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March 2016 Major Sponsors
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Reform – Stopping All Stations Being a journalist is a privilege. That may come as a surprise to many who read that Forbes magazine has ranked it the worst career of 2015. After 40 years in the industry, you come to realise that Forbes is just another squawk in a raucous farmyard but it is exactly this cacophony of opinion that makes the job exciting – and career deﬁning. Whose opinion is worth noting? After a lot more listening, whose opinion is worth reporting? What is my opinion? Am I sufﬁciently informed to have one? I am a subscriber to the more you learn, the less you know theory so I ﬁght mightily to keep an open mind. Of course no one’s perfect and a hastily hatched idea can prove to be one of many red-faced moments in a long career. A couple of weeks ago a doctor asked me what was in this job for me. It made me think. I am not a glory seeker, nor do I particularly desire foisting my own opinions on unwilling or unsuspecting readers, but this is the editorial after all! So after years of listening to tens of thousands of machinations, frustrations and humiliations, mostly off the record, what’s in it for me – and you – is information. Journalists can’t say to a patient, this is what’s wrong and this is what we can do to improve it; they can’t make politicians do the right thing – whatever that is! What we can do is try to gather as much information as possible, tell our audience what we’ve found and perhaps, if we’re super-egos, draw some lines between the dots. This may, but mostly may not, spur the reader to dust off his or her democratic rights and assert their indisputable inﬂuence in our society. Perhaps, even, a call to arms? To enable me to sleep at night, I say to myself, I can only let people know when I think a train wreck is coming. I can’t push them out of the way. OK, so is a disaster on its way? That’s easy, there’s always a disaster waiting to happen. The fact we avoid so many of them is testament to the robust nature of our libertarian society and the checks and balances we have in place. This is going to be a big year in the history of our country and for the fortunes of our health system. The past 18 months, with a marked crescendo since Malcolm Turnbull became Prime Minister, the political narrative is reform; the political imperative is cost-cutting. The two are irritable and incompatible bed-fellows unless, of course, they mean the same thing?
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That really would be a disaster and a shameful loss of opportunity to create a better health system that will steer us to a sustainable future. May’s Federal Budget will reveal which way this Government will point the ship. We all know we’re heading to the polls, sooner rather than later. When you start with ‘everything on the table’ and then one by one (GST Brussels Sprouts and Lambs Fry g and reform Medicare) they are removed, an election is looming becomes a moveable feast. The RACGP last month released its pre-budget submission calling on the Government to lift the freeze on MBS indexation, fund 400 new intern community placements by 2020-21, make a $162.m investment over three years to pilot a GP-centred Medical Home model to 500 practices and commit $27m over nine years for a general practice research program.
Ms Jan Hallam
The GP college is just one of many interest groups putting their wish list to the government. The AMA’s list is both extensive and expensive, with the national president Prof Brian Owler insisting the Government “not retreat from its health responsibility”. The implication here is don’t touch health with that dirty scalpel of yours! However, the detail settles into a narrative of indexation of patient rebates, increased hospital funding and more training places as well as equally thoughtful ideas for reform. The information input from just these two organisations alone is vast. Clever, caring people wanting new models of care that will take the health system into this new challenging era with an element of resilience; clever, caring people who want to ensure that their craft groups don’t get trampled on; clever, caring people protecting their patch – or, the more daring of them, moving into someone else’s. More of the same, then. I hear the train a’comin’.
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MARCH 2016 | 1
March 2016 14
FEATURES 14 Spotlight: Newspaper Cartoonist Dean Alston 16 Proﬁle: Dr Penny Flett 18 Mental Health Reform 24 Medicolegal: Dr Rod Moore 34 Lean Thinking at WA Health NEWS & VIEWS 1 Editorial: Reform – Stopping All Stations 4
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Ms Jan Hallam Letters: Collateral Damage of Pell No-Show Dr Richard Sallie Best Practice & Experience Dr Fraser Brims & Dr Annette McWilliams Abortion and Population Decline Dr Colin Smyth Abortion Medical not Criminal Dr Kamala Emanuel Mental Health Support Ms Debbie Guest Curious Conversations Dr Peter Wutchak Meet the CEO: Ms Pip Brennan Have You Heard? PainHealth Website Impact of OTA Review Dealing with Family Violence
37 38 42 49
Rural Medicine Dr Fintan Andrews Primary Care for Frequent Fliers Beneath the Drapes Hospitals in the NMHS
LIFESTYLE 52 Ride for Youth Dr Phil Downing 54 History Inspires Book Dr Peter Burke 55 Nail Brewing Review: Dr Sergio Starkstein & 56 57 58 59
Dr Bradleigh Hayhow WASO has the Passion The Riders Hits High Note Funny Side Competitions
FIND US ON FACEBOOK & TWITTER! /medicalforumwa/
MAJOR SPONSORS 2 | MARCH 2016
Dr Tony Barham Lesions of the Sebaceous Glands
Dr Max Majedi Complex Regional Pain Syndrome
Dr Sarah Pickstock Managing End-Of-Life Pain
Prof Eric Visser Chronic Lower Back Pain
Dr Tim Welborn Testosterone Revisited
Dr Mark Schutze Candidates for Back Injection
Dr Sara Damiani App Review: HealthDirect
Ms Kate Ryder When Death Comes a Knockin';
A/Prof Angela Alessandri Cultivating Positive Workplaces
Ms Nina Butler No Limits to Life
Dr Tim Smart Innovation – Cliché or Reality
Lean Thinking at WA Health Page 34
INDEPENDENT ADVISORY PANEL for Medical Forum John Alvarez (Cardiothoracic Surgeon), Peter Bray (Vascular Surgeon), Chris Etherton-Beer (Geriatrician & Clinical Pharmacologist), Joe Cardaci (Nuclear & General Medicine), Alistair Vickery (General Practitioner: Academic), Philip Green (General Practitioner: Rural), Mark Hands (Cardiologist), Pip Brennan (Consumer Advocate), Olga Ward (General Practitioner: Procedural), Piers Yates (Orthopaedic Surgeon), Stephan Millett (Ethicist), Kenji So (Gastroenterologist) MEDICAL FORUM MARCH 2016 | 3
Letters to the Editor
Collateral damage of Pell No-show
Best Practice and Individual Experiences
Dear Editor, I recently saw a frail woman, in her 80s with an illness that meant continued work among Aboriginal people in WA’s North West was impossible and which necessitated her return to Victoria to be cared for by her Order. Since 1895, hundreds of young Catholic women have bravely left home at 18 or 19, made long, often dangerous and arduous journeys around the world, usually with little more than the clothes they wore, to spend their lives, as my patient had done, living in inhospitable circumstances selﬂessly caring for the sick often suffering untreatable (at the time) infectious diseases like tuberculosis, typhus and leprosy. The contrast with the recently departed Cardinal Pell—who’s taste for, and spending on, ﬁrst-class air travel, luxury accommodation and bespoke tailored clothing, drew recent sharp rebuke from the Pope— is stark. George Pell may have no regard for the victims of child sexual abuse or fear of the Royal Commission into that abuse but he (and the Church) should understand that it is the tradition of the true Catholic values of Thomas Aquinas—compassion, justice and respect—embodied by those courageous young nuns that he is currently spitting on and contemptuously destroying. Dr Richard Sallie, Hollywood ED: Richard’s letter to the Sydney Morning Herald offering his medical assistance to ensure Cardinal Pell’s safe return to Australia to give evidence at the Royal Commission made nationwide news. We asked him if he had anything more to add and he penned the above for Medical Forum. His deep feelings encompass compassion for the victims of child sexual abuse, their relatives and friends, and also to “decent hard-working people of faith” whose work and reputations may be tarnished by this sorry chapter of the Catholic Church’s history
Dear Editor, We read with interest the recent article (How lucky am I? February) detailing an experience of an asymptomatic early stage lung cancer detected by lowdose CT and treated with surgery. This is undeniably great news for the author. Individual experiences are powerful anecdotes in medicine and when considering best practice in screening for lung cancer we should remain cognisant of the current evidence and guidelines. Screening for asymptomatic disease is a population-based concept and with lung cancer it is only effective when a high-risk population can be identiﬁed.(1) Even then, the number needed to screen to save one life from lung cancer is ~255. The recent Standing Committee on Screening position statement highlights signiﬁcant concerns that need to be addressed before Australia will formally endorse this practice.(2) Lung cancer screening is associated with harm. Up to 50-75% of scans performed on current or ex-smokers will identify a noncalciﬁed pulmonary nodule of some size, of which the vast majority will be benign. In the National Lung Screening Trial the 3 lives/1000 saved was (partially) offset by signiﬁcant harm (death or hospitalisation) in 3/1000 investigations performed as a result of ‘false positive’ ﬁndings.(3)
For this and others reasons, a screening program utilising CTs needs to be coordinated by an experienced multidisciplinary team of radiologists, pathologists, respiratory physicians and thoracic surgeons skilled in minimally invasive surgery.(4) Whilst it is fair to contend that the radiation from a low dose CT is now acceptably low, it is the radiation from unnecessary or incorrect follow-up scans, harm from biopsy and even unnecessary surgery for benign lesions that may still cause harm. In Australia, CT screening for lung cancer is currently neither accepted nor funded. Should clinicians have patients they feel may be at high risk we would encourage referral to the NHMRC-funded LungScreen WA project, examining the role of lung cancer screening in Australia commencing in mid-2016. Phone 1800 768655. Dr Fraser Brims. Dr Annette McWilliams References 1. Tammemagi MC, Church TR, Hocking WG, Silvestri GA, Kvale PA, Riley TL, et al. Evaluation of the lung cancer risks at which to screen ever- and never-smokers: screening rules applied to the PLCO and NLST cohorts. PLoS Med. 2014;11(12):e1001764. 2. DoH. Position Statement: Lung Cancer Screening using Low-Dose Computed Tomography. Canberra, Australia Department of Health, Australian Government, 2015. 3. Aberle DR, Adams AM, Berg CD, Black WC, Clapp JD, Fagerstrom RM, et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. The New England journal of medicine. 2011;365(5):395-409. 4. Brims F, McWilliams A, Fong K. Lung cancer screening in Australia: progress or procrastination? The Medical journal of Australia. 2016;204(1):4-5.
Abortion in Era of Population Decline
I don't deserve this award, but I have arthritis and I don't deserve that either. Jack Benny
In the February edition of Medical Forum, there was an article on Abortion Law Reform. Almost as an aside, it quoted that the number of abortions per year had remained static at 80,000. In 2014, there were 299,700 births in Australia. A recent article in the Sydney Morning Herald (October, 2015) discussed
continued on Page 6
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The support of all advertisers, sponsors and contributors is welcome. Neither the publisher nor any of its servants will have any liability for the information or advice contained in Medical Forum. The statements or opinions expressed in the magazine reﬂect the views of the authors. Readers should independently verify information or advice. Publication of an advertisement or clinical column does not imply endorsement by the publisher or its contributors for the promoted product, service or treatment.
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Letters continued from Page 4 the declining birth rate in Australia over recent years. From the above ﬁgures, there were approximately 379,900 pregnancies in 2014 but 21% of them were aborted. This is an incredible and I believe tragic loss of potential Australians.
anyone experiencing mental health or life challenges and we are also introducing online counselling.
Dr Colin Smyth, Northam
In September last year we rebranded from Arafmi to Helping Minds to reﬂect our commitment to providing quality education, respite and support services. Our new tagline, ‘Helping You’ underscores that Helping Minds is here to support and understand carers and clients as they try and live their best life possible.
www.helpingminds.org.au or 1800 811 747.
I ﬁnd it hard to believe that this fact is not mentioned when declining birth rates are being discussed.
Debbie Childs, Executive Director, Helping Minds
Mental Health Support
Dear Editor, It is timely to advise your readers that we at Helping Minds (formerly Arafmi) offer help and support for both carers of someone with a mental health issue or who are themselves experiencing a mental health condition. The organisation was established in 1976, providing mental health services and carer support for 40 years in Western Australia. The majority of our services are free and focus on advocacy, understanding the mental health system, education, counselling and support, school holiday programs and respite. We have a professional and compassionate team of staff and dedicated volunteers who provide quality, conﬁdential support and services to children, youth, adults and families In order to help more people, we are now offering services online. This allows us to accommodate the busy needs of people and the fact that not everyone can get into an ofﬁce, or has access to support locally in their community. An online support program called Recovering Our Families is available now for
Abortion is Medical not Criminal
performing the abortion. While many women would turn to their GP for a consultation and referral even without this law, it imposes an extra cost and time burden that wouldn’t be necessary if no referral was needed (as in NSW and Victoria). It also has a gatekeeper effect, in practice enabling doctors with personal objections to abortion to hinder access by refusing to discuss or refer for abortion. It is not unheard of for women to see several doctors seeking abortion referral before being able to ﬁnd one who will refer them for a procedure that the majority of the population agrees should be up to her to decide. This is despite the fact that although the WA law explicitly prevents anyone from being obliged to take part in performing abortion, it doesn’t exempt doctors from providing information or referral for abortion. We don’t know how many women in WA continue unwanted pregnancies because of such obstacles to accessing abortion. But the potential is clearly there.
Dear Editor, I support the thrust of Caroline da Costa and Heather Douglas’ call (February) for consistent national abortion laws to improve access to legal abortion for women regardless of the state or territory they live in. Much more needs to be done to remove practical barriers for women to access abortions they seek (including improving public provision and expanding access to medical abortion). But legal obstacles are a signiﬁcant barrier to women accessing early, safe termination of unwanted pregnancy. It is still a crime in WA for a doctor to provide a woman with an abortion unless she has seen another doctor ﬁrst, to be given ‘appropriate counselling’ about the medical risks, and to be offered a counselling referral – all of which could and should be provided by the doctor
Victoria’s laws offer an improvement on WA’s in every regard. Their provision obliging conscientious objectors to refer their patients to a practitioner who does not object to abortion, and to perform abortion if needed to save the woman’s life, would particularly be an advance in WA. That said, it is important that any changes to abortion law don’t introduce any new restrictions on women seeking abortion. Rather than introducing laws to say when and where abortion can be performed, it would be preferable to follow the Canadian road and just remove all laws restricting abortion, allowing it to be treated as a medical matter, not a criminal one. Dr Kamala Emanuel, GP, Perth ........................................................................
Practice Makes Perfect The physics of cricket and golf are the things Collie GP Dr Peter Wutchak would love to master with surgical precision. One of the things I’m most proud of is… my practice and my team. They’re all absolutely wonderful and the recent RACGP award is a testament to their hard work. My wife and children are pretty wonderful, too. If I could say one thing to Dr Kim Hames it would be… don’t overlook the beneﬁts of General Practice in the delivery of health. The old adage that an ‘ounce of prevention is better than a ton of cure’ is so true. The cost-drain of the public hospital system is enormous and primary care will help to ease the pressure. One of the best mentors I’ve ever had was… my former partner, Dr Keith Meadows. He had great skills in surgery, obstetrics and
6 | MARCH 2016
anaesthetics and was the epitome of a procedural, rural GP. Dr Peter Wallace is also a great inspiration, he does wonderful work away from the consulting room and I share his philosophy of medicine. If I was forced to choose a career other than medicine it would be… engineering with a business focus. I ﬁnd the practical application of physics very interesting and I enjoy the ‘business’ side of medicine. If I could pick one sport to be exceptionally good at it would be… a toss-up between cricket and golf. Both sports are psychologically demanding and ask hard questions in different ways. To be honest, I’m a ‘sports nut’ and would happily be exceptional in any sport! ED: The Collie River Valley Medical Centre won the 2015 General Practice of the Year. The practice principals are Peter and Dr Jan Van Vollonstee
Dr Peter Heenan
HL Skin Pathology Part of Perth Medical Laboratories P/L (APA):
Peter Heenan graduated from UWA and is internationally recognised for his expertise in skin pathology. Peter's extensive contributions to the field encompass diagnosis, teaching and research.
Independent, Pathologist Owned and Operated. Contact Phone: 93863500q'BY93863511 26 Leura St Nedlands WA 6005
Lesions of the Sebaceous Glands Sebaceous glands are present in the skin throughout the entire body except on the palms and soles, and are particularly numerous on the face and scalp. They release oily secretions (sebum) into hair follicles and subsequently onto the skin surface. Sebum moisturises and lubricates the skin and hair, and inhibits microbial growth. The most common skin lesions composed of sebaceous cells are benign, non-neoplastic conditions. Sebaceous neoplasms are relatively rare, but are of clinical importance due to their association with Muir-Torre syndrome (see below).
Sebaceous carcinoma is a rare but clinically important lesion. Most (75%) occur in the periocular region. Periocular sebaceous carcinoma may form a nodule similar to a basal or squamous cell carcinoma, but some cases clinically resemble blepharitis or a chalazion, potentially resulting in delayed diagnosis. Metastatic and mortality rates have been reported to be as high as 30%, although recent reports indicate a mortality rate of 6%.
Sebaceous neoplasms are usually sporadic lesions, but they are also an important feature of Muir-Torre syndrome (MTS). This is an inherited condition characterized by the combination of at least one sebaceous neoplasm and at least one visceral malignancy, the latter most often involving the gastrointestinal or genitourinary tracts.
Non-neoplastic lesions These are very common on the lip and buccal mucosa, consisting of 1 to 3mm yellow to white papules known as Fordyce spots. Similar papules occurring on the areola are known as Montgomeryâ€™s tubercles. Sebaceous hyperplasia This typically presents as a 1 to 5mm ďŹ‚eshcoloured papule on the forehead or cheek of an adult. Not infrequently, it is mistaken for a basal cell carcinoma. Naevus sebaceus QFig1: Sebaceous adenoma from the groin of an 81 year-old female.
Sebaceous neoplasms Sebaceous adenoma (Fig. 1)
Demonstration of MSI requires molecular analysis by PCR. A more widely available technique is immunohistochemical staining for MMR proteins (Fig. 2). This method is not deďŹ nitive, as loss of MMR protein may occasionally occur in sporadic tumours; furthermore, some mutations may cause loss of MMR activity but still result in production of an antigenic (albeit non-functional) protein. Nevertheless, immunohistochemistry is a useful tool for detecting possible cases of MTS. We routinely stain sebaceous neoplasms using immunohistochemistry and recommend further investigation if there is loss of MMR protein expression. References available on request.
This is a benign tumour that essentially recapitulates the normal sebaceous lobule and consists predominantly of mature sebaceous cells. It presents as a tan, pink or yellow papule or nodule, usually on the head or neck of an older adult. Sebaceoma This tumour is also benign and is clinically similar to sebaceous adenoma. It is distinguished from sebaceous adenoma by a predominance of immature (germinative) sebocytes over more differentiated sebaceous cells.
MTS is a variant of hereditary non-polyposis colorectal cancer (HNPCC). It results from mutations within genes encoding DNA mismatch repair (MMR) proteins. The gene most commonly involved in MTS is MSH-2 (90% of cases). Abnormal MMR function results in a detectable genetic marker known as microsatellite instability or MSI. Microsatellites are short repeated sequences of non-coding DNA, the lengths of which are normally maintained during cell reproduction. Loss of MMR function, however, allows â€œslippageâ€? of DNA during base pairing to go uncorrected, resulting in an altered number of repeats (instability).
Ectopic sebaceous glands
This is a hamartomatous lesion, most frequent on the scalp. It consists of a smooth, waxy and hairless plaque, usually present at birth and becoming more raised and warty at puberty. Although sebaceous glands are usually prominent, naevus sebaceus also incorporates other skin structures including epidermis and hair follicles.
Dr Tony Barham Tony Barham graduated from the University of Newcastle and undertook his pathology training in Western Australia. Tony's interests include skin, gastrointestinal and gynaecological pathology.
QFig2: Normal expression of MSH-2 within the epidermis (brown staining) but loss of MSH-2 expression within the neoplastic sebaceous cells (arrow)
‘When Death Comes a Knockin’…’ RN Kate Ryder has seen both in her work and in her own family how dangerous our health system can be and calls for change. Nothing can prepare you for the sickening and heart-wrenching moment on a plane to England when you realise that your mother is probably going to die as a result of negligent treatment by a locum GP, and that you had a chance to save her by calling an ambulance yourself from Australia.
I thought, like many of us, that I had the knowledge to keep my family and friends safe…I was wrong, and my mother died.
I will always remember the locum’s glib, throwaway comment ‘She was full up to her pelvic rim’ on that fateful Sunday evening when I spoke to him on the phone, and the ensuing silence when I asked him why he hadn’t sent her to hospital on the preceding Friday when he saw her, especially as he knew she had been constipated for ﬁve days and had diverticulitis.
was going to be ‘OK, now. The pain has gone. It was really bad, but it’s gone now…’ I will always remember that terrible moment when I realised that her bowel had already perforated. And I never will be able to forget lying down beside her on the ICU bed and holding her while she died.
Was he being dismissive in his silence? Did he think he’d done anything wrong? I will always remember silently blaming my father for not calling an ambulance when I asked him to, even though I knew he wasn’t the type of person to ‘make a fuss’. I should have also anticipated that he wouldn’t have wanted to offend the doctor by calling an ambulance himself. I will always remember my mother’s frail and thready voice trying to reassure me that she
As a nurse with over 20 years’ clinical experience and former Senior Investigation Ofﬁcer with the Health Care Complaints Commission (NSW), I thought, like many of us, that I had the knowledge to keep my family and friends safe from the pitfalls of the health system. I was wrong, and my mother died. I often think about that locum doctor and wonder if he ever thinks about my mother and the role he played in her distressing, preventable and untimely death. I am also
reminded of all the other clinicians who have been the ‘secondary victims’ of their own medical errors, as I am of mine as a nurse. In doing so, I am reminded of the old adage: ‘There by the grace…’ I’ve taken a different approach to the problems within our own health system, which recognises that patients themselves have an important and understated role in preventing medical errors. I have sought to empower them by writing what I describe as a ‘patient’s safety manual’, which informs patients of what they need to know to keep themselves safe from us all in the health system. It recognises that health practitioners are not perfect and that some of us are, at times, downright dangerous, and that we need patients to help us to help them. If we are to have any kind of chance of keeping our own family and friends safe inside the health system, then we have to work together to ensure the safety of all patients.
Meet the CEO
How Consumers Will Aid Reform Ms Pip Brennan was appointed ED of the Health Consumers Council of WA last year and it was a ‘coming home’ for the long-time advocate. “My ﬁrst paid health job, after eight years working in the museum sector, was as an advocate here at the council. Working alongside [former council ED] Michele Kosky and Maxine Drake, I learnt so much about advocacy. Like a lot of arts graduates, I have amassed a long and varied work history but I had done signiﬁcant work at the grassroots level around health consumer rep work and grant writing.”
ED position at HConC WA came up and in her own words “brought everything I’m interested together – advocacy, consumer representation and running NFPs.” The health sector is in a volatile state and Pip sees the obvious challenge for her organisation is the changing structure of the health department as of July 1 with devolution to four area health services boards – North, South, East and Country.
Pip has also seen the work from the other side of the complaints coin when she worked as conciliator at the Ofﬁce of Health Review where mediating between provider and consumer gave her a deeper perspective of the landscape. However, her interest in consumer support led her to running Midwifery WA which provided postnatal support services and antenatal education and inevitably a broader understanding of NFP fund-managing.
“We are working with the interim boards to discover how that structure is going to work. In the past we would take issues to the Director General who would decide to take them up or not. If he said yes, essentially it was job done. Now we will have to pitch to the various health services, which will mean we must spend a lot of time building up a number of relationships.”
After a year working for WACOSS researching outcomes-based contracting in Health, the
Will the quadrupling of work beneﬁt the consumer?
8 | MARCH 2016
“It’s the age-old question of Ms Pip Brennan centralisation versus localisation and there are difﬁculties in both. The potential opportunities for consumers are the more localised solutions to population and health needs. It could be a fantastic opportunity to close the gap on fragmented care once a consumer leaves hospital.” “Together with the parallel reform in primary health, with WAPHA as a single entity running the state’s Primary Health Networks, we could see some really big wins.” “But we have to wait and see. The actual personalities behind these reforms will make or break them. Having the right people on the bus is so important.”
By Jan Hallam
MARCH 2016 | 9
Have You Heard?
AHPRA state of play AHPRA has recently released its annual report and, as its principal ‘shareholders’, you will probably like to know that it’s stayed nicely in the black the past ﬁnancial year with a net surplus of $1.8m. Income (88.23%) was derived from registration fees ($150.4m) and 5% from application fees ($8.5m). In WA there were 10,246 registered medical practitioners with 419 notiﬁcations (4.1%); WA recorded an increase in notiﬁcations (781, across all registrants) from the previous year (750). There were 37 mandatory notiﬁcations issued
to WA doctors across three main categories – standards/impairment; alcohol or drugs; and sexual misconduct; while 554 were being actively monitored (343 for eligibility/ suitability; 55 for conduct; 74 for health; and 82 for performance). Some good news is that resolution wait-times are lower than the previous year.
Inquiry heat on AHPRA The AHPRA annual report shows the local ofﬁce has been hot on practitioners’ heels, second only to NSW for the number of
notiﬁcations. The agency’s national activity has come to the attention of the Senate Community Affairs References Committee, urged along by South Australian Senator Nick Xenophon, and it will be inquiring and reporting on the medical complaints process. It will look into the prevalence of bullying and harassment in the profession and the roles of the Medical Board, AHPRA and others in managing investigations into professional conduct. It also turns the spotlight on the National Law as it relates to the complaints handling process and there’s sure to be
He Can Still be a Hero A lot of words have been written since pop legend David Bowie died on January 10 but we found this blog – written as a thank you letter to the singer by Cardiff palliative care consultant Dr Mark Taubert – particularly moving. Mark had never met Bowie but was an out-and-out fan. More powerfully, from a medical point of view, Mark thanked Bowie and his courage to document his dying in his last album, Blackstar, especially the single and its video, Lazarus. It enabled Mark to open conversations about death and dying with his patients like nothing had done before. Discussions about dying a “good death” at home, symptom control, advance care planning, no-resus orders – all became easier through the ﬁlter of “what did Bowie do?”. For one patient they wondered together “who may have been around you when you took your last breath and whether anyone was holding your hand. I believe this was an aspect of the vision she had of her own dying moments that was of utmost importance to her, and you gave her a way of expressing this most personal longing to me, a relative stranger. Thank you.” http://blogs.bmj.com/spcare/2016/01/15/a-thank-you-letter-to-david-bowie-from-apalliative-care-doctor/
10 | MARCH 2016
Have You Heard?
plenty of doctor input into that one. The committee is expected to report on June 23.
Never let facts get in the way We have been told that under the current Medical Board and AHPRA, a patient can make a false complaint; it can be fully investigated, including unfavourable judgement by a medical expert, without the expert saying they lack speciﬁc knowledge in what you do; the MB can require you to do things to keep them happy (e.g. attend courses), based on this report; and a black mark remains against your name as long as the Medical Board wants.
Whistle while you wait … and wait
Stats all in together Our ears pricked up when we read in the national media that Bupa was going to name and shame individual high-rolling specialists. We thought it sounded too crystal clear to be that transparent. A Bupa spokesperson told us that it will use “aggregated claims data from its 4m members to help consumers understand the average for typical surgical procedures”. Not quite as ‘courageous’ as ﬁrst thought, however, the idea behind it is interesting. Bupa will begin publishing the average costs for common procedures, state-by-state, but not what individual surgeons charge, by the ﬁrst quarter of 2016 and it hopes this will create competition and drive down prices. Without consumer action that might be a long
What is going on at the PBS Authority line? We have had a second complaint from a local doctor about the length of time it’s taking to get scripts authorised. To paraphrase Oscar Wilde’s Lady Bracknell once is a misfortune, twice looks like carelessness. In November we reported a doctor’s complaint (described to us as “ridiculous delays” of at least ﬁve minutes) to the Department of Human Services. We reported faithfully its statement that, oops, “oneoff technical issue”, “normally very low wait times” and how about an average speed of answer of 42 seconds. This latest complaint reports unreasonably long delays “every day”, which have forced doctors in this particular practice to write scripts at home at night because the waiting time is less. They claim that in the past couple of months they have lost more than half an hour each day waiting for a phone authorisation. A department response to one of the docs at least acknowledged a problem “they are working on”. The ofﬁcial media response was a carbon copy of the ﬁrst, except the average speed of answer has blown out to 47 seconds. Alarmingly the statement says the line has been operating normally even bettering its average speed of answer in January to 23 seconds. You can accept a one-off spot ﬁre but when lightning strikes at the same place twice, the smoke alarm is well and truly ringing. At the time of going to press, Alan Tudge had just been sworn in as Human Services Minister. We will give him time to ﬁnd his coffee cup then we will ask the politician to respond. If you have experienced problems, send us an email at firstname.lastname@example.org.
continued on Page 12
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MARCH 2016 | 11
Have You Heard? continued from Page 11 time coming but then again if private health insurance premiums rise as the companies hope, pressure might be applied from all sides.
Morton ﬁghts on She may have had a slap-down from her party but Mental Health Minister Helen Morton won’t lie down. She and Police Minister Liza Harvey announced a $6.5m trial that could make a signiﬁcant difference to outcomes. Senior mental health clinicians will work with police in special teams to respond more effectively to callouts that relate to mental health and drug and alcohol incidents. Since 2007 the number of such calls has risen from 4766 to 17,498 last year and police ﬁgures show that 70% of welfare checks involve self-harm.
My DNA, Your Info Wow, is there anything pharmacies can’t do? Apart from dispensing statins, ﬂu jabs and anti-depressants, some pharmacies are now offering to test customers’ DNA. The myDNA pharmacogenomic test (which identiﬁes gene variations in enzymes) apparently can predict the correct medication and dose for an individual based on their DNA. The media release said 10,000 GPs and specialists have been asking patients to have the test done – if you’re out there, we’d love to talk to you. About 200 Chemmart Pharmacies across Australia are conducting the tests – 27 in WA are ready to go with another 47 interested. Analysis is being conducted by Clinical Laboratories and clinical interpretation by My DNA Life. We’re told 265 West Australians have already had the test.
Safe access zones in WA Abortion is an emotive and volatile issue. This month’s letters page is testament. It has come into sharp focus locally with the opening of the new SJG Midland Public Hospital and its refusal to perform such procedures for public patients on religious grounds. With the Midland Marie Stopes clinic now performing those terminations and contraceptive procedures with State Government funding, it has attracted the attention of the religious organisation 40 Days for Life, which was to start a Lenten prayer vigil outside the Dr Marie premises from February 10. The organiser Joanne Cicchini didn’t return our calls but the Australian CEO of MSI Alexis Apostolellis told Medical Forum that his organisation had petitioned for the introduction of safe access zones at all its sites and “zoning is critically needed for WA”. “Every woman has the right to access medical treatment without prejudice or harassment. Every staff member has the right to go to work without being shamed for doing so, particularly when their role is to support the health and wellbeing of others.”
WAGPET: all OK here There was an almighty brew-ha last month over the backlog of 15,000 provider numbers waiting issue for this year’s GP registrars. The Rural Doctors Association was in uproar. But the issue caused barely a ripple here in the West. According to WAGPET, the sole training provider in WA, there are “no problems here”! CEO Dr Janice Bell added that, in fact, fewer
12 | MARCH 2016
Dr Rohan Gay and Dr Elizabeth Gray
WAGPET announces its stars WAGPET has just announced its 2015 award winners with Dr Rohan Gay’s Walter Rd East practice named training post of the year. Readers will be aware of Rohan’s enthusiasm for GP training through these columns, now his students have given him the thumbs up. Registrars have been equally glowing of the practice staff, led by practice manager Cheree Matthews. WREPG has been taking GP registrars for 13 years with 23 graduates passing through its doors, including this year’s Registrar of the Year, Dr Elizabeth Gray. Elizabeth was nominated for her “exceptional care and follow-up both in and outside of practice hours, and her thorough and holistic approach to managing acute problems and chronic conditions, preventative health and screening tasks”. Her training adviser was Dr Wence Vahala who gave her a key bit of advice about general practice: learning to deal with uncertainty. It has resonated with her and powered her enthusiasm for the keystone of general practice – continuity of care. Dr Byron Manning won the Prevocational Community Medicine Award. The ADF doctor completed a 21-week Community Residency Program rotation in General Practice, Acute Medicine and Aboriginal Health at the Roebourne and Nickol Bay Hospitals.
Dr Byron Manning
slip-ups than usual (“and there are always a few”). With a turbulent year of policy change behind them, WAGPET’s business-as-usual approach seems to have protected it from the worst of transition vagaries.
Cat among the pigeons Nurse and consumer advocate and former investigator for the Health Care Complaints Commission (HCCC) in NSW Kate Ryder says another title of her book, Getting the Best out of the Health System, could also be known as
‘Setting the Cat Among the Pigeons’. Kate, who writes a guest column in this edition, has said that the book, which is aimed at health consumers and details the sometimes poor practices especially in hospitals that cause patients harm, has had a mixed reaction among colleagues, though generally received positively. Kate will be in Perth to speak at the Health Consumers Council’s Patient Experience Week on April 29.
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MARCH 2016 | 13
By the Point of a Pen It’s a part of thousands of West Australians' morning ritual – Alston and a cup of tea. The morning newspaper’s chief cartoonist, Dean Alston, is a kid at heart. The West Australian’s resident cartoonist likes to stir the pot and that’s exactly what Dean Alston has been doing for the past 25 years. Along the way he’s penned more than 13,000 cartoons and won a prestigious Walkley award. He reckons it’s the greatest job in the world. “I get to my desk just after midday, have a look at what’s going on and then we have an editorial news meeting at three o’clock. That gives me an idea what’s going into the paper on the following day and I’ll work on the main cartoon between 4.30 and seven in the evening.” “It’s just so enjoyable, there are different issues popping up every day and that means a huge variety of possibilities with the drawings. It keeps me thinking. There’s a bit of pressure heading towards deadline and it’s a good brain workout every day. I’m working with people who are bright, well-read and can write.”
and Opportunity Commission ruled that the cartoon made inappropriate references to Noongar beliefs but did not breach racial discrimination law. “It’s important to push boundaries and challenge political correctness. The latter is a cancer in our society and goes way too far sometimes. Alas Poor Yagan rufﬂed a few feathers and was a pretty difﬁcult time, although the newspaper ended up winning the case.” “I tend to shy away from an ideological position when it comes to politics but you do need to have a point of view on some issues. And sometimes I do end up dancing on the borderline of slander.” Late last year Dean couldn’t resist yet another somewhat delicate ‘soft-shoe shufﬂe’. His ‘take’ on feminism raised more than a few hackles when six panels depicting ‘Camp Femdom’ portrayed a group of militant women declaring they intended to ‘shatter the
glass ceiling’, but not before they’d ‘sipped a latte, waxed and had their hair done.’ Nonetheless, there is one line he refuses to cross. “I don’t do lunches with politicians. In fact, apart from putting them in my cartoons, I don’t have anything to do with them.” Dean’s career had been creative and colourful and it would seem that Perth’s politicians will be in his cross-hairs for some time yet. “I stay pretty active, run three days a week and go to the gym on the other days so hopefully old age is still a fair way around the corner. I’ve had over two decades at The West and I must have drawn thousands of cartoons. The words, I don’t want to go yet will be on my tombstone.”
By Peter McClelland
“I’m here six days a week with Sunday my only day off and, as far as I’m concerned, I’ll be doing this forever. I’m going to die at my desk!” Dean has always been a bit of a larrikin and in his pre-cartooning days he was a part-owner of the Carine Tavern. “Some people say it was because I spent so much time in there but, in fact, I’d never been there at all. A partner and I bought the freehold, ran it for 14 years and then I sold my share, got married and went to England.” “I worked for British Gas in London and the Lands Department back here in Perth and brought a bit of unconventionality to both those places. I honed my cartooning prowess by painting pictures for tourist books and annoying people mercilessly. I’ve been lucky enough to continue in that vein.” “I also had the good fortune to have wonderful parents and to grow up near the Canning River, it was terriﬁc! As early as I can remember I was drawing and in the days before television I’d sit at our lounge-room table doing just that.” “And at school there’d be the occasional, ‘Alston… get out!’ because a drawing of mine would go around the room and end up at the front of the class. It was all good fun!” There’s often a cutting ‘edge’ to a cartoonist’s pencil and Dean Alston is no exception. In September 1997 a cartoon, entitled Alas Poor Yagan, landed both The West Australian and the cartoonist in the Federal Court. Accusations of racism were levelled at the newspaper and, indeed, the Human Rights
14 | MARCH 2016
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The Quiet Revolutionary Transforming a couple of old-school nursing homes into a multi-faceted, ďŹ‚exible and successful organisation has been Dr Penny Flettâ€™s lifetime achievement. Sometime in the middle of March, Dr Penny Flett will hand over her Brightwater CEO keys to Ms Jenny Lawrence after 29 years but donâ€™t call it retiring. Not only does Penny think the term â€œsillyâ€? and â€œanachronisticâ€? but, as those who know her already understand, itâ€™s also way off the mark. The work â€“ and passion â€“ will continue. â€œBrightwater is such a big and complex organisation. It encompasses aged care, disability, brain injury, health, research and teaching. When I think where weâ€™ve come from when I ďŹ rst arrived 29 years ago â€“ those two big nursing homes that were the Homes of Peace â€“ itâ€™s been a remarkable journey.â€? â€œIâ€™m proud to be passing it on to someone who will be taking it further and a little sad because itâ€™s the people who make an Dr Penny Flett organisation â€“ the people weâ€™re here for and the people I work with. I shall miss all of them. This is a complicated business and a business of high worth but fundamentally itâ€™s all about people and Iâ€™ve learnt so much from them.â€?
market; or organising research, or tackling governments and sticking my neck out when things werenâ€™t quite right; if I knew that I would have trembled at the knees and done something else.â€? â€œBut you donâ€™t know and that protects you and leaves your future open according to the opportunities that present themselves and my career has been wonderful. Brightwater has been a place where I dared to dream because I wasnâ€™t constrained by what people usually expect of medicine and doctors.â€? The aged care sector has always had its challenges but never more so than the looming â€˜baby boomer bubbleâ€™, the challenges of which, Penny says, are evolving so fast that even the government has to confess it canâ€™t plan successfully. â€œPersonally I ďŹ nd that exciting in itself because it is down to human beings to devise what to do.â€? While Penny will take a step back from the frontline, she says sheâ€™s eager to return to medicine and her clinical interests â€“ â€œthings I have had to forgo for a long time.â€? Penny will in fact be hands-on at a facility she campaigned for and achieved 23 years ago.
Fears and opportunities
Ahead of the game
But it may not have been where she dreamed of being as a medical student four decades ago. Indeed, itâ€™s a universe away.
â€œDeveloping brain injury rehabilitation programs was a dream. Most people didnâ€™t understand that we were getting incredible results with brain injured people long after they had left hospital. Brain plasticity is the big thing now but weâ€™ve been doing it for 23 years when there was not that much support for it.â€?
â€œI donâ€™t think many of us knew where weâ€™d end up. I didnâ€™t think Iâ€™d be running a complex business; or running a laundry in a competitive
Penny is of course referring to the Brightwater Oats St residential rehab facilities, which put interdisciplinary treatment at the forefront.
Does your experience of mental health leave you feeling hopeless?
â€œOats St is a special place of huge courage. Iâ€™m inspired each time I go there. How these people can ďŹ nd the courage to do what they do is a lesson for all of us.â€? Brightwater Oat St began when Penny came across a number of headinjured young people institutionalised at the Homes of Peace who were improving without treatment.
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