while working from Sullivan Nicolaides Pathology (part of the Sonic group) in Brisbane.

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“Genetic testing includes rarer Mendelian single gene inherited disorders such as cystic fibrosis or haemophilia, genetic testing on cancers, cytogenetic testing for chromosomal disorders such as Down syndrome or balanced chromosomal rearrangements associated with infertility. Though tests are limited, there is also a lot of interest in the genetic basis of more common diseases.” “For example, children with developmental delay; a microarray test has come into clinical practice in the last 3-4 years that is replacing chromosomal karyotype screening. Microarrays are zoomed in tests that look at small deletions or duplications of pieces of chromosomes, which has increased the diagnostic yield in these children from 3-4% to about 10%. Developmental delay or autistic spectrum disorder affect around 3% of children, and the test looks for a contributory factor to the child’s presentation.” The technologies to emerge from the human genome project fuelled initial excitement but genetics has suffered a reality check in the clinical world. “When new things come in, they can be overstated. Genome-wide association studies so far have provided a lot of useful information on the pathways that underlie common disease but they haven’t yet provided clinically useful tests that predict risk better than a good family history. Some

Q DNA spiral

direct-to-consumer companies, mainly overseas, use this genome-wide association research to give people a risk profile for common diseases. Clinical labs don’t offer this testing because clinical utility is currently low. For example, a test that shows you have a 1.5 greater than background risk of developing Crohn’s disease may not alter patient management. Compare this to a BRCA1 mutation which may mean you have an 80% lifetime chance of developing breast cancer; this is significantly more than the 10% risk amongst all women and can lead to surveillance or treatment decisions.” The emerging technologies have made it easier to research cancers. “Cancers are really an accumulation of genetic mutations in growth and apoptosis pathways; these mutations can help guide treatment. Researchers are carrying out ‘cancer genome mapping’ where they are

trying to sequence the DNA from a lot of cancers from different patients to try and find out common changes that might be targeted. There will be a big growth in testing for cancer mutations that can help direct treatment,” James suggested. With genetic counsellors and clinical geneticists also in short supply, a growing need for genetic scientists in labs, various new tests vying for position on the MBS schedule, and varying advice about whether current tests should be restricted to specialists (currently, Factor V, haemochromatosis, a fleet of cytogenetic or chromosomal tests, and microarray testing are not), and disparity of funding between states, there is much for the experts to work through. Whatever happens, there is much for us all to learn. “A greater education in genetics is needed, starting from medical school and through general practice and the specialties – every single branch of medicine involves genetics, and there will be growing interest in genetic testing. I would like to see a point where nonspecialists have enough knowledge regarding certain disorders so they are comfortable counselling a patient and can do it safely. I don’t think we are there yet.” O

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Web: www.heartcarewa.com.au 43

CLINICAL UPDATE

Erectile dysfunction: often hidden significance

By Dr David Millar, WA Sexual Health Centre. Tel 93891400

T

o paraphrase Oscar Wilde: Sex is too important not to take seriously. Erectile dysfunction (ED) – the persistent inability to develop and maintain an erection for satisfactory sexual intercourse – has a surprisingly high incidence (see below) and occurs at all ages, increasing with age. The cause is usually a mix of organic, psychological and relationship factors, which tests the skills of every doctor.

Biomarker or hidden association From a doctor’s perspective, ED is as important a biomarker as BP, BMI or PSA. It may be the first indicator of vascular disease – the most common cause of ED is endothelial dysfunction and atherosclerosis of the penile arteries. Exactly the same process is almost certainly occurring in the carotid, peripheral and cerebral arteries. Many Cardiologists consider ED as a marker of CAD until proven otherwise. ED also has a close association with diabetes, metabolic syndrome, lower urinary tract symptoms (LUTS), sleep apnoea and androgen deficiency. From a psychological perspective there is bidirectional relationship with depression and anxiety. Understandably, ED can profoundly affect relationships and lead to various avoidance strategies by the males (watching late night NCIS repeats, working late), which in turn can lead to all manner of negative conclusions by their partner. In fact, sometimes it is the partner who triggers the initial consult for ED.

What does the ED sufferer think? From a man’s perspective, the greatest fears around ED are: t UIFJS JOBCJMJUZ UP TBUJTGZ UIFJS QBSUOFS t UIF JNQBDU PG &% PO UIFJS SFMBUJPOTIJQ (22%) and t UIF JOBCJMJUZ UP IBWF TFY (2). For married men, the ability to overcome ED is as much to do with maintaining their relationship as it is about sex. These men say the problem is on their minds constantly and nearly half (43% in this study) admit that even the thought of sex can make them anxious (2).

Barriers to seeking help There are many things that stand in the way of men seeking professional help. They are ashamed, feel inadequate, isolated, or a failure and do not discuss the problem with their friends, family or workmates. Moreira ED et al (3) found that only 20% of Caucasian males approached their doctor with the problem and even smaller percentages of Asian males did so. Some will discuss the problem with their partners who often instigate medical help. The remainder surf the Internet, receive all manner of disinformation and can end up taking counterfeit PDE5-I medications with medicalforum

varying degrees of the real compound and all manner of potentially dangerous fill-in chemicals. Some on-line “services� lock men into expensive contracts often with nonproprietary products.

Overcoming barriers by making ED acceptable Initially, it is important to reassure the man that the problem is very common (“you’re not

alone, a fair number of your mates have the same problem�), that there is a physiological basis and that there are effective lifestyle changes and treatments. We talk about blockage of arteries due to diabetes, hypertension and hyperlipidaemia, which can easily lead the conversation to “do you know that the smallest and often first artery to become narrowed is the penile artery?� It is important to address any psychogenic component (performance anxiety) as this is likely to be a part of or, particularly in younger patients, the major factor. A phrase like, “Did you know that adrenaline is the greatest erection killer on the planet?� again gives a physiological basis. If PDE5-I medications are prescribed it is important to consider the relevance of “making dates� versus the need of the man for spontaneity (e.g. re-starting dating) to determine if the drug is used on demand or on a once-a-day basis e.g. Cialis 5mg.

Important scenarios not to miss The take home point is that ED is an opportunity for increasing our level of care for men and their relationships. Five not-to-miss situations and how to begin a conversation are:

1. Newly diagnosed or existing patient with hypertension, hyperlipidaemia or diabetes: “We need to consider the effect on all arteries including the heart and penis, have you any heart problems, chest pain or problems with erections?� 2. Patient with sleep apnoea or significant LUTS: “There is a close association with this and erection problems, so are you experiencing any hassles there?� 3. Patient presents with anxiety or depression: “Doctors are aware depression and anxiety often go hand-in-hand with erection problems – is this an issue for you?� 4. Patient asks for Viagra or its equivalent (often as they are getting up to leave): “Okay, it is safe for me to do this, I will give you samples if you will come back in 1–2 weeks to see how they are working. And for me to help you find the cause, please book a long consultation.� 5. If you prefer to refer once ED is uncovered, a Sexual Health Clinic is appropriate: “These people know how sensitive a matter this is and if you want, are happy to include your partner in things, in confidence, of course.� References: 1. Chew KK et al. J Sex Med 2008; 5 (1): 60-9 2. Galaxy Research. Erection problems: Voice of the Patient survey, 2011. Prepared for Eli Lilly Australia. 3. Moreira ED, et al. Int J Clin Pract 2005; 59(1): 1 – 16. O

FACTS: Erectile Dysfunction t 3FMBUJWFMZ DPNNPO "CPVU PVU PG QBUJFOUT BHFE o PVU PG BHFE o BOE PVU PG BHFE o t 3FNFNCFS UIBU &% NBZ TJHOJGZ PUIFS IFBMUI QSPCMFNT QIZTJDBM QTZDIPHFOJD BOE SFMBUJPOTIJQ t .FEJDBM 1SBDUJUJPOFST BSF NPTU RVBMJGJFE UP BEESFTT UIJT QSPCMFN BOE UIF BTTPDJBUFE NFEJDBM IFBMUI JTTVFT

Competing interests declaration: Dr Millar is a member of the Eli Lilly advisory board for Sexual Health and Androgen Therapy. Nil else. 45

CLINICAL UPDATE

Fifth metacarpal neck fracture F

ifth MC neck fracture (‘boxer’s fracture’) is usually caused by punching a solid surface, and is most common in young males aged 10-29. This fracture accounts for 20% of hand fractures – as well as local bruising, oedema and pain, the 5th metacarpal head may be less pronounced (volar angulation).

Angulation critical While a patient presenting with <300 volar angulation can usually be managed non-surgically with satisfactory functional outcome, there should be no rotational deformity. In 5% of cases, significant rotational deformity (i.e. >100) shows in finger flexion, as the small digit crosses the palm or points toward the ulnar side of the hand (Fig 1). An x-ray confirms the diagnosis (Fig 2).

Management Treatment goals are: t 4UBCJMJTF JO HPPE GVODUJPOBM BMJHONFOU FBSMZ t $PSSFDU BOE QSFWFOU SPUBUJPOBM EFGPSNJUZ t 3FTUPSF SBOHF PG NPWFNFOU BOE TUSFOHUI t &BSMZ SFUVSO UP XPSL Splinting with a hand-based ulnar gutter design immobilises the metacarpals of the 4th as well as the 5th digits in 300 flexion. The wrist, inter-phalangeal (IP) joints and uninvolved digits are kept moving (Fig 3). A buddy strap or sleeve allows the patient to perform assisted exercises at the IP joints, reducing the risk of rotational deformity. Activities are limited to prevent further injury (e.g. tight grasping and impact activities, such as Q Fig.2

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By Ms Alex Retallick, Occupational Therapist/ CertiďŹ ed Hand Therapist. Tel 0414 305 435. hammering) while light functional tasks continue with the splint and buddy strap on. Graded exercises of the MCP joint lead to resistive exercises as healing occurs, with splint use until there is satisfactory healing (up to 6 weeks post fracture). Return to impact activities such as hammering, rattle guns and jack-hammering is usually safe after 12 weeks.

Q Fig.1

Coinciding crushing of surrounding soft tissue risks adhesion and stiffness, and in a small number of cases, a rupture Q Fig.3 of the extensor digit minimus tendon shows as inability to actively extend the PIP joint. O Competing interests: the author provides hand rehabilitation services

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Boys’ Toys

You tell your patients to get outside and have some fun, now it’s your turn. Medical Forum has done a reconnaissance of some of the best sporting equipment on the market and found some cool toys for all kinds of weather.

SNOWBOARDS The profile shape has changed dramatically over the past few years, particularly the contours on the bottom of the board. It’s moved from a traditional ‘camber’ shape (plenty of daylight underneath when the board is flat on the ground) to ‘rocker’ which is, in effect, ‘camber’ turned upside down. This minimises the likelihood of your board catching an edge in soft powder conditions and you ending up on your bottom in the wet snow. Most snowboarders opt for mid-range boards. They’re quite easy to ride at the novice level but sophisticated enough to allow more advanced manoeuvres as the rider progresses. Recommended Brands: Burton and Lib Tech, $500 entry-level up to $600-$800

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Recommended Brands: Burton and DC, $250-$500

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By Mr Peter McClelland

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medicalforum

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49

Kitchen Confidential

Cabramatta can be a violent place. How did you cope with that? I was in my teens during the violent era of Cabramatta and, I must say, if my parents didn’t fill all my time with restaurant work, I could easily have got myself into some trouble. I think team sports and hard work is a great way of keeping teenagers out of mischief. Racism can be a real problem in Australian society. Did you feel accepted as a child and teenager? It was very hard for boat people to be accepted in Australia. The Vietnamese experienced a lot of racism throughout the years, in fact we still do. We have all fallen in love with Vietnam through your cooking shows on SBS. How important was it to reconnect with your family’s heritage? It was very important for me to reconnect not only with my family’s heritage, but also my own Vietnamese culture. I arrived in Australia when I was very young, so I really wanted to learn more about Vietnamese history and, of course, discover regional Vietnamese cuisine. It was something I needed to do as an adult and I feel very lucky that I can make it part of my work and share it with the rest of Australia and the world. What emotions do you feel when you return to Vietnam? I have never lived in Vietnam, however, every time I return, I feel like I have arrived home. I definitely have a close connection to the country. I am constantly learning when I am there – something new every day. I learn more about my language, culture, history and of course the food. Do you have a favorite region in a culinary sense?

10 minutes with... Luke Nguyen Sydney chef Luke Nguyen has taken us on armchair travels to his native Vietnam with his SBS food show, now he’s coming to Perth to tantaslise tastebuds at the Good Food & Wine Show. What was it like growing up in Cabramatta in the 1980s? It was tough. My siblings and myself were very young, we all worked day and night at my parents’ restaurant, but was also expected to score high grades at school. We didn’t have much of a childhood really. It was all work, work, work. In your book, Secrets of the Red Lantern, food was at your family’s heart. How did cooking bring you together? Working at the restaurant was the only ‘family’ time we would share outside of the house, cooking together at our home kitchen was always special. We would then, of course, enjoy the many courses we cooked, over several hours. Is your family still in the kitchen together? Our family is all quite dispersed now, my brother is in London, and I spend my time between Vietnam and Sydney, but when the family gets together it inevitably involves food, lots of it.

The Good Food & Wine Show is at the Perth Convention Exhibition Centre July 19-21. For your chance to win a double entry pass, go to the competitions page for details. 50

My favorite region for food would have to be Saigon, as it is the most diverse and contemporary. It has tropical weather, which means it is more abundant in herbs, fruits and vegetables and it is also close to the Mekong River and the sea, so the seafood is incredibly fresh. We hear that you are to be on the first series of MasterChef Vietnam. What do you think will come from the show being produced there? I decided to be a judge on MasterChef to promote Vietnamese cuisine and to put it on the world culinary map. It is currently airing in Vietnam and it is getting rave reviews. The great thing about MasterChef is that it gets people cooking, and especially the younger generation who are sadly cooking less and moving towards fast foods. Is traditional Vietnamese cooking under threat from the West and fast food? Absolutely, which is one of the main reasons why I wanted to be involved in MasterChef. I have noticed during my travels through Vietnam that the children are becoming overweight because of all the western fast food available. There are a lot of herbs and vegetables used in Vietnamese cooking, it is such a healthy cuisine, so for me, it is extremely sad to see the younger generation eating so badly. You’re heading West soon for the Good Food & Wine Show. Do you have a favourite restaurant/chef here? I have only been to the West once, and it was for only five hours, so unfortunately I didn’t get a chance to check places out. This time will be different though… What dish could you never remove from the Red Lantern menu? Chilli salted squid What would be your last meal? Banh Xeo – A crisp rice flour crepe, filled with mung beans, tiger prawns, pork belly, bean sprouts, spring onions and wrapped in fresh mustard lettuce and perilla leaves, dipped in a sweet fish sauce. O

By Ms Jan Hallam medicalforum

Wine Review

Fermoy

GOING FROM

STRENGTH TO STRENGTH

Fermoy Estate 2012 Sauvignon Blanc " WFSZ QSFUUZ XJOF XJUI MJNQJE CSJMMJBODF JO UIF HMBTT 5IF OPTF EJTQMBZT QVOHFOU HSFFO GSVJU MJGUFE BOE CSJHIU 5IF QBMBUF GPMMPXT XJUI DSJTQ DMFBO UJHIU GMBWPVST BOE DSVODIJOH BDJE PO UIF GJOJTI " ZPVUIGVM QIFOPMJD FEHF JT RVJUF BDDFQUBCMF BOE XJMM NFMMPX RVJDLMZ

By Dr Craig Dummond, Master of Wine

Fermoy Estate Semillon Sauvignon Blanc (JWF NF .BSHBSFU 3JWFS 4FNJMMPO EPNJOBOU XJOFT BOE *hN JODMJOFE UP HP B CJU XFBL BU UIF LOFFT 5IBU XPOEFSGVM hGSFTI DVU HSBTTh DIBSBDUFS BMXBZT HFUT NF *U T DMFBS XIZ UIJT WBSJFUBM CMFOE GSPN UIJT SFHJPO IBT CFFO TP TVDDFTTGVM *U IBT JEFBM XFJHIU BOE UFYUVSF CFBVUJGVM SJQF (SBOOZ 4NJUI BQQMF GMBWPVST BOE ESJOLT XFMM XJUI PS XJUIPVU GPPE BOE JO BOZ TFBTPO *U XJMM BMTP ESJOL XFMM GPS B GFX ZFBST ZFU

I haven’t seen the wines of this Margaret River estate for some time and I’m somewhat impressed with their continued progression . The plantings in the heart of Wilyabrup in 1985 , with ďŹ rst vintage in 1988, makes Fermoy one of the established producers in the region. Some of its neighbours have soared to impressive heights, while others have fallen by the wayside over the ensuing years. 5IF 'FSNPZ WJOFZBSE DPWFST IB QMBOUFE XJUI UIF BMM LFZ .BSHBSFU 3JWFS WBSJFUJFT o DBCFSOFU TBVWJHOPO TFNJMMPO TBVWJHOPO CMBOD DIBSEPOOBZ BOE NFSMPU BOE NPSF SFDFOUMZ TIJSB[ 5IF PSJHJOBM PXOFST OBNFE UIF FTUBUF BGUFS UIFJS IPNF UPXO PG 'FSNPZ JO $PVOUZ $PSL *SFMBOE *O UIF T %VUDI CVTJOFTTNBO )BOT )VMTCFSHFO CPVHIU UIF QSPQFSUZ BOE JOKFDUFE B MPU NPSF DBQJUBM .PSF SFDFOUMZ 'FSNPZ IBT DPNF VOEFS "VTUSBMJBO PXOFSTIJQ BOE JT HPJOH GSPN TUSFOHUI UP TUSFOHUI 5IF XJOFT BSF NBEF CZ -J[ %BXTPO *UhT HSFBU UP TFF MPDBMT NBL JOH UIFJS XBZ JO UIF JOEVTUSZ -J[ JT B QSPEVDU PG PVS PXO $VSUJO 6OJWFSTJUZ 8JOF 4DJFODF DPVSTF HSBEVBUJOH JO )PXFWFS *hN TVSF TIF FOKPZFE B MPU PG hGJOF UVOJOHh CZ QSFWJPVT XJOFNBLFS .JDIBFM ,FMMZ 8JOFT BSF NBSLFUFE JO UISFF UJFST 5IF '& DMBT TJD SFE BOE XIJUF XJOFT BSF GPS FBTZ FBSMZ ESJOLJOH BOE FOKPZNFOU 5IF &TUBUF SBOHF JT UIF NBJOTUBZ PG 'FSNPZ XJUI BMM GJWF XJOFT SFWJFXFE CFJOH GSPN UIJT TFHNFOU "U UIF UPQ FOE PDDBTJPOBM SFMFBTFT PG DIBSEPO OBZ DBC TBW BOE TFNJMMPO BSF NBSLFUFE BT UIF h&TUBUF 3FTFSWFh XJOFT "U BMM MFWFMT UIF XJOFT BSF WFSZ XPSUIZ ESJOLJOH

medicalforum

Fermoy Estate 2010 Shiraz " OPUF GPS UIPTF 4ZSBI <BMJBT 4IJSB[> 'SBODPQIJMFT BNPOHTU ZPV * XPVME DMBTT UIJT XJOF NPSF BT B $PSOBT UIBO B )FSNJUBHF PS $SP[FT )FSNJUBHF 5IF OPTF IBT SFTUSBJOFE TQJDF CVU UIF QBMBUF IBT HSJQQZ UBOOJOT XJUI TXFFU SFE CFSSZ GSVJUT 5IFSF JT OJDF QFSTJTUFODF * BN PQJOJPOBUFE BCPVU .3 4IJSB[ BT PWFSBMM * DPOTJEFS UIF SFHJPO UPP XBSN BOE NPEFSBUF UP NBLF OPUBCMF FYBNQMFT )PXFWFS * NVTU BENJU UIJT JT B HPPE XJOF Fermoy Estate 2010 Cabernet Sauvignon Merlot /PX XF BSF HFUUJOH UIFSF 5IF TJHOBUVSF .3 SFE CMFOE 5IJT JT GVMM CPEJFE BOE JOUFOTF XJUI HSBWFMMZ .BSHBSFU 3JWFS UBOOJOT XIJDI XJMM OFFE B ZFBS PS UXP UP TPGUFO *U EJTQMBZT UZQJDBM CMBDLDVSSBOU BOE CMVFCFSSZ 5IF 'FSNPZ NPVME JT FWJEFOU BT UIFJS $BCT BSF HFOFSBMMZ TPGU BOE HFOFSPVT XJUI OJDF QMVNQ GSVJU " OJDF SJQF XJOF XJUI B GVUVSF Fermoy Estate 2011 Cabernet Sauvignon *U JT HSFBU UP DPODMVEF B UBTUJOH XJUI UIF UPQ XJOF PG B HSPVQ 5IJT JT B TNPPUI TVQQMF DPNQMFY XJOF *U TIPXT GJOF HSBJOFE JOUFHSBUFE UBOOJOT CMVFCFSSZ BOE NPDIB BSPNBT B TMJHIUMZ CSJBSZ FEHF UP UIF QBMBUF XJUI CMBDLDVSSBOU GMBWPVST *U IBT B SFTUSBJOFE FMFHBODF 5IF XJOF JT UIF QSPEVDU PG BO BNB[JOH WJOUBHF BT XBSN ESZ DPOEJUJPOT NFBOU UIF $BC 4BW XBT IBSWFTUFE XFFLT FBSMJFS UIBO VTVBM * IPQF 8" UBLFT GVMM BEWBOUBHF PG UIJT WJOUBHF CFDBVTF NVDI PG UIF &BTUFSO 4UBUFT IBE B DBMBNJUZ PG B WJOUBHF 5IJT JT B ZFBS XJOF

WIN a Doctor's Dozen! Which wine in Craig’s tasting had evidence of the ‘Fermoy mould’? Answer:

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

Name:

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Please send more information on Fermoy Estate Wines offers for Medical Forum readers.

51

Dance

BANG CAN the

There must be something in the clean air of the small rural community of Te Awamutu on the North Island of New Zealand. Not only has it raised the famous Finn brothers – Tim and Neil – but also international opera singer the late Oscar Natzke and now 25-yearold dancer Ian Vincent can add his name to the list. *BO IBT CFFO POF PG UIF TUBST PG UIF EBODF BOE SIZUIN IJU TIPX 4UPNQ GPS UIF QBTU TJY ZFBST BOE JT IFBEJOH UP UIF 3FHBM 5IFBUSF 4VCJBDP OFYU NPOUI XJUI IJT EBODJOH TIPFT BOE IJT SVCCJTI CJO MJET UP QVU TPNF IFBU JOUP PVS DPME OJHIUT 4UPNQ XBT MBTU JO 1FSUI GJWF ZFBST BHP CVU JU IBT CFFO TIPXJOH TPNFXIFSF JO UIF XPSME TJODF XJUI POF PG JUT CJHHFTU TUBHFT CFJOH UIF DMPTJOH DFSFNPOZ BU UIF -POEPO 0MZNQJDT MBTU ZFBS BOE *BO TBZT JU XBT POF PG UIF NPTU BNB[JOH FYQFSJFODFT PG IJT DBSFFS

fuku

www.thefuku.com booking - internet

20 glyde st mosman park R i n g 04 03 4709 64 to arr a nge private room for presentations

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By Ms Jan Hallam

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medicalforum

Ballet

RUSSIANS cast their One of Russia’s a’s great ballet companies, an the St Petersburg Ballet, is heading to Perth this month to stage one of the great classical ballets, Swan Lake.

For producer Andrew Guild, [pictured], who has worked with Russian arts companies for more than 40 years, there is something very special about this famous company and its performance of this timeless classic with its magical score by Tchaikovsky. i5IFSF T B SFBM SPNBODF BCPVU 3VTTJBO EBODF JU T GVMM PG SJDI IJTUPSZ BOE USBEJUJPO BDDPNQBOJFE CZ TVQFSC QSFDJTJPO BOE GMVJEJUZ PO UIF TUBHF 5IF EBODFST BSF TP GMFYJCMF BOE UIJT QSPEVDFT B XPOEFSGVM FYQSFTTJPO JO UIFJS NPWFNFOUT 4U 1FUFSTCVSH #BMMFU TQFDJBMJTFT JO GVMM MFOHUI QSPEVDUJPOT TVDI BT 4XBO -BLF XIJDI JT B QFSGPSNBODF BMNPTU FWFSZPOF LOPXT FWFO GPS UIPTF XIP POMZ HP UP UIF CBM MFU PODF FWFSZ GFX ZFBST w i4XBO -BLF IBT BMM UIF JOHSFEJFOUT PG B DMBTTJ DBM CBMMFU o CFBVUJGVM CBMMFSJOBT XFBSJOH XIJUF UVUVT QJOL QPJOUF TIPFT BOE B IBOETPNF QSJODF *U QBJOUT B QJDUVSF UIBU FWFSZPOF T GBNJMJBS XJUI BOE UIPSPVHIMZ FOKPZT w "OESFX T FYQFSJFODF CSJOHJOH 3VTTJBO TQFD UBDVMBST UP "VTUSBMJB CFHBO XJUI .JDIBFM &EHMFZ &OUFSUBJONFOU i5IBU XBT EVSJOH UIF 4PWJFU QFSJPE JO UIF NJE T "U UIBU UJNF ZPV IBE UP BDUV BMMZ HP UIFSF CFDBVTF UIFZ E OFWFS BOTXFS B UFMFQIPOF :PV IBE UP IPQ PO BO BFSPQMBOF BOE TQFOE B DPVQMF PG XFFLT TJUUJOH EPXO XJUI UIFN 5IFTF EBZT EPJOH CVTJOFTT JT TP NVDI FBTJFS BOE JU DBO BMM CF EPOF JO B CSJFG FYDIBOHF PG FNBJMT PS PO 4LZQF w i5IF NPTU EJGGJDVMU QFSTPOBMJUZ * WF FWFS XPSLFE XJUI XBT 3VEPMG /VSFZFW )F XBT B GBCVMPVT UBMFOU CVU BU UJNFT DPNQMFUFMZ JSSB

medicalforum

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By Mr Peter McClelland

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53

Competitions

Entering Medical Forum's COMPETITIONS has never been easier! Simply visit www.medicalhub.com.au and click on the 'COMPETITIONS' MJOL CFMPX UIF NBHB[JOF DPWFS PO UIF MFGU

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Major Sponsors

54

Heenan Lam Skin Pathol ogy

May 2013

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medical forum ANAESTHETIST

MT LAWLEY Dynamic specialist anaesthetist(s) required to replace retiring member. Share rooms with long established hospital based group. There will be no joining fee. Accreditation at Mercy Hospital is mandatory. Computerised billing system with excellent administrative/secretarial support. For further information please call Lorraine on (08) 9370 9733

BOARD MEMBER WANTED Fremantle Women’s Health Centre seeks a female GP (VR) as a Board member. This is a voluntary position that would suit someone with expertise in women’s health medicine and an interest in the governance of a not-for-profit organisation. FWHC is a community facility providing medical and counselling services, health education and group activities. The Board currently has 8 members who are responsible for the governance and strategic direction of the organisation and meets monthly. For more information check www.fwhc.org.au or contact Diane Snooks 9431 0500 / director@fwhc.org.au

FOR LEASE AVELEY Suitable for dental practice and/or allied health services (eg. Physiotherapy, Psychology, Podiatrist, Radiology etc). Medical centre located in the same building. Located in a fast growing community beside a shopping centre, close to secondary schools, primary schools, church and Child Care Centre. Contact: 0400 814 091 MURDOCH Murdoch Specialist Centre, brand new stylish large rooms. Please email you interest to admin@sleepmed.com.au NEDLANDS Medical Specialist Consulting Rooms Fully serviced rooms and facilities for Specialist Consulting are available t 4VJUF )PMMZXPPE 4QFDJBMJTU $FOUSF 95 Monash Avenue, Nedlands. Any enquiries can be directed to Mrs Rhonda Mazzulla, Practice Manager, Suite 31 Hollywood Specialist Centre 95 Monash Avenue Nedlands, WA 6009 Phone: 9389 1533 Email: suite31.hollywood@bigpond.com JOONDALUP Modern sessional suites available in Joondalup CDB Secretarial support available if required. Phone 9300 3380

NEDLANDS Hollywood Medical Centre- Sessional suites available with Secretarial support if required. Please contact 0414 780 751

MANDURAH SPECIALIST CENTRE Fully furnished consulting suites are now available on a sessional basis in the new Mandurah Specialist Centre. Reception support available if required. Phone: Graeme Dedman on 0413 065 009 Email: graemed@wacardiology.com.au

WEST LEEDERVILLE Specialists Consulting Suite (waiting room, office, consulting rooms). Onsite parking. Easy access to freeway. Phone: 9380 6457

JOONDANNA New medical centre in Joondanna. Only 5km from CBD. Excellent position on Wanneroo Rd, with ample parking. Suit GPs and / or allied health. Pharmacy and pathology on-site. For further details, contact Wesley Williams Ph 0414 287 537 Email williams.wesleyk@gmail.com SHENTON PARK Medical Rooms in Shenton Park for Lease. Newly furnishing premise with two medical consultation rooms available. The rooms are approved by local council for medical use. Premise is well located off Onslow Road. Ample street parking available. Suitable for medical practitioners or specialists to setup. Call Kevin on 0413 969 003 now! MANDURAH Mandurah Fully furnished rooms in large medical complex available for part or full time leasing. Within physiotherapy practice who supports multidisciplinary approach to treatment and 29 General Practitioners. Reception support available. Ideal for any medical professional looking to open their own practice or expand an existing practice. Email: enhancephysio@gmail.com

FOR SALE MEDICAL SUITE(S) 10 McCOURT STREET WEST LEEDERVILLE These well located 61sqm medical suite(s) with two car bays each are located opposite St John of God Hospital and ready for immediate occupation. GORDON TUCKER R/E 0408 093 731 gtrealestate@iinet.net.au

FOR SALE OR LEASE

WEST LEEDERVILLE Rare opportunity to secure a long term future in West Leederville. Property located on McCourt Street Subiaco – Available immediately. Well Presented premises – 113 m2 with ample off Street parking. All enquiries to Brad Potter – 9315 2599 / 0411 185 006. WEST PERTH Lincoln House, Ventnor Avenue, WEST PERTH t TRN 0GGJDF BSFB t VOEFSDPWFS DBS CBZ t 0OTJUF 1IBSNBDZ BOE $BG¸ Suit Medical Practitioner. Contact Lee Taylor on 0434 520 036 to arrange a viewing. Darrell Crouch & Associates Pty Ltd. (08)9242 3000 Email: leet@crouchgroup.biz web: www.crouchgroup.biz

LOCUM WANTED PERTH Locums / Associates wanted. Perth Medical Centre, Hay Street Mall. Busy accredited privately owned practice, private billing, flexible hours. Excellent remuneration for suitable candidates. Phone: 9481 4342 Mobile: 0408 665 531

RURAL POSITIONS VACANT ALBANY VR GP required to join our 4 Doctor, busy, friendly family practice. Full or Part time. We are Accredited, computerised, full nurse support, experienced Admin team. Excellent remuneration. Clinipath pathology on site. Phone Gaye - Practice Manager 9841 6711 Email: admin@hillsidefp.com.au BRIDGETOWN FT VR GP required to join our busy, long established country practice. DWS, RA3 We are non-corporate, fully accredited, computerised (Pracsoft / Medical Director) and mixed billing. Two nurses, experienced administration staff and well equipped practice. After hours and on call shared roster of one in five days and hospital admitting rights will be required. Generous remuneration. Contact Practice Manager – Leisha Blechynden 08 9761 1222 Email: btn_medical@wn.com.au

URBAN POSITIONS VACANT WEMBLEY GP wanted for long established private, accredited Wembley Practice. Sessions are negotiable but ideally Thurs/ Fri am or Mon to Fri pm or part thereof. Our practice is fully computerised using Med Director/Pracsoft. Practice Nurse on site, pathology and theatre. Adjacent services include Physiotherapist, Podiatrist, Psychologist and Dietician including diabetic educator. Please phone Pauline on 9381 9010 Email: wembleygp@westnet.com.au MT LAWLEY Edith Cowan University, Student Health Services, Mt Lawley campus. Part time VR GP with an interest in Women’s and Student Health required. Well-equipped medical centre, accredited, excellent work environment, Registered Nurse support, flexible work arrangements. For information: Dr Robert Chandler Phone: 08 6304 5618 E-mail: r.chandler@ecu.edu.au HILLARYS Exciting Opportunity. Join us in our brand new General Practice located NOR. Non-corporate. We require a full-time or part-time GP for our practice. Hours to suit. No evening or weekend work required. The practice is fully computerised and well equipped. Private Billing and some bulk-billing Full-time Nursing support. Pathology on site. Please contact Practice Manager on 9448 4815 or Email: smc@westnet.com.au FREMANTLE General Practice in Fremantle requires VR GP FTor PT for privately owned family practice. Accredited, computerised with fulltime Nurse support available. 65% of billings. Phone: Practice Manager 9336 3665 CANNING VALE Part time VR doctor wanted to join very busy family practice. Fully computerised, excellent treatment room with full nursing support. Opportunity to extend hours in the near future. Email your resume to kate.westlake@canningvalemedical.com or telephone Neda 0414 641 963 SOUTH PERTH VR GP required FT & PT Excellent River location in South Perth. Non-corporate, private billing, fully computerised. Friendly and efficient support staff. F/T registered nurse and onsite pathology. For more information contact Paris on 9367 1185. Email: bhabibi@bigpond.com

AUGUST 2013 - next deadline 12md Tuesday 16th July - Tel 9203 5222 or jen@mforum.com.au

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

WEST LEEDERVILLE - GREAT LIFESTYLE Part time VR GP invited to join long established West Leederville family practice. Computerised, accredited and noncorporate with an opportunity to 100% private bill if desired. Lots of leave flexibility with six female and one male colleague. Email: practicemanager@eftel.net.au or Jacky 9381 7111 FREMANTLE Fremantle Women’s Health Centre requires a female GP (VR) to provide medical services in the area of women’s health 1or 2 days pw. It is a computerised, private and bulk billing practice, with nursing support, scope for spending more time with patients, and provides recently increased remuneration plus superannuation and generous salary packaging. FWHC is a not-for-profit, community facility providing medical and counselling services, health education and group activities in a relaxed friendly setting. Phone: 9431 0500 or Email: Diane Snooks - director@fwhc.org.au or Dawn Needham clinical-manager@fwhc.org.au MELVILLE Rare chance for happy and motivated GP to replace long-term colleague moving soon from our stable, unique & boutique private, 6 Dr, General Practice here in Melville. Great Staff, Nursing & Allied Health support. Confidential enquiries welcomed to Robyn (Mgr) Tel: 9330 3922 a/h 0417 920 525 Email: health4u@westnet.com.au BENTLEY GP VR needed for privately owned family orientated practice. 15mins from Perth CBD, AGPAL accredited, fully computerised using MD/Pracsoft. Private billing. Supported by clinical and CDM nurses operating from purpose built practice. We offer 65% of billings. Contact Alison on 0401 047 063 BEACONSFIELD Well established, niche family friendly practice seeking VR Female GP to work flexible days and hours. Fully computerised and accredited. Good mix of private and bulk billing. Please contact Practice Manager Linda on 9335 9884 or Email: centralavenuemc@optusnet.com.au

NORTH PERTH View Street Medical requires a GP F/T or P/T. We are a small, privately owned practice with a well-established patient base, computerised & accredited with nurse support. Ring Helen 9227 0170 MT HAWTHORN Mt Hawthorn Medical Centre, a noncorporate accredited long established practice situated in a fast growing inner city suburb of Perth, seeks a part time or full time VR GP to join this highly desirable practice. Fully computerised, Nurse Assistant. Phone Rose 9444 1644 NORTH BEACH Part time GP to join our GP owned practice 18 minutes north of the Western Suburbs. Flexible hours and mixed billing. An interest in either women’s health or men’s health will assist our two existing GP’s. A recent closure in a neighbouring suburb has increased the demand for appointments. On site pathology, psychologist and nurse support. Supportive allied services close by. Please contact Helen or David 94471233 to discuss or Email: reception.nbmc@ bigpond.com UNIVERSITY OF WESTERN AUSTRALIA, CRAWLEY VR GP required for our fully computerised, accredited, well equipped and newly renovated practice. Our busy centre is complimented with full time nursing staff, Mental Health Nurses, Physiotherapy and onsite Pathology and Pharmacy. Sessions negotiable - no evening or weekend work required. Very friendly team, attractive remuneration and free, reserved bay parking on campus. Please contact Judi Hicks, Practice Manager, judith.hicks@uwa.edu.au or Dr Christine Pascott christine.pascott@uwa.edu.au Ph: 6488 2118 DIANELLA Non Corporate practice requires F/T and P/T VR GP’s to join 6 female and 1 male doctor team. Our newly extended, long established, accredited, fully computerised practice is supported with 4 excellent nurses and 5 very friendly admin staff. Our practice is mostly private billing and we offer excellent remuneration. Please contact Practice Manager on 9276 3472 Email: dfmc@dianellamedical.com.au MADDINGTON Maddington (DWS) is looking for a VR full-time GP. This privately owned and managed practice will offer up to75% billing to the right doctor. Various locations North, South and CBD also available. Please contact Phil on 0422 213 360 Email: phil27bc@gmail.com

BAYSWATER Wanted General Practitioner (VR) F/T or P/T required within our friendly non corporate medical practice. We are a fully computerised, wellequipped, teaching, accredited general practice seeking an enthusiastic person to join our team with a view in assisting our growing patient load. We are a proudly independent practice which offers a friendly environment, flexible working hours, pleasant rooms, great staff, with wonderful patients. Email resume to: manager@walterrdegps.com.au or Fax: 9279 1390 MOSMAN PARK A friendly, non-corporate, fully computerised practice in Mosman Park is looking for a GP to work part or full time. Hours and days flexible. Remuneration 70% of gross billings. Tel: Jacinta on 9385 0077

MANDURAH - YOUTH HEALTH Peel Youth Medical Service is seeking a youth-friendly GP for 1 – 2 sessions per week. Exciting opportunity to work with young people, with a focus on mental and sexual health in a supportive practice. Flexible session times available. Contact Sharlene 9581 3352 Email: sharleneh@gpdownsouth.com.au PORT KENNEDY Port Kennedy Medical Centre requires a full time general practitioner. Walk into a full patient base from day one with the support of experienced administration staff, nursing support and practice manager. The centre has a four bay fully equipped treatment room, with two procedure rooms and onsite pathology. This is a great opportunity to join a wellestablished and busy bulk billing clinic. For confidential enquiries contact: esther.mortimer@ipnet.com.au or 0418 371 724. PARMELIA Parmelia Medical Centre This SOR practice requires a full time general practitioner. No patient base is necessary for this predominantly bulk billing practice. You will be supported by diligent administration, nursing support and longstanding experienced practice manager. This spacious practice consists of a six bay treatment room, two procedure rooms and thirteen consult rooms. Pathologist, Pharmacist, Physiotherapists and Podiatrist is conveniently located onsite. For confidential enquiries contact: esther. mortimer@ipnet.com.au or 0418 371 724

79 MINDARIE URGENT Harbour Side Medical Centre is looking for a female VR GP. 70% billing. Open 7 Days. On site pathology. Please contact on 0417 813 970, 9304 6098 or Email: mmutahar@ harboursidemedicalcentre.com.au

FREMANTLE Part time or Full time (preferably VR) GPs wanted. ELLEN HEALTH is a doctor-owned and managed General Practice operating from two locations in port city of Fremantle. Well established patient base, offering a broad suite of services including nutrition and lifestyle, specialised pregnancy and midwifery care, community mental health nursing and skin clinic consultations. If you were to join our team we will offer you: t " HSPXJOH EBUBCBTF PG 1SJWBUF Billing patients t " QSPGFTTJPOBM BOE EFEJDBUFE support team t " MJGFTUZMF UBJMPSFE UP UIF MPDBUJPO t )PVST PG XPSL UP TVJU PVS CBMBODFE lifestyle approach - Practice hours are Weekdays 8am-6pm, Saturday, 8am-4pm - No after hours, on-call or hospital work required at this time t )JHI MFWFM PG FBSOJOHT Contact Practice Manager Bridie Hutton 0413 994 484 Email: bridie.hutton@ellenhealth.com.au

APPLECROSS FULL TIME GP wanted. A rare opportunity to join Reynolds Rd 7 Day Medical Centre has just presented itself as a long term colleague moves out of general practice. Commencing now, don’t miss out on your chance to join this private billing, vibrant practice with immediate access to a full patient data base. Confidential enquiries to the practice manager 9364 6633. MINDARIE Experienced GP required Part time / After Hours at busy Northern Suburbs Clinic. Billing percentage dependant on experience. Fully computerised and accredited. Flexible hours. Open 8.00am to 9pm daily. On site Physio, Dietician, Psychologist, Pathology, Diabetic Educator. Please call Dr Melad Benyamine on 0412 902 522 to arrange an interview.

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AUGUST 2013 - next deadline 12md Tuesday 16th July - Tel 9203 5222 or jen@mforum.com.au

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medical forum

NEDLANDS Full time or sessions available for VR GP in brand new 2-doctor, non-corporate practice in shopping centre Predominantly private billing, weekends optional. Close to UWA. Onsite practice nurse, pharmacy, physiotherapy, podiatry and dietitian in shopping centre. Please contact Vasanthi at 0402 440 966 Email: nedlandsdoctor@yahoo.com.au

INGLEWOOD / Mt LAWLEY GPs Required for Skin Checks Unique opportunity to join a busy noncorporate skin cancer practice. Friendly atmosphere with strong emphasis on quality and patient service. Urgent need for VR doctors to perform skin checks. No dermoscopy experience required. Flexibility to explore any area of skin cancer medicine of your choosing, from dermoscopy, biopsies, to surgical procedures. Fully computerised, with modern facilities and nurse support. Great peer support with continuing education and training. Suit VR doctors looking for reduced paperwork, flexible hours and above average income. Please contact admin@skincheckwa.com.au

QUEENS PARK Looking for GP VR to join our growing medical centre. Efficient, helpful admin staff and RN support. Mixed billing, excellent facilities, accredited and fully computerised. On-site physiotherapy, occupational health and pathology. Please phone Tim 9356 8993 Email:admin@queensparkmedical.com.au Website: www.queensparkmedical.com.au WOODLANDS P/T or F/T VR GP wanted to join happy, non-corporate, mainly private billing practice. Good mix of patients, no weekends or afterhours. Great location, RN support. Would suit female GP. Contact help@thewoodsmedical.com.au or 9204 3900 MANDURAH Mandurah coastal lifestyle 40 minutes from Perth. VR non VR doctor required short term or long term. No weekends or after hours. Good remuneration. Clinic has full time nurses, pathology, psychology, hearing centre, dermatologist and orthotics. Contact practice manager Elaine 9535 8700 Email: elaine@mandurahdoctors.com.au

CANNING VALE Seeking GP’s to work in a new purpose built practice in Canning Vale. Modern, Fully computerised and equipped with a Practice Nurse available. Also Pathology and Dental onsite. Please forward interest to ahgpcvale@gmail.com or contact the Practice Manager on 0416 022 721 GREENWOOD Greenwood/Kingsley Family Practice In today’s market where there is an oversupply of GPs, are you feeling frustrated that you have to work exceedingly long hours and with little take home income? Are you pressurised to bulk-bill in order to stay afloat on today’s competitive GP market? Are you committed to offer quality personalised services to your patients? Are you to looking for likeminded GPs to work with? Come and have an obligation free confidential chat with us. Average gross billing $ 2500 to $ 3000 a day achievable for GPs who offer exceptional services to our clients. Contact Dr Chao 0402 201 311 or Email shenychao@hotmail.com Sorry we do not have DWS status.

SORRENTO V/R GP for a busy Medical Centre in Sorrento. Up to 75% of the billing Contact: 0439 952 979 BULLCREEK Come and join us in our New General Practice located SOR. Non-Corporate Practice. We require a Part-time VR GP for our Surgery. Tuesday afternoon, Wednesday All Day, Thursday mornings and Friday Morning’s available. The surgery is Computerised, Private and Bulkbilling. Practice Nurse available part-time. Please contact the practice manager Annette on 9332 5556

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Looking for a lifestyle change? A great opportunity exists in the Western Australian town of Cunderdin. Be your own boss and become part of a warm and friendly community. The Cunderdin Medical Practice is a well supported computerised practice that is now for sale! Get the right work/life balance with part-time or full-time hours available. As Cunderdin is part of the Wheatbelt region of Western Australia, the successful general practitioner will receive generous incentives through the Southern Inland Health Initiative plus take home 100 per cent of billings (estimated $500,000), with minimal outgoing costs. The practice has been established for 17 years and is accredited until May 2015. The package includes a Shire supported five bedroom furnished house and two suite surgery, both rent and maintenance free, with car and fuel supplied.

If you are looking for a change of pace, contact Brad Potter at The Health Linc on T 08 9315 2599 today to enquire about this unique opportunity!

www.ruralhealthselect.com.au AUGUST 2013 - next deadline 12md Tuesday 16th July - Tel 9203 5222 or jen@mforum.com.au

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CVS are a leading cardiology practice that provides high quality diagnostic stress testing services. We are seeking medical practitioners who meet the following pre-requisites: ‡ 5HJLVWUDWLRQ ZLWK WKH $XVWUDOLDQ 0HGLFDO %RDUG ‡ 0HGLFDO ,QGHPQLW\ ,QVXUDQFH ‡ /LIH 6XSSRUW 6NLOOV RU H[SHULHQFH ‡ +LJK UHJDUG WR GHOLYHU RXWVWDQGLQJ SDWLHQW FDUH ,I \RX PHHW WKHVH SUH UHTXLVLWHV ZH ZHOFRPH \RX WR MRLQ RXU WHDP RI VSHFLDOLVHG 0HGLFDO 3UDFWLWLRQHUV 6WUHVV 3K\VLFLDQV $V D 6WUHVV 3K\VLFLDQ \RX ZLOO ZRUN ZLWK VWDWH RI WKH DUW GLDJQRVWLF HTXLSPHQW FRQGXFW TXDOLW\ VSHFLDOLVW WHVWLQJ DQG LPSURYH \RXU GLDJQRVWLF (&* VNLOOV $Q DWWUDFWLYH UHPXQHUDWLRQ SDFNDJH ZLOO EH RIIHUHG WR VXFFHVVIXO FDQGLGDWHV DV ZHOO DV H[SHULHQFLQJ H[FHOOHQW MRE VDWLVIDFWLRQ DQG ZRUNLQJ FRQGLWLRQV CVS locations include: Joondalup, Karrinyup, Nedlands, Midland, Mt Lawley, Leeming, East Fremantle and Rockingham. 3OHDVH SKRQH $GDP /XQJKL WR GLVFXVV RSSRUWXQLWLHV DW &96 RQ 1300 887 997 or 0402 825 570 RU YLD H PDLO info@cvs.net.au

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stralia’s Coral Coast.

Exciting new business opportunity Exmouth, a beautiful coastal town in the north of Western Australia, has brand new premises available for an entrepreneurial general practitioner, providing you with the opportunity to run your own practice as the first private general practice in town. There is also potential to focus on occupational and dive medicine as well as family practice.

Brand New State of the Art Medical Centre

Open now iin Armadale Cannington cent centre opening soon Candiid Candidates idates must have FRACGP or equivalent. Centre rees ar aree located loca lo c t in DWS areas. Centres

Exmouth offers a wonderful lifestyle. It is located on the edge of the pristine Exmouth Gulf which is the gateway to Ningaloo Reef and Cape Range National Park, providing access to some of the most stunning scenery and wildlife in the State.

If you are looking for a rare opportunity to combine business and lifestyle, this is the practice for you! For further information, contact Rural Health Select on: T 08 6389 4500 | E recruit@ruralhealthselect.com.au

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

www.ruralhealthselect.com.au

85% take home,

enjoy exible hours, less paperwork, & interesting variety...

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

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

Contact Trudy Mailey at WADMS

(08) 9321 9133

F: (08) 9481 0943 E: trudy.mailey@wadms.org.au www.wadms.org.au

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

ARE YOU READY FOR A CHANGE? We are looking for specialists and GP’s to join the expanding team! Tenancy and room options available for specialist’s. Procedural GP’s and ofďŹ ce based GP’s well catered for. Contact Dr Brenda Murrison for more details!

9791 8133 or 0418 921 073

WADMS is AGPAL registered (accredited ID.6155)

AUGUST 2013 - next deadline 12md Tuesday 16th July - Tel 9203 5222 or jen@mforum.com.au

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