Challenges t New DGâ€™s Vision t AGPAL Transparency? t Whoâ€™s Using Telehealth t Guest Columns: Marriage Equality, Hooked on Phones t Clinicals: Testosterone; Male Suicide; Iron; Hep C; Diabetes & More...
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Freedom, or Nothing Left to Lose? It’s been brewing for a while, this dilemma about who we can trust. FIFA, CCC, the ongoing sexual abuse crisis within the Catholic Church and other institutions entrusted with the care of young lives. Corruption or the temptation to act corruptly seems to be a contagion in our society, or is it that we just get to hear about these crimes more often these days? This Th past month the media have focused fo on the death of the entrepreneur, en Alan Bond. The oftrepeated re phrase that grabbed our attention at was “the end of an era”. Of O course, in this context it was Mr M Bond’s inextricable link to the businessmen b and politicians of the t ‘heady’ 1980s – the group of characters c we now collectively dub, WA W Inc. When W the empty Bollinger bottles were swept away and the state sobered up, it was the start of the recrimination season bringing with it several prison terms and, we were told, the ushering in of a new era of unprecedented governance, transparency and accountability. Ms Jan Hallam
Journalists were quite rightly criticised for ﬁddling while Rome burned or, worse still, letting the then Premier write their stories for them. The legacy and burden of the Burke era of government was the spawning and subsequent proliferation of the spin industry that now inﬁltrates every pore of society, health included. Spin is the disrupter of truth and truth seeking, so when we think we know more about what’s going on in the world, the bald fact is that we only know what we’re allowed to know. More information does not equate to receiving the right information. The few warriors of truth left in our newsrooms would probably all tell you that they are, or have been, in receipt of letters from defamation lawyers because they have asked too many of the right questions. If spin hasn’t dulled our hunger for truth, transparency and accountability, the aftermath of the 9/11 attacks has given our governments even more power to control what we’re told by adding fear to the national conversation and this has had ﬂow-on effects. If governments can withhold information or act by proxy without consultation in our ‘best interests’, it gives permission for other organisations to do likewise.
PUBLISHERS Ms Jenny Heyden - Director Dr Rob McEvoy - Director ADVERTISING Mr Glenn Bradbury (0403 282 510) email@example.com
EDITORIAL TEAM Managing Editor Ms Jan Hallam (0430 322 066) firstname.lastname@example.org Medical Editor Dr Rob McEvoy (0411 380 937) email@example.com
Last month there was disquiet in the profession about how insular our representative organisations are becoming with accusations that the views of those within the inner sanctum are unresponsive to the views of the wider membership. If members of organisations are not informed by way of statutory reporting and disclosure then those organisations are no longer representative at all; they are merely ﬁefdoms and hence their inﬂuence to shape and dictate the public agenda should be subject to greater scrutiny. Medical Forum has a history of posing difﬁcult questions to organisations that directly impact on the way doctors go about their business but persistence doesn’t always reap meaningful answers. A case in point? We still await responses to questions from AGPAL regarding their governance issues. Perhaps it thinks our readers are not important, or those general practices that pay money for accreditation services trust them so implicitly they don’t need to bother. The professional watchdogs AHPRA and the Medical Board have acknowledged in our magazine that they need to communicate better with the profession. But apparently when it comes to questions about transparency, particularly in the area of panel selection, it’s in the public’s interest to say nothing rather than to eradicate the shadows of rumour and innuendo by stating the facts. So what are we all left to think? As a media organisation, experience suggests there might be something to hide. Why else would you allow a chorus of dissent to become a crescendo? As readers and as individuals open to its judgements, a perception of unfairness creeps in before the conversation has even begun. In the so-called communication age, this is a patently absurd situation. More than ever, as the health budget continues to soak up national revenue and governments search for creative ways to save money rather than improve outcomes, we will be relying more on NGOs and private businesses for service delivery. We desperately need laws that insist on transparency and accountability. We can start by insisting that our leaders stop behaving as if we don’t really matter much at all and we can all continue to ask questions.
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10 FEATURES 10 Spotlight – Swimmer Shelley Taylor-Smith 16 21 22 25
NEWS & VIEWS 1 Editorial: Freedom, or
Mr Peter McClelland
Nothing Left to Lose
Trailblazer – Dr David Russell-Weisz Flight to Freedom – Dr Hussein Farah Curtin Medical School Where to Telemedicine?
Ms Jan Hallam
Letters: Picking a Psychologist Dr Jillian Horton PhD
Snowball Report Delayed Ms Barbara Levings
What’s in a Name? Dr Mark Hanikeri
LIFESTYLE 48 Boston Marathon – Dr Jane Deacon
Competitions Wine Review: Schild Estate Dr Martin Buck
52 52 53
Funny Side Theatre: Hamlet Musical: Dirty Dancing
Keynote Speaker? Try the App Mr Sam Lynch
Curious Conversations: Dr Will Patterson
12 15 18 33 35 41
Have You Heard? Male Suicide; Medical Board; Bullying Transparency and AGPAL Beneath the Drapes RACGP Budget Submission Testosterone Replacement Dr Rob McEvoy
Our cover: Dr David Russell-Weisz.
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Dr Clare Matthews App Reviews: Smiling Mind; Mindshift
Dr Johan Janssen Cardiology & Diabetes
Mr Jonathan Kester Stressors of our Times
Dr Darryl Menaglio Suicide Resurgence in Men
Dr David Millar Testosterone Prescribing
Dr Sonja Raven Back Pain – MRI?
Dr Steve Ward Tips for Iron Deﬁciency
Ms Louise Keyes Iron in Pregnancy
Dr Brionhy Smith Chronic Hepatitis C
Ms Maxine Drake Gay Pride and Prejudice
Dr Lucia Kelleher Smart Phones – Good, Bad and Ugly
A/Prof Sam Winter Lost in Transition
Dr Adam Dunn Who Funds Must Win
INDEPENDENT ADVISORY PANEL for Medical Forum John Alvarez (Cardiothoracic Surgeon), Peter Bray (Vascular Surgeon), Chris Etherton-Beer (Geriatrician & Clinical Pharmacologist), Joe Cardaci (Nuclear & General Medicine), Alistair Vickery (General Practitioner: Academic), Philip Green (General Practitioner: Rural), Mark Hands (Cardiologist), Michele Kosky AM (Consumer Advocate), Olga Ward (General Practitioner: Procedural), Mike Ledger (Orthopaedic Surgeon), Stephan Millett (Ethicist), Kenji So (Gastroenterologist) MEDICAL FORUM
Letters to the Editor
Picking a psychologist Dear Editor, The regulation of psychology training under APHRA has changed, important when making an informed choice about where to send patients for psychotherapy. Currently, psychologists can only hold general registration and the title â€˜psychologistâ€™ applies to multiple standards of training. A registered psychologist may have, in addition to a four-year undergraduate degree in psychology: sĂĽ TWOĂĽYEARSĂĽOFĂĽSUPERVISIONĂĽor, sĂĽ AĂĽONE YEARĂĽPOSTĂĽGRADUATEĂĽDEGREE ĂĽPLUSĂĽONEĂĽ year of supervision (this is new) or, sĂĽ TWO YEARĂĽMASTERSĂĽSPECIALISED ĂĽDEGREE ĂĽPLUSĂĽ two yearsâ€™ (specialised) supervision or, sĂĽ AĂĽTHREEFOURĂĽYEARĂĽPROFESSIONALĂĽDOCTORATE ĂĽ plus (specialised) supervision or, sĂĽ RESEARCHĂĽ0H$ĂĽPLUSĂĽSUPERVISIONĂĽ Everyone above can call themselves a â€˜psychologistâ€™ and can practise unrestricted in all professional areas of psychology. Australia has one of the lowest standards for registration and professional practice in the OECD. However, psychologists with at least a Masters degree plus two years of specialised supervision, can be â€œendorsedâ€? to use expert titles. There are nine endorsed titles in Australia: Clinical Psychologist, Counselling Psychologist, Educational and Developmental Psychologist, Health Psychologist, Clinical Neuropsychologist, Forensic Psychologist, Organisational Psychologist, Community Psychologist, and Sport Psychologist.
International training standards (UK and USA) require a minimum of masters training plus specialist supervision to be fully registered. International standards are met by psychologists in Australia who have completed a two years masters or professional doctorate plus specialist supervision. They will have one of the nine endorsed titles listed above, for example, the terms â€˜Clinical Psychologistâ€™ or â€˜Counselling Psychologistâ€™ would be appropriate for someone referred for psychotherapy. Dr Jillian Horton PhD, Senior Clinical Psychologist, President Australian College of Advanced Postgraduate Psychologists ........................................................................
Snowball Report Delayed On June 14, we wrote to Mr Jack Snelling, MP, Chair, COAG Health Ministersâ€™ Council, including copies of articles on AHPRA and the Medical Board from the March, May and June editions of Medical Forum magazine. We included comments and polled opinion from doctors in WA. We pointed to considerable disquiet in WA about how AHPRA and the WA Medical Board conduct their affairs, particularly over the lack of transparency and accountability, and suggested that not releasing the report by Kim Snowball on the performance of AHPRA and the Medical Board at the endof-April as originally ďŹ‚agged, simply deepened the perception of lack of accountability and transparency. This is the response we received.
an extensive consultation process which included over 230 written submissions and the involvement of more than 1000 individuals in consultation forums held in each capital city. This level of consultation has allowed the consumers, practitioners, health and education providers, professional associations, National Boards and other stakeholders to raise their concerns directly with the Independent Reviewer. Health Ministers acknowledge the work of Mr Snowball in ensuring a comprehensive review process. At their meeting on 17 April 2015, Health Ministers noted that the recommendations arising from the NRAS Review are designed to enable the National Scheme to fulďŹ l the objectives as set out by Health Ministers at the time of its establishment. Given the wide ranging nature of the NRAS Review and the importance on the National Scheme to the health system, Health Ministers have requested time to consider the recommendations from the NRAS Review in detail and have agreed to consider each of the recommendations at their meeting in August 2015. Pending these discussions, the Ministerial response and the Final Report will be made publicly available. Ms Barbara Levings, Secretary, COAG Health Council Secretariat ........................................................................
Whatâ€™s in a name? Dear Editor,
Thank you for your email regarding the Final Report on the Independent Review of the National Registration and Accreditation Scheme (NRAS) for health professions (â€˜the Reviewâ€™).
Dr Oates makes several good points about the lack of regulation of the cosmetic surgery industry in his letter (Cosmetics Need Review, June edition). I agree that the AHPRA
The NRAS Review was conducted by Mr Kim Snowball, the former Director General of WA Health. The NRAS Review comprised
continued on Page 6
Dear Dr McEvoy
Medicine of the Air Dr Will Patterson, Clinical Lead RFDS, has a day job that shakes off the surly bonds of earth but retains a strong focus on family life. The scariest moment Iâ€™ve had in an aeroplane wasâ€Ś actually, Iâ€™ve yet to feel that way. In fact, I wanted to be a ďŹ ghter-pilot! My greatest thrill was doing aerobatics in the school Air Training Corps and the ďŹ‚ying I do today is very tame compared with a â€˜stall turnâ€™ in a RAF trainer. If I could take one year off and do something other than medicine Iâ€™dâ€Ś host a radio show asking people why they came to Australia, what they miss about their old life and if their dreams have been fulďŹ lled. I ďŹ nd peopleâ€™s stories fascinating and I also think we underestimate the resilience required to leave family and friends behind.
I think one of my greatest strengths isâ€Ś staying focused and balancing the needs of three young children while doing three jobs that are pretty full-on. This only works because my wife and I are a great team. One person who had a profound effect on me wasâ€Ś my mother, who came from a generation that embraced self-sufďŹ ciency, determination and personal sacriďŹ ce. Such qualities are, in todayâ€™s entitlement culture, sadly lacking. In 10 yearsâ€™ time Iâ€™d love to beâ€Ś respected by my children who will be 13, 15 and 17 year-old teenagers. A potential nightmare! We can only do our best as parents and if theyâ€™re healthy, manage to avoid drugs and are passionate about their choices in life, Iâ€™ll be more than happy.
Letters to the Editor continued from Page 4 review of this regulation is appropriate and well overdue. In addition to regulation of the industry, there is a long overdue need for regulation and enforcement of rules pertaining to representation of specialist credentials. Doctors who label themselves by titles that are not representative of their fellowship qualiﬁcations and advanced training are misleading their colleagues and patients and in my opinion, this has the potential to produce adverse outcomes. All Plastic Surgeons have trained in bony ﬁxation and management of hand fractures. They do not mislead their patients or colleagues by calling themselves “Hand Orthopaedic Surgeons” or “Orthopaedic Surgeons”. The lack of regulation of the cosmetic surgery industry and the secondary gain associated with using the term “Plastic” in one’s title has led to surgeons from a variety of specialty backgrounds inserting the term “Plastic” into their descriptor and on occasion completely dropping the actual descriptor of their primary qualiﬁcations from their titles in marketing, websites and stationery. This could mislead doctors and patients to believe they have advanced training in areas of surgery that no such training has been achieved.
Editorial Comment Readers have asked about how we handle Sponsorship… Medical Forum ﬁercely protects its editorial independence, the main reason for the magazine’s high readership in WA. We know doctors scan for bias and reject any editorial considered ‘cash for comment’, and so do we. To be extra sure, we ask clinical authors to provide competing interest declarations. While we aim to give advertisers and sponsors the best exposure – their support allows doctors to read Medical Forum free-of-charge – we set ethical limits and guidelines to protect our readers. For example, ‘Advertising Feature’ is added to anything where confusion arises over authorship, and no advertiser is shown independent editorial before publication.
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.
Dr Oates rightly points out that it would be inappropriate to require psychological assessment for teenagers seeking otoplasty. However, psychological assessment is entirely appropriate for teenagers seeking breast cosmetic surgery (lift, reduction or augmentation), rhinoplasty or body contouring surgery at this age. Psychological testing in this age group would aid in determining the maturity of the patient to accept a change in their physical appearance or even their ability to accept the implications of an adverse outcome. I agree with Dr Oates’ concluding statement that, “We need to keep reviewing how we provide the service in a way that beneﬁts the patient”. I believe this should start with accurately presenting our specialist qualiﬁcations. Dr Mark Hanikeri, Specialist Plastic, Reconstructive and Cosmetic Surgeon, Subiaco ........................................................................
Keynote speaker? Try the app
inviting their participation becomes easy with an integrated event app. A well-designed and easy-to-navigate app uses maps and diagrams to show attendees the way to their next session, how long they have to get there and even directions to a particular exhibitor in the Expo Hall. There is no need for a printed guide. Continuing education is a key component of conferences today. A mobile app can help attendees track the session they attend and provide real-time information on their Continuing Professional Education status and qualiﬁcations, even up to the session they just completed. You can also provide access to ePosters and have all the session presentations immediately available from within the app. Some conference organisers use event apps well and others not so well. Given the maturity of the app market, conference attendees should be demanding a useful, engaging and easy-to-use app at all the conferences and events they attend. Mr Sam Lynch, Project Manager, JomaBlue ........................................................................
Dear Editor, RE: Mobile Apps for Health, April edition. There is an App for just about anything these days and there is an expectation that conferences and events you attend have their own mobile app. Many conferences can tick the ‘event app’ box, but, without engaging user features and user experience, a conference app can be a waste of time and money. A good conference app will never force attendees to behave in ways that are unfamiliar – like sending messages through an app when they are already familiar with SMS messaging – and never make them use the app to accomplish something they already have a favourite app to do – like note taking using Evernote or OneNote.
We welcome your letters and leads for stories. Please keep them short. Email: firstname.lastname@example.org (include full address and phone number) by the 10th of each month. Letters may be edited for legal issues, space or clarity. You can also leave a message, completely anonymous if you like, at www.medicalhub.com.au.
Providing timely and accurate information to conference attendees becomes simple with a good event app. When attendees can create their own event schedule, sending last minute changes to the event schedule automatically notiﬁes those attendees. An app is also a great tool for inviting audience participation during sessions, like asking questions of the session presenter and submitting votes via real time polling features. Engaging the audience and
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Gay Pride and Prejudice As marriage equality looms larger, disability advocate Ms Maxine Drake reﬂects on her lifelong journey against prejudice. At 52, my adult life has tracked the last major era of gay liberation in this Western country of Australia. I have been ‘proud’ most of that time, blessed with no religious upbringing or deep prejudices of my own to battle through, just those views reﬂected back to me from the society I was forming in. I also entered my adult life in a city that I did not grow up in, one of thousands of transcontinental refugees in Australia at the time, so was permitted freedoms that come from relative anonymity. As a patient in medical encounters, I know that I have moved from awkward silence about my sexuality to being able to declare it as a statement of fact, amongst many other facts about who I am. My journey is the community’s journey in large part, from awkwardness to some new maturity about the bestowed nature of homosexuality. The imprint of prejudice stays with me though because the general shape of prejudice comes from an averaging out of the hateful with the generosity that people can show to you – in
the context of the leeway society gives us to be either hateful or friendly. There is still some permission within social discourse for people to hold and express views that demean our humanity, so we remain vulnerable, whether we are young and new to our emerging sexuality or older and a bit tougher. All we need from our doctors is that any personal prejudice not show. We accept prejudice but we expect professionalism.
The imprint of prejudice stays with me though because the general shape of prejudice comes from an averaging out of the hateful with the generosity that people can show to you – in the context of the leeway society gives us to be either hateful or friendly.
Church organisations may be holding onto some outdated claim to be explicitly discriminatory but that is an ‘outlier’ position in the modern world. Free speech permits expressions of opinion about homosexuality and heterosexuality and all the variations on that continuum but there is no place for these in the medical consultation. As a patient I am not a stereotype to be tested but will happily answer genuine questions based in a willingness to understand. The Irish referendum result moved me to private tears. Brand new, repressive Russian laws are a shocking reminder of the fragility of our progress and make our freedoms bittersweet when we know peers are being killed with the sanction of that state. Here in Australia we are in a season of open discussion of a deeply private and important human and civic question. ‘Do no harm’ applies equally to us all.
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Caution: Dangerous When Wet The personal challenge of competition has spurred world swimming champ Shelley Taylor-Smith to great heights both in and out of the water. The only woman to compete with men and beat them in one of the toughest sports imaginable is WA’s own Shelley Taylor-Smith. At the end of her career she topped the world rankings in Open-Water Marathon swimming and pushed out the boundaries for female athletes. Not bad for a kid who once staggered around Tuart Hill High School crippled with scoliosis. “When I look back at some of the roadblocks in my life – my spinal problems and my father dying from emphysema when I was 15 – there’s no doubt they helped to foster a great deal of resilience and certainly prepared me for life as a marathon swimmer.” “I only started swimming as a kid because my younger sister was asthmatic, and back then she was the one with all the talent!” “Dad’s death had a major impact on our family. He worked as a chaplain in the navy, but he was also a stoker and that’s where the lung cancer stemmed from. Mum became an armed forces widow but it took her 30 years to ﬁnally receive a pension and it was never back-dated. It made life very tough for all of us.” Fighting to stay in the swim “We were very much working-class but we never wanted for anything and always felt loved. The doctors wanted to put a steel rod in my back which would’ve meant the end of swimming for me. I begged mum and dad not to let that happen and they supported me. I owe them a lot.” Throughout the 1990s Shelley was smashing world records from Manhattan to Wollongong but it didn’t begin quite so auspiciously.
Shelley’s Record så åXå7OMENSå7ORLDå-ARATHON Swimming Champion så åXå7INNERå-ANHATTANå)SLANDå3WIM så å7ORLDå3WIMMINGå2ECORDS så å)NDUCTEDå)NTERNATIONAL Swimming Hall of Fame så 3WANå2IVERå4RUSTåANDå"URSWOOD Park Board Member
“I failed miserably in 1991 and had my ﬁrst DNF [Did not Finish] and that’s something no athlete wants to see on their record. One of my competitors came up to me after the race and said, ‘Thank God, you’re human after all!” “I was suffering from severe hypothermia and my coach saved my life by pulling me out of the water. It was exacerbated by my menstrual cycle because that affects your body temperature, but nonetheless I felt overwhelmed by guilt and shame. I always took representing Australia very seriously.” “I spoke to an Argentinian competitor who was regarded as the King of Marathon swimming and he reminded me that how I responded to this setback was completely up to me. Two weeks later I ﬁnished ﬁrst in Atlantic City, the ﬁrst woman to win a professional event open to both men and women.” “I owe a lot to my male competitors because they brought out the best in me. That very same Argentinian swimmer later said to me, ‘Shelley, you are dangerous when wet!” Perils of swimming Towards the end of that golden decade it all came crashing down for Shelley Taylor-Smith and the catalyst was a training swim at a beach with an all-too familiar name. “In 1997 I was swimming at Shelley Beach near Manly in Sydney and my skin started to sting. The local sewerage pond had overﬂowed and I was swimming in it! My body felt as though it was burning and I must have ingested toxins because within hours I had vomiting and diarrhoea.” “It tipped me over the edge and I was having trouble even ﬁnishing a training session. Needless to say, I wasn’t selected in the Australian team but I continued preparing for a professional World Series race in Argentina.
A doctor told me I had Giardia, jaundice and Candida with Irritable Bowel Syndrome thrown in for good measure!” “He also said to me that if I didn’t heed the warning signs I’d be dead in six months.” Once again, Shelley’s resilience came to the fore and a race mid-way through the following year brought down the curtain on a stellar career. “I wanted to go out with a big win so I did one last deal with my body. On July 14, 1998, I won in Manhattan and that was 10 years to the day since my ﬁrst world title in France. That was as good as it gets and I stepped away from my sport doing exactly what I loved – racing men!” Swimming is a metaphor for life, says Shelley and she reinforces the importance of teaching children to feel conﬁdent in the water. “My motto is that if you don’t quit you’ll make it! The only limits are the ones we put on ourselves. I’m also pushing hard to get compulsory swimming back on the WA education syllabus. It’s the only sport that saves lives!”
By Mr Peter McClelland
Shelley Taylor-Smith in action at the 6th FINA World Championships in Perth in 1991 where she won the gold medal in the Wrold Open Water event (above).
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Have You Heard?
GPs lukewarm for PIP
PHNs kick off
The after-hours GP PIP announced in the May budget was welcomed by RACGP President and Mandurah GP Dr Frank Jones as a unique opportunity for GPs to provide continuity of care. But before the corks are popped, how the $98.8m for 2015-16 will be allocated is a little more complicated. There will be ﬁve levels ranging from $1 per Standardised Whole Patient Equivalent (SWPE) to $11 per SWPE depending on where and when after-hours services are delivered. Frank said general practice could certainly deliver urgent access services after hours (till 10pm depending on ﬁnances, manpower and local need). However, early results of a RACGP survey (actual numbers not ﬁnalised), were tepid with 54% encouraged by the payment. How the PIP will impact on or enhance the mobile after-hours services in WA remains to be seen. The patient demographics, problems dealt with, and testing, prescribing, and referrals generated for each AH service would interest us all.
The Primary Health Networks have ofﬁcially kicked in from July 1 and will receive $900m over three years to concentrate on six priority areas – mental health, ATSI health, population health, health workforce, e-health, aged care – with the aim of improving access to frontline services. PHNs will be aligned with local hospital area networks. A new national strategy for chronic disease management will replace the one devised in 2005. Diabetes has been ﬂagged as a priority. The mental health nurse program will be supported in 2015-16 for the 54,000 people with severe persistent mental illness living in the community. In WA, the three PHNs are being coordinated by the WA Primary Health Alliance. As reported, WAPHA’s board has Peel GP Dr Richard Choong as chair along with HealthEngine CEO Dr Marcus Tan, Dr Damien Zilm, and Dr Neil Fong among others. The WAPHA CEO is Ms Learne Durrington, former CEO of PCEM ML; the GM for Country WA is Ms Linda
Richardson, former senior manager of mental health services at PCEM, Perth North GM is Mr Andy Barnes, formerly of Price Waterhouse Cooper, and WAPHA was still recruiting the GM for Perth South at press time.
Disability hotline An abuse reporting hotline set up by People with Disabilities WA (PWdWA) and Developmental Disability WA received calls detailing complaints against a variety of WA institutions. PWdWA executive director Samantha Jenkinson told Medical Forum there were several complaints against schools that had a locked room restraint policy, while issues of physical and sexual abuse in disability enterprises and historic claims were also raised. Two callers were referred to the Royal Commission into Institutional Child Sexual Abuse. None of the calls involved aged care facilities. A report was presented to WA Senator Linda Reynolds to be included in the current Senate inquiry.
Healthdirect, check the checker Despite it losing its GP Helpline in the May budget, Healthdirect is forging on with a new initiative called Symptom Checker, the software for which comes from UK ﬁrm Capita Healthcare Decisions. You can’t miss it on Healthdirect’s website. However, giving it a test run, a couple of things struck us. Firstly there is a persistent pop-up that describes acute symptoms that might require an ambulance. That’s fair enough but it does get you edgy and returns at frequent intervals. Onto the survey, and for a UTI we were alarmed to be recommended to go to an ED for run-of-the-mill symptoms simply because there was no ﬁlter on the questions. As unnecessary ED attendance is the very thing Healthdirect is working toward, this needs reﬁning. Flu was a different matter entirely! In its media release it cites that 80% of Australians seek health information online – we suggest good information.
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Naming rights We have had calls this month over who should and shouldn’t call themselves surgeon, a particularly sensitive issue in the cosmetic medicine branch. The NSW Parliament is take a giant leap further by preparing legislation to ban GPs and other non-surgical specialists from claiming the title surgeon. Under the draft Bill, “Only medical practitioners who have been registered in the speciality of surgery (after completing extra training in the surgical specialty of choice) will be permitted to use the title ‘surgeon’. If passed penalties for breaches would be overseen by the current regulatory authorities. This move seems to be almost entirely motivated by complaints within the cosmetics ﬁeld, which reiterates the need for a thorough review of the sector by AHPRA… but legislation?
Healthway legislation delayed The interim board of Healthway has been announced (see Beneath the Drapes, P33) and it certainly struck us that the State Government appears to have made a thorough sweep of its executive ﬂoor to ﬁll the board positions. There is a swag of directors general keeping the Healthway wheels ticking over. However, the new legislation has been held up and by the time of us going to press, it looked unlikely to be introduced into Parliament before it rose on June 25. The Health Minister’s ofﬁce has promised a rundown after the winter break.
Minister backs nurses Australian Practice Nurses Association (APNA) was given a boost by the Health Minister Sussan Ley at its recent Gold Coast conference when she pointed out Medicare reforms were on the way and practice nurses were going to be important to them. She said the number of nurses working in general practice had doubled in the last 10 years to 12,000 (at least one nurse in two thirds of practices). With universities providing more undergraduate primary care courses, the Minister said the government recognised that practice nurses could deliver primary care services. (It was under Tony Abbott Health Ministership in 2004 that practice nurse Medicare item numbers for immunisation and wound care were introduced.) Expect more nursing roles under Minister Ley’s reforms – in areas of chronic disease management, service delivery, funding models and hospital interconnectivity, as well as consumer rules for better use of Medicare. The government recognises the need for better service delivery for people with chronic disease with block funding, and a focus on keeping people well and out of hospital.
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The WOMEN Centre has assembled a team of practitioners. Mel Mosey Midwife, Clinical and Research Nurse
Dr Paige Tucker Clinical and Surgical Assistant PhD Candidate
Dr Fred Busch Obstetrician & Gynaecologist
Dr Timothy Pavy Chronic Pain Specialist
Dr Paul Cohen Gynaecologist, Cancer Menopause Specialist Clinical Research Fellow
Dr Jeremy Tan General, Upper Gastrointestinal & Bariatric Surgeon
Dr Stephen Lee Obstetrician & Gynaecologist
Dr Lesley Ramage Women’s Health GP
Dr Jason Tan Gynaecologic Oncologist
Sarah O’Sullivan Genetic Counsellor
Helena Green Clinical Sexologist & Counsellor
Kealy France Women’s Health Physiotherapist
Dr Clay Golledge Physician in Infection Management
Jackie Framjee Clinical Nurse and Ward Nurse, SJOG, Subiaco
Because no one person has all the answers. As respected as our Gynaecologic Oncologist is, he’s no Sex Therapist. Our OB/GYNs are skilled at delivering babies, but can’t coax mothers with PND to bond with theirs. Part of being a great doctor or health professional is realising when you need to call on the support of others, to ensure your patient’s total wellbeing. When you refer a patient to the WOMEN Centre, you’re making sure she will be cared for physically and mentally by a team that includes a Gynaecologic Oncologist, Gastrointestinal and Bariatric Surgeon, Obstetrician and Gynaecologist, Physician in Infection Management, Women’s Health GP, Chronic Pain Specialist, Physiotherapist, Psychologist, Sexologist, Genetic Counsellor, Midwives, Nurses and quality improvement/research fellows. She can draw on as many, or as few, of our services as she needs.
Our dedicated Upper Gastrointestinal Surgeon will be on hand to assist should the cancer be metastatic and require extensive debulking to achieve nil macroscopic residual, which is the single most important prognostic factor in overall survival. If post-surgery issues arise, our Physician in Infection Management swiftly deals with them. Our experience has taught us that the beneﬁts of integrated care extend to every stage of a woman’s life. To reduce patient stress even further, our Administration team act like a concierge service, anticipating needs and seamlessly co-ordinating appointments. Whether it’s endometriosis, pregnancy or menopause, we don’t just manage the condition – we treat the whole person.
For cancer patients especially, this holistic Survivorship model is considered best practice and has been shown to improve quality of life.
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WOMEN stands for Western Australia Oncology, Menopause, Endometriosis and New mothers.
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Endometriosis and chronic pelvic pain Sexual intimacy enhancement Complex medical conditions requiring contraception
Genetic Counselling Physiotherapy Psychology Issues arising from surgical and natural menopause
News & Views
Tackling male suicide In this month’s issue one of our clinical contributors looks at the increasing rate of suicide among men and how difﬁcult it is to identify people at risk when there is such a stigma for men to reveal to their family, friends and doctors how they are feeling. This reluctance to consult is being tackled in research sponsored by Beyond Blue and the Movember Foundation. Thousands of men have been recruited, including AFL players, refugees and FIFO workers into the STRIDE (Stigma Reduction Interventions: Digital Environments) project which was announced during last month’s Men’s Health Week. Six small yet keenly targeted projects will use, among other techniques, apps and websites to ascertain their efﬁcacy when it comes to changing men’s attitudes to their emotional and mental health. The projects are: så 9å&RONTSå!NåAPPåFORåREGIONALåANDåRURALåWORKERSåINCLUDING ﬂy-in ﬂy-our workers så 4ELLå9OURå3TORYå!NåONLINEåEDUCATIONåPROGRAMåFORåREFUGEESå så 4HEå2IPPLEå%FFECTå!NåONLINEåEDUCATIONåPROGRAMåFORåFARMERSå affected by suicide så #ONTACTåå#ONNECTå!NåEDUCATIONåPROGRAMåFOR unemployed construction workers delivered by SMS which is linked to a website så 2EALå#OURAGEå!NåONLINEåEDUCATIONåPROGRAMåFORåPAST AFL players, past coaches and construction workers så /UTåOFåTHEå"LUEå$EDICATEDåWEBSITESåFORåBOTHåMENåLIVING with HIV and for gay men in heterosexual relationships The projects will run for two years before being evaluated then results will be analysed to ﬁnd the most effective ways to reduce stigma. This creative and practical approach to research may have ripple effects in other areas of public health management.
Medical Board KPIs Fall Short A review of WA Medical Board panel hearings is provided at www. ahpra.gov.au/Publications/Panel-Decisions.aspx but KPIs are lacking, such as the time interval from when a ﬁle is opened on a complaint (notiﬁcation) and ﬁnal judgement given. We looked at December 2013-14 and found that 50% of displayed complaints in WA are ﬁnalised as “no case to answer” and “no further action” (n=19). Nine complaints (25%) had only a caution issued, eight for “unsatisfactory professional performance” and one for “unprofessional conduct”. Ten complaints (28%) resulted in “conditions” being imposed on the practitioner’s way of practising, with a “reprimand” or “caution” also given in eight cases. In four instances, no further action was taken even though either “unsatisfactory professional performance” was said to have occurred (twice) or “unprofessional conduct” (once), with one notiﬁcation marked “no further action” without specifying if they had a case to answer. On May 28, we asked AHPRA (via their website) to explain and received notiﬁcation on June 6 that the enquiry had been “escalated” but no response by June 18. We were particularly interested to know what proportion of total notiﬁcations for WA were deemed of “educational and clinical value” and therefore put up on their website. Which practitioners are investigated and who ends up with a caution is currently open to conjecture. One female doctor told us she disagreed
with the ﬁnal judgement but on advice paid the $5000 and was told in jest by her MDO lawyer that this would buy them morning tea at AHPRA.
Bullying and Anxiety A casual barmaid employed by Riverton Rossmoyne Bowling and Recreation Club Inc claimed damages for psychiatric injury caused by workplace bullying. She had been there about 21 months when verbal abuse and threatening behaviour from a customer triggered the claim, backed by a year of undue stress and anxiety imposed by her employment, she said. The plaintiff claimed Riverton failed to take appropriate action in breach of its statutory duty under the Occupational Safety and Health Act 1984 and breached other contractual obligations. The medical evidence consisted of psychiatrist Dr Ng estimating the plaintiff’s Whole Person Impairment (WPI) at between 8% and 19%, inﬂuenced by time and surveillance footage he was shown. Another psychiatrist Dr Terace assessed WPI at 0% and both questioned the veracity of the plaintiff’s presentation after considering the surveillance footage. The judge dismissed the claim in its entirety after questioning the truthfulness of the plaintiff’s evidence. Of the two psychiatrists, he preferred the medical evidence of Dr Terace and said the plaintiff had not reached the required threshold under the Act.
Prepared for the Challenge Personal drive has pushed Dr David Russell-Weisz from small projects to juggernauts like Fiona Stanley Hospital. The experiences have led him to the DG’s chair. Dr David Russell-Weisz – or Russ to most people – enjoys challenges and creating tangibles from a mass of ﬁgures and ideas. At least that’s the impression he gave when interviewed on his last day of commissioning Fiona Stanley Hospital (FSH). After a couple of months in the UK and France, recuperating with his young family, Russ is headed for his next big challenge in August – the Director General’s job. He’s totally absorbed in his work but says his wife is keeper of his work-life balance!
The FSH experience
Coming from a medical family, Russ trained in Dundee and did his threeyear GP training in urban Croydon in SE London, where his love of variety and challenge was satisﬁed.
Medical Forum received a spate of vitriolic anonymous emails pointing to deﬁciencies in clinical care at FSH. And 54% of doctors we polled in the June edition said media reports suggested more than ‘teething problems’ (32% said no). Russ, thinking like the next DG no doubt, has the big picture in mind even though he admits that problems and deadlines at FSH kept him awake at nights.
“In Croydon there are lots of different ethnic backgrounds and very busy jobs, up to 6000 deliveries a year, so you were up all night doing epidurals and deliveries.” He became skilled in anaesthetics and obstetrics but the ultimate challenge was outback general practice in Australia. He said he met some inspirational and resourceful people while doing GP locums in Bourke, Broken Hill (RFDS), Kalgoorlie, Kellerberrin and Australind. How it all started He stumbled into administration when he temporarily replaced the chief medical ofﬁcer in Broken Hill. A doctors dispute taught him the importance of having clinicians in management who understand the clinical environment. “Prof Stokes [then Chief Medical Ofﬁcer] suggested Port Hedland, with 50% management and the rest emergency department general practice and anaesthetics, which I just loved. It was such an authentic environment, everyone got on with each other. We had a hospital where there were GP procedural lists – it was real medicine at the frontier.” He must have done something right because after four years he became Director of Clinical Services for the whole North West, based in Broome. He noticed he worked better with people around him and there was no turning back. He left clinical medicine at the end of 2004. He became Medical Director at King Edward Memorial Hospital just after the Douglas inquiry, then, after 12 months, the CEO position came up at Charlies, and he went for it for six years, even though he was told it was lonely at the top.
“Then this role came up and Kim Snowball twisted my arm. It has really stretched me. You don’t get to commission an 800-bed hospital every day and it will be commissioning for some months to come.” “All the clinical work ﬂows were done as best we could – 118 robust service plans – we’ve had to review some of them but at least we had a starting point.”
“The negativity has been a shame but we did get through the opening smoothly. There are a lot of people very tired and worn out who have put their hearts into this project. Listening to how others have done it, they say the one thing people forget about is all the commissioning problems once you open. When you are suddenly a busy operating hospital there is no down time.” “WA has gone through massive development over 10 years and it needs time to settle.” He was referring to hospital infrastructure projects from Albany to Broome, with FSH as the ﬂagship. Of course, there is also Midland and Perth Children’s Hospital coming on line, with impact from the new medical school. The people issues The human element has added some realism to an otherwise inanimate chess-board shufﬂe – people had to cope with shutting Kaleeya and Shenton Park, changing focus for RPH and Fremantle Hospitals as well as inducting 5000 staff at FSH. “Here at FSH, we worried about clinical engagement. We were inundated with people here late at night wondering how their new departments would work. We wanted to get it safe. We’ve married two cardiothoracic teams together, busier than ever doing heart and lung transplants and coping with water leaks in theatre. Would I have liked longer? Absolutely! On the ground it works really well, so all you hear in the media isn’t how it happens.” In the ﬁrst month, Russ admits FSH was swamped with numbers in ED, oncology and general surgery, into which, he says, they are making inroads.
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“The more difﬁcult thing to measure is the culture of patients and staff – communication between them. It’s the team that matters – and the reason we got over the line here.” We put to him that many doctors have experienced ‘boring’ medical administrators and the death of initiative at the hand of protocols and certiﬁcation. What’s Russ’s take on this?
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While some consider the Director General’s job something of a ‘poisoned chalice’, for Russ it seems the logical next big challenge and he goes into it with eyes wide open, particularly the political overlays.
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“I’m not a fan of being overly bureaucratic. You have to have a balance between policies, procedures and the doing. I want to ﬁx things and move on to the next issue. Have we become too policy driven? In some areas, probably ‘yes’ but we improve patient safety by looking at data and getting people to report. Our credentialing of medical practitioners, some of whom are not used to it, becomes more comfortable when we say ‘Can you do that procedure so it is safe for patients?’.”
“My jobs with North Metro and the QEII redevelopment, Joondalup, and here have given me a very good taste of politics. The one thing that WA has done well is the ‘bible’ as I call it, the clinical service framework which is a plan for the system.”
“I’ve thought about it long and hard. It is quite an honour to be at the top of an organisation where you can shape its strategy and how it moves forward. There are huge challenges for health – we have 28% of the budget, we’ve built all these new facilities, and we need to get back to basics by providing the best care for patients. There is more to do, it will be at a slower pace and whatever we do has to be ﬁnancially sustainable. There are obviously budget challenges for the State and health is the biggest spender so the focus will be on health.” You get the feeling he will enjoy tweaking the whole health picture, away from the hospital focus he has had for many years. “There is too much focus on hospitals. I want to do a stocktake – where are we today and what the policy drivers of government are. I’ve worked with the Health Minister closely over the last few years of massive change. The questions now are, how do we consolidate the system? How do we become sustainable and rein in costs?” “We have a whole suite of partners, like Silver Chain and other NGOs, and we are getting better at it. We have the new Primary Health Networks coming through – it’s not just about memorandums of understanding but how we can deliver care in the community that is appropriate and take the burden off the hospital sector. I will get shot down for saying this but there are patients who can be treated for complex conditions by GPs, having been one, and who don’t need to be in hospital.”
I want people around me who challenge me; I don’t want ‘yes’ men. People will say I am driven, I want an outcome.
you can’t be a darling to everyone, so it is ﬁne when people don’t like you. But I also like to have some humour in the team – these are hard jobs, so we need that balance.” Russ says he plans to give the DG’s job ﬁve years before carefully reconsidering but he thinks it won’t have the overt intensity of FSH. “When we started in 2012 we were a couple of dongas out the back and a team of 20-odd people. Looking at it now, you have to pinch yourself, it’s such a big hospital. I think I would have found it more difﬁcult to apply for the DG’s job without having done this one ﬁrst.”
By Dr Rob McEvoy
“We will be looking for efﬁciencies. For each occasion of service there is a price and a cost and we are more costly than other states, sometimes for good reasons because our salaries are higher but sometimes it’s because we are not as efﬁcient. It’s not just about grabbing money but investing in efﬁciency as well.” We raised the subjects of empire building by clinicians and the vagaries of political cycles always counteracting the efforts of people like Dr Simon Towler who try to get everyone singing from the same song sheet (in his case, clinical networks). Russ points to, by way of example, the success of the stroke network with protocols and robust stroke units producing results based on good evidence. What does he bring to the DG’s job? “I hope I’m seen as collegial but I always want to get things done. I would be aiming to develop a team in the department of health and the area health services so we work as one, but each concentrates on their own area. Most of my life has been as an operational man – in area health services, in rural general practice and hospitals – I bring a lot of on-thejob experience.” “Hopefully my work as a clinician gives me clinical credibility. What I have learnt from FSH is the importance of getting the right people and the right structure – having a real rigor for delivering the project.” “I want people around me who challenge me; I don’t want ‘yes’ men. People will say I am driven, I want an outcome. They might criticise by saying I micromanage sometimes. I say it’s usually when I’m worried about something, or I’m not convinced by the material I’m getting.” “My father was a great mentor and he said
17 1 7
How Transparent is AGPAL? ‘It seems no-one associated with the day-to-day running of AGPAL will respond fully to our questions. Why?’ The April edition of Medical Forum detailed the responses of seven medical organisations to questions about board governance. Responses to our questions illustrated different levels of transparency and accountability, key attributes of good governance, which we considered critical to creating public trust in medical organisations. Noticeably absent was the not-for-proﬁt organisation Australian General Practice Accreditation Ltd (AGPAL). We thought we were a shoe-in to get an open and transparent response from AGPAL. Having met the boss Stephen Clark, we contacted him through his email address, sent him our explanation and questions and said. “As AGPAL is all about ‘standards’ in general practice we thought starting with it was an obvious choice.” We were surprised to receive a short response from him that in essence said AGPAL was proud of its governance but did not comment to the media or in the public domain about governance. He said he was available on his mobile. This unusual response prompted us to look more closely at AGPAL through its website to ﬁnd: så !'0!,åSAYSåITåISåGOVERNEDåBYåNINEåWELL known medical organisations and has the important task of accrediting general practices Australia-wide to assure health consumers that accredited practices meet standards that measure quality and performance in service delivery. It uses RACGP standards to do this. så 4HEREåWASåNOåMENTIONåOFå3TEPHENå#LARKå (Group Chief Executive) anywhere on either the AGPAL or its subsidiary, QIP, websites. (This was remedied in late May, around the time we pointed this out.) så 4HEREåWEREåNOålNANCIALåSTATEMENTSåORå annual reports to indicate how the many thousands of dollars practices pay for accreditation is used. så !NåAPPARENTåLACKåOFåINFORMATIONåABOUTå board governance particularly on issues such as perceived or potential conﬂicts of interest. Some readers will recall that AGPAL was established in 1997 using a $2.5m Commonwealth grant and the backing of 10 groups (AAGPT has since disbanded). We understand AGPAL has had to become self-funding. Our email to Stephen raised the same questions on governance as it had with the other organisations that we featured in April viz: så 3ELECTIONåOFåTHEåBOARDåANDåTENUREåOFå members? så 2EMUNERATIONåORåNOTåOFåBOARDåMEMBERS så (OWåBENElTSåANDåCONmICTSåOFåINTERESTåAREå dealt with?
så 4RANSPARENCY så 0ERFORMANCEåREVIEWåOFåBOARDåMEMBERSåIFå controversy arises? så 0UBLICåPERCEPTIONåOFåBOARDåMEMBERS We raised some issues unique to AGPAL, asking for comment. AGPAL endorsement of HealthEngine – through its partnership agreement and free subscription to AGPAL members. Whether HealthEngine’s promotion of some general practices as sources of referrals for specialists who advertised on Health Engine was an issue for AGPAL? We asked about qualifying criteria for AGPAL Executive Partnerships and the role of the Board in choosing AGPAL partners. How AGPAL deals with perceived conﬂicts of interest – the example offered up, while in no way suggesting any breach of AGPAL policy or in its governance, nor any impropriety by any AGPAL or other ofﬁce holder, was that Dr Richard Choong, chairman of the AGPAL Board since 2006, a Federal AMA nominee and GP, was also an immediate past president of AMA WA. The CEO of Health Engine, Dr Marcus Tan, was given as Assist Hon Sec to AMA WA and is also a GP. HealthEngine has a partnership with AMA Recruit to handle job vacancies via their website. When Stephen Clark failed to respond to our repeat request we forwarded to each of the heads of the governing organisations our email to Stephen, along with his response, asking if their organisation had a position on any of the points we raised. The response from each organisation is summarised as: så Consumers Health Forum (CHF) – no response (to three emails via website contact and one phone call). så National Association of Medical Deputising Services (NAMDS) – Pres Dr Stuart Tait said they ceased involvement with AGPAL, including attendance at AGMs and board meetings, about four years ago. så Australian Association of Practice Managers (AAPM) – CEO Gillian Leach said AAPM did not comment on governance procedures of any other organisation. This response did not alter when we said that AAPM part-governs AGPAL. så Australian Practice Nurses Association (APNA) – CEO Alexis Hunt said APNA has always had a good working and transparent relationship with Stephen Clark and AGPAL. She said APNA has no role in directing or determining the governance mechanisms or methodologies of AGPAL and is not a governing organisation for AGPAL. (APNA is a listed partner with AGPAL, which we believe involves co-sponsorship arrangements).
så Australian College of Rural and Remote Medicine (ACCRM) – No response to two emails via website contact and one phone call. så Australian General Practice Network (AGPN) – No response to two emails via website contact. så Royal Australian College of General Practitioners (RACGP) – Response from Dr Frank Jones failed to address any issues except encouraging our stance on accountability and transparency! så Rural Doctors Association of Australia (RDAA) – CEO Jenny Johnson said on May 18 she would respond ASAP but hasn’t. så Australian Medical Association (AMA) – Secretary General Anne Trimmer said the AMA was not in a position to address the questions we raised. She said the AMA had a nominee on the Board of AGPAL but was not involved beyond that in the operations of the organisation. It seems no-one associated with the day-today running of AGPAL will respond fully to our questions. Why? AGPAL says transparency is one of six founding principles of its approach to providing accreditation services. It also has Quality Innovation Performance (QIP) which accredits a range of health organisations outside general practice (see www.qip.com.au). As a mark of its standing, AGPAL says it in turn is accredited by the International Society for Quality Health Care (ISQua) to ensure their service provision is consistent with international best practice. ISQua is another not-for-proﬁt accreditation organisation based in Ireland. ISQua’s relationship with AGPAL is another story.
By Dr Rob McEvoy
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The Privilege of Medicine Politics and war made GP Dr Hussein Farah a refugee desperate to ﬁnd a place to call home. After heartache and terror he found his place here in Perth. rth. The Ethiopian Civil War began in 1974 and lasted for 17 years scattering families all over the globe. Dr Hussein Farah is a member of one of them and has seen life from almost every angle. Once a refugee himself, he sees it as a rare privilege to help those who have been displaced by conﬂict and famine. Life before war Hussein freely concedes that life before the war was comparatively privileged for his family. “My father was a diplomat and, in the 1960s, one of very few Somalis who had the opportunity to have an education. He was appointed to the embassy in Cairo and ended up being in charge of the Arab Section in the Ministry of Foreign Affairs. As a family we travelled to most countries in the region.” “I studied medicine in Egypt. My sister is an ophthalmologist practising in the Emirates. It’s a six-year program with a highly competitive entry requirement. Only about the top ﬁve per cent get into medical school and then you do two years of science subjects before a gradual transition to clinical studies.” “I worked in a hospital in Mogadishu during the war before ﬂeeing to Egypt as an illegal alien. I had no papers and the immigration police were picking people up and sending them to a ‘no-man’s land’ wedged between Sudan and Libya. There was nothing there except desert, I knew several people who ended up there and I don’t know what happened to them.” “Luckily, I spoke ﬂuent Arabic and the police always let me go but my heart was pounding. I’d lost one of the most precious things of all, my own freedom.” “I was classiﬁed as a refugee by the UNHCR after a seven-year process of queuing in a Cairo street. You’d get hostile looks from people, it was degrading and frustrating and it wasn’t an easy time.” The detention process is, for all intents and purposes, punitive in nature. Hussein had a number of hurdles to clear before he was able to resume his medical career.
New beginnings: Dr Hussein Farah and his wife Halise and daughter Noor. The pair married once Hussein settled in Perth.
swing and people were talking about ‘queue jumpers’. In those situations there are no queues to jump!”
resurfacing and provoking some unpleasant feelings. I’m able to manage it and I talk this through with my colleagues.”
“My medical qualiﬁcations weren’t recognised when I arrived in Perth so I registered with Centrelink but that made me uncomfortable because I don’t like getting handouts from anyone. They wanted to give me 500 hours of language tuition but I pointed out that I was speaking to them in ﬂuent English at the time!”
“It makes me more receptive to my patients’ stories and that makes me a better doctor. I know modern medicine is obsessed with speed and if you can’t formulate a diagnosis and treatment plan in ﬁve minutes there’s something wrong with you.”
“In 2001 I was accepted into the WA Health Training Scheme and its CMO, Dr Brian Lloyd, helped me to get into the advanced training program in Public Health Medicine. After gaining limited registration with the Medical Board I went to Kalgoorlie and worked as a trainee registrar with Dr Charles Douglas.”
“It was a horrible situation, although I’d have to say that the detention centres here in Australia seem like ﬁve-star hotels compared with those in Cairo. The UNHCR decide where you’re going to go, they call it a ‘durable solution’. I told them I was studying for the American medical exams and could do the ﬁnal component in that country. The woman looked at me and said, ‘What do you think we are – a travel agency?’”
“After that it was off to Darwin for two years at the Centre for Disease Control and then, in 2009, I commenced with the Humanitarian Entrance Health Service (HEHS).”
Starting from scratch
“Sometimes when I hear their stories I don’t sleep well for a few nights. It reminds me of things buried deep in my memory that keep
“When I eventually arrived in Australia in 2001 the Children Overboard saga was in full
There are aspects of the work with HEHS that take a personal toll, says Farah. But he also reafﬁrms the positives for both himself and his patients.
“But it’s so important that you allow these people to tell their stories and this is one of the few chances they have to tell them. I speak a number of different languages and it makes it much easier for people to express themselves in their own words. An on-site interpreter is the second-best option but you can lose a lot of important detail because many things just can’t be translated.” “The refugee experience is not ‘one-size-ﬁtsall’. Every person is an individual and every journey is different. It’s a privilege to care for these patients.”
By Mr Peter McClelland
Curtin Medical School Curtin University has ﬁnally been given the green light and its head of Medical Education, Prof William Hart, explains the medical school’s primary care vision. Curtin University’s medical curriculum emphasises a career in general practice. Commentators in Australia, Britain and the US all warn of a looming crisis in the general practice workforce. While there has recently been a welcome increase in GP training numbers in Australia, in a survey of 2519 ﬁnal year students in 2012, only 371 (15%) opted for General Practice as their ﬁrst preference. We want our GP trainees to see it as their career of choice.
Prof William Hart
More than ever, the bulk of modern medicine is delivered in the community, not in tertiary hospitals. Students need to participate in community medical care to a much greater extent than previously.
GPs are four times more prevalent in the Western Suburbs of Perth as in the Eastern Suburbs. Rural and regional towns ﬁnd it
difﬁcult to attract and retain doctors. More overseas-trained doctors (OTDs) service our under-resourced areas (38%), than the national average (26%). Even with 1150 more OTDs than the national average, WA is still 950 doctors short. Dr Felicity Jefferies’ independent report commissioned by Curtin in 2013, conﬁrmed doctor numbers in WA are not only inadequate but they are seriously maldistributed. It concluded that: “The real impact of a new medical school will be its capacity to focus on producing graduates who will be predisposed to practise in areas of highest need, most notably general practice, rural, remote, and outer metropolitan areas.” Curtin University now has Federal government approval to start a new medical school that will work to increase the rates of doctors interested in working in outer metropolitan, rural and regional areas and improve their readiness for a generalist medical career. It will have a different ethos and approach to many established medical schools.
Learning from experience Between 2006 and 2012, I helped to establish a new rural campus for the Monash medical course, the Gippsland Medical School; we were trying to attract and prepare students for a career in rural general practice. James Cook University, among others, has shown that investing in rural medical education can produce an appropriately trained rural medical workforce. Factors that increase the probability of graduates working in rural medicine include: applicants with rural origins; Aboriginal or Torres Strait Islander ancestry; a genuine interest in rural, remote, Indigenous, and tropical medicine; and providing rurally located training places and support. The ﬁrst Monash Gippsland students graduated in 2011. The following year, all available intern positions in rural Gippsland were ﬁlled by Monash graduates. I have interacted closely with students in several different medical education programs; to discuss the career intentions of commencing and later-year students, and to explore what attracts particular students. I’ve also studied aspects of the medical course that either reinforce or weaken a student’s initial
Investing in Midland is a Great Thing Midland GP Dr Colin Hughes is thrilled that a medical school will be opening in his area, giving both the local community and current doctors new purpose and opportunities. Prime Minister Tony Abbott has an excellent grasp of the issues. WA has a shortage of over 900 doctors and a reliance on 38.2% of overseas trained doctors (OTDs) compared with a national average of 26%. Waiting times in the public sector are totally unacceptable for those in debilitating pain and with cancer.
Dr Colin Hughes
The AMA was the most vocal critic saying that there were not enough training positions for residents. Yet the PM has guaranteed that with WA Government support, there will be.
Critics say there won’t be enough teachers yet Curtin’s Medical School will establish a train the trainer approach where established doctors will be upskilled to quality teachers; the one step that has fallen by the wayside since the collapse of the RACGP’s Family Practice Training Program.
The Curtin model, which is an undergraduate ﬁve-year program, will use GPs as clinical tutors ensuring that graduates will be ready after internship to enter the GP or specialist training programs competent in patientcentred practice. We all know the current system of training is wounded if not severely injured. The shift to private medicine has seen less training opportunities in the public hospitals and less qualiﬁed and dedicated clinicians willing and able to teach. I nostalgically remember the ward rounds at KEMH followed by morning tea where consultants shared, taught and encouraged students and residents. That was until the bean counters stopped the sandwiches and consultants became specialists and moved to the private hospitals. The Australian Medical Council is expecting that the current intake of OTDs of 1500 a year will continue for at least the next 10 years. Surely amongst those 1500 it is possible to recruit well-qualiﬁed Heads of Department and clinical lecturers if they cannot be found in Australia? It is true that UWA has increased its intake to 320 but comments from students indicate this is too many and teaching is suffering. If, and I
say if, it is apparent that in many years to come WA is reaching saturation point, then it would be sensible to reduce the intake at UWA rather than oppose the establishment of the new Curtin University Medical School. The Premier Colin Barnett made the valid point of the moral dilemma of accepting so many OTDs from developing countries where those doctors were sorely needed. By all means, OTDs should be allowed to upskill and study in Australia but tenure should be limited and Australian students should be given the chance to study medicine. One of the main reasons local GPs are excited at the Curtin proposal is the shortage of Australian-trained GPs in the Eastern suburbs and rural and remote WA. The Curtin model will give application credits to those applying from a disadvantaged publically educated, rural or indigenous background. At last Midland and the Eastern suburbs will have a university hospital and clinical school that will inspire local students to study hard and strive for excellence. It can only be good for WA.
Curtin 6OJWFSTJUZMidland Campus
with many of the examples drawn from rural practice. We will also engage with competent and compassionate clinicians as role models, such as GPs who enjoy their clinical and educational work. We already know that a rural background and positive experiences in rural placements both increase the likelihood of young doctors doing some of their postgraduate training in a rural location. In addition, we will be setting a minimum 25% intake of students from rural backgrounds. Curtinâ€™s course, scheduled to start in 2017, will be a ďŹ ve-year direct-entry MBBS degree. We are committed to ďŹ ve years of medical training, rather than graduate-entry, in terms of lower cost, longer career and fewer years at university.
career intentions. Important factors include: location, reputation, ethos, curriculum context, experiential learning and role modelling. Students might be attracted to either a â€˜big cityâ€™ lifestyle with big tertiary hospitals, or a rural lifestyle with GP-led country hospitals. Curtin University is located in the South Eastern suburbs of Perth, in an area underserved by doctors. The university also teaches in Kalgoorlie and Margaret River, as well as in Miri (Sarawak), Singapore and Sydney.
The generalist context Curtin, the largest provider of undergraduate health science education in WA, has a reputation for equity and patient-centred teamwork. We will build upon this in the medical school to focus on general medicine in underserviced and disadvantaged areas, providing students with practical clinical experience in GP clinics and rural settings. We will place curriculum materials into a rural generalist context where appropriate,
The University has responded to concerns about rapid growth in student and graduate numbers by starting later and smaller than originally proposed: we will commence with 60 places, rising to 110 over ďŹ ve years. We agree that the steady expansion of clinical training places is very important for our health system and we are pleased that the State Government has guaranteed enough places for all Curtin Medical School graduates. The ďŹ rst new Curtin medical graduates will be prepared for PGY1 in 2022. We are serious about it â€“ our graduates will be committed, competent and compassionate generalists. References on request
This Deal Is About Votes Not Health Curtinâ€™s medical school will not reap its touted beneďŹ ts and will put a training system already under strain to breaking point, says AMA (WA) President Dr Michael Gannon. As President of the AMA in WA it is my role to ďŹ ght for the profession and for public health in our state. The decision to establish WAâ€™s third Medical School at Midland will have an impact on both like few other decisions we have seen in our professional lifetimes. In my initial statement after the Federal Governmentâ€™s announcement, I called it one of the worst decisions in WA health in decades. For this remark I was criticised by some. Dr Michael Gannon After talking with many colleagues and hearing their extensive concerns about training bottlenecks as they already exist, I do not resile from this view. Since then, statements from a range of Government ofďŹ cials have conďŹ rmed that the decision was more about votes, property development and urban renewal.
As everyone knew, the Midland area needed a key tenant for the State Government to get its remake of the area underway. A new medical school was ideal. The local business community was desperate for something â€“ anything â€“ to give their area a boost. No attention was paid to the impact a third medical school would have on the quality of health or medical education. This was a backroom deal struck by a small number of powerful players with vested interests, none of whom would have been able, or indeed willing, to provide critical thought on the likely impact on training places, on already limited teaching opportunities, or ask in a genuinely critical way how another 60 or 100 medical graduates will provide more GPs to remote and rural areas.
General or the Health Department, who will have to ďŹ nd employment for all these new doctors. The Federal Health Minister, Ms Sussan Ley, arrived late at the dance with the issue already settled by the Prime Minister. There were no defenders of health in that backroom. There was no debate, no thought, no consideration of the impact on training places, or the already stretched State budget The politicians were there to win marginal seats, business was there to invigorate commerce, and Curtin University was there to promote itself in the competitive world of tertiary education. The AMA (WA) was supportive of a second medical school at Notre Dame. A decade after its opening, it is still, in some respects, ďŹ nding its feet.
When Curtin University and Government have raised this issue in the past, they have done so in the open and public debate was permitted. As a result approval was not given. This time the decision was taken in the dark with no alternative opinion.
Clinical placements for medical students and training places for JMOs are already tight. The worst thing we can do is to open a third medical school. The parties promoting it are not focused purely on the quality of teaching or the quality of healthcare that eventuates. But their short-term interests have been served.
The Minister for Health, Dr Kim Hames, was informed less than 24 hours before the announcement. No one told the Director-
The rest of us, who were not in that backroom, will be the ones to clean up the mess.
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Where to Telemedicine? Is telehealth an acceptable form of medicine? Using it to help the disadvantaged seems a world away from those who seek to make money from it. Last edition we detailed how consumer demand for convenience was largely dictating what happened in the urgent afterhours space for general practice. Patients would rather ring late, declare their problem ‘urgent’ and wait at home on the lounge for the doctor to come to them. So it is for telemedicine, but this time its specialists mostly involved. Both generate Medicare costs, so any scheme that says it doesn’t sacriﬁce popular consumer convenience but reduces Medicare costs will get the ear of government. Will IT save the day? We ﬁrst contacted Dr James Freeman in 2013 when GP2U national telemedicine was two years old and the RACGP had queried patient safety around video consultations between doctors and patients unknown to each other. The ability of patients to form a relationship with their doctor and be examined by him/her was integral to the RACGP’s ‘medical home’ model that also included patient registration at a practice. Telstra prepares to strike Today, GP2U says it has 13,000 patients and 600 doctors on its books, handling 30,000 consults a year – about 50% of them by
psychiatrists. James said after four years and multiple movements of the goalposts (see below), GP2U is one of the last telehealth services standing. Is he right? Medibank Private recently sold its telehealth service Anywhere Healthcare to Telstra. Although the service was performing only 8000 consults a year, Telstra has indicated it wants to expand the service into aged care
Goal Post Changes on Telemedicine A target of 500,000 Medicare funded consults with specialists from 2011 to 2014 but only 150,000 eventuated. så Early 2012. Medicare decides patient assignment of beneﬁts needs a retrospective permission from patients, going back six months. så End of 2012. Government restricts Medicare eligibility to particular geographical areas, removing about 8m patients from the Medicare funded scheme (mostly cities). Earlier, the 15km minimum distance rule was introduced because of reports of specialist rorting. så Jan 2014. Changes to depreciation tax laws make infrastructure investment unfavourable. så July 2014. Incentive payments to doctors abolished after limited uptake and reports of doctor rorting to claim the $6000 initial bonus. (About 90% of the 200 specialists who signed up with GP2U only did one consult in the ﬁrst year, presumably to claim the bonus.)
and rural and remote areas. How? At www.telstra.com.au/telstra-health we are introduced to ReadyCare, Telstra’s own telehealth service that we assume is initially servicing the patient base acquired from Medibank. “Solutions like ReadyCare and HealthEngine bring Australians greater ﬂexibility when accessing medical care. ReadyCare, in partnership with Europe’s leading telemedicine company Medgate, is a new way to connect to a GP. Together, we’re creating Australia’s ﬁrst purpose-built telemedicine centre, where patients can make a phone or video call to a doctor and receive diagnosis, prescriptions, care and treatment,” the website says. In the six months to December, Telstra Health is said to have made $31.5m. Telstra’s foray into health is all about integration and some of its acquisitions have included hospitalbased products. Problem with funding models GP2U has run out of Hobart since it started four years ago but most of its doctors are on the mainland. “The bits we do are around convenience for the doctors and patients – appointments, linkage, remote prescriptions, online version of Best Practice, document store and forward billing – a virtual practice in a box,” Dr Freeman said. The service provides prescriptions, referrals (including to the specialists on its books) and medical certiﬁcates. “Telehealth works well from a patient care perspective but the funding models are wrong. Only 5% of all medical consults are Medicare telehealth-funded, that is 33% of Australians in an eligible area, while 15% of all consults by specialists are handled as telehealth.” The current eligible area for either GP or patient Medicare funding is the Australian Standard Geographical Classiﬁcation Remoteness Areas (ASGC-RA) in regional, rural and remote Australia, that is, outside Major City RA1 areas (see www.mbsonline.gov.au/telehealth). By March 2014, 169,000 telehealth services had been provided nationally to over 62,000 patients by over 9700 practitioners, including in 221 residential aged care facilities. There were 519 psychiatrists providing services, with the next biggest specialist groups being paediatricians (291) and cardiologists (195) – a total of 3364 different specialists. With no geographical restrictions on them and a 50% fee loading, it is said specialists can afford to bulk bill eligible concession cardholders, and many do.
Dr James Freeman
James said telehealth is just part of an increasing health spend per person. continued on Page 27
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Where to Telemedicine? “It’s expected to go from $2800 to $6500 in 2050, in aged care $625 to $2500, NDIS from $20 to $1000 per head – these trends are in place and no amount of saying ‘no’ will change it. Health expenditure is a quarter of our tax revenue at present. If we don’t look at some substantive changes then we’re in strife. The demographics were put in place 60 years ago. There is no wiggle room left.” He is referring to the ageing baby boomers and shrinking health workforce and revenues – market forces that will support the convenience of telemedicine. For example, he said the Adelaide craniofacial unit now used telehealth, rather than the more costly ﬂy-in, for both preand post-op care of people from out of town. “We support Casson Homes in Perth, which looks after mental health patients from group home, hostel, and nursing home phases. We provide contracted GP services.” “What might be uncertain value for money does occur where geriatricians do GP-type work in RACFs via telehealth (see www. uq.edu.au/coh/telemedicine-in-aged-care). We think it would be inﬁnitely preferable to allow GPs to telehealth in RACFs at under one third the cost of a specialist service, given that vast disparity in MBS schedule fees.” Along the way, the excessive behaviour of some doctors has been detrimental to the cause (see inset). Role of GPs Although the service is called GP2U, James says uptake of Medicare-subsidised telemedicine amongst GPs has been “spotty at best”. This is understandable he said. For GPs to claim back anything from Medicare, it is for being handmaidens to specialists – organising referral and paperwork for an eligible patient to be in the room so GP and
patient can consult with the specialist (for which the GP gets an insulting 35% loading and the specialist 50%). Instead, most GP business consists of private consults with patients, marketed by word of mouth. “In the general practice realm a patient who ﬁrst consulted one year ago will have had 3.2 telehealth appointments, on average.” This rate is about half their visits to a GP in a year, despite all GP telehealth consults being privately billed at typically $49-$69 for 15-20 minutes (Paypal or credit card). “We see a lot of second opinion stuff – consumers have Googled and they say their doctor hasn’t told them about this or that. There are people in the city with mobility issues, executive types who just want it done quickly, and locations that may have some service issues. It’s more about, ‘I’m not being listened to or the treatment I’m using isn’t working’. Sometimes getting a second opinion gets them the right treatment because second opinions aren’t easy to get where they are.” He believes subspecialisation in general practice is coming – for those who want to add value to what they do and escape bulk billing. He believes all GPs have areas of expertise. “There is a component of general practice that must take place in the room. The interesting thing is that patients self-triage which means
Patients outside the pink areas are eligible for Medicare-funded telehealth consults.
about 1% of patients are referred on for a faceto-face consultation with their usual GP instead of the expected 10%. Patients say, ‘If the GP doesn’t touch me, why do I have to go there?’”
continued on Page 33
The WA Telehealth Experience In WA, an attempt to bring geriatrician consultations into RACFs using nurse practitioners has just failed because of costs. The GP component continues. Otherwise, GP uptake of telehealth has been limited due to cost, geographical restrictions for Medicare rebates, tax disincentives and compliance work involved. If some decent broadband connections can be sourced in the Far North, there is a chance to improve ear health of children using telehealth. With cost cutting and consumer convenience as new drivers, the HDWA, HealthEngine and the new WA Primary Health Alliance are mentioned. We note the Australian Practice Nurses Association is independently moving towards telehealth and appears to have had an injection of funds. As Dr Mike Civil from the RACGP says, “Telehealth has such potential. We were bitterly
disappointed to see the MBS rebates go for telehealth in our outer metro practice. Our experience showed that it is often the convenience beneﬁts to the more elderly patient, rather than the Dr Mike Civil tech-savvy younger generation, that most beneﬁt the use of telehealth.” He believes telehealth is a ‘no brainer’ for those in remote and rural WA for ophthalmological, dermatological and ENT issues and any threat to their expansion and take up, beggars belief.
skin problems in distant patients. ACCRM just announced that Dr Rachael Foster from WA has joined Dr Jim Muir from Queensland as their new tele-dermatologist. She has experience in Kalgoorlie, the South West and the Kimberley, along with rural Queensland. “If we are not able to offer these services to those patients who need them, then it will no doubt fall to the telcos to pursue this space, with the attendant fees. And how much input will they seek from those experienced with telehealth in practice,” Mike said. “We should be able to have the ﬂexibility to offer telehealth to all those whose psychosocial or medical situation dictates would beneﬁt from it, and not just those with the right post code.”
ACCRM is using Telederm, a store and forward way of using telehealth to diagnose and treat
Smart Phones – Good, Bad and Ugly Some new research linked with endocannabinoids in the brain brings a cognitive slant to addiction and Dr Lucia Kelleher (PhD) turns its spotlight on the Smart Phone. Most of us have a Smart Phone. I’ve just returned from trekking the Himalayas and, just like us, all the guides and porters had one as well. And that was good because within hours I was able to contact Base Camp and ﬁnd out if our Nepalese friends were safe after the recent devastating earthquake. This technology has been with us for a while now and most of us like the convenience of instant and multifaceted communication. We can check that people we love are OK, we’re reassured if our children are out late at night, we can Google an answer to almost any question imaginable and, yes, there’s more than enough social media to go around! Now, the bad. We see people every day of the week driving their cars while chatting away on their phones despite the threat of hefty ﬁnes. In the workplace it can have costly consequences. An actual case? A worker fails to replace a differential sump-plug on a truck because he’s talking to his mate and it ends up costing his company $35,000. And dining at a restaurant? What an interesting social experiment that is these days with people texting and chatting while
Who just posted on Facebook, who liked my latest Instagram, who just Snap Chatted me and have I just missed something? The latter – what have I missed? – is the real driver of BMS. completely ignoring their meals, the waiter and their friends. The ugly Smart Phone is a reality and it’s linked with Busy Mind Syndrome (BMS). This is a consequence of the constant distraction of 24/7 connectivity and it is proving to be highly addictive, as so many parents will attest. GPs are seeing more people in their surgeries asking for advice and strategies to break the cycle of their teenager’s endless ‘chat’. BMS is a condition in which people are constantly thinking about their phones. Who just posted on Facebook, who liked my latest Instagram, who just Snap Chatted me and
have I just missed something? The latter – what have I missed? – is the real driver of BMS because it creates a sense of anxiety when people are separated from their phones. The longer the separation, the greater the consequent distress. The insidious thing about BMS is that it is unconscious and sits just below a level of general awareness. Most people don’t realise it’s occurring and the vast majority certainly have no concept of its addictive nature. This increasingly common syndrome is a direct consequence of the way the brain attempts to adapt to an overloaded external environment. There’s just too much ‘stuff’ coming at us all the time! There’s a physiological cause for this condition and a practical solution does exist. It’s a process of increasing the awareness of unconscious behaviour linked with addictive tendencies and it’s really no different from similar approaches to other addictions such as smoking. Nice to end on a good note about Smart Phones.
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Lost in Transition The issue of trangender mental health is growing faster than dedicated services but as A/Prof Sam Winter suggests, a positive community attitude can make a huge difference. In March, and with surprisingly little fanfare, the First Australian National Trans Mental Health Study was published. The Curtin University study examined the emotional health and wellbeing of nearly 950 transgender Australian people. Transgender (or ‘trans’) people are those who experience an incongruence between the sex they feel they belong to and the sex assigned them at birth. Across much of the world, trans people’s daily experiences of stigma and associated discrimination, harassment and abuse, are often so marked and consistent as to push them out towards the margins of society, at cost to their emotional health and well-being. They often leave (or are forced out of) their families and schools, have great difﬁculty getting a job, and experience problems with housing. Many end up in poverty. Some live on the street. Healthcare can be a major problem; especially that which aims to bring their bodies more in line with their experienced gender. Curtin researchers found that trans people were four times more likely to have been diagnosed with depression as the general population, and they were one and a half
times more likely to have been diagnosed with an anxiety disorder. Trans people had higher rates of depression or anxiety than the general population, in all age groups. These ﬁndings mirrored those from La Trobe University nearly 10 years earlier; during one year depressive episodes was over ﬁve times more likely for trans people than in the general population, more so for trans women (i.e. ‘male’ at birth but identifying as women). In the Curtin study, gender afﬁrming treatment was clearly associated with improved mental health. Those receiving treatment (whether by cross-sex hormones or surgery) were 30% less likely to have depressive symptoms. What factors were associated with poor mental health? Some were broadly social in nature: unemployment, low income, and difﬁculty changing the name on documents. Others focused on healthcare: discomfort in disclosing being trans to their doctor, and wanting hormone therapy or surgery. Many participants had unpleasant experiences when visiting a doctor and spoke of discrimination, providers who knew little about their needs,
and of difﬁculty accessing good hormonal and surgical healthcare. Here are just a few of the researchers’ recommendations. så %VERYåSTATEåANDåTERRITORYåSHOULDåHAVEåAå multidisciplinary gender clinic, with clear referral pathways understood by doctors and patients alike. Treatment protocols should be based on an informed consent model rather than on the hurdles and hoops of gatekeeping. så 4RAININGåCURRICULAåFORåPROFESSIONALSåWORKINGå with trans people, including doctors, should include an element devoted to trans healthcare. The implications for WA’s new medical school are clear. så 3TATESåANDåTERRITORIESåSHOULDåUSEåAåSIMPLEå and consistent procedure for trans people to change their legal sex – without the input of doctors. With three countries allowing trans people to declare their own legal status (and a fourth, Ireland, soon to follow) this is a subject for future discussion. ED: Sam Winter is Associate Professor at Curtin’s Department of Sexology.
HeartsWest is pleased to announce some important new developments. Dr Peter Dias has joined our practice. Peter is a Cardiologist with subspecialty expertise in echocardiography, heart failure and transplantation. He works as a Specialist Cardiologist, Heart Failure and Transplant Physician at Fiona Stanley Hospital and will consult at our Rockingham and Armadale rooms, reporting echocardiograms at these sites. Echocardiography. We are upgrading our echocardiography machines with Speckle Tracking Strain imaging, a new modality that allows detection of ventricular dysfunction before any reduction in function is detected by conventional means. It is particularly Useful for those with hypertrophic conditions and those who have had cardiotoxic pharmacotherapy. Stress echocardiography Service. Expansion of this service should allow a minimal wait for stress echo appointments for patients. Smartphone monitoring. We have access to AlivCor home monitoring that allows patients to make ECG recordings on a Smartphone during symptoms, sending them electronically to HeartsWest for review. Smartphone lease or purchase of a device that attaches to their Smartphone is available. This system is designed to diagnose infrequent arrhythmias not detected on Holter monitoring, without the need for implanting a monitoring device.
Telephone 9391 1234 Fax 9391 1179 Email firstname.lastname@example.org www.heartswest.com.au
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Test performance in most common sex aneuploidies1 N
95% CI H
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Source: Verinata Health Inc. (2012). MX â€“ Monosomy X (Turner syndrome) â€“ XXX, XXY, XYY: Limited data of these more rare aneuploides preclude performance calculations.
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What will the results say?
Expansion into twin pregnancies.
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An easy, non-invasive blood test delivering the answers you seek in just days. 191&D?15>1->D?::=01=-909110>:97D->58;71 .7::0>-8;71 &58;7D/:8;71?1191->$=19-?-7 %1<@1>?:=8-90-0A5>1D:@=;-?519??:-??190- 191-/:771/?5:9/19?=1K59)1>?1=9@>?=-75-?41 /:771/?5:9/19?=15>:77DB::01=?575?D19?=1K2:= ?415=.7::0?1>? ->D?:=1-0=1;:=?>-=1-A-57-.71 B5?459 B:=65930-D>2=:8>-8;71=1/15;?
A Genea Prenatal Request Form is available from www.hollywoodivf.com/doctorsinformation/useful-forms.aspx
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Who Funds Must Win Health Informatics expert Dr Adam Dunn sounds a warning over the inherent conďŹ‚icts of â€˜independentâ€™ research funded by industry. Two recent high-proďŹ le examples of new industry partnerships in Australia have stirred up concerns about industry affecting the evidence we rely on as patients and providers of care. Swisse Wellness has given La Trobe University $15m to establish a new research centre in Melbourne, and Blackmores is providing University of Sydney with $1.3m to support a new professorial chair. Some of the products that Blackmores and Swisse sell to consumers have ďŹ‚imsy support from clinical trials. So it might be reasonable to ask: if there are gaps in the evidence not being ďŹ lled by public funding, and the companies that ďŹ ll those gaps have no say in how the research is conducted, why should we be concerned? Industry funding makes a difference to clinical practice. Drug and device companies spend billions of dollars on doctors and hospitals every year, and they would not do so unless it was useful for increasing sales. Evidence concludes that pharmaceutical representatives do affect what doctors prescribe, and not in ways that are better for their patientsâ€™ health. Industry funding also makes a difference to clinical research. The companies that seek to proďŹ t from healthcare are deeply embedded
in the processes that go into producing and translating evidence into practice. About half the clinical trials that help guide decision-making in clinical practice are funded by drug and device companies. Evidence from these trials makes its way into practice by inďŹ‚uencing policy, guidelines, systematic reviews and the opinions of those clinicians from whom advice ďŹ‚ows freely. And clinical trials funded by industry are much more likely to produce favourable results, or to remain unpublished. But industry-funded research differs from publicly-funded research in another way. The data behind the trials are more likely to remain hidden and if allowed to remain so, could be reported in ways that make an intervention look safer or more effective than it really is. With rosiglitazone (Avandia), trials funded by the company as early as 1999 were designed and reported in ways that hid the truth about problems with cardiovascular risks, including the apparent mislabelling of individual participants who died of myocardial infarction. When a meta-analysis showing the drug was unsafe was ďŹ rst published in 2007, it was met with a mountain of editorials and opinions from ďŹ nancially-conďŹ‚icted researchers supporting the safety of the drug.
Avandia is an exemplar of problems associated with industry funded research but there are many more. Around one in four of all approved drugs are eventually withdrawn or have their labels changed to reďŹ‚ect safety issues. Another effective strategy for increasing drug sales is to expand its indications or the criteria for one of the indications, so wider sections of the community are covered, as recently occured with statins. Here in Australia, my concern is that the trials designed and run using private funding will not provide independent access to patient-level trials data; that investigators will â€˜spinâ€™ the results to ensure continuing industry support. And I am concerned that academics will lend their credibility without declaring their conďŹ‚icts of interest. Whereas consumers might receive their advice from celebrities like George Calombaris and Sonia Kruger when it comes to complementary medicines, by adding the credibility of established clinical researchers, I see a slippery slope between the appropriate use of complementary medicines and use that causes real harm in the community. ED: Dr Dunn is Senior Research Fellow at the Centre for Health Informatics, Macquarie University
Website for FH - www.athero.org.au/calculator sĂĽ ONEĂĽCLICKĂĽSCOREĂĽCALCULATIONĂĽONĂĽCOMPLETIONĂĽ of questions. sĂĽ DETERMINESĂĽLIKELIHOODĂĽOFĂĽ&(ĂĽANDĂĽPROVIDESĂĽ management recommendation. sĂĽ SUMMARYĂĽOFĂĽCALCULATIONĂĽDETAILS ĂĽRESULTSĂĽ and recommendation can be copied and pasted into patient notes. sĂĽ SUPPORTEDĂĽBYĂĽUSEFULĂĽINFORMATIONĂĽVIAĂĽ the drop-down menu from the â€˜Health Professionalsâ€™ tab. sĂĽ REALIGNSĂĽTEXTĂĽSOMEWHATĂĽFORĂĽSMALLERĂĽPORTABLEĂĽ devices using standard browsers.
Clinical context Familial Hypercholesterolaemia (FH) is the commonest autosomal dominant disease in our community, inevitably leading to later health problems unless diagnosed and managed early. This website assists with the diagnosis of FH in often symptomless patients using the Dutch Lipid Clinic Network Criteria Score (DLCNCS). Alternatively, just Google â€œDutch lipid calculatorâ€?. There is a greatly increased risk of premature coronary heart disease â€“ 50% for males <50 years and 30% for females <60 years. Once one family member is identiďŹ ed, cascade screening can detect other family members, ideally in childhood, reducing early cardiovascular events and mortality. Normal cardiovascular disease (CVD) risk calculation is unsuitable for people with FH as they are very high risk, regardless. Even DNA testing does not always diagnose FH, since it is not possible to test for all mutations. It is worth calculating a DLCNCS for anyone with an LDL â‰Ľ 4.0, using blood results and any known relevant personal or family history, presumably after exclusion of secondary causes (e.g. renal or liver disease, hypothyroidism, steroid use).
What could be improved? The â€œcopy to clipboardâ€? button works better in some browsers than others, but in all browsers it is easy to copy and paste directly from the desktop webpage (Ctrl C, Ctrl V). By Dr Jacqui Garton-Smith, General Practitioner
Useful features sĂĽ INTUITIVEĂĽmOWĂĽ ĂĽADDITIONALĂĽQUESTIONSĂĽAREĂĽ revealed as you answer, so only relevant questions appear. sĂĽ ITĂĽFACTORSĂĽINĂĽUNKNOWNS sĂĽ EASYĂĽ,$,ĂĽADJUSTMENTĂĽFORĂĽCURRENTĂĽLIPIDĂĽ lowering therapy.
The results page has a â€œGuidelinesâ€? link to a model of care page with links to articles, but access is required to view the full articles.
Author competing interests: no relevant disclosures. Questions, contact the author Jacquie.Garton-Smith@health.wa.gov.au
Belvidere Health Centre Iron Infusion Service The Belvidere Health Centre has played a key role in facilitating primary healthcare reform by providing innovative integrated service delivery models that aim to ﬁll healthcare gaps within the community. The Iron Infusion Service is a prime example. In August 2013, the initiative was developed in response to an identiﬁed lack of available intravenous iron infusion services within primary health care. The service provides Ferric carboxymaltose (Ferinject®), an iron complex that consists of a ferric hydroxide core stabilised by a carbohydrate shell. Administered intravenously, it is effective in the treatment of iron-deﬁciency anaemia, delivering a replenishment dose of up to 1000mg of iron (maximum dose 20mg/kg bodyweight per week). The minimum infusion administration time is equal to 15 minutes as opposed to 3-4 hours of comparators. Results of several randomised trials have shown that Iron Infusion Referral Statistics between January to May 2015. intravenous iron rapidly improves haemoglobin levels and replenishes depleted iron stores in various populations of patients with iron-deﬁciency with or without anaemia, including those with inﬂammatory bowel disease, heavy uterine bleeding, postpartum iron-deﬁciency and chronic kidney disease. Ferric carboxymaltose is, therefore, an effective option in patients for whom oral iron preparations are ineffective, cannot be tolerated or who require rapid replenishment of iron stores. Operating six days a week, the service averages 90+ patients per month with a 1-2 week wait list. The Iron Infusion Service currently offers Bulk Billing to patients with a valid Medicare card and is looking to expand its service over the coming year in response to increased referral demand and also concurrent interest from major tertiary facilities.
Opening Hours: Monday to Friday 8.30am – 4.30pm Saturdays 8.30am – 6.00pm
For any additional information and referral details please contact the Belvidere Health Centre on 08 6253 2100 or email@example.com 32
Apps Make for Happier Patients For a GP, psychological medicine is a core part of our day. Despite the government making psychological assistance more accessible with the EPC rebates for psychologists, it remains out of reach for many, for reason of access, ﬁnances or being just too scary for some. I have found that offering people the chance of experiencing some of the psychological methods through an app makes them so much more accessible. I have certainly found this helpful when meeting anxious /depressed or just stressed out young people.
Pluses: Free, a relaxing Australian male voice, not too ‘new age’, wide appeal (children and adults), and no ads. Minuses: App needs an Internet connection to sign on and download activities.
Reviews by Dr Clare Matthews, GP Claremont
manage anxiety and worry. I like the way one can set up a list of favourite methods and sayings for when anxiety hits. It has some CBT techniques around ‘thinking right’ – recognising damaging thought patterns and identifying more realistic and helpful self-talk. It contains some good ‘chillout tools’ including relaxation and mindfulness exercises, with male or female voice possible. Pluses: Easy to follow, intuitive navigation. Free, works without Internet connection, choice of male and female voices, no ads. Minuses: Canadian voices where used.
Author competing interests: no relevant disclosures. Questions? Contact the author on 9385 2288.
Details: For patients. Free, 44MB, iPhone or android, Australian. Requires internet connection and login. Linked to www. smilingmind.com.au Recommendation from: A country GP dealing mainly with youth mental health problems. Overview: Developed by psychologists from a not-for-proﬁt organisation, aimed mainly at young people, introduces them to modern meditation to bring a sense of calm, clarity and contentment into their lives. Combines both an App and website (smilingmind.com. au) although either is standalone. Provides led (voice) meditation sessions suitable for adults and children from seven upwards, taking you through multiple different mindfulness activities. Easy to use and each session is divided into accessible chunks of 3-8 minutes. There is useful section on anxiety in sport, designed in partnership with Cricket Australia’s Sport Psychology Team.
Details: For patients. Free, 37MB, iPhone or android, Canadian. No internet connection required. Password protection optional. Can keep notes. Recommendation from: Can’t remember! Overview: Developed by a Canadian not-forproﬁt organisation that also produces www. anxietybc.com. Easy to follow suggestions aimed at youngsters and younger adults to help them dealing with anxiety and stress; guides the user through identifying anxiety symptoms and occasions which trigger anxiety. Explains what’s behind the physical symptoms and offers different techniques to
Where to Telemedicine? continued from Page 27 Compliance vs time wasting He says the medical profession is partly to blame for non-compliance. Bringing people back for normal results or a repeat script when they have no symptoms and are not examined, seems to the consumer unnecessary time wasting. “Our patient demographic is those dissatisﬁed with conventional care. I heard a story of a girl in Esperance who had symptoms of UTI on Thursday and the local practice told her she could get an appointment on Monday. WA has problems with doctor resources while there are doctors elsewhere twiddling their thumbs.” He says the 80% bulk billing rate may be OK for some doctors making money out of
Medicare. However, with the impression that these doctors are employed by the patient through their insurer (and no money changes hands between patient and doctor) it is hard to build a fulﬁlling occupation. “When you look at complaints that the doctor wouldn’t speak to me or just wanted to give me a script, you can understand the pressures doctors are under when you run a bricks and mortar practice with all the costs that go with that.” “Telehealth delivers a patient-centric service, like home visits. If you look at the trends across society, consumers are demanding things on their terms. Demand drives change. There will be an increased uptake of online services as in the US.”
By Dr Rob McEvoy
s The make-up of the interim Healthway Board has been announced. Ms Maree De Lacey, the former DG of the Department of Water, is its new chair. Acting DG of Health Prof Bryant Stokes is deputy chair. Other board members are DG of Sport and Recreation Mr Ron Alexander, DG of Child Protection Ms Emma White, WA Local Government Association chief Ms Ricky Burges and DG of Culture and the Arts Mr Duncan Ord. s The new Primary Health Care Advisory Group will include three West Australians – HBF CEO Mr Rob Bransby, former head of the Rural Clinical School, Prof Geoff Riley, and Broome GP Dr Catherine Engelke. The Minister Ms Sussan Ley also announced the MBS Review Taskforce. There are no West Australians on that body. s Prof Nigel Laing, head of the Neurogenetic Diseases Laboratory at the Perkins Institute was made an Ofﬁcer of the Order of Australia in the Queen’s Birthday Honours. Retired GP Dr Bill Peasley was made a member of the Order of Australia for his work with indigenous communities. s Ms Bev East has been appointed GM of St John of God Social Outreach. s SJG Murdoch Hospital welcomed visiting North American Orthopaedic Fellows, Dr Rajiv Gandhi, from Toronto Western Hospital, and Dr Sanjeev Kakar, from the Mayo Clinic in Rochester. Prof Piers Yates hosted the pair during their time in Perth. s Dr Roslyn Carbon has left as Medical Director of the Department of Corrective Services. Dr Fraser Moss is acting in the position.
News & Views
RACGP Into the Fray The RACGP recently released its new funding model for primary care. This discussion paper Vision for the Sustainable Health System, sought further feedback after initial consultation with grassroots GPs informed the model. The discussion paper says: sĂĽ (EALTHĂĽCOSTSĂĽAREĂĽRISINGĂĽDUEĂĽTOĂĽCHANGINGĂĽPOPULATIONĂĽDEMOGRAPHICS ĂĽ health consumer expectations, and more expensive medical services. sĂĽ 0EOPLEĂĽWITHĂĽPOORERĂĽACCESSĂĽAREĂĽTHEĂĽAGED ĂĽCULTURALLYĂĽDIVERSE ĂĽ!43)ĂĽ people, and rural folk. sĂĽ !CHIEVINGĂĽBETTERĂĽHEALTHĂĽOUTCOMESĂĽINĂĽGENERALĂĽPRACTICEĂĽISĂĽHAMSTRUNGĂĽ by lack of money, poor targeting of remuneration, failure to support diversity and ongoing care, inadequate preventive health, and over specialisation of the medical workforce. sĂĽ (IGHĂĽPERFORMINGĂĽGENERALĂĽPRACTICEĂĽWILLĂĽSAVEĂĽMONEYĂĽBYĂĽDECREASINGĂĽ%$ĂĽ presentations, and lessening hospital initial admissions, length of stay, and readmissions. It also says a sustainable (read affordable) health system needs a supported and ongoing doctor/patient relationship, early intervention and prevention, better chronic disease management, a dominant focus on primary health care, and a commitment to quality and efďŹ ciency. There are few who would disagree with these ideas but how the medical profession and general practice in particular, gets there, might create arguments. This RACGP Consultation Paper suggests these methods: sĂĽ 2EPLACEĂĽ)NCENTIVEĂĽ0AYMENTSĂĽ0)0SĂĽĂĽ3)0S ĂĽWITHĂĽ0RACTITIONERĂĽANDĂĽ Practice Support Payments that reward practices and doctors who deliver a broad range of services, provide continuous care for patients and operate in areas of greatest need. sĂĽ 6OLUNTARYĂĽ0ATIENTĂĽENROLMENTĂĽWITHĂĽANĂĽOPT INĂĽ'0 The college has called this overall re-arrangement as the â€˜medical homeâ€™ and funding, as always, will be the biggest hurdle. After an initial investment, the college says things will be cost-neutral. The big question is whether the â€˜medical homeâ€™ model delivers government a way of moving the goal posts to save money and further desecrate general practice, and whether the RACGP will resist this at all costs. Government could make these changes: sĂĽ #HRONICĂĽDISEASEĂĽMANAGEMENTĂĽPATIENTSĂĽANDĂĽDOCTORĂĽSHOPPERSĂĽAREĂĽFORCEDĂĽ to register (i.e. no longer optional) with their practice of choice initially, then everyone must register, then with practices within a deďŹ ned zone. sĂĽ &EEĂĽFORĂĽSERVICEĂĽISĂĽLARGELYĂĽREPLACEDĂĽBYĂĽ0)0SĂĽTHATĂĽLOSEĂĽTHEIRĂĽOUTCOMESĂĽFOCUS If the RACGP has an effective plan to ďŹ ght political misuse of its ideas, then it is safe to be at least talking cost-effectiveness with government, which is what government wants to hear, not how we should grow the funding cake.
By Dr Rob McEvoy
PIVET MEDICAL CENTRE Specialists in Reproductive Medicine & Gynaecological Services
by Medical Director Prof John Yovich
Sacrocolpopexy â€Ś a nifty, effective laparoscopic procedure for a common problem Pelvic organ prolapse (POP) causes one third of menopausal women to attend for gynaecological procedures, traditionally performed as various types of vaginal surgeries.
Clinical Professor John Yovich
Risk factors for POP include age >45 years, BMI>30 Kg/ m2, increased gravidity, parity and vaginal deliveries, big babies, prolonged second stage of labour, and raised intra-abdominal pressure from chronic obstructive pulmonary disease, smokers Dr Philip Rowlands placing the polypropylene mesh from the vaginal cough, chronic constipation vault to the sacrum (using ProTacks) and strenuous activity. As along the right pelvic sidewall. with all disorders, there is a VWURQJJHQHWLFLQĂ XHQFH and Caucasian women seem particularly prone (compared to Asian or African women). There are strong family history associations and 5-fold likelihood with twins. Modern studies are beginning to With assistant Dr Kedar Jape, deftly identify genetic mutations closing the peritoneum over the related to the oestrogen mesh to avoid complications. receptor ER-Îą, collagen 3A1, chromosome 9q21 as well as an association with 6 SNPs (single nucleotide polymorphisms). One type of POP which has challenged gynaecologists in the past has been the vaginal vault prolapse, following previous hysterectomy. Various surgical corrections have been GHVFULEHGEXWPDQ\KDYHSURYHQGLIĂ€FXOWWRSHUIRUPZLWKD range of complications ensuing and high recurrence rates. In recent times the sacrocolpopexy procedure has become repopularised, particularly using a polypropylene mesh to elevate the vaginal vault and anchor it to the sacral promontory. Again complications have been reported, particularly ileus and small bowel obstruction, and even osteomyelitis at the sacral site. However the newer mesh and ProTacker devices have proven very popular and complications have become rare in the hands of advanced laparoscopic gynae surgeons who deftly exteriorise the mesh from the peritoneal cavity in a day-case procedure.
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Cardiology & diabetes – a holistic approach Randomised controlled trials provide compelling evidence that the microvascular complications of diabetes mellitus (DM) are reduced by tight glycaemic control, which also exerts a favourable, although smaller, inﬂuence on cardiovascular disease (CVD) that becomes apparent after many years. However, intense glucose control and lipid lowering appear to markedly shorten the time needed to make improvements in the rate of cardiovascular events(1). Intensiﬁed glucose lowering in microvascular disease (retinopathy, nephropathy and neuropathy), targeting an HbA1c of 6.07.0%, has consistently been associated with a decreased frequency and severity of microvascular complications. This applies to both type 1 DM and type 2 DM. Although there is a strong relationship between glycaemia and microvascular disease, the situation regarding macrovascular disease (cerebral, coronary and peripheral artery disease) is less clear. The reasons, of which there are several, include the presence of multiple co-morbidities in long-standing type 2 DM and the complex
risk phenotype generated in the presence of insulin resistance. In the ACCORD trial, 10 251 type 2 DM patients were randomised to intensive glucose control (HbA1c 6.4%) or standard control (HbA1c 7.4%). The trial was prematurely stopped because of excess death in the intensiﬁed control group (14/1000 vs. 11/1000). However, a recent extended follow-up of ACCORD did not support the hypothesis that severe symptomatic hypoglycaemia was related to the higher mortality. Meta-analysis of several studies suggested that an HbA1c reduction of 1% was associated with a 15% relative risk reduction in non-fatal myocardial infraction. Patients with a short duration of type 2 DM beneﬁted the most from intensive glucose lowering. In the EDIC study, 93% of the cohort was followed for 17 years, showing the risk of any cardiovascular event was reduced in the intensive group by 42% (2,3). The inﬂuences on quality of life, adverse effects of polypharmacy and inconvenience of intensiﬁed glucose control-lowering regimes have to be carefully evaluated for each individual with DM. Each individual should be
The new stressors for our times Working extensively with couples and individuals, I see relationships ﬂounder because of the stressors in daily lives. These take many forms but probably the commonest is the lack of time people make available to enjoy their relationships with each other. People are increasingly time poor because of excessive work requirements, demanding family responsibilities and the large amount of time being spent using computers, smart phones, tablets and other forms of IT. This leaves them less time to relax and actually share thoughts and feelings with each other face-to-face each day. Many couples complain they are simply too tired at the end of a day for quality time with each other. Many use alcohol to relax at the end of the working day. Unfortunately, beyond a well-controlled minimum amount, drinking can easily dull the senses and seriously compromise the quality of any attempt to be truly present with their spouse or partner. Lost connection When life makes so many demands on
people’s time they seem to ﬁnd it very difﬁcult or impossible to change what they are doing and re-establish the emotional connection that nourishes us all in our relationships. This lack of connection then leads to recognised or unconscious feelings of deprivation and isolation. This can easily lead to arguments that escalate into hostile confrontations. Alternatively, many couples have become quietly and inexorably estranged from each other and feel like they have little or nothing left in common. They report that the spark has gone from their relationship and, while they may still be sharing sexually to some extent, this is rarely sufﬁciently satisfying of itself and they cannot see any way to reconnect in other meaningful ways.
By Dr Johan Janssen, Cardiologist
encouraged to achieve the best compromise between glucose control and vascular risk and, if intensiﬁed therapy is instituted, the patients must be informed and understand the beneﬁts and risks. Offering patients a holistic approach to their risk management is the cardiologist’s aim. References: 1. Gaede P, Lund-Andersen et al: Effect of a multifactorial intervention on mortality in type 2 diabetes. N Engl J Med 2008: 358:580-591 2. Nathan DM, Cleary PA et al: Intensive diabetes treatment and cardiovascular disease in patients with type 1 diabetes. N Engl J Med 2005:353:2643-2653 3. UKPDS group: Effect of intensive blood glucose control with metformin on complications in overweight patients with type 2 diabetes. Lancet 1998:352: 854-865.
Competing interests declaration: nil relevant. Questions: contact author on 9346 9300. Western Cardiology contribute to production costs.
By Jonathan Kester, Psychotherapist, Fremantle
Counselling supports clients to ﬁnd their own solutions to their relational difﬁculties. It can also be helpful to offer people ways to reframe their beliefs and attitudes towards work, home life and especially their relationships. Then they can make the signiﬁcant adjustments to reclaim the quality of connection they wish to experience again.
Author competing interests: no relevant disclosures. Questions to the author please phone 9298 9915.
Another commonly reported source of stress is the imbalance felt by the wife (occasionally husband), who sees their partner as not pulling their weight at home with the care of children, housework and ﬁnancial arrangements they have to manage. This is often due to the long hours their partner has to devote to their job in order to meet the monetary commitments they have created together.
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By Dr Darryl Menaglio DPsych, Clinical & Forensic Psychologist, President, Institute of Clinical Psychologists
Suicide resurgence in men Suicide amongst men in Australia remains unacceptably high â€“ at least ďŹ ve of the seven people who suicide each day are men. In 2013, males aged over 85 years had the highest number of suicides with males aged 45â€“54 being the second highest. The peak in the over 85 age group deďŹ ed a declining trend in the number of suicides for both men and women that began in 1963. Whether this increase in suicides for men aged over 85 is a spike or a trend is unknown, as is why there was a peak in this age group. Perhaps it was sparked by the debate around assisted suicide that may have caused older men to consider suicide as a digniďŹ ed end to their lives? The Australian Institute of Male Health Studies argues suicide is the number one killer of men under 44 years of age. Most men are successful ďŹ rst attempt. Those at greatest risk are not engaged in mental health services; most frightening is that front line health services rely on a diagnostic system that depends on the patient being open and candid if he is suicidal; and men typically do not want to tell.
Risk hard to unearth The apparent suicide and subsequent murder of all his innocent passengers of the young co-pilot of the German plane in France has thrown light onto just how inadequate current diagnostic procedures are. Work by Professor Nock from Harvard University Psychology shows promise. Reaction time to visually presented subliminal stimuli could be a diagnostic tool in detecting suicide contemplation, particularly where suicide involves a high risk of harm to others. When we have patients who are reluctant to reveal signs of suicide, we must rely on the factors associated with suicide risk.
Depression is a risk factor in all age groups. In men, other factors change with age: in teenagers, risky behaviours, substance abuse and failure to develop can give warning; in their 20s, attempting to respond to excessive work or study demands; in the 30s early 40s, marriage failure and domestic violence; in mid 40s to 50s, unemployment and perceived failure to achieve; late 50s and 60s, marriage failure and illness; and in the 70s, loss of spouse, loneliness, pessimism and cynicism. For now it is better for all that we over-estimate the risk of suicide in our patients. Patients can be observed or referred for treatment until it is clear they are either no longer a risk, or that that risk was minimal.
Key Points: Suicide in Men sĂĽ &IVEĂĽMENĂĽSUICIDEĂĽEACHĂĽDAY sĂĽ -IDDLEĂĽAGEDĂĽANDĂĽELDERLYĂĽMENĂĽMOSTĂĽOFTEN sĂĽ -OSTĂĽMENĂĽAREĂĽSUCCESSFULĂĽlRSTĂĽATTEMPT ĂĽANDĂĽ may not hint at suicide beforehand. sĂĽ (EALTHĂĽPROFESSIONALSĂĽSHOULDĂĽBEĂĽMINDFULĂĽ of risky situations, should paths cross for other reasons.
Author competing interests: no relevant disclosures. Questions? Contact the author 9388 3767.
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Questions around testosterone prescribing What is good clinical practice for testosterone replacement therapy (TRT)? There is a 1% decline per year in serum total testosterone, starting in the late 30s. Andrology Australia suggests that androgen deďŹ ciency (AD) affects 1 in 10 men over 60 years. Clinical features of late-onset testosterone deďŹ ciency include: sĂĽ ,OWĂĽLIBIDO sĂĽ !BSENCEĂĽOFĂĽMORNINGĂĽERECTIONS sĂĽ 2EDUCEDĂĽENERGYĂĽLEVELSMOTIVATION sĂĽ -OODĂĽSWINGSĂĽANDĂĽREDUCEDĂĽCOGNITIVEĂĽ capacity sĂĽ 0OORĂĽSLEEPĂĽQUALITYĂĽAFTERĂĽEXCLUDINGĂĽSLEEPĂĽ apnoea) sĂĽ 2EDUCEDĂĽMUSCLEĂĽMASSĂĽANDĂĽSTRENGTH If a patient complains of some of these symptoms, especially absent morning erections and marked mood swings, and his wife mentions low libido, then investigation for primary hypogonadism is indicated. This involves testing two early morning blood samples for testosterone/free testosterone and LH/FSH. If the testosterone level is less than 8nmol/L and the calculated free testosterone levels are signiďŹ cantly below the normal range (<180pmol/L), with LH and FSH normal, then a diagnosis of primary hypogonadism should be entertained. After checking for sleep apnoea, prolactin levels (to exclude a prolactinoma) and ferritin levels (to exclude haemochromatosis), TRT can be offered if there is clear evidence of symptoms. This agrees with various reputable clinical guidelines. The trial of treatment is usually 3-6
By Dr David Millar, Sexual Health Physician
months â€“ patients should be assessed for symptoms important to them, not according to the agenda of the physician. Well recognised beneďŹ ts of TRT for aging hypogonadal men include increased lean body mass (DEXA scans prior to treatment and 12 months later is a valuable reference tool). Older men treated outside of PBS guidelines should be told that long-term risks/beneďŹ ts are not yet documented. Regular monitoring for prostatic cancer and polycythaemia are indicated. Why change PBS guidelines? It would seem that the primary motive is cost cutting. Compared with other countries (e.g. EUA, ISSM, ESS and ISMH), Australiaâ€™s previous qualifying guidelines for TRT were already conservative. Who has been abusing TRT? No GPs that I know of. There are anecdotal reports of occasional GPs assisting weightlifters and other sportsmen to receive performance enhancing testosterone. How will new PBS thresholds cause problems? Those patients whose testosterone levels are/ were above the new thresholds and who gain signiďŹ cant clinical and quality of life beneďŹ ts from testosterone therapy, will either pay for a private prescription or cease TRT. This seems particularly unfair to those patients who fell within the previous guidelines but have had the goal posts shifted. Other consequences will include reduced bone mass (osteoporosis), reduced lean tissue (muscle) and increased visceral adipose tissue. Further investigation is ongoing as to the
medical/ďŹ nancial consequences of this. Those patients whose testosterone levels fall below the new threshold of 6 nmol/L or whose testosterone levels are 6-15nmol/L plus a high LH (greater than 1.5 times the upper limit) can continue therapy after review by an authorised specialist i.e. GPs are not considered competent to assess this and patients will have an added/delayed step to continue with a PBS Authority script. For patients who cannot afford private scripts but face losing TRT under the new guidelines, what can be done? They will have to cease TRT and see if their levels drop below 6.0 before pituitary stimulation of testosterone occurs. This can take up to 6 months. Andrology Australia says doing this may be necessary, along with the return of symptoms but fail to give a time scale (see www.andrologyaustralia.org/2015/06/ pbs-testosterone-criteria/). Who do you see making up the predicted increase in patients on private scripts? In my patient group, about 70-80% will not ďŹ t into the new set of â€œnumbersâ€? despite a very strong clinical picture of testosterone deďŹ ciency and who would be expected to respond very well to TRT. The â€˜average personâ€™ would be a man in his 50s or 60s, single/married, who would be expected to have symptoms return within days/weeks/ months of ceasing TRT. Any other comment? The vast majority of experts in Andrology recommend that free testosterone (active testosterone) levels should be used in deciding on late onset hypogonadism; which seems to have been ignored in these guidelines.
Men Will Suffer From TRT Cutbacks Maybe the pollies havenâ€™t heard the last of this one â€“ men are a bit slow off the mark but gender wars may fuel disquiet over testosterone availability.
fatigue, and osteoporosis. The extra cost generated by more tests and the consultation with a specialist must be outweighed by savings from these changes.
Recent changes to the PBS rules for testosterone prescribing take the decision from the GP and give it to specialists. If the endocrinologist, urologist, or registered member of the Australasian Chapter of Sexual Health Medicine (are there any in WA?) want to diagnose an established pituitary or testicular disorder then prescribing is all right.
Many GPs, especially those in rural areas, have said the restrictions are draconian and delays are bad for some patients. To accommodate this disquiet, the PBS has said the GP may contact the appropriate specialist by phone, email or fax to comply (â€œin consultation with one of these specialistsâ€?) and for those delayed by waiting for a specialist assessment, simply making that appointment is good enough to re-prescribe meanwhile.
subsidised TRT must cease. A recent drop in the PBS threshold for TRT, from 8 to 6nmol/L, does not include a â€˜grandfather clauseâ€™ for those caught up in this change. The consequences of cost-saving
If androgen deďŹ ciency is due to just ageing, the sole reason for testosterone replacement therapy (TRT), then the PBS script is no longer covered.
While most people we talk to are concerned about over-use of testosterone scripts, everyone seems to see this as a cost saving exercise, beyond the need to slow down the reported 17-fold increase in PBS testosterone scripts. No one is pointing to aberrant doctors prescribing testosterone to body builders and athletes.
If someone suspects that mumps or suchlike has led to androgen deďŹ ciency, documented in the past as between 6-8nmol/L, then
The consequences may be that older men who canâ€™t afford private scripts are back on the road to grumpiness, weakness and
Andrology Australia has suggested men on TRT for some time but who fall into the 6 to 8nmol/L gap, might just come off it, wait the
continued on Page 43
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Low back pain: MRI or not?
By Dr Sonja Raven, Consultant Radiologist
With the number of MRI scanners in WA increased from 11 licences in 2006 to the current 38 licensed and unlicensed magnets, availability has become less of a hindrance. But when is a MRI indicated for low back pain (LBP) and when is plain radiography or CT preferred? Non-speciﬁc LBP does not require initial imaging as it often improves within the ﬁrst month on conservative treatment. If pain persists it is reasonable to perform plain radiography. This could demonstrate: fractures; possible infection; malignancy; degeneration of the discs, facets and SI joints; transitional anatomy; spondylolysis; later changes of axial-SpA; scoliosis; instability; and positioning of past surgery. Further imaging of these with CT or MRI is often indicated.
(l to r) Three imaging techniques for the lumbar spine: sagittal CT, T1 (basic MRI sequence that shows anatomical detail) and STIR (fat suppression MRI sequence that often highlights pathology). Bone metastases within vertebral bodies (arrows) are often better visualised on MRI than on CT.
MRI indications LBP associated with sciatica or spinal canal stenosis. MRI provides better deﬁnition of disc herniation and its effect on the nerve roots than CT. Initially, conservative treatment of sciatica is reasonable, but MRI is indicated if the pain does not improve or if there is a progressive neurological deﬁcit. Cauda equina syndrome requires urgent referral and MRI imaging. Central spinal canal stenosis is better graded on MRI, especially in terms of the compression of the cauda equina. Lateral canal stenosis and compression of the nerve roots along the sub articular recesses are best visualised on MRI.
Red ﬂags for serious pathology (see Table). The initial imaging is plain radiography, but MRI is indicated if the cause remains uncertain.
damage that comes later, by several years. MRI helps identify patient response to anti-TNF therapy and can be used to predict SI joint and spinal fusion.
Inﬂammatory back pain where axial spondyloarthropathy (axial-SpA) is suspected (e.g. ankylosing spondylitis). MRI is very helpful in the early diagnosis as it can show active inﬂammation at sites where ligaments attach to the vertebrae and intervertebral discs, along the vertebral endplates and the SI joints. In contrast, plain radiography and CT reﬂect the structural
Previous disc surgery with recurrent symptoms. A MRI with contrast helps differentiate between a recurrent disc herniation and post surgical scar tissue.
Red Flags for Serious Pathology Cancer
History of cancer, unexplained weight loss, lack of improvement after 1 month, > 50 years.
Older age, prolonged steroid use, severe trauma.
Fever, drug abuse, immunosuppression, HIV.
Other. Although CT gives better bony detail for treatment planning, MRI is best to determine the age of a fracture or pars defect, and is helpful to determine if disc and facet joint degeneration is symptomatic as it can show bone oedema, which indicates active reactive changes. MRI is preferred in young people to mitigate CT radiation risk.
Author competing interests: no relevant disclosures. Questions? Contact the author on 9246 8800 (SKG Radiology).
Men Will Suffer From TRT Cutbacks continued from Page 41 3-6 months it takes for their own pituitary to kick in (if it does at all), and if remeasured testosterone levels are below 6 nmol/L on two morning samples (taken on separate days), then they again qualify for TRT. The affected men will just have to put up with symptoms meanwhile! The common sense approach to anyone with borderline testosterone levels but symptoms, is a properly monitored therapeutic trial. If they don’t need it, take them off it. Testosterone marketing Market forces are at play, however. Drug companies like promotion of the concept of andropause in men with age-related declines
in testosterone (and some countries allow direct-to-consumer advertising). With this goes TRT. Others say we are not pushing too hard but simply increasing awareness to where it should be because experts say androgen deﬁciency affects 10% of older men?
is. Others say once the gender prejudice and costs are set aside, not much will change with testosterone prescribing. People need it or they don’t. There will be just more men on private scripts and government will save that money.
On the other hand, Prof Handelsman, professor of reproductive endocrinology and andrology at the University of Sydney, reportedly said tightening the PBS prescribing criteria would help curb inappropriate prescribing of testosterone for functional causes of low serum testosterone. Such misguided, wasteful prescribing could be putting patients at risk, he said.
The real farce for the profession is how any specialist can distinguish between functional androgen deﬁciency and pathological hypogonadism in older men? They will go off the new ‘6’ limits like anyone else.
Some doctors say tightening restrictions is not the answer but auditing and educating
By Dr Rob McEvoy
Will these new PBS guidelines see some hypogonadal men suffer so the GP can measure the <6 nmol/L results, ready for the specialist appointment?
Iron deďŹ ciency quick and simple tips Iron metabolism disorders are very common: up to 20% of young women have chronic iron deďŹ ciency; and iron overload is frequently seen. To make things harder, interpretation of iron studies and associated tests is not easy and there are many traps. Test usefulness Serum Iron (Fe) is virtually useless, merely reďŹ‚ecting recent intake of iron and the amount circulating. Transferrin (TF), the transport molecule for iron, rises with iron deďŹ ciency and pregnancy and is low in â€˜chronic diseasesâ€™. Transferrin saturation (TF%) is a calculated value from these values: small changes in serum iron (which is quite labile) or transferrin can skew the result quite markedly. Ferritin is the iron â€˜store roomâ€™. Blood levels usually reďŹ‚ect storage iron levels and are the best measure of iron stores. Low levels conďŹ rm iron deďŹ ciency. Ferritin is raised by inďŹ‚ammation and infection as well as iron overload, making it less useful in these settings (e.g. iron deďŹ ciency can be masked by a falsely elevated ferritin with co-existing inďŹ‚ammation). Diagnosing iron deďŹ ciency Recent Royal College of Pathologists of Australasia guidelines recommend a ferritin cut-off of under 30umol/L to diagnose iron deďŹ ciency. Levels 30-100 are uncertain, not excluding iron deďŹ ciency if an acute phase
Summary points: sĂĽ 3ERUMĂĽIRONĂĽISĂĽNOTĂĽHELPFULĂĽINĂĽASSESSING iron stores sĂĽ ,OWĂĽFERRITINĂĽCONlRMSĂĽIRONĂĽDElCIENCY Normal ferritin does not exclude it. sĂĽ )RONĂĽDElCIENCYĂĽISĂĽUSUALLYĂĽAĂĽSLOWLYĂĽ progressive chronic problem. sĂĽ /RALĂĽIRONĂĽISĂĽALMOSTĂĽALWAYSĂĽTHEĂĽlRSTĂĽLINEĂĽOFĂĽ therapy if the patient is haemodynamically stable. sĂĽ 3EVEREĂĽIRONĂĽDElCIENCYĂĽANAEMIAĂĽREQUIRESĂĽAĂĽ very low Hb and MCV with haemodynamic compromise. response is present. Usually ferritin over 100 indicates adequate iron stores. Haemoglobin and MCV are not always helpful, depending on where you are in the three step process of iron deďŹ ciency anaemia. First, storage iron is lost, with low ferritin (the actual level is irrelevant in assessing severity, low is deďŹ cient). Then, microcytosis occurs with progressively smaller MCV. Third, haemoglobin drops with the onset of anaemia. Patients feel tired in stage one (often tolerating and compensating for a long time) and it slowly progresses. Remember not all hypochromic, microcytic anaemia is due to iron deďŹ ciency, with thalassaemia and cases of chronic disease being other reasons.
Iron in pregnancy? Having re reviewed the evidence evidence, we should not rout routinely give iron supplem supplements to all pregnant women. However, it seems that iron supplementation with identiďŹ ed ide iron deďŹ cien deďŹ ciency anaemia is invalua invaluable. For the ďŹ rst time, a re recent BMJ review has identiďŹ ed identi that anaemia is associated associa with low birth weight, a and correcting ana anaemia is reverses this tre trend. Ho can too much How ir iron be given? A Hb >130 is associated with poorer fetal and maternal outcomes (Cochrane). M concern is if we My recomm recommend that all women
are supplemented with iron in pregnancy, this could lead to overuse of IV Fe (driven partly by commercial advantages) and avoidance of oral Fe supplements altogether. If IV iron is given in excess, the body has no mechanism of getting rid of it, whereas oral iron supplements will not absorb from the gut if the woman is iron replete. The other problem seen more often in Australia is women with Thalassaemia. These diseases (including the traits) can be associated with iron loading and we could again do more harm than good in recommending universal iron supplementation. Pregnancy unique Iron metabolism is very complex, more so in pregnancy as the fetus/placenta have a signiďŹ cant hold over the processes involved. The overriding message continues to be â€˜show cautionâ€™ (with an urgent need for large scale multicentre RCTâ€™s to assess important longterm outcomes). It is far more important to ensure all women eat
By Dr Steve Ward, Clinical Haematologist, Nedlands
Identify the cause. This includes vegan diet, malabsorption (coeliac disease, gastric or duodenal surgery), and blood loss (menstrual loss, ulcer, angiodysplasia, inďŹ‚ammatory bowel disease, tumour). Treatment Iron therapy is safe and simple: oral iron tablets, in sufďŹ cient dose to be effective (80-100mg elemental iron daily). Avoid â€˜homeopathicâ€™ iron preparations containing under 10mg iron. They are woefully inadequate as we only absorb 5-10% of the dose. Reserve iron infusion for those who truly do not tolerate oral iron, have malabsorption or where oral iron has been insufďŹ cient to replenish stores after an adequate trial. The onset of beneďŹ t from oral iron is just as quick as intravenous iron. I do not use or recommend IM iron due to difďŹ culty with the injection technique and staining, large volumes, and many injections required. IV iron is now much safer and easier to administer, with the PBS listing of FerinjectÂŽ, but is still associated with reactions and potential for anaphylaxis.
Author competing interests: no relevant disclosures. Questions? Contact the author on 6142 0970.
By Louise Keyes, Chair Australian College of Midwives, WA Branch KEMH
a healthy balanced diet and those faced with deďŹ ciency (and perhaps anaemia) receive upto- date information on the correct dose of oral iron supplements, and treatment follow-up. The author acknowledges Debbie Pinchon, Clinical Nurse Consultant KEMH, in preparing these comments. ED. Louise was responding to a USA report using 1999-2006 data, where iron deďŹ ciency affected 18.6% of pregnant women, with 16.2% anaemic. However, the Preventive Services Taskforce said there is no evidence that either routine screening of asymptomatic pregnant women for iron deďŹ ciency or routine iron supplementation during pregnancy results in overall improved maternal health or birth outcomes (e.g. caesarean delivery, preterm delivery, infant mortality, or low birthweight). In Australia, the RANZCOG advises a screen of Hb at the ďŹ rst antenatal visit and at about 28 weeks with investigation of any anaemia detected, but no routine iron supplementation in pregnancy.
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Chronic Hepatitis C â€“ rationalising care A high proportion, about 75%, of individuals exposed to Hepatitis C Virus (HCV) develop chronic infection (CHC), which is characterised by the presence HCV RNA and conďŹ rmed by PCR. Advanced liver disease (cirrhosis and hepatocellular carcinoma) generally occurs after 20-30 years of infection, with higher rates in those who drink excessive alcohol, have metabolic syndrome or are co-infected with Hepatitis B or HIV. An estimated 230 000 Australians currently have CHC, with 80 000 having moderate to severe liver disease. In 2013, 630 deaths were attributed to HCV. With this lag between contracting HCV and clinical disease, rates of advanced liver disease due to CHC are rising. Traditional interferon-based therapies for HCV have multiple limitations that prevent widespread use. Treatment is long (24-48 weeks), associated with multiple side effects and needs signiďŹ cant treatment infrastructure. Cure rates vary from 50-80% and are signiďŹ cantly lower in those with advanced liver disease. Treatment-related toxicity becomes a major limitation to ongoing treatment. It is contraindicated in those with decompensated liver disease. Breakthrough CHC treatments create dilemmas
By Dr Briohny Smith, Gastroenterologist & Hepetologist, South Perth
Hep C Key Points sĂĽ ĂĽĂĽ!USTRALIANSĂĽHAVEĂĽ#(#ĂĽADVANCEDĂĽ liver disease emerges after 20-30 years of infection, and prevalence is increasing. sĂĽ 2EFERĂĽANYONEĂĽWITHĂĽANĂĽ(#6ĂĽ0#2ĂĽPOSITIVEĂĽ result for assessment of underlying liver disease and ďŹ brosis. sĂĽ )NTERFERON BASEDĂĽTHERAPIESĂĽHAVEĂĽBEENĂĽ superseded by Direct Acting Antivirals (DAAs), which have higher cure rates and low toxicity but are costly. sĂĽ %ARLYĂĽACCESSĂĽTOĂĽ$!!SĂĽNOTĂĽ0"3ĂĽLISTEDĂĽASĂĽ yet) seems most appropriate for those who have advanced liver disease, are liver transplant recipients, have extra-hepatic manifestations of HCV, or are at risk of transmitting HCV to others. individuals such as those with advanced liver disease or previous liver transplant. In March 2015, the PBAC recommended that a single pill ledipasvir/sofosbuvir, sofosbuvir (alone) and daclatasvir be PBS listed for treatment of CHC. It comes at a cost; in the US a 12-week course of sofosbuvir costs $84 000. The Drug Utilisation SubCommittee has estimated that treating 62,000 patients in Australia will cost $3 billion over the next ďŹ ve years.
to speciďŹ c sub-groups, opening a Pandoraâ€™s box on determining which individuals with CHC would most likely beneďŹ t. Groups identiďŹ ed to most beneďŹ t from immediate access to DAAs include: sĂĽ THOSEĂĽATĂĽRISKĂĽOFĂĽLIVER RELATEDĂĽCOMPLICATIONSĂĽ (individuals with advanced liver ďŹ brosis, compensated cirrhosis or liver transplant recipients) and those with extrahepatic manifestations of HCV such as cryoglobulinaemia, sĂĽ THOSEĂĽWITHĂĽCOEXISTINGĂĽLIVERĂĽDISEASE ĂĽANDĂĽ sĂĽ THOSEĂĽATĂĽRISKĂĽOFĂĽTRANSMITTINGĂĽ(#6ĂĽTOĂĽOTHERSĂĽ (active IDU, incarcerated persons and women wishing to get pregnant). If individuals with stable liver disease (low or absent ďŹ brosis) are not eligible for immediate treatment, they should be monitored carefully for progressive ďŹ brosis and be offered treatment on progression or when more affordable treatment becomes available. Parliamentâ€™s response to the PBAC recommendations should be known later this year, along with any budgetary measures to limit supply of these revolutionary and much needed treatments. Only after this announcement will ďŹ rm guidelines on CHC treatment in Australia be possible.
The American and European and even the World Health Organisation recommend that the majority of individuals with CHC be treated with DAAs. However, cost is going to put them beyond the reach of most with CHC worldwide. In Australia supply may be limited
References available on request.
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Direct-acting antiviral (DAA) regimes (interferon free) have recently become available. These all-oral regimes have universally high (>90%) cure rates, minimal side effects and are safe and effective in typically difďŹ cult-to-treat
Parmelia Hilton Perth www.ruralhealthwest.com.au 22-24 Australia and New Zealand Breast Cancer Trials Group Annual ScientiďŹ c Meeting Pan PaciďŹ c Hotel, Perth www.anzbctg.org/content/33/annualscientiďŹ c-meeting 26â€“27 General Practitioner Conference and Exhibition Perth Convention & Exhibition Centre www.gpce.com.au
14-18 Australian Orthopaedic Association WA Annual ScientiďŹ c Meeting Rendezvous Scarborough www.aoa.org.au
Author competing interests: no relevant disclosures. Questions? Contact the author on 6102 2030.
16-18 Australian Hand Therapy Association Annual Conference Rendezvous Scarborough www.ahta.com.au
26-30 AMSA Global Health Conference
20-22 Oceania Tobacco Control Conference
Perth Convention & Exhibition Centre http://ghc2015.amsa.org.au
Perth Convention & Exhibition Centre www.otcc2015.org.au
17-21 Asian PaciďŹ c Conference of Nephrology (APCN) & ANZSN ASM 2016
13-15 State Conference of Science and Medicine in Sport and Exercise
Perth Convention & Exhibition Centre www.apcn2016.com.au
Bayview Geographe Resort, Busselton www.sma.org.au/conferences-events
Cool Running GP Dr Jane Deacon put her best foot forward over and overr again to clock a personal-best time in one of the world’s oldest st athletic events. She writes heree of her experiences. Dr Jane Deacon - the day before the race
The Boston Marathon is a highlight on the international running calendar with plenty to see and do away from the track. Boston is the largest city in Massachusetts and also its capital. It hosts the world’s oldest annual marathon, ﬁrst held in 1897 following the the revival of the race in the 1896 Athens Summer Olympics. The ﬁrst event attracted 18 runners to a slightly shortened version but in 1924 the starting line
was moved to Hopkinton and the distance increased to 42.195km. By 1970 the ﬁeld had grown to more than 1000 runners and two years later women were lining up alongside the men.
26km and 34km mark. There’s also an overall all decline of 140m which means Boston doesn’t ’t satisfy the necessary criteria to ratify a world d record time.
The course winds its way through eight Massachusetts towns before ﬁnishing in Boston. It gently undulates for most of the journey but there are four challenging hills between the
That might have been a source of disappointtd ment for the elite runners at the front of the ﬁeld but I had other concerns on my mind. Would I make it to the ﬁnish-line and how bad were those hills? Running around Boston Stepping away from the track for a moment, there’s plenty to see in Boston. Founded in 1630 it’s one of the oldest cities in the USA and there are lots of well-preserved historic buildings along the Freedom Trail, a 2.5km walking track. You can see Paul Revere’s house, museums, an excellent aquarium and the Boston Common – the oldest public park in America. My training for the Boston Marathon began in Perth, December 2014. As the days became hotter and my training distances got longer I rose early, trying to catch the coolest part of the day and I’d often be out the door well before sunrise. My long runs were mostly near the beach, it’s reasonably well-lit, has regular drinking fountains and I enjoyed a dip in the ocean when it was over. I’d see a smattering of other runners, cyclists, ﬁshermen and surfers – as well as drunken revellers who hadn’t quite ﬁnished their celebrations.
Hopkinton, Boston 48
In contrast, Boston was experiencing one of the
The race begins! School-bus ride to the Boston Marathon Start Line
coldest and snowiest winters on record. It was interesting, and slightly ironic, to be receiving regular emails from the Boston Athletic Association (BAA) with helpful hints on how to run safely in sub-zero temperatures and snow. Boston Strong
Tribute to a bomb in
I wasnâ€™t the only runner in Boston. About 30,000 other competitors descend on the city as well! Itâ€™s a public holiday and the atmosphere
Medical Notes sĂĽ (YPOTHERMIAĂĽWASĂĽTHEĂĽMAINĂĽMEDICALĂĽISSUE sĂĽ !CTIVEĂĽWARMINGĂĽINĂĽTHEĂĽ@"AIRĂĽ(UGGER with a heated airďŹ‚ow system. See: Forced-Air Warming www.fawfacts.com and www.youtube.com/embed/0j9W5brozV4 sĂĽ #IRCUS SIZEĂĽ-EDICALĂĽTENTĂĽnĂĽĂĽBEDS ĂĽ laboratory, respiratory and intensive care units staffed by 450 medical volunteers. sĂĽ ĂĽRUNNERSĂĽTREATEDĂĽANDĂĽĂĽTRANSPORTED to hospital. sĂĽ 0HEIDIPPIDESĂĽRANĂĽTHEĂĽlRSTĂĽ@MARATHONĂĽINĂĽ 490BC and dropped dead in Athens â€“ 100% mortality rate in the ďŹ rst event!
is wonderful wonderful, the barely suppressed excitement of the marathon runners tinged with sadness at the memory of the 2013 bombing. â€˜Boston Strongâ€™ banners are strung all over the city.
three hours after the ďŹ rst starting gun was ďŹ red ďŹ red.
The BAA has had 119 yearsâ€™ practice organising marathons, and it shows. The organisation is superb, even with the necessity of increased security measures. From Bib collection at the Expo, mass bus transport to the start-line and drink-stations all the way to the ďŹ nish, it ran like clockwork. There are literally thousands of volunteers!
It was cold, too. Around 7C with a light rain falling most of the day but that didnâ€™t stop thousands of spectators lining the course and cheering us on. I had a great run, tackling the hills without slowing down too much and from the 35km mark it was all downhillâ€Śwell, mostly. As I approached the ďŹ nish-line the crowds were deafening and I ended up clocking a personal-best (PB) time.
On race day I made my way to Boston Common and jumped on a bus to the start-line. Disabled participants head off ďŹ rst, followed by elite runners and then it was my turn, roughly
I collected my medal (most important!), a thermal cape, food and water and suddenly it was all over. I couldnâ€™t have been happier!
After all the weeks of training I was ďŹ nally running the Boston Marathon. It was amazing!
Entering Medical Forum’s competitions is easy!
Simply visit www.medicalhub.com.au and click on the ‘Competitions’ link (below the magazine cover on the left).
Movie: Mr Holmes Ian McKellen is an ageing Sherlock Holmes, retired and living alone except for his housekeeper and her young son. Holmes grapples with his diminishing cognitive abilities but can’t let go of the unsolved case that forced him into retirement. McKellen renders a beautifully sensitive performance of the ageing sleuth. In Cinemas July 23
Movie: Fantastic Four Four young outsiders teleport to an alternate and dangerous universe, which alters their physical form in shocking yet powerful ways. Their lives are irrevocably upended but the team must learn to harness their new abilities and work together to save Earth from a former friend turned enemy. Strap in for Marvel adventure In Cinemas July 23
Movie: Ricki and the Flash Is there nothing Meryl Streep can’t do? Here’s she’s a singer who’s left her husband and children to pursue the life of a rock’n’roll singer. Streep apparently set about learning guitar and wherever she goes a legion of stars follow. Kevin Kline plays her ex-husband, Streep’s own daughter Mamie Gummer plays Ricki’s divorced daughter and Australian rocker Rick Springﬁeld is in the band. All good fun. In Cinemas, August 13
Movie: Irrational Man Joaquin Phoenix stars alongside Emma Stone in Irrational Man, which sees director Woody Allen return to his homeland for this latest project set on a small-town-American college campus. Phoenix plays a philosophy professor in an existential crisis when a relationship with his student (played by Stone), gives his life new purpose. In Cinemas, August 20
Musical: Dirty Dancing
Winners from the May issue
Doctors Drum: Medical Board & AHPRA
Theatre – Horsehead: Dr Elena Monaco
Crown Perth, August 2-30; Medical Forum performance August 5, 8pm
t Medical Apps
Music – Carmina Burana: Dr Michael Hart Dance – St Petersburg Ballet’s Giselle: Dr Suzanne Gray
The time is summer 1963, when we were all “having the time of our lives” and Baby is a teenager and dance teacher Johnny Castle at Summer camp teaches her some spectacular moves. What else could it be but the reprise of Dirty Dancing? Producer John Frost brings a talented young Australian cast to Perth for this iconic romantic romp.
t Teaching Ethics t Cosmetic Cowboys t Primary Care Changes t Ebola Intervention Major Sponsors
Dance – Australian Dance Theatre: Dr Kathi Bleeker-Sauzier, Dr Kiran Mirle Ramegowda Movie – Far from the Madding Crowd: Dr Amit Malik, Dr Katherine Shelley, Dr Trixie Dutton, Dr Tony Connell, Dr Mathew Carter, Dr James Flynn, Dr Yohana Kurniawan, Dr Alem Bajrovic, Dr Andre Chong, Dr Suzette Finch Movie – Gemma Bovary: Dr Joanne Keaney, Dr Kamlesh Bhatt, Dr Simon Carrivick, Dr Yvonne Tan, Dr Lyn Stoltze, Dr Rosemary Quinlivan, Dr Patrick Mulhern, Dr Smita Samuelraj Movie – Aloha: Dr Kellie Ashman, Dr Stanley Khoo, Dr Kylie Seow, Dr Max Traub, Dr Moira Westmore, Dr Maggie Juengling, Dr Graham Hocking, Dr Helen Slattery, Dr Michelle Bennett, Dr Senq J Lee
Theatre: Bell Shakespeare Hamlet Hamlet is the giant of roles for young male actors for good reason. Its depth and complexity makes cowards of us all! Bell Shakespeare returns to Perth with director Damien Ryan at the wheel of this theatrical Everest promising political intrigue and sociological and psychological thrills and spills. Heath Ledger Theatre, August 12-15; Medical Forum performance August 12; Albany Entertainment Centre August 6; Bunbury Entertainment Centre August 8
from Schild Estate
Classic Barossa In terms of Barossa wine history, Schild Estate is a newcomer with the family purchasing vineyards in Lyndoch in 1952. After a period of consolidation the family established the Schild Estate label in 1998 and currently have extensive plantings in the Southern Barossa. With some of the oldest vines in the Barossa under their control, the Schild Estate winemakers have a reputation for big, classic Barossa red wines.
By Dr Martin Buck
1. 2013 Schild Estate Shiraz This is a young wine with plenty of potential. Fruit is sourced from Lyndoch and Rowland Flat vineyards and the wine is a deep purple with typical Barossa hues. There are dark berries, leather and spice aromas with a palate of young vibrant fruit. This wine will improve with medium-term cellaring. 2. 2012 Edgar Schild Reserve Grenache Grenache is a favourite of mine and those from the Barossa have a special quality. The example is a masterpiece. Made from 80-90-year-old bush vines, planted high on the eastern hills of the Barossa, this is well-crafted wine. It is a lighter-style wine with a nose dominated by dark plums and spice. There is great complexity on the palate, lingering fruit ﬂavours and soft tannins which make this a Barossa classic. This is a wine made for great foods such as slow-roasted lamb or just enjoying on its own. 3. 2012 Schild Estate Grenache, Mouvedre Shiraz Blends can often complement the varietal Grenache by adding more depth and ﬂavour. This wine is a marriage of three classic Barossa varieties with Grenache being the dominant partner. It’s a big-ﬂavoured wine. There are aromas of charry oak and plums, a palate of juicy fruit, ripe tannins and good complexity. It will continue to improve, but if patience is not one of your virtues, ready for immediate drinking.
WIN a Doctor’s Dozen! Name Phone
4. 2012 Schild Estate Cabernet Sauvignon Fruit for this win is sourced from cooler vineyards. In the glass the wine is a dense, deep red hue with a palate of perfumed fruit and cedar hints. Maturation in oak for 12 months has balanced the persistent, berry ﬂavours with soft, lingering, ﬁne tannins. This is a wellmedalled wine that is great value and showcases one of the less appreciated Barossa varieties. 5. 2011 Ben Schild Reserve Shiraz If you like Barossa reds then this Reserve Shiraz is likely to press all your buttons. The fruit is sourced from a single vineyard at Angus Brae, made in open fermenters and then matured in oak for 24 months. The wine in the glass is like purple squid ink with a really complex nose of cedar, spices, berries and sandalwood. There is a creamy, berry laden palate of fruit and chocolate which gives way to well integrate tannins. For me, this is a superlative wine and highly recommended.
.. or online at
Wine Question: Which Schild Wine has fruit sourced from cooler vineyards?
Email Please send more information on Plantagenet Wines offers for Medical Forum readers.
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, 2015. 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.
1. In order to do anything with them, you have to turn them on; 2. They have a lot of data but still can’t think for themselves; 3. They are supposed to help you solve problems, but half the time they ARE the problem; and 4. As soon as you commit to one, you realise that if you had waited a little longer, you could have got a better model.
WHERE THERE’S A WILL … An elderly gentleman had serious hearing problems for a number of years. He went to the doctor and the doctor was able to have him ﬁtted for a set of hearing aids that allowed the gentleman to hear perfectly.
ED: Truth is stranger than a lame joke. In Latin America computer is a feminine noun, la computadora. In Spain it is a masculine noun, el ordenador.
The elderly gentleman went back to the doctor after a month and the doctor said, “Your hearing is perfect. Your family must be really pleased that you can hear again.” To which the gentleman said, “Oh, I haven’t told my family yet. I just sit around and listen to the conversations. I’ve changed my will three times!”
OLA! A Spanish teacher was explaining to her adult language class that in Spanish, unlike English, nouns are designated as either masculine or feminine. ‘House’ for instance, is feminine: ‘la casa.’ ‘Pencil,’ is masculine: ‘el lapiz.’ A student asked, ‘What gender is ‘computer’?’ Instead of giving the answer, the teacher split the class into two groups, male and female, and asked them to decide for themselves whether computer should be a masculine or a feminine noun. Each group was asked to give four reasons for its recommendation. The men’s group decided that computer should deﬁnitely be feminine (‘la computadora’), because: 1. No one but their creator understands their internal logic; 2. The native language they use to communicate with other computers is incomprehensible to everyone else; 3. Even the smallest mistakes are stored in long term memory for possible later retrieval; and 4. As soon as you make a commitment to one, you ﬁnd yourself spending half your wages on accessories for it. The women’s group, however, concluded that computers should be masculine (‘el computador’), because:
The phone rang. The lady of the house answered. “Yes?” “Mrs Ward, please.” “Speaking.” “Mrs Ward, this is Dr Jones at the Medical Testing Laboratory. When your doctor sent your husband’s samples to the lab, samples from another Mr Ward were sent as well and we are now uncertain which one is your husband’s. Frankly, it is either bad or terrible.” “What do you mean?” Mrs Ward asked. “Well, one Mr Ward has tested positive for Alzheimer’s and the other for AIDS. We can’t tell which is your husband’s sample.” “That’s terrible! Can we repeat the test?” asked Mrs Ward. “Normally, yes, but Medicare won’t pay for these expensive tests more than once.” “Well, what am I supposed to do now?” “The people at Medicare recommend that you drop your husband off in the middle of town. If he ﬁnds his way home, don’t sleep with him.”
HARD TO DIGEST A hospital’s consulting dietician was giving a lecture to several community nurses. He said: “The rubbish that we put into our stomachs and consume should have killed most of us sitting here, years ago. Red meat is horrible. Fizzy drinks eat your stomach lining. Chinese food is loaded with MSG. Vegetables are now ‘iffy’ because of fertilisers and pesticides... However, there is one food that is incredibly dangerous, and we all have, or will (likely), eat it at some time in our lives.” “Now, is anyone here able to tell me what food it is that causes the most grief and suffering for years after eating it?” A 65-year-old nursing sister sitting in the front row raised her hand, stood up and said, “Wedding cake”.
To Be, Or Not To Be … There’s not much Sean O’Shea hasn’t done in his 20 odd years on Australian stages – from romantic heroes to villains, contemporary drama to the classics – making him one of the most versatile actors going around. While he has, not so long ago, assumed the mantle of media tycoon Rupert Murdoch in David Williamson’s latest play, for many theatre lovers he is synonymous with Shakespeare and it is in this guise Perth will see him next when he tours WA in Bell Shakespeare’s production of Hamlet. Apart from being a requirement for every secondary student in the land, Hamlet is happily one of Shakespeare’s most enduring and relevant plays. “While there are young men out there who are confused and conﬂicted about who they are, where they’re going and about the women in
D Director Damien Ryan put it this way:
their lives, this playy will always resonate,”” Sean told Medical al Forum. g “It is a play brimming with extraordinaryy ideas about the big g questions of life.” Sean contributes to the young man’s angst in his role as King Claudius, Hamlet’s uncle who marries his mother when his father is murdered. And in just that simple triangle there is a world of complexity. Add Hamlet’s deep passion for a young woman, who is tossed this way and that by the toxic politics of the court and you have the recipe for high drama and perfect theatre.
Damien D Ryan said: “Hamlet is one of the most complete experiences theatre can provide – extraordinary th poetry, po intense passion, dazzling int intelligence, terror, casual slaughter, friendship, frie humanity, great humour and an great grief. Shakespeare cas his spell through the sheer casts sco scope and grandeur of this story – beginning with a dead man walking beg and ending with a stage littered with bod bodies.” Bell Shakespeare’s Hamlet will tour Albany Alba (August 6) and Bunbury (A (August 8) before its Perth season at Heath Ledger Theatre opens on August 12.
By Ms Jan Hallam
Down and Dir ty Ladies, date night: the 10th anniversary production of Dirty Dancing is heading to town.
In 1987, a low-budget sleeper of a ﬁlm with few stars of note but some great songs and hot dance moves burst into popular consciousness making Patrick Swayze and Jennifer Grey part of the Hollywood ﬁrmament and its producers a lot of money. The ﬁlm was, of course, Dirty Dancing, and while there have been half-hearted attempts to drag it from its Summer of ’63 roots, no Hollywood producer has been brave enough to walk over the Swayze legend. It has left the way clear for the stage to grab the glorious tunes, the coming-of-age tale of ‘Baby’ Houseman’s awakening from awkward teen to dancing queen and her ﬂuttering romance with ace dancer (from the wrong side of the tracks) Johnny Castle and the oh-so-sexy moves of the original choreography by Lenny Ortega. Australian producer John Frost has restaged DD for a 10th anniversary tour with Perth’s turn hitting the Crown stage from August 2. In the role of Johnny is Queenslander Kurt Phelan who spoke to Medical Forum a few days before he was to go on stage for the 200th show. Good times roll The 33-year-old NIDA-trained performer is having the time of his life as the romantic lead and it’s clear that many of the females in the audience are as well. “When you leave the big two cities of Australia you notice the audiences are a lot hungrier to have a good time. They’re the crowds that cheer and clap along and not afraid to have a bit of fun,” he said. “At NIDA we discussed the open communion between the audience and the stage. Some
productions, it’s not so crucial but in other shows, it’s vital. Dirty Dancing is the latter. On Saturday nights we have a few hens’ parties in and I’m shirtless and they’re hollering out. It can get a little hairy sometimes when you leave stage door but that’s all part of the fun.” Kurt was born in the small town of Ayr, an hour’s drive south of Townsville, and grew up wanting to be Gene Kelly. His sister attended a dance class in Townsville and, as Kurt describes, he got tired of waiting in the car for her class to end so jumped out and joined her. “I loved sport and loved dancing. At 15 I decided I was better at dancing than rugby league so I made the choice. It is never easy to be a boy who dances in a country town but when Patrick Swayze came along I thought whoa, here’s a man doing modern dancing.” “I was really touched when people from home came backstage after the Brisbane shows to congratulate me for sticking to my guns.”
Kirby Burgess (Ba by) and Kurt Phelan (Johnny). Pictures: Jeff Busby Usually we know what we’re good at and what we’re not so good at, so there’s not that much jealousy or inﬁghting. It’s a nurturing environment.” Asked if the Swayze legacy puts pressure on him, Kurt is philosophical.
Childhood ambition realised Kurt moved to Sydney in 2000 and found himself in both the opening and closing ceremonies of the Sydney Olympics, created by theatrical producer David Atkins. Two months after the Games, Atkins was pulling together a national tour of Singin’ in the Rain and cast young Kurt in the chorus alongside stars Todd McKenney, Rachael Beck and Jackie Love. “I did 487 shows and loved every minute of it. I was one of those kids who bought the programs and buried myself in researched and then there I was standing next to the people I had been reading about. I was petriﬁed for the ﬁrst two month but I snapped out of that!” “The musical theatre crew is a big family.
“As an actor, a performer and a human being, I need to do what I’m best at, and that’s interpreting a role and bringing a part of myself on stage. The movie is famous because the two leads were so fantastic and because the role was written for Patrick, there are moments that are inherently his.” “So when I ﬁrst approached the role I thought, they’ve hired me because they see Johnny in me and, to the best of my ability, I reconstruct the character not as Patrick Swayze but as myself. Of course I give the audience those key Swayze moments they wait for as homage to him. I hope I do it justice.”
By Ms Jan Hallam
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NEDLANDS VR GP looking for sessions or PT Next to UWA in busy shopping centre Fully accredited Mixed billing Contact Suzanne at 9389 8964 Email: firstname.lastname@example.org MADELEY VR & Non VR General Medical Practitioners required for Highland Medical Madeley which is located in a %JTUSJDUPG8PSLQMBDF4IPSUBHF Highland Medical Madeley is a new non corporate practice with 2 female & 1 male General Practitioners. Sessions and leave negotiable, salary is compiled from billings rather than takings. Up to 70% of billings paid (dependant on experience). Please contact Jacky on 0488 500 153 or E-mail to email@example.com
KARRINYUP Langford Medical Centre now has an opening for a Full Time Bulk Billing Female GP commencing early August 2015. This Practice is one of the closest to the $#%UIBUTUJMMRVBMJGJFTBTB%84 %VFUPBDPMMFBHVFMFBWJOHJOFBSMZ"VHVTU FULL patient list waiting Huge demand for Womens Health Services 65% pay. This is truly a lovely multicultural Family Practice treating the full range of conditions over a range of demographics. Confidential enquiries to PM Rita firstname.lastname@example.org or 9451 1377 HAMILTON HILL A female GP required for a clinic JOB%84BOE"0/BSFB 5 minutes drive from Fremantle. %PDUPS(11SBDUJDF Part time or Full time doctor considered Fully computerised practice. Rates negotiable Contact Eric on 0469 177 034 or send CV to email@example.com CHURCHLANDS Herdsman Medical Centre in Churchlands requires a Part time VR and FRACGP qualified GP. We are a friendly western suburbs practice. 4 â€“ 6 sessions per week required, 1 Saturday morning per month. Practice culture is quality care and we private bill all patients except at %PDUPSTEJTDSFUJPO Computerised, well-staffed, practice nurse. Please forward CV with references UP.T%JBOOF4XJGUCZFNBJM firstname.lastname@example.org BERTRAM 4PVUIPG3JWFS %84"SFB
Experienced FT GP required Busy computerised practice Nurse and Admin support Earn up to 70% of billings Flexible hours Non VR welcome to apply Enquiries to Phil: email@example.com
St Luke Karrinyup Medical Centre Great opportunity in a State of art clinic, inner-metro, Normal/after hours, Nursing support, Pathology and Allied services on site. Privately owned. Generous remuneration. 1MFBTFDBMM%S5BLMB0439 952 979
WEMBLEY DOWNS Opportunity to join our privately owned practice. Private Billing Flexible hours On site pathology Fully computerised All Correspondence in confidence &NBJM%JBOFQNHS!PWNDDPNBV JOONDALUP CANDLEWOOD MEDICAL CENTRE GP required to join our friendly team for a busy computerised practice in Joondalup. Very attractive remuneration. Privately owned. AGPAL accredited general practice. Contact John Wong P: 08 9300 0999 M: 0414 981 888 E: firstname.lastname@example.org
Duncraig Medical Centre Osborne City Medical Centre Require a female GP. Flexible Mon to Fri hours. (after hours optional) Excellent remuneration. Modern, predominantly private billing practice. Fully computerised. Please contact Michael on 0403 927 934 &NBJM%S%JBOOF1SJPS email@example.com
CANNING VALE $BOOJOH7BMF %84 SFRVJSFTGVMMQBSUUJNF or locum VR GP urgently. Rates negotiable. Privately owned practice - fully computerised, huge consulting rooms, spacious treatment room with RN, and on-site pathology with other health alliances in the complex. Phone: Julie 9456 1900 Email: firstname.lastname@example.org KARDINYA Kelso Medical Group presents an PQQPSUVOJUZGPSB73(1 %84BGUFSIPVST only) practice for two evenings per week along with Saturdays to establish a new after hour service. Please forward CV to email@example.com or call 0419 959 246 for further information.
SHOALWATER MANDURAH Modern Medical Clinics team is looking for new doctors to assist with our expansion plans. Mandurah is currently recognised as an area of need and district work shortage but this will not last for long. If you would be interested in moving to the paradise of Mandurah in the next few years to join our team, Please contact Steve or Carol for a confidential discussion firstname.lastname@example.org
SORRENTO F/T or P/T GP for busy Sorrento Medical Centre, Normal/after hours available, we are like family, nurse & allied services on board, remuneration (70%-75%), 1MFBTFDBMM%S4BN0439 952 979
HELENA VALLEY General Practitioner FT/PT VR for privately owned general practice in Scott Street, Helena Valley. The well-established clinic is fully accredited and computerized with full time RN support. 60-65% billings + pip incentives. Mixed billings. Please contact: email@example.com or call 9255 1161
BUTLER Are you looking for doctors for your medical practice? Australian Medical Visas is owned and run by 2 Practice Managers based in WA, XIPIBWFPWFSZFBSTFYQFSJFODFPGUIF UK and Australian healthcare systems. We currently have a number of doctors who are looking for positions in Australia. We are able to assist practices with all paperwork involved including the migration process (if required). Please visit our website www.australianmedicalvisas.com.au or contact Jacky on 0488 500 153 or Andrea on 0401 371 341.
Connolly Drive Medical Centre VR GP required for this very new, state of the art, fully computerised, absolutely paperless, spacious medical centre. Fully equipped procedure rooms and casualty, well-furnished consult rooms, pathology, allied health, RN support. "CVOEBOUQBUJFOUT %84 non-corporate. Generous remuneration. Confidential enquiries %S,FO+POFTPO 9562 2599 Tina (manager) on 08 9562 2500 Email: firstname.lastname@example.org
F/T VR GP required for our brand new medical centre located in Shoalwater %84 PQFOJOH Offering modern surrounds and fully computerised clinical software. We are a friendly, privately owned and run centre. A full complement of nursing staff/ admin team as well as onsite allied health/specialists and pathology. Remuneration negotiable. Please phone Rebecca on 08 9498 1099 or Email CV to email@example.com
JOONDANNA We are seeking a VR GP to join our friendly team on a part-time or full-time basis. New, state of the art medical centre. Flexible hours and billing. Percentage negotiable. Fully-computerised. /VSTJOHTVQQPSUGPS$%.1 Please call Wesley on 0414 287 537 for further details. WILLETTON Herald Ave Family Practice We are looking for a suitable full time or part-time, VR GP to join our friendly team. We are a small, non-corporate practice, fully computerised and accredited, with registered nurse support. If you would like to join us: Email: firstname.lastname@example.org or call 9259 5559 www.heraldavefamprac.com.au YANCHEP /PSUIPG3JWFS %84"SFB
Experienced FT GP required Busy computerised practice Nurse and Admin support Earn up to 70% of billings Flexible hours Non VR welcome to apply Enquiries to Phil: email@example.com
Reach every known practising doctor in WA through Medical Forum Classifieds...
AUGUST 2015 - next deadline 12md Tuesday 14th July â€“ Tel 9203 5222 or firstname.lastname@example.org
ARE YOU WANTING TO SELL A MEDICAL PRACTICE? As WA’s only specialised medical business broker we have sold many medical practices to qualiﬁed buyers on our books.
Sessional Rooms available Full practice management Sessional Rooms are available at the St John of God Murdoch Medical Clinic. * full-time/part-time/sessional * medical systems and secretarial support * adjacent to Fiona Stanley Hospital More information phone: 9366 1802 or email: email@example.com
Your business will be packaged and marketed to ensure you achieve the maximum price possible. We are committed to maintaining conﬁdentiality. You will enjoy the beneﬁt of our negotiating skills. We’ll take care of all the paper work to ensure a smooth transition.
PERTH CLINIC IS SEEKING A GENERAL PRACTITIONER
To ﬁnd out what your practice is worth, call:
Brad Potter on 0411 185 006 Suite 27, 782 - 784 Canning Highway, Applecross WA 6153 Ph: 9315 2599 www.thehealthlinc.com.au
Myaree Medical Centre seeks a full-time VR GP for our modern, expanding, south of the river practice. We are a private billing, non-corporate practice servicing a predominantly younger demographic. Supportive, experienced GP’s would welcome a motivated doctor with experience in women’s health. Excellent remuneration with generous incentives. Weekdays only, no after hours. Fully computerised, onsite pathology. All applications considered.
Conﬁdential enquiries to Julia firstname.lastname@example.org or 9317 8882
Perth Clinic, a private 100 bed psychiatric hospital in West Perth is a leader in assessment, treatment and evaluation of psychiatric problems. We are currently seeking applications for a suitable, qualiﬁed and experienced General Practitioner to provide the following services to our clinic: Perform routine physical admission assessments. Non-urgent reviews. General medical problems. All billing for this service is provided by Perth Clinic staff along with free onsite parking. We require a service for 2-3 hours per day from a GP who holds a current, unrestricted APHRA registration as a General Practitioner. To express your interest please send your application with a current CV and two professional referees to Rachel Whiteley at email@example.com PERTH CLINIC 29 Havelock Street, West Perth WA 6005 Phone: (08) 9481 4888 www.perthclinic.com.au
EXMOUTH-Ningaloo reef Brand new premises available for entrepreneurial GP. Be the ﬁrst private GP in town, with opportunity to focus on occupational and dive medicals.
AUGUST 2015 - next deadline 12md Tuesday 14th July – Tel 9203 5222 or firstname.lastname@example.org
Metro Area GP positions availab av ab able le VR & Non – VR Dr’s are welco come co m to ap appl plyy. pl y. Send applications to email@example.com
HEALTH WATCH CLINICS MELVILLE / JANDAKOT / COTTESLOE Health Watch Clinics requires a PT/FT VR GP for work at each of its clinics. Health Watch Clinics are accredited fully computerised practices with an interesting mix of general practice and occupational health. Health Watch is associated with a Jandakot based air ambulance for those with an interest in some air ambulance work or repatriation work.
See: www.healthwatchclinics.com.au www.medicalair.com.au Enquiries to: firstname.lastname@example.org or (08) 9383 3435
At IPN, we’re looking after you We take care of running the medical practice so you can focus on your patients and enjoy a greater work-life balance. I.T. Resources
To view videos of Doctors sharing their own personal experiences partnering with IPN, visit: www.ipn.com.au/testimonials 1800 IPN DOC (1800 476 362)
AUGUST 2015 - next deadline 12md Tuesday 14th July – Tel 9203 5222 or email@example.com