DECEMBER 2011 $10.50
WA’s Independent Monthly for Health Professionals
Breast FNA, LAA Occlusion, Hand Trauma, SIRT for Liver Tumours, Thyroid Nodules
• Medical Pioneer: Dr Kevin Yuen • Travel Medicine: Patients & Exotic Locations • Year in Review, Photography, Wine, Humour and more
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Travel Medicine Patients & Exotic Locations
Pioneer Dr Kevin Yuen
Dr Julie Moore
Fresh Start Funding Review
Mr Peter Abetz MP
4 Have You Heard 13 The Year in Review 15 Letting Patients Book On-line Dr Rob McEvoy
19 AAPM National Conference
Ms Kathy McGeorge
Giving Your Business Real Direction
Ms Sue McDiarmid
21 WA Travel Doctor Survey 24 Beneath The Drapes 44 Primary Care Research
Dr Mark Neville
7 Occlusion of the Left Atrial Appendage
Dr Eric Yamen
33 Chlamydia: Could Your Patient Have It?
Dr Donna Mak
35 Tips For Hand Trauma
46 The Funny Side Competition Winners – October 47 Wine Review – Frankland Estate 50 Competitions 51 Photography Gems
Drs Charley Nadin, Robert Davies, Charles Armstrong, Tony Tropiano and Farhat Mahmood, and Mr Clive Addison
Dr Joe Cardaci
38 Incidental Thyroid Nodules
Dr Brett Sillars
41 Rehabilitation – “What Happens Next”
Dr James Savundra
37 Treatment of Liver Tumours With SIRT
Christmas Lunch in the Park
Lifestyle & Entertainment
3 Breast Fine Needle Aspiration
2 Letters Milking the Media
Christmas Nice Idea or Essential?
News & Opinion
Dr Anne Brady
43 Problem Behaviors in Autism
Dr Charna Mintz PhD
52 Clinical Services Directory
Guest Columns 14 To Our Integrity, Do No Harm
Cover image. Santa will be pleased to learn that the International Scientific Forum on Alcohol Research has backed up the finding of a Norwegian study that alcohol consumption reduces the rate of heart attack quite significantly, often at low doses of consumption, and via mechanisms outside the observed raising of HDL cholesterol. WA’s Prof Ian Puddey contributed to the study critique.
Dr David Borshoff
17 Rural Teaching’s Cultural Shift
A/Prof Mike Mears
25 More On E-health Security
Dr Trish Williams PhD
39 Taxing Junk Food Advertising
Dr David Roberts
PUBLISHERS Ms Jenny Heyden - Director Dr Rob McEvoy - Director
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Letters to the Editor Send your letter to: email@example.com
Fresh Start funding review Dear Editor, I read with interest your editorial (Stolen Scripts Just a Symptom, October edition) in which you make points relating to the Education and Health Standing Committee report Changing Patterns in Illicit Drug Use in Western Australia. I am very familiar with this report as I serve on the committee that produced it, and I have taken a keen interest in drug rehabilitation work for many years, including running a drug rehab support group for recovering addicts and their families.
Milking the media Dear Editor, I was fascinated by the article by social media expert Mr Damien Cummings (Social Media Lessons, October 2011). He used the example of working with “a baby milk brand who was marketing their products directly to women in the early stages of pregnancy”, recognising that at this stage “there is a large amount of doubt and risk” for women - their online relationship strategies were a great commercial success. It surprised me that in an article aimed at health professionals, no reference was made to the ethics of this strategy, which is consciously exploiting that doubt and fear. I wonder also how he reconciles it with the Marketing in Australia of Infant Formulas (MAIF) Agreement - “5(d) Marketing personnel, in their business capacity, should not seek direct or indirect contact with pregnant women or with parents of infants and young children.”
You neglected to say why the report recommended freezing of funding (Recommendation 13) to the Fresh Start Recovery Program that uses naltrexone implants to treat heroin addicts. The reason is very important. One of the conditions of some special funding provided to the Fresh Start Recovery Program in 2009-10 was for Fresh Start to agree to a Drug and Alcohol Office appointed person conducting a Research and Data Review, and a Service and Clinical Review. Fresh Start welcomed these conditions and gave every co-operation to the Drug and Alcohol Office. The Drug and Alcohol Office dragged its feet for over 18 months before appointing the persons to conduct these reviews.
Recommendation 13 simply expressed the committee’s view that the reviews which the Drug and Alcohol Office was to conduct needed to be done urgently, and until that work was done, no further funding should be made available. Given that Fresh Start does the lion’s share of rehab in WA, we knew that if Fresh Start would not get any funding, the Drug and Alcohol Office would not be able to cope with the demand on its services. Thus we hoped our recommendation would put pressure on DAO to fulfill their obligation that flowed from the special grant given to Fresh Start in 2009/10. And it appears to have been effective, as the Research and Data Review is now complete, and the Service and Clinical Review is underway and expected to be completed later this year. I would not like your editorial statement to be misinterpreted as meaning our committee had serious doubts about the value/effectiveness or professional quality of the services rendered by the Fresh Start Program. That would not be correct. Mr Peter Abetz, Member for Southern River Ed. The full report, published in May this year, can be seen at www.parliament.wa.gov.au/publications/ by Googling the report name. Spokespeople from the Drug & Alcohol Office were invited to respond.
Doctors who are providing information and support to women to help them breastfeed their babies may have no idea of the power of the subtle and disguised commercial interests that undermine their message. Ultimately, these practices may deprive women and their families of the right to make an informed choice based on accurate information which may lead to regret about the many negative health, financial, and emotional consequences of a misinformed choice not to breastfeed their babies. The Australian Breastfeeding Association (www.breastfeeding.asn.au) is a good resource for evidence-based, friendly and accessible information, and 24/7 breastfeeding counselling support can be contacted on the ABA Helpline, 1800mum2mum. Dr Julie Moore, Perth Ed. The subtle driving of consumer demand through dissemination of biased information or failure to disseminate unfavourable findings is not limited to product manufacturers. The medical profession has been accused of much the same, so as a profession, the onus is on us to stamp out the misuse of power or influence, as Julie Moore rightly points out. Mr Cummings was invited to respond.
Correction This is Anaesthetist Dr Twain Russell, pictured in Canada with his son while there completing his fellowship. Twain won our Whisson Lake Doctors Dozen prize (September edition). Sorry about the wrong photo caption Twain! Enjoy! 2
Take steps to protect men’s health Helpful to any GP or practice nurse who sees male patients, the Men’s Health Clinical Summary Guides provide concise, evidence-based information on the management and treatment of men’s health conditions. Register now to receive your set, free of charge, only from Andrology Australia. 1300 303 878 www.andrologyaustralia.org
Breast Fine Needle Aspiration Clinical Considerations Traditionally, deciding the nature of a palpable breast lump has involved excisional biopsy and histopathology, with or without intraoperative frozen section. Unfortunately, the patient either faced a GA without knowing if mastectomy would be performed (as guided by the frozen section), or they faced two GA’s if the lump proved to be malignant on later pathology report. We now know that almost 100% sensitivity and specificity can be achieved using the ‘triple test’ of clinical assessment, radiological investigation and cytology. The positive predictive value of a malignant diagnosis should be greater than 99% and the false negative rate should be less than 2%. Best results and efficiency come from the same person staining the aspirate immediately and reporting, the final step in the diagnostic process, after history and examination. Furthermore, immediate feedback as to the adequacy of an aspirate means the aspirator can repeat it if necessary, while the patient is still on-site. Performing a breast fine needle aspiration (FNA) is an acquired skill and a well-trained pathologist aspirator can increase sensitivity by about 10%.
Benefits of FNA in managing palpable breast lumps
• Rapid diagnosis of malignant, hyperplastic, inflammatory or cystic masses. • Permits diagnosis of some ‘non-surgical’ lumps, relieving patient anxiety and the need for hospitalisation.
• Helps discover the need for further diagnostic tests e.g, pre-operative staging investigations (bone scan, liver scan, etc.) if the lump is malignant. • Allows cases to be prioritised while waiting for surgery. • Provides diagnostic information for operative planning (e.g. lumpectomy plus sentinel node biopsy, or mastectomy plus axillary clearance), fuller preoperative counselling and reduces the need for frozen section diagnosis. • Removes the need for excisional biopsy in advanced disease, elderly patients, or when non-surgical treatment is best e.g. neoadjuvant chemotherapy.
By Dr Mark Neville
The optimal use of FNA in the diagnostic pathway
Other benign patterns
Clinical assessment: Palpable lump
Scenario 1 1. Clinically benign 2. Fine needle aspiration: Benign. 3. Negative mammogram >40yrs. Outcome: Continued review.
1. Complete aspiration of non-bloodstained fluid.
Scenario 2 1. Clinically benign. 2. Fine needle aspiration: Suspicious or Malignant. 3. Mammogram. Outcome: Not all three positive, so proceed to core biopsy. If negative, either continue review or remove the lump (depending on how confident the cytology report is and whether the mammogram is positive or negative). If positive, proceed to definitive treatment of breast cancer.
2. Foam cells, “cyst debris” +/- apocrine or ductal cells. Fibroadenoma Usual findings 1. Benign pattern, as above, but cellularity is much higher. 2. Fragments of fibromyxoid stroma.
Scenario 3 1. Clinically malignant. 2. Fine needle aspiration. 3. Mammogram. Outcome: If 1, 2 and 3 are all positive, proceed to definitive treatment of breast cancer. If not all three are positive proceed to core biopsy, as above.
Technical aspects These have been discussed in previous articles. The size of needle used, performing the FNA with suction or without suction (the so-called acupuncture technique), or using a butterfly needle with an assistant manipulating the syringe are largely a matter of personal preference.
n Figure 1. Ductal cells (yellow arrow), fibromyxoid stroma (blue arrow), blood vesseal (red arrow) – Pap stain.
The typical benign pattern
Benign pattern, intermediate between that of fibroadenosis and fibroadenoma.
Smears of fairly low cellularity.
Clusters of ductal epithelial cells: they have small cytoplasm and uniform round-to-ovoid nuclei, with fine chromatin, regular nuclear membranes and indistinct nucleoli.
Benign pattern, as above, but cellularity is somewhat higher, often with foam cells and apocrine cells.
Myoepithelial nuclei visible within epithelial cell aggregates. Single or paired bare oval nuclei in the background. These are identical in size and shape to the ductal cell nuclei and may be myoepithelial, stromal or epithelial (with “stripped” cytoplasm) in origin. Smears of higher cellularity, but otherwise similar in appearance, would suggest a diagnosis of localised fibroadenosis.
Most common malignant pattern – infiltrating ductal carcinoma NOS Usual findings 1. Absence of benign features listed above. 2. Highly cellular smears containing cytologically malignant cells lying singly and in disorganised, discohesive aggregates +/mitotic figures and necrosis.
• Allows the cytopathologist to recommend further investigation of atypical or suspicious lumps e.g. core biopsy.
Main Laboratory located at 647 Murray Street, West Perth Contact 9476 5222 for General Enquiries or 9476 5252 for Patient Results. Information on our extensive network of Collection Centres, as well as other clinical information, can be viewed at www.clinipath.net.
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14 Cardiologists, together with Ancillary Staff, provide a comprehensive range of private Adult and Paediatric Services.
Occlusion of the left atrial appendage An alternative to warfarin for stroke prevention in AF on-valvular atrial fibrillation (AF) is a very common problem, and its prevalence increases with age. The most important source of mortality and morbidity in AF is ischaemic stroke. It is now well established that the pattern of AF (paroxysmal vs. persistent vs. permanent) and treatment strategy (rhythm control vs. rate control) do not influence the rate of stroke, but rather it is the use of appropriate antithrombotic medicines (aspirin or warfarin/dabigatran).
The CHADS2 score is a simple system for assessing the risk of stroke in AF. One point each is given to a history of Congestive heart failure, Hypertension, Age > 75 and Diabetes, and 2 points for a previous Stroke or TIA.
high risk of stroke. In the follow up period, the device was non-inferior to warfarin at preventing ischaemic stroke, and patients with the device had significantly less haemorrhagic stroke.
Warfarin is notoriously difficult to manage, with multiple drug and dietary interactions and a need for close monitoring; this is less of a problem with newer anticoagulants such as dabigatran. More importantly, anticoagulation with warfarin or dabigatran is associated with increased risk of life threatening bleeding. Risks are higher in the elderly, patients with comorbidities and those prone to falls. However these same groups may have the greatest stroke reduction with anticoagulation.
However, implantation of the device was associated with adverse events in about 8% of patients, which included haemopericardium, access site bleeding and ischaemic stroke due to air embolism. It was noted that there was a procedural learning curve and that complications decreased with increased operator experience. Current registries of the WATCHMANTM device (which is now TGA approved) show complication rates of 1-3%.
Dr Eric Yamen, Cardiologist
About the Author Eric Yamen graduated from UWA with honours in 1998. He trained in clinical cardiology at Sir Charles Gairdner Hospital before completing fellowships in interventional cardiology (coronary angioplasty) at Concord Hospital in Sydney and Stanford University Medical Centre. He has a clinical appointment at Sir Charles Gairdner Hospital. Eric’s interests include management of complex coronary disease by angioplasty, and minimally invasive therapies for atrial septal defects, patent foramen ovale, hypertrophic cardiomyopathy and valvular heart disease. He has a special interest in percutaneous (minimally invasive) management of aortic valve disease. He consults at Subiaco, Applecross and Joondalup.
A second device, the AmplatzerTM cardiac plug, is also TGA approved for LAA occlusion. Advantages of the plug include increased choice of sizes, and the lack of requirement for postoperative warfarin. Procedural complication rates in published series are 1-5%. Left atrial appendage occlusion is currently being offered at Sir Charles Gairdner Hospital by Dr Eric Yamen of Western Cardiology. References available on request.
Percutaneous left atrial appendage occlusion About 90% of thrombi in AF arise from the left atrial appendage (LAA), a small outpouching of the LA. Recently, devices have been developed that can seal or occlude the LAA, excluding it from the circulation and doing away with the need for anticoagulation in patients at risk for both stroke and bleeding. These permanent prostheses are composed of a nitinol frame and fabric to fill the LAA or encourage tissue ingrowth over the LAA os. Implantation takes place in the catheterisation laboratory under general anaesthetic and takes about 90 minutes. The patient is discharged the following day. Depending on the device used and success of occlusion, the patient may take aspirin and clopidogrel or warfarin for a few months, but ultimately can be managed on aspirin alone. The PROTECT-AF trial (Lancet; 2009) compared the WATCHMANTM device (Figure 1) to warfarin in patients with AF at moderately
n Figure 1. WATCHMAN® left atrial appendage closure device (Boston Scientific), shown before and after placement.
Take home messages
• Stroke is the greatest source of morbidity and mortality in patients with AF.
• Anticoagulation with warfarin or dabigatran may be too hazardous to use for some AF patients; they may then be exposed to ongoing risk of stroke. • Percutaneous LAA occlusion is a reasonable alternative to anticoagulation in many of these patients, with acceptable short term complication rates and long term stroke protection similar to warfarin.
Who to refer Patients with paroxysmal or chronic AF with a CHADS2 score ≥ 1, and contraindications to anticoagulation (advanced age, comorbidities) or previous bleeding related to anticoagulants.
Visit www.westerncardiology.com.au to search information on locations, cardiologists and services.
Main Rooms: St John of God Hospital, Suite 324 / 25 McCourt Street, Subiaco 6008 Tel 9346 9300 • Country Free Call: 1800 702 600. Urban Branches: Applecross, Balcatta, Duncraig, Joondalup & Midland Regional Clinics: Busselton, Geraldton, Kalgoorlie, Mandurah & Northam After Hours on call cardiologist: Ph 08 9382 6111 SJOG Chest pain Service 0411 707 017 medicalforum
Working in travel medicine is a great foil for GP work which can be quite stressful
By Peter McClelland
Travel Medicine: Patients, Pitfalls and Exotic Locations Three doctors share their passion for travel medicine, having toured the world and returned home happy and healthy. Now they want to ensure others do the same. Dr Stefanie Bracknell, Dr David Rowse and Dr David Rutherford all acknowledge that you need a lot more than a diploma in tropical medicine and a penchant for exotic locations to be an effective travel medicine specialist. They shared with Medical Forum their stories on the complexities of travel medicine, their approach and experiences with patients. All show a passion for travel and dealing with the unique health challenges that travel brings in our evershrinking world [see our survey of 15 other travel medicine specialists, page 21].
She works at two locations, the Travelbug Vaccination Clinic in East Fremantle and the Travel Medicine Centre in the CBD.
Diverse backgrounds and beginnings
All three doctors sing the praises of mixing travel medicine with other clinical interests. For example, David Rowse combines his travel medicine work at Capstone Health with emergency medicine.
“I really enjoy travel medicine and never feel that I’m actually going to work,” Stephanie explained. “After graduating from UWA, I worked with Medecins Sans Frontieres in Sudan and Kenya. Those experiences were the real reason I got into travel medicine when I came back to Perth.”
“We have a Yellow Fever licence at Travelbug and I see my GP patients there as well. About 10% of my workload there is travel related – vaccinations, antimalarial medications and advice. The Travel Medicine Centre is part of the national Travel Medicine Alliance and focuses entirely on that sector. Travel medicine is a great foil to my GP work which can be quite stressful. It’s becoming an increasingly specialised field with plenty of opportunities for further qualifications in specific areas.”
“It’s quite a small area and I don’t think you’ll find too many doctors who only do travel medicine. It’s certainly a growing sector. We’ve got no shortage of people coming in for advice
Survey: Travel Medicine Drs (see page 21) If a traveller neglects to take a non-compulsory travel health measure, as recommended by you, what is the usual reason for doing this, in your experience [multiple choice]? Expense.................................................... 93% Dislike of vaccinations or medications.... 53% Prefer to take the risk than be proactive... 40% Can’t be bothered..................................... 27% Say there is not enough time.................... 27% Had conflicting advice elsewhere............ 20% Other........................................................ 13% Never happens............................................ 0%
’Other’ response explained. “Some travellers would say something like, ‘I have been to e.g. Bali before and never had X disease’.” “Cannot always afford them; make informed decision to take some precautions but not others e.g. avoid animal bites rather than have rabies pre-exposure prophylaxis.”
and this is reflective of the increasing number of people heading overseas. With a combination of the low dollar and budget airlines, people are travelling much further afield compared with 15 years ago,” he said. David Rowse knows all about travelling further afield. After graduating from UWA in 1989, he worked in Abu Dhabi and London and has travelled in Central America and the Middle East. His favourite travel destination is Nepal with its spectacular scenery. “After growing up in Perth, the mountains of Nepal are a fantastic experience. The landscape gets you first and then there’s that wonderful experience with the local people.” Dr David Rutherford, the Medical Director at the Travel Doctor Fremantle Clinic, is something of a renaissance man – he plays soccer, coaches his son’s team and also finds time to play the trumpet in the WA Doctors’ Orchestra. He combines his travel medicine role with working as a GP in a paediatric refugee clinic at PMH. “As a young student doctor I did an elective in Zambia and Zimbabwe and that was my first exposure to developing countries. That’s a very special kind of travel - you become part of a local community and work with local doctors and nurses. The crossover with tropical illnesses and my student experience is one of the reasons I work with refugees now. The PMH patients are from South-East Asia, Sub-Saharan Africa and the Middle East. It certainly makes for an interesting case-load. We see malaria of course, plus cases of schistomiasis and strongyloides,” he said. All three doctors can relate diverse experiences linked to their special interest. One of the most interesting areas for David Rowse was his
international retrieval work based in London in the 1990s.
monkey bites are becoming a real problem,” said Stefanie.
“It wasn’t an air ambulance function – that’s highly specialised – but usually involved travel between countries aligned with the travel insurance industry and one-on-one care for people who were designated as high-risk by international airlines. It’s specifically designed to prevent an in-flight diversion, which is very costly for an airline. There’s one I remember clearly – a nurse and I flew to Sydney to pick up a young Irish guy and bring him home. He’d broken his neck diving into the surf - a very sad case indeed and it required quite a bit of sophisticated medical care,” said David.
David Rutherford agrees and he’s got statistics to back it up.
A unique patient group
“We’ve had 40 post-exposure rabies cases from Bali in the first half of this year. An at-risk scratch or bite needs to be treated along WHO guidelines. A lot of people are letting their guard down in Bali,” he said.
Swimming in a dirty puddle in Malawi can pose a challenging diagnostic puzzle David Rowse
One of the unique aspects of consultations around travel medicine is that the patients are usually not actually sick. “The people coming through the door are healthy, happy and excited about travelling. They’re keen to listen to our advice and you also get to meet some really interesting people,” said Stefanie. David Rutherford agreed. “Apart from making sure all the vaccinations are up to date, the consultations are designed to make people aware of the risks. We focus on food and water-borne illnesses, mosquito related disease, safe-sex issues and provide information sheets on access to English-speaking doctors overseas. We even supply medical kits so people can selftreat if they need to,” he said. David sees a lot of returning travellers who need medical attention but outward travellers can present really difficult moments.
“The work can be a bit fiddly and there are other complexities too. Some people choose itineraries that aren’t particularly suitable – pregnant women heading off to high-risk malaria areas and others whose health isn’t really suitable for their planned itinerary. Trekking in the Andes isn’t such a good idea for someone with chronic bronchitis.” Despite the increasing number of travel websites, some patients come through the door lacking critically relevant information. Stefanie elaborated. “A lot of travel medicine is education and providing people with relevant strategies. They might have some awareness of the more common infections
Stefani says the most common medical complaint is the dreaded ‘Bali Belly’. “Although people don’t get really sick from this, it can ruin your holiday. Our advice is to only drink bottled water, eat food that’s been well-cooked and avoid raw salads and vegetables. There’re some really effective antibiotics for this, but we’re starting to see some resistance patterns developing so we try to tailor medication to a particular region,” she said. The time factor in relation to seeking treatment on return is critically important, as David Rowse explains.
and tropical diseases, but we often need to point out a previous medical condition such as cardiovascular disease is potentially far more serious. And, for young travellers, we highlight risks associated with STDs and issues surrounding alcohol and illegal drugs. Some websites point out the risk of contracting something exotic such as cholera, which is actually pretty unlikely. It’s much more about tailoring specific information to individual travel plans.”
The Bali experience and beyond For an increasing number of West Australians, travel plans can be summed up in one word – Bali. It’s a destination with quite specific and under-rated risks. “A lot of people go to Bali without seeking proper advice. There’s a perception that it’s on our doorstep and patients say, ‘I’ve been ten times before and I’ve never caught anything!’ We’re hearing reports that GPs all over Perth are seeing a lot more cases of dengue fever and
“If a patient comes back with an illness – stomach, fever or a strange rash – and sees us promptly it’s easier to diagnose. If you have to try and join the dots a long way back it’s much more complex. Swimming in a dirty puddle in Malawi four months ago can pose a challenging diagnostic puzzle,” said David Rowse. Health concerns aside, travel is a wonderful circuit-breaker, for patients and doctors.
“It’s so important for doctors to take a break and broaden their horizons. Our children are at a better travelling age now - we went to Borneo this year and next year we’re planning on Vietnam and Cambodia,” said Stefanie. David Rutherford says there is a professional spin-off: “It’s definitely an advantage if you’ve travelled a lot. You’ll lose credibility with your patients if you haven’t.” And David Rowse has some advice for that all-too-familiar situation for doctors travelling overseas. “There are no hard and fast rules regarding a medical situation on board an aeroplane. Most doctors will put their hand up to help. You might even get an upgrade, although the aeroplanes are usually so full these days that it’s far more likely to be a free drink,” he said. n
The crossover with tropical illnesses and my student experience is one of the reasons I work with refugees now David Rutherford medicalforum
www.dfat.gov.au www.smartraveller.gov.au www.australiatravelsearch.com/trc/ozemb www.cdc.gov.travel www.who.int/csv www.SmartTravel.gov.au www.who.int/en www.traveldoctor.com.au www.travax.com www.usembassy.state.gov
Medical Pioneer By Peter McClelland
Dr Kevin Yuen: Palliative Care and Social Justice The son of illegal immigrants, Dr Kevin Yuen’s demeanour and personal philosophy has earned him respect in palliative care, his focus for the relief of suffering. Kevin Yuen cares deeply about people. A strong current of social justice and compassion runs through his family background and medical career. “I come from a working class background – my father was head chef at PMH for many years and my mother’s family had very strong roots in Labor Party politics. I’ve got one brother who’s involved in the trade union movement and another with a long-standing commitment to the people of East Timor. We all feel very deeply about suffering and struggle,” said Kevin. From the outset, this suffering of others has shaped Kevin’s professional career and it has been underpinned by his strong religious belief. “I was in the Young Christian Movement as a medical student and we did a lot of work in community housing. After my residency at Sir Charles Gairdner Hospital I spent a year in the UK doing anaesthetics before going to Cambodia with Medecins Sans Frontières. The country was coming out of a war and it was difficult to provide appropriate treatments, particularly from a Western point of view. There were a lot of avoidable deaths from things like tetanus and diphtheria and it was quite a distressing thing to see.”
If you’re able to provide some insight and allow people to feel a sense of peace about the process that’s a wonderful thing
Kevin moved from general practice to become Medical Director of the Silver Chain Hospice Care Service and the Cancer Foundation Cottage Hospice. He is now a senior palliative care consultant at RPH and Medical Director with Donate Life WA. But it is a very near thing that Kevin Yuen is here at all. “My father was an illegal immigrant. He came here in the Merchant Navy at the end of the war and was nearly deported back to China under the White Australia Policy even though he had a wife and three children. Of course, I hadn’t even been thought of at that stage.” Palliative care, according to Kevin, requires a high dose of humanity and humility with a continuous infusion of compassion. He has a keen interest in community medicine and pain management, cross-cultural palliative care and competency based education. He speaks regularly at postgraduate medical and nursing forums and in 2000 became a Foundation Fellow of the Australian Chapter of Palliative Medicine. “There are always memorable moments in palliative care. Just the other day I sat with a Chinese family struggling to come to terms with the impending death of their grandfather. It’s so important for people to understand what they’re confronted with and acknowledge their bravery. If you’re able to give them some insight and allow them to feel a sense of peace about the whole process then that’s a wonderful thing.” He feels deeply for his patients but his emotions are often rather mixed. “I’ve only ever cried twice – the first time was a 30-year-old guy when I was with Silver Chain and the second 10
a young mother with kids. I just resonated with both situations. I do feel the suffering and empathise but it doesn’t make me sad. In fact, there are some really good moments when you see great courage and humanity in others.” Surprisingly, he says doctors in palliative care burn out much less than other specialities, perhaps because they work in supportive teams and have a different philosophical outlook. However, working in a hospital has unique challenges. For example, intensive care doctors have much to offer with technological and pharmacological support but it is important to understand that technical decisions are intermingled with important quality-of-life issues. Can these doctors be healers when there is no possibility of a cure? In palliative care the goal is to minimise the distress for the patient, family and treating team. Respecting the patient and caring for the family remain the key issues and can provide their own restorative balm. “People are pretty philosophical when it comes to the final stages of life. There’s often a real ‘time’s up’ and ‘runs on the board’ sense of acceptance. That’s not to say it’s always easy. In one case [at RPH] the wife was spread over the bed of her recently deceased husband. There was a cross-cultural element here - she wanted
us to kill her so she could accompany him to paradise. With a lot of care and emotional support we were able to make the situation more comfortable for her.” “We have a high number of elderly patients coming through RPH and sometimes we find it very difficult to give them really good outcomes. Some of the decisions made in the heat of an Emergency Department might have been better made within a community setting.” It is the importance of end-of-life decisions and palliative care that has prompted Kevin to become heavily involved in training and education. “There’s always a new generation of doctors who need to be more informed. I’ve just been marking a medical student’s palliative care assessment and it was so satisfying to see that he’d done some very deep self-reflection about these sensitive situations.” With greater understanding has come greater professional recognition. “We’re receiving a lot more acceptance from our professional colleagues. Palliative care physicians are not foretellers of doom and death – we have a lot to offer and contribute a great deal to a person’s life when it’s coming to an end.” n
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Mental Health : Training, The Minister, Carers, Detention Guest Opinion: Caesareans, Mandatory Reporting, Shanks’ Pony Clinical Updates: Colitis, Aortic Valve, Depression The Funny Side: Exercise, Stress Puppies
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Here at Medical Forum it’s been paradise one minute and purgatory the next. But there’s one thing for sure, there are plenty of interesting and challenging things to say with a strong, independent WA voice. Some don’t like bits of our commentary but we are very proud that the door is always open to them at Medical Forum. We value the wonderful support of our major sponsors, the professional expertise of our editorial advisory panel and the many thoughtful responses to the E-Polls – topics from national registration to kid’s sport sponsorship, public health performance, and Medicare Locals. It all makes, we think, for a pretty impressive industry publication and a valuable platform for clinicians and related health professionals to make their voices heard. First up, our Major Sponsors for 2011 and a very warm festive thank you to all of them. Western Cardiology Clinipath Perth Pathology Avant Silver Chain Medical Forum is both pleased and proud to have had them with us in 2011. And the same goes to every Specialist and Service within
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your interest in attending the conference and receiving further updates by emailing firstname.lastname@example.org will be held in Bundaberg in March 2012. We look forward to welcoming you as a delegate, sponsor or exhibitor. Register Following the success of last year’s event, Best Practice Software is excited to announce that the next Best Practice Summit
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copy, of course):or call for the free DVD and experience these and other features for yourself – with your own practice data (from a back-up www.bpsummit.com.au in the coming months for further information. And if you haven’t yet tried Best Practice, send directions for Best Practice, integration with other packages and conversions, etc. Keep watching the Best Practice website: Workshops will include training sessions on various aspects of Best Practice Clinical and Management as well as future
Feature articles, written specifically for our readership of every GP and Specialist, have tackled contentious topics like caesarean rates, cancer research, racism, drug law reform, rural GPs, professional ethics, organ transplantation and social media use.
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It has been a very interesting year, to say the least. Local politics is going a lighter shade of conservative blue, and revelations about Rupert Murdoch’s News of the World have Updates shown how some unscrupulous players can work the media. Fortunately, ethical players Clinical like Medical Forum can publish stories that on merit stimulate local media into supporting the doctors’ perspective. Such things as dysfunctional families at the root of SociAl young male MediA Medicos using violence, the difficulties female GPs face in their work, patient knowledge on WA HRT, and Fingertips doctor concerns over illicit opiate scripts have all been taken up by the lay media. at your
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Following the success of last year’s event, Best Practice Software is excited to announce that the next Best Practice Summit will be held in Bundaberg in March 2012. We look forward to welcoming you as a delegate, sponsor or exhibitor. Register your interest in attending the conference and receiving further updates by emailing email@example.com
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Two sections in the magazine have been particularly strong this year - Guest Columns and Clinical Updates. Subjects were wideranging from e-Health and Indigenous Health, to Rare Diseases and Opiate Monitoring. Thank you to all the authors of these diverse, informative and impressive articles. We appreciate the hard work that goes into producing articles to our standard. We look forward to reading a lot more of them in 2012. Three highly impressive women were in Spotlight’s beam - the quiet achievers Dr Anne
Christmas is the silly season after all and that means it’s a great time to mention Wendy Wardell, our resident satirist. Who could forget Snow White’s 18th Birthday Breast Augmentation in the July issue? Thanks Wendy… and thanks to our cartoonist, Dave Freeman. What a great cover to top the year off! We’ll be back in February.
Have a wonderful Christmas and see you in 2012!
From Ms Jenny Heyden RN and Dr Rob McEvoy. We appreciate your interest in Medical Forum, our ‘labour of love’ for the profession for well over 10 years. The magazine’s quality content each month stems from the friendships we have built with many doctors, the hard work of a small dedicated team of reporters and help from our many contributors. The support of our sponsors and advertisers is critical, as is our reputation for ethical balanced journalism as we move amongst competing interests and seek to both inform and entertain WA doctors. We hope you look forward to your free copy each month, and get some enjoyment from a snippet or two. Happy reading!
To Our Integrity, Do No Harm Dr David Borshoff laments the profession’s acceptance of self-promotion and questions its effect on our integrity in the eyes of the public. I remember sitting in a New York subway, scanning the advertisements above the seats on either side. It seemed that on every third poster there was a medical specialist with outstanding, if perhaps questionable, qualifications and pearly white teeth. Even then, as a naïve, impressionable young doctor in my twenties, I felt that doctors didn’t belong with the haemorrhoid creams in a subway carriage. Thankfully, I had thought, it was unlikely we would be reduced to this back home. My woeful ability to predict trends has again been confirmed as I notice now that most weekend papers have a specialist or two selling their wares. They are well qualified and ‘well equipped’ to carry out their procedures, and I suspect, they do so with hard-earned expertise – but I wonder if all this marketing is necessary? The issue of flaky qualifications was also foreign. Our specialist colleges demanded the highest level of training, theoretical knowledge, and practical skill before they awarded candidates their fellowship. The general public could be relatively certain
that if someone called himself or herself a surgeon or physician then, in old school terminology, that’s what they were … well, at least before Botox and liposuction arrived. These latest medical miracles and the development of highly sophisticated equipment created the opportunity for many doctors to diversify. This has stimulated rather robust discussions amongst the ‘properly qualified’ proceduralists, who despair at the lesser training and claims of some others.
Are we the healer, the businessman or the charlatan The most recent example discussed in our staff room was that of a tattoo removalist who enjoyed press coverage as a ‘cosmetic surgeon’ rather than a general practitioner with an interest in cosmetic procedures. A combination of advertising and arguable representation of our qualifications sends a message to the public about our professionalism. It may also confuse our image – are we the healer, the businessman,
or the charlatan – and how does the public decide? In the same way that many of us feel a collective sense of responsibility when a member of the general public is harmed by the profession, I believe all of us are lessened as doctors when any colleague trades for the ‘filthy lucre’. The successful practitioner doesn’t change. They provide a good service, genuinely care for their patient, are honest and never lose respect for the privilege of practising medicine. Both colleagues and patients sense this, and the doctor is always in demand. It beats the glossy advertisement or website wizardry hands down, although to those practitioners and patients in the know, the ‘website sign’ can be an indicator of practitioner skill. As young medical students, a gentle, old physician instilled in us the Latin phrase primum non nocere when embarking on the potentially hazardous pathway of patient treatment. Perhaps applying this same principle to our profession, we can maintain the privilege and respect our predecessors earned and of which we have been the beneficiaries. n
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IT in Practice
Letting Patients Book On-line Limited on-line bookings for particular patient groups could have advantages. On-line or internet-based patient booking systems for medical practices are getting a look in these days but uptake is limited. Most practices are staying with an experienced receptionist or practice nurse to triage appointments, particularly emergency and long appointments. While some software vendors have included online modules, stand-alone products are available, usually designed to fit a variety of businesses. ClinicConnect have the franchise for GObookings, a web-based appointment scheduling system developed in Queensland and adapted for a variety of health practitioners that includes GPs. GObookings says it ‘ticks all the boxes’ from SSL encrypted security and synchronisation with practice management systems, to permission levels for use and reporting and search functions. Anyone booking an appointment can elect to receive an email or SMS reminder. Practice manager Liana Diacicov from Murray Medical Centre said they have been using ClinicConnect for over nine months and about 10-15% of total appointments are now booked on-line. The figure grows as they add another
doctor from the 19 working there. “The limit is given by the number of appointments we make available online but here we’re talking a really busy practice, booked ahead for weeks and weeks,” she said. She listed two main benefits; “Capturing another segment of the market – the ‘on-liners’ or younger patients – and less stress at reception level, which is the biggest gain in my opinion. At the beginning it was younger computersavvy patients using the system most but now it’s a mix really.” Cancellation of an on-line booking can only be made on-line, not on the phone or in person, but Liana says this is “no major drama”. She said support from ClinicConnect has been brilliant. Kelvale Medical Group Business Manager Mike Bowles says their 10-doctor practice has used the GObookings system on a very limited basis for the last six months, and while the system stays in its current form, use remains limited. “The system is very good for basic standard appointments and we had a reasonable response from our patients,” Mike explained, adding there is still an additional administrative workload.
“Our problem is that a majority of our appointments require a concurrent appointment with a practice nurse, primary care nurse or counsellor and this is a variable that the system doesn’t cater for. Most times the patient doesn’t know that a concurrent appointment is required. It also sometimes requires a change in doctor to match up with nurse availability. So the system is not suitable for our complicated appointment system.” When we checked the seven general practices listed at the ClinicConnect website, a minority were using their system as intended to list bookable appointments with GPs. Dr Marcus Tan says they will be attaching a similar booking system to their HealthEngine practitioner on-line database. If they can enlist a critical mass of practices that feel the need to compete for last minute available appointments (do they exist?!), then a searchable list will be a friendlier system for health consumers who will also be spared the hassle of a phone call. The big question is whether enough practices want to enroll. n
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Rural Teaching’s Cultural Shift Setting up a ‘bottom up’ teaching site at Esperance has fulfilled an ambition of A/Prof Mike Mears to mentor students towards his brand of medicine.
If I could stay one step ahead of the students, this was a great opportunity to learn all the medicine I hadn’t been taught in London! And maybe I could be their role model, in contrast to my experience as a student – my professional career was now varied and fulfilling, home life great, and the recreational opportunities exceptional. Eight years on, the Rural Clinical School has achieved a great deal. Progress is being made to increase the number of rural doctors although the lead times are long. We have had a number of graduates in the Prevocational General Practice Placements Program (PGPPP) working in Esperance and next year
northone C E N T R O
But the relationship is dynamic and many of the benefits of moving undergraduate teaching to the country have been subtle but no less
Specialists have become colleagues, with much greater mutual respect after my years of examining students in both the city and country. This will only increase as more specialists have country experience. The students have wrought unexpected benefits; my rurally educated children have had role models in the students and are now moving into their own university careers. GP colleagues who were becoming tired and burnt out have developed new career opportunities. The Rural Clinical School has shifted the focus of medical training not only to the country but also into primary care. It never made sense to me that medicine was learnt on the rarest and most unusual teaching hospital cases and the bulk of human suffering was never seen as it never reached such hallowed environments. Surely it makes more sense to learn medicine from the ground up rather than top down? Build the foundations first and then add the wings, turrets, gazebos, the follies and hahas later!
n A/Prof Mike Mears welcome. Less often do I feel that yawning cultural divide as I phone a specialist registrar in the city to be told ‘just send them to the clinic tomorrow’; often now I’m speaking to one of my ex-students who understands perfectly my patient’s situation, and mine. An understanding of the geography of WA is essential to the practice of medicine here. I know that better than most having spent my first three years in WA as a ‘Flying Doctor’.
As my wife remarked after she delivered specimens to our ED and noted three students busy there, one with the ophthalmologist, one examining a patient, and another stitching up his preceptor who had cut himself with an angle grinder, plus the ex-Rural Clinical School doctor setting a fracture; ‘These students have breathed life back into this place - it feels like a real teaching hospital’. The good news is, all our country hospitals are now ‘real teaching hospitals’ and this is because of the students, the teachers and those with the vision to make it happen. Why was it ever otherwise? n
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‘Doctor’, I vaguely remember, comes from the Latin verb ‘docere’, meaning ‘to teach’. The teaching role of the doctor was inculcated early in my professional life in London but the registrars were bitter and struggling up an impossible career ladder and the consultants were distant, austere and taught by anecdote. Clinical reasoning and evidence based medicine were largely unknown. Simple humanity was lacking. I left my medical school with a cynical mind and no role models, on a nomadic career path towards general practice that eventually found me in rural Western Australia. Whereas in England I felt my clinical skills atrophy under a load of administration, in rural WA doors kept opening and the opportunity presented itself, to open a Rural Clinical School site in Esperance and teach medical students.
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Christmas: Nice Idea or Essential? Warren Palmer gives us food for thought
Christmas evokes mixed reactions from different sectors of our community. Whatever that is, none of us can argue with the significant pressure and stress, high expectations, and frantic pace leading up to the big day. Is the picture of families sitting around the Christmas tree, opening gifts, and sharing in a special Christmas meal just a silly ideal or are there greater benefits for our personal well-being and for our community?
health and well-being. A small tear in the fabric of our community can rip into the very unity of families, causing great distress and despair. Homelessness is hopelessness; it just doesn’t have an address! The Salvation Army endeavours to fight these social diseases by restoring hope and self-esteem of individuals so they can believe that a better life is possible with support and positive choices. The Salvation Army is called upon by more than 150,000 West Australians each year. Over 90,000 (and increasing) are supported through financial hardship, 400 people a year initiate drug and alcohol rehabilitation and 300 people a night who are homeless are accommodated. Our role is to journey with people who are in crisis. It is about humanity at its core as we counsel and provide support to deal with life’s many challenges.
Those of us who deal directly with the very personal rawness of people’s lives, such as doctors, would no doubt understand the impact of life’s pressures on health and well-being. How many people fall into depression because they perceive that their life is unmanageable? How many feel trapped by financial hardship that causes their health and that of their children to suffer? How many fall into substance addiction due to loneliness and abuse, their lives spiralling out of control and sometimes ending in premature death?
A common thread of inspiration for all of us is a selfless desire to benefit humanity. Whilst medicines, technology and practices continually improve, it is the personal approach of being interested in someone’s life that remains unchanged.
I believe in a very close link between the many complexities of social issues and our
Christmas can be seen as a perfect ideal but in my view, it is a vital shot of hope into the arm of our community. It is the one time of year that is not about any individual but about family members relating to each other as a family is designed to do; to laugh, to listen, and to connect with each other. Perhaps it’s more about our expectations. The connection of our communities builds strength and well-being. This Christmas, we hope to extend to as many as possible the opportunity to share in the spirit of Christmas. You can join us by donating at 137258 or www. salvationarmy.org.au. n
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AAPM National Conference, Perth By Kathy McGeorge, AAPM WA President
AAPM WA secured dual Olympic hockey goldmedallist Jenn Morris as a keynote speaker. She represented Australia from 1991 to 2000 and was one of the original players from the Ric Charlesworth era, undefeated in major tournaments for almost a decade. Jenn spoke about success in achieving goals, drawing on her experience with the Hockeyroos, and teamwork. On the lighter side, she shared stories about life in the Olympic Village. The conference covered two keys areas of change, the personalised electronic health record and the 4th edition standards for general practice. Key points about the implementation of the PEHR included: • The shared health summary can only be updated by three groups: medical practitioner, registered nurse, and Aboriginal health worker. • The patient controls who accesses their PCEHR, whether to use it, and they can opt in or out at any time. n Dr Con Anastas, winner of the Hentley Farm Doctors Dozen.
We had one ophthalmologist pleased to be walking out of the Medical Forum office with the Hentley Farm Doctors Dozen. It was his brother’s birthday and he said a bottle of the superb 2009 Barossa Valley ‘The Beast’ Shiraz was destined for the celebrations later in the evening. Picking up his wine prize was one of the best reasons he could think of for taking a short break from the Cambridge Eye Clinic in West Leederville. Apparently, the wine winners circle at Medical Forum was becoming something of a family affair. Con’s father, Nick – retired from clinical orthopaedic practice and currently working in medicolegal – has won in the past. Con son is aged 10 handing on the baton to the Anastas dynasty is some way off.
• The PCEHR is limited and does not replace the normal health record. • The system is targeted at, and is most beneficial for, frequent flyers in the health care system. • The patient can say no to information posting by any health professional, otherwise it is assumed it is OK. The new 4th edition standards are another area of change. If the practice accreditation expiry is between April 1 and July 31, 2012, you may choose 3rd or 4th edition. Expiry after • August 1, 2012, means you must be assessed under the 4th edition standards. The Commission has developed 10 Standards aimed at protecting patients from harm, and improving the quality of health and service provision. Three key areas of change are: • Patient feedback. Now more complex, and probably done by an RACGP approved company (there are two at the moment). • Clinical Equipment. 3rd edition practices must have a maintenance schedule, while 4th edition practices are required to maintain equipment in accordance with that schedule, and in line with manufacturer’s recommendations. • Patient identification. To be done using three of either patient name (family and given names) , date of birth, gender, address, and patient record number (where one exists). Next year’s AAPM National Conference is in Brisbane. n
By Ms Sue McDiarmid, ChoiceOne HR Coach.
Businesses that grow have a high link between their strategy and what everybody does every day. Research shows that most businesses have no link. HR Coach Institute of Australia surveyed Australian businesses to find only 22% had employees actively engaged in activities that aligned with the purpose and objectives of the business and these successful businesses reported low people turnover, high productivity, motivated and engaged teams and most importantly, a healthy bottom line. Their approach is focused and deliberate. • Clearly identify what needs to be achieved.
• Identify and list their business’ capability to achieve this. • Design the optimal people structure to support this. • Detail the absolutely critical and nonnegotiable behaviours and skills that all employees need to display in order to achieve this. • Recruit, induct, set performance standards, and coach – measure performance against these. Creating and maintaining a clear line of sight between the organisation’s business strategies and aligning them to relevant and critical competencies is the key to success. It is not rocket science, if you do not understand what is needed for your business to achieve your vision how can you ever expect your people to understand and deliver? n
Bentley Rooms For Lease Id as eal f Ce or ntr An al aes Ro th om eti s– cG Op rou p. p o Be r S ntl pe ey cia Ho lis sp ts ita l
General practice, specialist practice, dental and allied health were all represented by both delegates and the 95 exhibitors during the recent conference. Human resource management, marketing, patient services, industrial relations and team work were among the issues discussed. Practice managers were able to research new products, software and ideas at the trade exhibition as well as network.
Giving your business real direction
This is a spacious purpose built Medical Centre capable of expansion to adjoining ¼ acre block. It is luxurious in its appointment with no expense spared in construction/fit out and has a minor theatre, industrial high quality carpets throughout with spacious waiting and consulting rooms and definitely the best in Perth. A rare opportunity to set up practice in a huge catchment area with Bentley Hospital set to develop further in the near future. Patient’s drain area extends over the entire South Metro and only 6klms from the CBD. Ideal for a large Anaesthetic Group or Specialist central rooms. No better value in town.
For further information, please contact Dr Tony Taylor on 0418 945 047 19
The doctor-financial advisor relationship. It’s a matter of trust.
almost twenty years ago, Perth G.P. Dr Franz bumped into Brad Gordon at a friend’s wedding. And Brad’s been taking care of Dr Franz’s financial affairs ever since. ‘I met Brad purely by chance, but I’m so glad I did,’ says Dr Franz. ‘He introduced me to the way Entrust manages their clients’ portfolios and I thought it was the perfect arrangement. Brad has my authority to buy and sell investments as he sees fit. He’s quite conservative, but very strategic, which suits my style of thinking.’ The big test of Brad’s strategy for Dr Franz came during the global financial crisis, which was felt by varying degrees by his clients. ‘I was lucky. A friend of mine in Germany told me he lost over half of his retirement savings.’ Dr Franz now only works a few days a week, and relies on supplementary income from his superannuation fund. ‘Brad’s always invested appropriately for my circumstances, and makes sure there’s always plenty of cash available for my immediate needs, like holidays. When I compare notes with my friends, I can see that their portfolios are nowhere in the same league as mine.’ I’m one of the fortunate ones. I have a financial adviser who I’m really happy with and, most importantly, can trust.
Entrust Private Wealth Management Pty Ltd Level 17, 140 St Georges Terrace Perth Western Australia 6000 Important Information. The circumstances described relate to a particular client and his particular circumstances, and are atypical. Investing in volatile and unpredictable markets car r y financial risks including the risk of loss of capital. Past per formance is not an indicator of future per formance.
Telephone 08 9476 3959 Email email@example.com Web www.entrustpwm.com.au AFSL No. 222152
change things for the better and help people adapt to today’s changed circumstances. Getting top billing is the $565m committed to the Southern Inland Health Initiative, stretching from Kalbarri and Meekatharra to Laverton and south to Esperance.
u Medical Forum satirist Wendy Wardell has won the Rostrum WA Speaker of the Year Competition and is now holder of the Arthur Garvey Trophy. u Dr Margaret Smith, well-known gynaecologist, women’s health advocate and author, is retiring. There will be a celebratory farewell on 14 December 2011. Contact: Judy 0423 627 984 u Dr Paul Bailey is the new Director Emergency Medicine at St John of God Hospital Murdoch. Paul’s previous positions include Deputy Director Emergency Medicine at Joondalup Health Campus and Director of Emergency Medicine at Peel Health Campus. He was most recently the senior clinician lead for implementation of the clinical reform program at Joondalup Health Campus. u Sarah Devereux was awarded the RACGP National Rural Faculty Medical Undergraduate Student Bursary 2011. u ECU’s Australian Indigenous HealthInfoNet (www.healthinfonet.ecu.edu.au) has won the Diversity category at the 2011 Australia New Zealand Internet Awards. The judges commented that many communities and projects from outside Australia could learn a lot from this important resource that appropriately respects the culture of our first nation people. u A/Prof Yuben Moodley who heads the Stem Cell Research Unit of the Lung Institute of WA (LIWA), has won the inaugural LIWA Glenn Brown Memorial Grant for research into cystic fibrosis and bronchiectasis. u Finalist for WA’s Scientist of the Year includes Prof Sarah Dunlop (Principal Research Fellow, the NHMRC and Winthrop Research Professor, UWA) while Early Career Scientist finalist is A/Prof Meri Tulic (Paediatrics and Child Health UWA).
n CHOGM, Polio and Monkeys
• $182.9m for the District Medical Workforce Investment Program to improve medical resources and 24-hour emergency response times.
During CHOGM, PM Julia Gillard announced Australia would commit $50m over four years to the Global Polio Eradication Initiative (while the Gates Foundation committed US$40m). Polio is still endemic in three Commonwealth nations, India, Pakistan and Nigeria.
• $147.4m for the District Hospital and Health Services Investment Program to upgrade hospitals at Mortham, Narrogin, Merredin, Katanning, Manjimup and Collie.
As the head of initiative pointed out, money was not the main issue, it was vaccinating the final 1% of children who were often in conflict zones or rural and very inaccessible areas. Of course, Australian company CSL is a major manufacturer of polio vaccine so how much of the $40m remains within our shores is uncertain.
• $20m for the Residential Aged Care and Dementia Investment program to encourage private providers to expand residential care and dementia care.
When we Googled polio vaccinations, we came across info suggesting injectable polio vaccine used in the 1960s and manufactured by CSL and others in the US was infected with monkey SV40 virus, later found to be carcinogenic. Some observers today believe SV40 is a cocarcinogen with asbestos fibres for the development of mesothelioma, both having a very long latency that makes study difficult.
n Rural Money While some think the Royalties for Regions thing is going overboard, it is hoped that putting some serious money into rural health will
By Fiona Wong Dip Pract Mgt, MAAPM
• $36.5m for ‘e-technology’ and telehealth across the region.
• $108.8m for the Small Hospital and Nursing Post Refurbishment Program. Funding 44 extra doctors for EDs plus GP services across eight districts.
n Anaesthesia Not A Gas The most recent ANZCA bulletin has highlighted concerns about the successful suicide rate (up to 25%) of anaesthetists, put down to their pharmacological knowledge and easier access to drugs. The college has increased its support services and is attempting to change the culture amongst anaesthetists so those in trouble more readily seek help. Doctors generally suffer more depression, anxiety, stress-induced problems and
A ‘must read’ for practice owners
u Contenders for WA’s Australian of The
Year include Dale Alcock (builder and philanthropist), Prof Donna Cross (children’s advocate), Gerard Neesham OAM (sporting mentor) and Corporal Benjamin Roberts-Smith VC (inspiring soldier) – quite a mix, without a medical contender amongst them. u The contracts totalling $55.3m for supply of Sharps Consumables (2 years) and Disposable Biohazard Containers (4 years) to WA Public Healthcare Units in regional WA has been won by a combination of B. Braun Australia Pty Ltd, Becton Dickinson Pty Ltd, Western Biomedical, Scientific Educational Supplies Pty Ltd, ASP Healthcare Pty Ltd and Tyco Healthcare P/L from amongst 14 applicants.
The Health Professionals and Support Services Award was introduced in January 2010. Non-compliance may mean a fine; up to $33,000.
Risk Fines If You DO NOT
• Have contracts for your staff (contracts dated pre-January 2010 may need to be modified to comply). • Keep accurate time and wages records. • Pay the award wage and additional (new) entitlements. • Pay appropriate overtime when it is worked • Provide the correct leave entitlements • You can find the awards here: www.fwa.gov.au/index.cfm?pagename=awardsfind It is your responsibility to ensure your practice is complying with the awards (and you may be covered by two different awards for your administration staff and your nurses). Check your individual circumstances to see if you need to comply. Please do not ignore this award. You never know when you may be audited. Plug! Register your Practice Manager or yourself as a member of AAPM to receive regular award updates and education.
Out & About
the funny side From Rob Fitzpatrick’s iphone Just in case you weren’t feeling too old today…
alcoholism than the general population, and while anaesthetists have about the same incidence of substance abuse (10-15%), they are six times more likely to abuse intravenous drugs. Of those who successfully seek help for drug abuse, only 1 in 5 remain in anaesthesia. With the introduction of mandatory reporting, where doctor conduct might put patients at risk, it was feared the new legislation would stop doctors seeking help. That is the main reason WA went it alone and made doctors treating a medical colleague exempt from the requirement. After 12 months, the impact of the laws seems mixed. The Australasian Doctors Health Network says only Queensland has reported a drop of in calls from doctors seeking help (WA does not report figures and Tassie and the ACT do not have a service). This is despite Qld stipulating it does not pass reports to the Medical Board. One senior anaesthetist said responding to suspected cases is rarely straightforward for the reporter or reportee, with error, failure, litigation and death all possible outcomes. Having clear cut protocols in place did not prevent erroneous complaints from a “health practitioner”, especially in the early stages.
n Deck The Halls With Folly The say medical practice is ‘recession proof. Spare a thought for other businesses in this downturn – debt owed by insolvent companies or individuals increased 35% to a staggering $5.3b during 2010-11, according to the ATO. Wind-ups increased from 493 in 2009-10 to 1,055 in 2010-11, with personal bankruptcies initiated by the ATO up 16% to 452. ASIC figures confirm the high number of companies that have collapsed into insolvency as more businesses are struggling to stay afloat, and the ATO is onto them. The vast majority of these companies are very small.
The people who are starting university this year were born in 1993. They are too young to remember the space shuttle blowing up. Their lifetime has always included AIDS. The CD was introduced eight years before they were born. They have always had email and the internet. They have always had cellphones and video cameras. They don’t have a clue how to use a typewriter.
Men’s Secrets to Keep Marriage Brimming Whenever you’re wrong, admit it. Whenever you’re right, shut up. The most effective way to remember your wife’s birthday is to forget it once... A good wife always forgives her husband when she’s wrong. Marriage is the only war where one sleeps with the enemy.
A man inserted an ‘ad’ in the classifieds: “Wife wanted”. Next day he received a hundred letters. They all said the same thing: “You can have mine.”
Christmas Cheer from the Oz Bureau of Statistics 19 have died in the last 3 years by eating Christmas decorations they believed were chocolate. Hospitals reported 4 broken arms after cracker pulling incidents. A massive 543 Australians visited EDs after opening bottles of beer with their teeth or eye socket. 142 were injured by not removing all the pins from new shirts.
n Mental As Anything
Cute advice from kids
Another mental health plan or report for WA. This time, the 10-year strategic plan Mental Health 2020: Making it Personal and Everybody’s Business launched by Premier Colin Barnett and Mental Health Minister Helen Morton.
“Never trust a dog to watch your food.”
Apart from a lot of talk about how things were going to improve, we learn the Mental Health Commission plans action in nine areas: good planning, services working together, a good home, getting help early, specific populations, justice, preventing suicide, maintaining a sustainable workforce and a high quality system.
“Don’t pull Dad’s finger when he tells you to.”
“When your dad is mad and asks you, ‘Do I look stupid?’ Don’t answer.” “Never tell your Mom her diet’s not working.” “When your Mom is mad at your dad, don’t let her brush your hair.” “Never let your three-year old brother in the same room as your school assignment.” “Felt-tip markers are not good to use as lipstick.” “Never try to baptize a cat.”
Are you wanting to sell your medical practice? As WA’s only specialised medical business broker we have sold many medical practices to qualified buyers on our books. Your business will be packaged and marketed to ensure you achieve the maximum price possible.
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An Old Favourite By the time John pulled into the little town, every hotel room was taken. “You’ve got to have a room somewhere.” he pleaded. “Or just a bed – I don’t care where.” “Well, I do have a double room with one occupant,” admitted the manager, “and he might be glad to split the cost. But to tell you the truth, he snores so loudly that people in adjoining rooms have complained in the past. I’m not sure it’d be worth it to you.” “No problem,” the tired traveller assured him. “I’ll take it.” The next morning John, came down to breakfast bright-eyed and bushy-tailed. “Never felt better.” he said The manager was impressed. “No problem with the other guy snoring, then?” ‘Nope. I shut him up in no time?” “How’d you manage that?” “He was already in bed, snoring away when I came in the room,” John said. “I went over, gave him a kiss on the cheek, said, ‘Goodnight, beautiful,’ and he sat up all night watching me.”
Best Wishes from WA’s Health Professionals christmas greetings supplement
Dr Kim Hames, Health Minister
Christmas can be a tough time for many people in WA and the medical profession is often the place they turn to in times of loneliness and need. There’s a real display of Christmas spirit when members of the medical profession take the time to talk to patients who may be on their own whilst others are celebrating. To those doctors, nurses and practitioners thank you. I would also like to thank everyone who is caring for those in need in WA hospitals during Christmas.
Dr Corinne Jones MBBS (UWA) FRACS FRCS
Specialist Breast, Thyroid and Parathyroid Surgeon
The Cardiologists and Staff of Western Cardiology wish all a very Merry Christmas and Happy New Year. Thanks to all referring doctors for their support during the year. We look forward to continuing quality care for your patients in the future. Dr Mark Hands Dr Eric Whitford Dr Stephen Gordon Dr Philip Cooke Dr Brendan McQuillan Dr Johan Janssen Dr Paul Stobie Dr Chris Finn
Dr Eric Yamen Dr Joe Hung Dr Michelle Ammerer Dr Luigi D’Orsogna Dr Darshan Kothari Dr Andre Kozlowski Dr Tim Gattorna
Wishing everyone a Merry Christmas and a special thank you to all referring doctors. A heart felt thanks for your patience and kindness following the tragic lung cancer deaths of my Mother in April 2011 and my Father in April 2009. Take time out over the festive season to share moments of food, joy, and song with those close to your heart.
I would love to spend a Christmas in Scotland with family, exploring my Scottish heritage. This would provide me with the proverbial White Christmas while discovering whether my origins reside in Robbie Burns or Bonnie Prince Charlie. Sipping on a single malt to wash down the Scottish sausage and Dr Peter Melvill-Smith haggis would be bliss, methinks! 26
I would like to extend my warmest greetings of the season and best wishes for the coming New Year to all. Thank you kindly for your continued support. I look forward to working with you in 2012. Wish best wishes Brad Potter. medicalforum
I’d love to see more Middle Eastern food on the Christmas table– it’s much more appropriate to our climate than heavy English fare. All those beautiful salads and spiced meats! In terms of Christmas tradition too, it’s much more Bethlehem than Birmingham which has to be a good thing. I’ll pass on the candied sheep’s eyes though!
Dr Phil McGeorge Dr Phil McGeorge and his team would like to thank you for your support in 2011. All the very best for a Merry Christmas and a Happy New Year.
CEOs Dr Shane Kelly and Peter Mott, together with caregivers of St John of God Hospital Subiaco and Murdoch wish all our referring doctors and medical practitioners a very safe, happy and prosperous Christmas and New Year.
Dr Sue Taylor
My most memorable ‘medical’ Christmas was at RPH as a surgical registrar in 1999. The whole world was quaking in its boots about the Y2K virus – computers, aeroplanes and stock markets were going to come crashing down around our ears. The ED was eerily quiet and the hospital put on a great meal. There was a real feeling of friendship between all of us who were stuck there – even some of the ‘big wigs’ came in to celebrate!
Dr Sanjay Nadkarni & Staff at Endovascular WA & Imaging Central Wishing all my colleagues and referring doctors a Merry Christmas & a Happy New Year. Thank you for your support in 2011 and I look forward to working with you in 2012.
Drs Phil McGeorge, Stuart Lockerbie, Kai Goh and Tze Lai wish all our referring doctors and colleagues an enjoyable Christmas and a Happy New Year. We look forward to working with you in 2012.
Elaine Pavlos together with the Executive team at Glengarry Private hospital would like to wish all our Specialists and referring Doctors a Safe and Merry Christmas and a Happy New Year Thank you for all your support in 2011, we look forward to working with you in 2012.
My most musical Christmas was few years ago when I conducted a People’s Messiah performance of Christmas carols at the Italian Consulate, three performances of Collegium Musicum Choir’s Christmas Tableau concert in UWA’s Winthrop Hall and then began choral rehearsals for the Messiah. I then flew to Sydney on Christmas Eve and saw a Salvation Army band playing carols in one of Sydney’s malls. Being involved in Christmas performances is an immeasurable joy it›s my gift to the community and their gift to me. To borrow a line from the Messiah – it’s a shared ‹goodwill to all men›.
Dr Margaret Pride – Musical Director, Collegium Dr Margaret Pride and the Collegium Symphonic Chorus – Handel’s Symphonic Chorus Messiah, Perth Concert Hall 17 December @8pm.
The Cardiologists and Staff from Heart Care Western Australia and Coastal Cardiology wish our referrers and their support staff a
Merry Christmas and Best Wishes for a Healthy and Prosperous 2012 We thank you for your support this year. We look forward to continuing high quality service to yourselves and your patients in 2012.
L to R: (rear) Dr Peter Thompson, Dr Randall Hendriks, Dr Mark Nidorf, Dr Alan Whelan (front): Dr Nigel Sinclair, Dr Donald Latchem, Dr Peter Purnell, Dr Isabel Tan, Dr Vincent Paul, Dr Xiao-Fang Xu, Dr Mark Ireland, Dr Bernard Hocking
MR I •
Merry C hristmas
X -R AY
& Happy New Year
U LTR AS OU N D •
Envision Medical Imaging would like to thank all our supporters for their dedication throughout 2011. We hope you and your family enjoy a wonderful and safe holiday season, and wish you all the very best for 2012. The Doctors and Team at Envision
178 Cambridge Street Wembley tel: 6382 3888 fax: 6382 3800 firstname.lastname@example.org w w w. e n v i s i o n m i . c o m . a u
Chlamydia could your patient have it? A service to WA doctors from
By Dr Donna Mak, Public Health Physician, Communicable Disease Control Directorate
The Department of Health’s new Chlamydia Campaign urges anyone who has had unsafe sex to get tested for chlamydia. The ‘get tested’ message raises community awareness about the asymptomatic nature of chlamydia and the importance of early detection and treatment. This means that patients are more likely to accept when you offer them a chlamydia test.
• People who are not using condoms every time they have sex and are not in a long-term monogamous relationship – ask about your patient’s relationship status. • Patients with a past history of STI – 1 in 5 patients with chlamydia get re-infected.
If your clinic is closed over Christmas, please inform your patients about free on-line chlamydia testing at: www.couldihaveit.com.au/onlineTesting.asp
These groups are at particular risk of chlamydia over the summer holiday season, when our patients may drink more alcohol than usual, meet new people and travel away from home: • Young people aged 16–29 years – especially school leavers. • Anyone who has had >1 sexual partner in the past 6 months – ask about new sexual partners during an overseas holiday or after a ‘big night out’.
For Doctors and Practice Nurses Want more information about chlamydia? See http://silverbook.health.wa.gov.au/ Want to earn CPD points for on-line learning about chlamydia? See http://sti.ecu.edu.au/
Prevention For Your Patients SKIN CANCER, MELANOMA, SUN SPOTS, ACCELERATED SKIN AGEING, SUNBURN...
The U-B-SAFE 1 monitors your exposure to the sun and plays a musical alarm when it’s time for you to find some shade.* Sun cream is not enough! Over 1 000 000 Australians, every year, see Doctors about sun damaged skin problems. The U-B-SAFE 1 is a personal UVB alarm monitor. All R&D done in W.A. We thank Dr Peter Randell and Dr Chris Quirk for their help over many years in the development of the U-B-Safe 1. It helps people get their regulated dose of vitamin D from the sun, without fear of sunburn or skin cancer. Dose alarm levels are set low and the U-B-Safe 1 even allows for unprotected skin. In addition, the U-B-Safe 1 accounts for different skin types and calculates UV exposure accumulatively across days.
*The U-B-SAFE 1 should not be used in a solarium, nor should it be relied upon by people with poor hearing.
• Water resistant • Remembers skin type • Made tough for kids and industry
• Solar powered • Continuous sun monitoring • Researched, designed, and manufactured in Australia
Purchase the U-B-Safe 1 directly from Healthtronics Sunsafe. Please phone us today with your inquiries or to obtain a free brochure.
P: +61 8 9470 5677 Healthtronics Sunsafe Pty Ltd 26/443 Albany Hwy, Victoria Park WA 6100 F: +61 8 9470 5589 E: email@example.com
ubsunsafe.com.au MedicalForum_HalfPgAd_v3.indd medicalforum
U-B-SAFE 1 has won: • The Australian Design Award • The ABC Inventors Award • The Peoples Choice Award 16/11/11 11:02:56 AM 33
General Practitioner Recruitment Service Rural Health West, the leading rural workforce agency in Western Australia, provides a fREE service offering:
P Professional expertise and advice P Case management approach P Orientation service P Access to Rural Health West programs
Do you want to experience the rural life? Is your practice looking for the right doctor?
Contact the Recruitment Team on: 34
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C L I N I C A L
U P D A T E
By Dr James Savundra, Plastic Surgeon, WA Plastic Surgery Centre, RPH, FH, PMH
Tips for hand trauma elayed treatment of hand injuries can often be very difficult and lead to worse outcomes. Here are some examples.
PIVET MEDICAL CENTRE Specialists in Reproductive Medicine & Gynaecological Services
Medical Director Dr John Yovich
Avulsion of a flexor digitorum profundus tendon typically happens when a grasped hand gets caught in a football jumper – often the ring finger. The finger is swollen, x-ray normal, and there is no obvious flexion at the distal interphalangeal joint, beyond perhaps a flicker of movement. If swelling prevents proper assessment, do not reassure, but review in a few days after swelling subsides. Otherwise, an uncertain patient without major discomfort will not seek medical advice, when it is early repair that generally leads to near normal function.
Missed flexor digitorum profundus laceration There is a laceration over the digit or palm, finger movement is painful, but they are still able to fully flex and extend the digits despite pain. Such a patient almost certainly has a flexor tendon injury: a 5% laceration will probably lead to good recovery eventually but if 95%, eventually this tendon will rupture. Knowing is important, so early exploration and perhaps primary repair will improve outcomes. This closed dislocation is common in sport, often reduced on the field by coaches and players alike. A postreduction x-ray is absolutely necessary, n The middle finger appears to have an insignificant laceration for which a true lateral view is critical. but the subtle abnormal posture Sometimes a joint is reported as of the finger compared to the “enlocated” without a true lateral view, others, suggests tendon injury. when it may not be. Repeating the x-rays a week after injury is good practice to rule out residual subluxation.
Closed hand fractures Hand injury with pain or swelling should have an x-ray of the painful part (e.g. when a single finger is injured, finger views are best). Fractures that require manipulation or surgical reduction are best treated in the first 1 to 2 weeks. If in doubt, most hand surgeons are happy to review (emailed) x-rays and advise on the need for treatment. The aim is to prevent late presentation of n The importance of two x-ray patients with hand fractures in need of views, with near normal AP and reduction, or malunited fractures.
Dr Santanu Baruah
In the earliest days of PIVET we described the first IVF Unit cases of heterotopic pregnancy – that is where pregnancy arose both in the uterus as well as the fallopian tube. Along with PIVET and KEMH colleagues we published our experience in the journal Obstet Gynaecol (64:855858, 1984). This described three cases, one presented in a shocked state requiring blood transfusion and subsequently aborted her twin gestation; the other two delivered healthy children following earlier salpingectomies.
With improved techniques, the world of infertility management has moved on to a more rational and controlled approach including an elective SET Policy (single embryo transfer) for 90% of cases. Vascular lump in left tubal stump Heterotopic pregnancies have once again become uncommon, however when they occur, they create a diagnostic challenge. We had a case recently where an additional ectopic gestation was diagnosed in a left tubal stump (previous bilateral salpingectomy) after D&C for a failed intrauterine pregnancy. The 46-year-old woman was allowed two embryos at transfer because of her complex past history of IVF failures. Fortunately, PIVET’s policy of routinely tracking all pregnancies through to successful outcome or bhCG <10 IU enabled an early diagnosis Extruding left tubal stump ectopic; in this case. oversewn after aspiration
obvious deformity on the lateral.
Patients with a closed mallet finger injury (extensor tendon avulsion/rupture) should have x-rays as any associated fracture may indicate treatment different to that for no fracture (which is splinting for up to 12 weeks, best via a hand therapy service). Refer mallet fingers with fractures to a hand surgeon.
Dr John Yovich
Prior to that, heterotopic pregnancies were rare, 1:30,000 but in the era of IVF and “enthusiastic” ovarian stimulation, rates as high as 5% were now recorded.
PIP joint dislocation
Mallet finger injury
NOW AT 2 LOCATIONS LEEDERVILLE & BUNBURY
For ALL appts/queries: T:9422 5400 F: 9382 4576 E: email@example.com W: www.pivet.com.au
C L I N I C A L
elective Internal Radiation Therapy (SIRT) using Yttrium-90 microspheres treats primary or secondary liver tumours not amenable to surgical resection or local ablation. Its advantage over these methods and external beam radiotherapy is that neither the number, location, distribution, nor size (beyond a minimum of ~1 mm) of liver tumours limits the scope for this therapy, so long as the patient has adequate liver reserve. An estimated one-third of patients with solid liver tumours die due to the local effects of metastases in the liver. Currently, SIRT is predominantly used late in the course of disease in patients with inoperable, chemo-refractory liver tumours. Phase III studies are in progress to assess the role of SIRT as first line therapy in colorectal liver metastases, in combination with chemotherapy and biological agents.
First line therapy that has evolved over the past decade for patients with unresectable liver metastases is generally systemic chemotherapy, often combined with biological agents (e.g. bevacizumab). These agents may control disease progression and prolong survival but when hepatic tumours become refractory to chemotherapy, SIRT may provide an alternative. When tumour is confined, or largely confined to the liver, liver-directed therapies (e.g. chemoembolisation for hepatocellular carcinoma; SIRT for primary and metastatic liver cancer) are particularly important in reducing the tumour burden, providing palliation of symptoms and increasing survival.
Mechanism of action
disease who have been heavily treated with chemotherapy may benefit from a “chemoholiday”, using SIRT for control of disease.
Patient selection criteria SIRT requires a detailed pre-treatment workup and review by a multidisciplinary team. However, in general terms, eligible patients have: • Disease primarily confined to the liver small volume extrahepatic disease (e.g. small lung nodules, lymph node metastases) do not preclude SIRT therapy but bulky extrahepatic metastases generally do. • Good ‘performance status’, with adequate bone marrow, renal and hepatic function.
Complications and precautions Most frequent is gastroduodenal ulceration due to irradiation of the gastric mucosa following reflux of spheres into the adjacent gastroduodenal circulation. Patients are routinely given a proton pump inhibitor post therapy and symptoms are usually self-limiting. Pain can occur during the administration of spheres as the microcirculation is embolised, resulting in capsular ischaemia – this generally lasts for a matter of hours.
Resin microspheres, impregnated with Yttrium-90, are distributed throughout the entire liver following injection into the hepatic artery but they lodge preferentially at tumour sites due to the greater arterial supply to tumours. Once delivered, the SIR-SpheresTM embolise the microcirculation and remain confined to the vascular rim of the tumours, where they emit a localised tumorcidal dose of beta-radiation over approximately two weeks. (Concurrent chemotherapy may be given to augment the radiotherapeutic effect.) Meticulous pre-treatment planning is required to ensure that the SIR-SpheresTM are appropriately targeted to the liver tumours, and exposure of normal liver tissue is within safe and tolerable doses for each patient. Diagnostic angiography, MAA nuclear scanning, and AngioCT are performed as part of the preprocedural workup to allow for therapy planning and dosimetry. The SIR-Spheres are then delivered into the hepatic artery via a transfemoral catheter, under local anaesthesia. SIRT should be part of a multidisciplinary approach in the treatment of liver tumours. Some patients considered unresectable can be downstaged to resectable disease following SIRT, and others with liver predominant
If patients with very extensive tumour infiltration and/or limited hepatic reserve are treated, liver failure may occur, but this should be avoided by careful patient selection.
The evidence base Metastatic colorectal cancer (mCRC)
Dr Joe Cardaci, Nuclear Medicine Physician, Hollywood Private Hospital
Should SIRT be first line treatment when colorectal liver metastases are diagnosed? This question is being addressed by two Phase III randomised controlled trials currently recruiting patients: the SIRFLOX study (Australia, Europe and USA) and the FOXFIRE study (UK) to evaluate prospectively the relative efficacy and safety of standard regimens of FOLFOX (+/- bevacizumab) with and without SIRT as a first-line treatment. Hepatocellular carcinoma (HCC)
Median survivals have varied widely (7-27 months) between studies, depending on performance status, extent of disease, degree of hepatic functional reserve, and presence or absence of cirrhosis. SIRT appears particularly promising for the subset of patients with intermediate stage HCC who are considered poor candidates for, or have failed prior chemoembolisation (median survival ~15 months). Overall survival with SIRT also compares favourably with sorafenib in advanced stage disease. Validation of this finding in a headto-head comparison of SIR-SpheresTM and sorafenib in a large Phase III study (SIRveNIB) is now ongoing. Another multicenter study (SORAMIC) will evaluate whether overall survival can be improved by combining sorafenib with either SIRT or ablation. Other tumours SIRT has been applied to a variety of other primary and secondary liver tumours. Whilst there have been encouraging retrospective publications of experience with these tumour types (especially neuroendocrine tumours), the evidence base in these cancers is less developed. n
In chemorefractory mCRC three prospectively collated datasets from Belgium, Germany and Italy have shown that SIRT prolongs local control of the disease in the liver (time to progression or progression-free survival) with a consequent prolongation in n Colorectal liver metastases: response 15 months after treatment with overall survival (8.3–12.6 SIR-Spheres + 5FU/LV. months) compared with best supportive care (3.5–4.5 months). In a Phase II study, SIR-SpheresTM added to a 5FU/LV regimen was associated with significant increases in response rate (72.7% confirmed response vs. 0%; p<0.001), time to progression (18.6 vs. 3.6 months; p<0.0005) and median overall survival (29.4 vs. 12.8 months; p=0.02) compared with The author thanks Rae Hobbs for assistance in article preparation. This systemic chemotherapy clinical update is supported by Hollywood Private Hospital. alone. 37
U P D A T E
Treatment of liver tumours with Selective Internal Radiation Therapy
Incidental thyroid nodules
C L I N I C
U P D A T E
(1) Benign. There is a <5% chance of malignancy. Most would recommend a repeat ultrasound in 6-12 months looking for nodule growth (>20% increase in 2+ dimensions) prompting another biopsy. Follow up from here onwards is contentious and can be by palpation or serial ultrasound.
By Dr Brett Sillars, Endocrinologist
hyroid nodules are a common incidental finding when performing neck imaging for another indication. The prevalence of thyroid nodules increases with advancing age and are found in over 50% of individuals at autopsy. Around 5% of thyroid nodules prove to be malignant. It is therefore not surprising that the incidence of thyroid cancer is rising due to the increased detection of small papillary thyroid cancers. Despite this increase, mortality from thyroid cancer remains similar, reflecting the rather indolent nature of these small cancers. The investigation and management of thyroid nodules can be challenging.
Initial investigation Investigation of a thyroid nodule(s) involves: (1) TSH; (2) Dedicated thyroid ultrasound: to confirm nodule, imaging characteristics, size, detect other nodules and lymphadenopathy; (3) Thyroid nuclear medicine scan. If the TSH is suppressed (<0.1 mU/L), thyroid scintigraphy should be performed as the nodule may be hyperfunctioning or “hot”. These have a low malignant potential and biopsy is rarely indicated. Consider an endocrinology referral for review and potential I131 therapy.
When to do a fine needle aspiration The decision to FNA is dependent on patient history (family history of thyroid cancer, previous neck irradiation, voice change), ultrasound characteristics and nodule size. High risk features on ultrasound include microcalcifications, hypoechogenicity, internal
vascularity, tall > wide, irregular margins and lymphadenopathy. Biopsy should be considered in most nodules greater than 1-1.5cm, however smaller nodules (>5mm) that display high risk ultrasound features should be considered for biopsy. Biopsy is not indicated for entirely cystic nodules. Fine needle aspiration is a very safe procedure and is generally performed under ultrasound guidance to improve diagnostic yield. Deciding which nodules to FNA in a multinodular thyroid can be difficult. Cancer within a multinodular thyroid is present in the largest nodule only 50% of the time. Generally speaking, those nodules with high risk ultrasound features should be preferentially biopsied.
Cytology results and follow-up Cytology reports from an FNA should fall within the following categories to guide further management.
(2) Malignant papillary cancer or (3) Suspicious for papillary cancer. Refer to thyroid surgeon. 4) Indeterminate (Atypical/Hürthle cell/ Follicular neoplasm). There is a 25% overall risk of malignancy within this group. Refer to thyroid surgeon. 5) Inadequate. Insufficient material to make a diagnosis. Repeat FNA is advised. Recommended resource: http://www. thyroidguidelines.org/revised/taskforce
n Figure 1: Ultrasound of incidentally found hypo-
echoic thyroid nodules. The smaller (marked) nodule with ill-defined margins had an indeterminate FNA and was subsequently diagnosed as papillary thyroid cancer. The larger nodule was benign.
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By Dr Anne Brady, Rehabilitation Physician, Mercy Hospital
Rehabilitation: “What Happens Next” R
ehabilitation Medicine is that part of the science of medicine involved with the prevention and reduction of functional loss, activity limitation and participation restriction arising from impairments. It involves the management of disability in physical, psychosocial and vocational dimensions, and improvement of function. Essentially, rehabilitation is “what happens next” after a person suffers a disabling injury or illness. Rehabilitation does not save lives, but makes the saved life worth living.
Knowledge and techniques in Rehabilitation Medicine have developed to such a degree that a comprehensive understanding and application of this specialty by every medical practitioner cannot be expected. It requires a skilled medical assessment at the onset of disability and at appropriate intervals thereafter and is aimed at the restoration of the disabled person to the fullest level of physical, mental, social and vocational functioning of which they are capable. This is achieved by the coordination of the disabled person’s interests and abilities with medical, social, educational, vocational, leisure and recreational resources. Rehabilitation Medicine was recognised as a Principal Specialty by the National Specialist Qualification Advisory Committee of the Health Insurance Commission in Australia in 1976. Rehabilitation Medicine physicians undergo advanced training through the Australasian Faculty of Rehabilitation
Medicine, a Faculty of the Royal Australian College of Physicians and hold the specialist qualification FAFRM (Fellow of the Australasian Faculty of Rehabilitation Medicine). The Specialist Rehabilitation Service at Mercy Hospital Mount Lawley is a 20 bed multidisciplinary rehabilitation unit that opened in December 2010. It is the first Rehabilitation Unit run by specialist Rehabilitation Medicine Physicians in Western Australia and therefore meets the Federal Government’s minimum requirements for Private Hospital-Based Rehabilitation Services for receipt of full Private Health Insurance benefits. There are currently two Rehabilitation Medicine Physicians working at the Specialist Rehabilitation Service, Dr Ian Wilson and Dr Anne Brady who are both
Fellows of the Australasian Faculty of Rehabilitation Medicine. They work as part of a multidisciplinary team, which includes physiotherapists, occupational therapists, dietitians, pastoral care and dedicated rehabilitation nurses. The rehabilitation unit has a gymnasium, patient dining room and access to a hydrotherapy pool. Rehabilitation is a process that occurs 24 hours-a-day throughout the inpatient stay in the Specialist Rehabilitation Service. The process begins prior to admission with the Referral Coordinator, Gaynor Taylor who meets with the patient and their family to assess suitability for a rehabilitation programme. On admission, patients are further assessed by each member of the team and an individualised programme is developed. Therapy occurs during allocated therapy times and also across a range of activities including group exercise classes, communal dining, walking programmes and promotion of independence with activities of daily living. Patients and their families are actively encouraged to participate in the process, including goal setting and discharge planning. Since opening in December 2010, the Specialist Rehabilitation Service has successfully rehabilitated increasing numbers of patients with a variety of conditions including fractures, joint replacements and reconditioning following major surgery and other medical conditions. Outcome measures are collected and benchmarked against 82 Private Hospital Rehabilitation units across Australia by the Australian Rehabilitation Outcomes Centre (AROC). The AROC report, covering the first 7 months of the Specialist Rehabilitation Service operation shows we are already meeting benchmark targets for length of stay, FIM (Functional Independence measure) and discharge destination for patients with fractured neck of femur, joint replacements and reconditioning following medical and surgical illness. The Specialist Rehabilitation Service accepts patient referrals from all hospitals in Western Australia, as well as community referrals from specialists and general practitioners. In the future the Specialist Rehabilitation Service plans to expand to meet the rehabilitation needs of a wider range of patients. This will include an Ambulatory Care Service to provide day rehabilitation and expanded outpatient services. n
Mercy Hospital Mount Lawley, Thirlmere Road, Mount Lawley 6050 • Tel 08 9370 9222 • Fax 08 9370 9488 • Email: email@example.com medicalforum
Annual PHCRED Research Conference
n (L to R) A/Prof Diane Arnold-Reed, Dr Robert Moorhead, Prof Max Bulsara, Marco de Assis
n (L to R) Prof David Preen (Director of the Centre for Health Services Research,
UWA), Dr Denise Findlay (Dir of Education at WAGPET), and Prof Alistair Vickery
round 50 attended this year’s WA Primary Health Care Research Evaluation & Development (PHCRED) research conference, representing general practitioners, researchers (in Primary Health), medical students, dieticians, podiatrists, exercise physiologists, nurse practitioner, and policy makers. Around half were engaged in academic research, with the PHCRED event aimed to increase the pool of researchers in primary health care.
n (L to R) Prof Jon Emery (Winthrop Professor of General Practice, UWA), Prof Sandra Thompson (Director Combined Universities Centre for Rural Health, Geraldton), Dr Hilary Fine, Dr Tim Leahy, Prof Tom Brett (General Practice and Primary Health Care Research Unit, Notre Dame Uni).
Dr Simon Turner MBBS, FRANZCOG, FRCOG
Dr Roger Perkins MBBS, BSc, DA (UK), MRCOG, FRANZCOG
Dr Lincoln Br ett BMedsC, BSc (Hon), MBBS, FRANZCOG
Dr Julia Barton MBBS, FRANZCOG
Dr Bill Patton MBBch, BAO, DCG, DRCOG, MRCOG, MRCPI, FACGO,
Dr Zhuoming Ch u MBBS, PhD, FRANZCOG
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WAGPET was major sponsor. Post conference, people are back hard at work. So much so for Prof Tom Brett – “up to my eyes with exams, work and research” – that he only had time to refer us to his article The Inverse Care Law - is primary care research funding headed this way? in the October edition of Australian Family Physician. There’s one good reason to open an edition. And a lot is happening in rural medicine, with much to research as efforts are directed towards increasing a depleted rural workforce. We asked Prof Sandra Thompson, who looks after the rural clinical school in Geraldton, what she thought should be a priority for researchers, given the limited resources on the ground and the community’s desire to make a difference in people’s lives. “That’s an interesting question. Firstly, lots of things that make a difference to people’s lives (and health) occur outside the health system, so I think reducing income disparities, social justice, removing discrimination in all its forms and improving education are all very important,” she said. “In terms of health, I would like to see investments occurring to strengthen primary care and see better integration of health service delivery between primary and hospital and specialist care.” “Instead of great ‘new’ initiatives, what we need are sustained programs, that is longterm funding not short initiatives, which are underpinned by quality improvement approaches using the best available evidence.” “For all of these it is important is that we learn to work together better and more effectively with the focus on health equity as well as the care of individuals,” Sandra added. n
On the Grapevine By Dr Craig Drummond
My first visit to WA’s Frankland River region remains vivid in my memory. It was one of those infamous post-exam celebrations in 1975. I was overwhelmed by its isolation (appropriate for the occasion), and its pristine pollution-free environment. The local wine industry was then very much in its infancy. Over the years ahead, as my wine experience grew, it became my favourite WA wine sub-region. In 1956, visiting Californian viticulturist Dr Harold Olmo realised the potential of the area and its “Bordeaux like” characteristics of cool nights and a marked diurnal temperature variation (which leads to high acidity in grapes for the level of ripeness), moderately cool summers, a frost-free environment, and soils of moderate fertility. Of those who have seized upon this, Frankland Estate haas become one of the very notable performers. In 1988, Barrie Smith and Judi Cullam, inspired by time spent working in Bordeaux during some vintages, began planting vines on their Frankland River sheep grazing property, a venture that has grown to over 34 hectares of vines. The operation was lifted
to another level in 1993 with the construction of a 300 tonne winery facility. Since then, they have gone from strength to strength. These strengths include a commitment to the environment (organic certification in 2009) and keeping the business entirely family owned and controlled, with son Hunter and daughter Elizabeth both highly involved. I have also been impressed with Frankland Estate’s commitment to the wine industry by sponsoring International Riesling Seminars, and by offering scholarships for overseas travel to promising young people in the wine industry. There has been a real commitment to the Riesling variety with several released each vintage to reflect the different soils on which they were grown. I tasted the 2011 Isolation Ridge Riesling. It showed the typical regional lemon citrus characters, with a spicy nose and river pebble minerality on the palate. The vibrant fresh fruit shows nice purity, with a linear focus and a racy clean acid finish. Having just been released, I feel a couple of months in bottle are needed to soften the edges on this wine, which will gain complexity and drink well up to 10 years. The 2010 Isolation Ridge Chardonnay is also very good. It is rich, ripe and complex with aromas of stone fruits and nice nutty oak. The flavours are of grapefruit and peach with a textural mealyness. A background acidity and minerality may give this wine a longer life than
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your average Aussie Chardonnay – up to 6 or 7 years. Three reds were tasted. The 2009 Isolation Ridge Cabernet Sauvignon was initially restrained, but then opened up with aromas of dark fruits and herbs leading to concentrated flavours of sweet red currants and blackberry. The tannins are fine grained and ‘punchy’, the oak integral. Overall, the wine is well balanced and will give pleasure for 8-10 years. The 2009 Isolation Ridge Shiraz is a very full bodied style, dense and dark, with savoury and cedary aromas, intense flavours of black fruits, wild herbs and cinnamon spice, with a youthful briary edge which will soften quickly. A wine that will optimise in 2 to 3 years, but Image: Rob Frith worthy of long cellaring thereafter. Each year Frankland Estate pay tribute to Harold Olmo by releasing a ‘Right Bank Bordeaux’ style appropriately called Olmo’s Reward. The 2009 Olmo’s Reward consists of 62% Cabernet Franc/17% Merlot/16% Malbec/5% Cab Sav. It shows the fragrance of Cab Franc on the nose, with violets and sweet fruit. The palate is wonderfully textured, supple, velvety, showing delicate flavours of dark plum and clove and indeed is very easy to drink. Again, a long term cellaring wine. The tasted wines are worthy of space in our cellars. n Ed. For more information or on-line purchase, see www.franklandestate.com.au
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Mission Australia’s Christmas Lunch in the Park By Peter McClelland
there is such a thing a as free lunch
… inside a large, white marquee in Wellington Square Park on Christmas day. There are bikies with babies, elderly people all on their own and migrant families spending their first day in Perth. Mission Australia dishes up Christmas lunch, entertainment and gifts for 2000 people inside the big, white marquee. And is there a doctor in the marquee? Yes, more than one actually! Drs Jane Gardner and Tim Isaacs, as roving medical officers, both applaud the charitable event and urge their medical colleagues to become involved. They are just two of around 500 volunteers who share their festive lunch with the people of Perth. And it is not just the homeless and destitute turning up on Mission Australia’s special day of the year. There are the recently widowed, the migrant families with children and the just plain lonely.
Voices in the marquee Sandy Wilson is the volunteer coordinator for Mission Australia and the only paid staff member involved in the Christmas lunch. “This is a WA only event for Mission Australia and it started in the mid-1970s for homeless people. It’s much more of a community event now and the diversity of the people is just incredible. It’s wonderful how it brings everyone together - we get people from as far afield as Albany and Port Hedland,” said Sandy.
This year will be the 36th Lunch in the Park and that means another long but enjoyable Christmas day for Sandy. “The lunch finishes about 2 o’clock but by the time we’re all packed up it’ll be around 6.30pm.” Frank Parker is Dr Jane Gardner’s brother-inlaw and has notched up 10 years as a volunteer coordinator. “There’s always magic in the air. You get a real sense of how fragile society is but you can also see its strengths on a day like this. You’re reminded just how easy it is to tumble from high places and end up on the street. Everyone here has a story and most people are doing the best they can. To bring everyone together at such a festive time is a wonderful thing,” he said. “We often have people sitting in Wellington
Square who are too shy to come in so we take the food out to them. I remember seeing a mother with tears streaming down her cheeks – she and her two daughters were from Yugoslavia. She was a medical n Mr Frank Parker technician there and, of course, her qualifications aren’t recognised here so she was cleaning hotel rooms for ten dollars an hour. They couldn’t afford Christmas dinner so we took it out to them and they were so grateful.” Frank also recalls a man who needed some help to get home after lunch. “He’d just come out of hospital after an operation and had been
living rough on the streets. We always have a pile of free taxi vouchers to give away so we made sure he was okay for a ride home. He was a Vietnam veteran who’d obviously fallen on pretty tough times – that’s one thing about lunch in the park, it’s always a great leveller.”
Doctors’ voices Jane Gardner’s medical career has prepared her well for this event and over the last decade or so she has become a familiar face on Mission Australia’s one big day of the year. “I’ve worked with a lot n Jane Gardner of minority groups and treated people who have serious social issues and personal dysfunction. I can see tension building in these sorts of situations – it might be a young mum struggling with her kids on a very hot day or someone who’s been in a fight the night before and needs some treatment from the emergency department at RPH,” said Jane. Jane grew up in Kenya before moving to Perth and graduated in medicine from UWA. She worked overseas in a children’s hospital in Canada and in child health in the Northern Territory before returning in the mid-1980s to work in the ED at PMH. It was there she realised that the abuse of children was a serious and under-reported issue. “I decided to train as a counsellor - everything from domestic violence, sexual abuse of children and drug and alcohol problems. I’m pretty much a full-time farmer now and living just outside Margaret River, but I still do some trauma counselling. My professional background
Lunch in the Park has been wonderful for me. It’s one of the few places where I can really be myself Dr Jane Gardner has certainly helped at the Christmas lunch. I’m pretty at ease in those situations and we do get people who are coming off drugs or affected by alcohol. Most of the time my role is making everyone feel welcome and we do have a few other doctors who volunteer as table hosts – they help to distribute the food and make sure everyone is relaxed and having a good time.”
works in private practice and at the Lion’s Eye Institute has a slightly different tale to tell. “I’ve only done lunch in the park once and that was in 2010, so I feel a bit of a fraud talking about it. It was a very difficult year with a marriage breakdown and I didn’t have my children with me on Christmas day. I don’t come from Perth and I found myself on my own which wasn’t much cause for celebration. So I decided I’d like to give something back to other people,” said Tim.
Jane also says there is an important medical aspect for doctors or paramedics involved. “On the day I am a bit of a roving medical officer. Last year I spotted a child who looked quite unwell, we sent her off to PMH and it turned out she had pneumonia. We certainly don’t offer a full GP service, but we do have St. John’s staff and an ambulance here if we need it. That’s good too, because it frees me up to walk around and talk with some of the Aboriginal people sitting in the park and anyone else who’s a bit shy about coming into the marquee.” For Jane, it is a reminder of the essential humanity of Christmas. “I love being part of this because so often there’s a great deal of social stigma attached to some of these people - even in a hospital environment. There’s none of that at the lunch… it’s just sharing with others and a wonderful reminder about being human.” In the early days, Jane’s family had to adapt “When my children were younger, they’d moan and groan a bit – oh no, mum’s going away again. But they got used to it and we’d always be together for an evening Christmas meal. The lunch in the park has been wonderful for me. It’s one of the few places where I can really be myself.” Perth ophthalmologist Dr Tim Isaacs who
Last year I didn’t have my children with me on Christmas day. So I decided I’d give something back to other people.
Dr Tim Isaacs
Due to the overwhelming number of volunteers, Tim almost didn’t get that opportunity. “They’re always swamped by offers of help. When I rang them I wasn’t planning to be there as a doctor, just helping to hand out lunches or wash up. They said they had more than enough people already, but when I told them I was a doctor they said, ‘Yes please!’ Not that there was much need for any medical intervention - my greatest contribution was digging a chunk of glass out of an Aboriginal person’s foot.” Tim is impressed with the work of the paramedics from St. John’s who are all too familiar with tackling large public gatherings, to the point they could teach the doctors a thing or two. He sees in Jane Gardner a message for all medicos. “Jane’s a medical stalwart at the lunch. You can tell that she really loves doing it and she’s so good with the people who come along. She’s an institution at the Mission Australia lunch. I found listening to the choir quite moving and I’d urge any doctors who might be considering it to give up a couple of hours and see how less fortunate people in our community celebrate Christmas,” Tim said.
Volunteer contact: Sandra Wilson, Mission Australia - 9225 0413 Location: Wellington Square Park in East Perth Marquee: 30x80m. It takes four days to set up and is ready on the 23rd December. 2000 meals: ham, turkey, salads, bread rolls and desserts. Volunteers: 500 on Christmas day. Shuttle Bus: Perth and Claisebrook train stations. Information: www.missionpromotion.com/clip and www.missionaustralia.com.au Highlights: 4.5 metre Tree of Hope with balloons, baubles and Christmas cards. medicalforum
One final anecdote from Jane Gardner epitomises her feelings about Mission Australia’s special day. “I remember seeing a very large man who looked a bit like a bikie. He was covered in tattoos and holding his new-born baby daughter who was fast asleep. It was really hot and we were a bit concerned so when she woke he gently carried her over and showed us that she was okay. On a Christmas day with everyone sharing lunch together things like that are so lovely.” n
Win a double pass (A Res) for opening night, with program/CD voucher. This West Australian Opera in collaboration with ThinIce and Perth International Arts Festival presents Richard Strauss’ ELEKTRA, directed by Matthew Lutton and conducted by Richard Mills. One of Western civilisation’s greatest stories of fanatical love and revenge, the first collaboration between Strauss and Hugo von Hofmannsthal, one of the most important composer-librettist partnerships in operatic history. First performed in Dresden in 1909. Startling visual intensity. WASO with CAST: Elektra - Eva Johansson, Chrysothemis - Orla Boylan, Klytämnestra - Elizabeth Campbell, Orest - Daniel Sumegi, Aegisth - Richard Greager. His Majesty’s Theatre, 7.30pm, February 8, 11, 14
Cinema: The Descendants
Win a double pass. A sometimes humorous, sometimes poignant journey for Matt King (George Clooney), an indifferent husband and father of two teenage girls, who is forced to re-examine his past when his wife suffers a boating accident off Waikiki. The event leads to a rapprochement with his daughters while Matt wrestles with a decision to sell the family’s land handed down from Hawaiian royalty. Also stars Beau Bridges, Judy Greer, Shailene Woodley and Robert Forster. In Cinemas January 12
Travel at its Best
Cinema: A Few Best Men
Win a double pass. Directed by Stephan Elliott (Priscilla Queen of the Desert) and starring Xavier Samuel (Twilight), Kris Marshall (Death At A Funeral), Kevin Bishop, and Olivia Newton-John as the mother of the bride. When English lad David announces he is marrying an Australian, his hapless mates give a whole new meaning to ‘for better or worse’! The chaosfilled wedding day tests their new marriage and challenges David’s relationships with his three best men. A hilarious culture clash. In Cinemas January 26
Cinema: The Grey
Win a double pass. Liam Neeson in the suspenseful man versus nature thriller. A group of oil-rig workers find themselves stranded on the freezing Alaskan tundra after their plane home crashes. Their efforts to survive and find a way home to their loved ones are threatened when the men come under attack by a pack of vicious, aggressive wolves. Director Carnahan looks set to return to the gritty realism of his breakout hit NARC. In Cinemas February 16
Win a family pass. About a family of “little” people beneath floorboards of a sprawling mansion within a magical overgrown garden in the suburbs of Tokyo. Tiny 14-year-old Arrietty lives with he parents in a house occupied by two old ladies unaware of their miniature tenants. They live by “borrowing” everything, from water and food to cooking utensils and treats. A 12-year-old boy moves into the mansion and discovers the adventurous Arrietty and a friendship begins to blossom... In cinemas 12 January 50
Dr Farhat Mahmood, Population Health Butcher’s shop in Islamabad. The carcasses were hanging for sale, open to flies plus the flying dirt from the wind and traffic, and the heat. ‘How safe was this meat for consumption?’ I asked the butcher. He said no-one had ever complained they had been sick from consuming his product. What more could I say?
Photography Dr Tony Tropiano, GP Just after sunset, burning off in spring. This Donnybrook shot was taken on the way home from a Pemberton photo weekend run by two pros, Tony Hewitt and Denis Glennon.
he dollar is sky-high and budget airlines are cutting fares to the bone – Asia and Europe beckon. We all know that Christmas is a fantastic time to get away from it all, an exotic destination with a Canon or Pentax in hand? You will not be the first. We asked Medical Forum’s photography fraternity to send in their most amazing photographs with an inspiring caption for the theme Travel at Its Best. Here’s the result – enjoy!
Charles Armstrong, O&G Swaziland stopover. I took a local bus while in Swaziland many years
Robert Davies, Urologist Never look back unless you are planning to go that way (Henry David Thoreau 1817-1862).
ago. I’ve always liked this picture –perhaps technically not brilliant as it was taken with a pretty basic camera – for its earthy naturalness, showing the local women selling fruit and produce at the bus stop.
It was 2009, in rural Vietnam with the Australian Urologists in Vietnam surgical aid project. After operating solidly for four days in Sa Dec we ventured down to the markets early one morning. Crossing a road, it was the child on the motorbike looking backwards that caught my attention.
Clive Addison, retired Sigma WA Manager. “el ultimo beso” stretches the imagination. Buenos
Aires abounds with quaint quirky cafes and restaurants. French themed, the owners of this one have collected thousands of pieces of non-matching china. Everyone is served with different pieces. They become conversation pieces. And try the ladies loos! A claw footed bath is filled with rose water and rose petals.
Charley Nadin, Bunbury GP anaesthetist France and a steam engine. Traveling in an open coach
immediately behind the steam engine was sublime. The mixture of oil and coal with steam evokes childhood memories of riding on the footplate of a small Thomas the Tank Engine in Cornwall. This was taken on the St Jean Du Gard line, a deep ravine in the heart of the Cevenne, with nearest large city Arles. St Jean du Gard hosted Robert Louis Stevenson who rode that area on a donkey.