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♦ Chlamydia testing North Coast Health Matters

♦ NORDOCS is a hit

♦ Govt gets us moving Spring 2018


in this issue Editorial - the Rite of Spring Health Minister retains portfolio A new driver for better primary care Many doctors in the house I'm losing my patients To market, to market Getting us moving Exercise and sports are good therapy New Clinical Guidelines for the treatment of Opioid Dependence in NSW Cricket charity bats for kids with disabilities CPAP Traps Medicine has become acutely chronic Saving paper with secure medical communication Novel prescriptions  The Physicians Exam: Putting Lismore on the national stage Paediatric bowel training Warmest welcome for UOW long stay medical students Doctors join push to recognise Indigenous rights Book Reviews Splendid response to chlamydia testing The rise of antibiotic resistance Data Transfer ReFormed The rise of antibiotic resistance Advanced Care planning and My Health Record Why I love being a HANDI-man Diabetes pen and hep C drug listed on PBS

3 4 5 6 8 9 10 11 12 13 14 15 17 18 20 21 22 23 24 27 28 29 29 30 31 31

Cover photo and pictures on page 27 by Cary Leabeater Thousands of mostly-young patrons attended the Splendour in the Grass music festival at North Byron Parklands in July. A significant number - how many is yet to be revealed, although it could be as high as five per cent - carried something invisible to security staff and fellow partygoers: the highly infectious disease chlamydia. In an innovative project, a NSW Health team took urine tests from more than 1,000 people... read the story on page 27.

editorial team Dr David Guest Clinical Editor

info@nrgpn.org.au

Dr Andrew Binns GP Contributor

info@nrgpn.org.au

Robin Osborne Editor

editor@nrgpn.org.au

Angela Bettess Graphic Design

angela@whiteduckdesign.com.au

gpspeak on the web:

www.gpspeak.org.au

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Editorial - the Rite of Spring by Dr David Guest, Clinical Editor Igor Stravinsky’s Rite of Spring, was first performed in Paris at the Théâtre des Champs-Élysées on 29 May 1913. It broke with many of the established musical traditions and challenged the perceptions of the traditional supporters of the ballet while being enthusiastically embraced by the avant-garde. During the opening night’s performance arguments developed between the two groups. Forty members of the audience were ejected in the fracas and one member of the orchestra reported, “Everything available was tossed in our direction, but we continued to play on”. The advent of the Spring season sees a new beginning for the North Coast Primary Health Network. In August Julie Sturgess took over the role of Chief Executive from interim CE, Sharyn White, following the departure of Dr Vahid Saberi. Julie has had extensive experience in corporate roles in eHealth, Aboriginal health services and community care. Prior to to joining the NCPHN she was the CE of Northern Australia Primary Health Limited (NAPHL) that delivered primary health care to the people of northern Queensland through contractual arrangements with the Northern Queensland PHN. On page 5 Robin Osborne reports on the challenges Julie faces as she takes the helm at the NCPHN. Springtime also sees new arrangements for the funding of activities previously provided directly by PHNs. NAPHL is a leader in commissioning and procurement, the mechanism favoured by the federal government for delivering human services. Under the arrangements that commenced on 1 July, 2018 the NCPHN will now oversee the awarding of contracts for health services to third parties through a competitive tendering process. Julie’s experience in her previous roles will be invaluable in this new environment. Tendering is not without its critics, however, and general practices will already have had some secondhand experience of this through their patients’ involvement with aged care services and now the NDIS. New arrangements take some time to bed down and there is the risk of both under and over provision of services, often with an associated mismatch in funding. On page 9 we review the Department’s goals for the

system and consider some of the criticisms levelled at commissioning. We have given considerable coverage to the Northern Rivers Doctors group (Nordocs) that held its inaugural meeting on 30 June at UCRH. More than a dozen speakers, GPs and specialists, presented on issues they felt were of importance to improving health care on the North Coast. The format of the day was that of an “Unconference” where the attendees are the speakers and the forum is open to any who wish to present. The day was considered a success by the attendees, and future gatherings are planned.

The risk to privacy from the MHR is greatest for the young and healthy, while the greatest potential is for those with multiple complex medical conditions. On page 30 Associate Professor Bronwyn Hemsley writes of her research into using the MHR as a repository for legally binding Advance Health Directives and the legal and clinical implications.

The Unconference talks were recorded and are being progressively released, along with the accompanying slides and articles on the Nordocs Facebook page and in GPSpeak. The intention is to make the material more widely available, particularly to those who could not get along and to those who have an interest in a particular topic.

Our cover story describes the excellent work being done by the local chapters of PASH and HARP - not widely known acronyms - in conjunction with the NSW STI program unit in detecting asymptomatic chlamydia in young people (page 27). It’s a tribute to their innovation that STI testing can have a ‘fun’ element.

The meeting was financed with funding from the NCPHN, the Northern NSW Local Health District and the Northern Rivers General Practitioner Network and administrative support was provided by North Coast GP Training. The venue was made available at no charge by UCRH and the day was made possible by the generous volunteer work of the organising committee.

Recent political upheavals and a Federal election due within the next nine months will almost certainly bring about further changes to the Australian healthcare system. As in other countries politics has become more polarised and policy will almost certainly shift from the middle ground after the next election.

One of the new commissioning tasks for the NCPHN will be to fund workforce development. In late August it put out a tender for expressions of interest in developing and supporting professional development, intra-professional networking opportunities, the establishment and maintenance of local clinical societies and consulting with organisers of other relevant educational activities. It is hoped that the Nordocs will qualify for support for its future activities under these new arrangements.

It takes several years for a new government to implement changes to health policy and it is largely unknown what the Australian Labor Party thinks of the current arrangements regarding primary health care funding. Inexplicably, the direct or indirect provision of health services is unlikely ever to be an election issue and as such we will have to await the election’s outcome. Both parties have promised to restore partial indexation of Medicare rebates but given past experience the profession would be wise to consider these non-core promises.

The My Health Record (MHR) threemonth opt out period commenced on 16 July 2018. The change in format has been roundly criticised by privacy advocates and received widespread media coverage. As a result the government decided to extend the opt out period by one month and change the legislation to require other government agencies to get a court order to access data held in the record.

In any event Spring is upon us, mercifully with some early rain, at least in coastal areas.. It is a time for a new beginning, a time to try new things. The Rite of Spring influenced musical composition throughout the 20th century and challenged the old order. It is still remembered for its experimentation “in tonality, metre, rhythm, stress and dissonance”. So it will go with the health system as well.

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Health Minister retains portfolio Amidst the recent political disruptions, Health Minister Greg Hunt (see photo) weighed in behind prime ministerial challenger Peter Dutton, whom a doctors’ poll once described as the worst health minister in 35 years, yet retained his portfolio in the new Coalition cabinet. Mr Hunt’s reappointment was announced by incoming PM Scott Morrison on 26 August, following the Liberal Party’s overthrow of leader Malcolm Turnbull. Aboriginal man Ken Wyatt AM continues as Minister for Senior Australians and Aged Care, and Minister for Indigenous Health. Medicare co-payments were the controversial topic in the portfolio until the emergence of the MyHealth Record, which attracted widespread criticism on the basis that patient records might be accessed by unapproved parties, including police. Following crisis talks with the AMA Mr Hunt confirmed that the My Health Record Act would be redrafted to ensure "no record can be released to police or government agencies, for any purpose, without a court order."

Another former Health Minister is Tony Abbott, widely seen as driving the leadership push against Mr Turnbull, who was also criticized for his performance in the portfolio. A later one was Sussan Ley, appointed by PM Abbott and retained by Turnbull until January 2017 when she resigned in the midst of an investigation into her travel expenses and entitlements. She has now returned as Assistant Minister for Regional Development and Territories. The Health ministry is often portrayed as a poisoned chalice due to rising health care costs resulting from Australia’s ageing population and mounting chronic disease incidence.


A new driver for better primary care by Robin Osborne

NSW’s seven least affordable LGAs are on the North Coast. These include Ballina, Byron Bay and Tweed.

It’s only day 12 in the CEO chair at one of Australia's most important health coordinating bodies and Julie Sturgess is understandably cautious to predict how the North Coast Primary Health Network will evolve under her stewardship.

Perhaps drawing on her previous life with Telstra Health and as Director for Digital Governance for eHealth Queensland, she raised the importance of using technologies to support local providers in developing viable services. She has not opted out of My Health Record and trusts that the current review will enhance privacy protection as well as encouraging patients and clinicians to recognise the scheme’s benefits, and to make use of it.

This is not to say she is unfamiliar with what the Commonwealth-funded PHNs, totalling 31 in Australia, are intended to achieve. In short, to quote the department, the PHNs are aimed at “increasing the efficiency and effectiveness Julie Sturgess, CEO North Coast Primary Health Network of medical services for patients, particgraphics Ms Sturgess sees “more similarularly those at risk of poor health outMs Sturgess regards the PHN’s relacomes, and improving coordination of care ities than differences” between northern tionship with general practice as “pivotal”, to ensure patients receive the right care in NSW and northern Queensland, not least again raising the benefits of technology in of which is the challenges presented by the a “catchment that has a strong focus on the the right place at the right time.” need to close the gap in life expectancy for patient-centred medical home.” “Building The simplicity of the aim belies the com- Aboriginal groups within the community. strong community patient health care is our plexity of the delivery, a point Ms Sturgess remit and GPs are at the centre… it’s vital “Both areas have many small remote hardly needs reminding of, having come that we incorporate their knowledge and locations that create problems for standhere from Townsville where she headed experience.” alone services, on top of which is the comNorthern Australia Primary Health Limited, plexity of delivering effective mainstream a comparable organisation charged with Noting that while the PHN’s focus is providing primary health care services to as well as community controlled services,” to commission and coordinate services, much of northern Queensland, including she said. support providers and advocate for primary the Torres Strait islands.

care, Ms Sturgess said the organisation also engages with the broader community (through public consultations) regarding needs assessment. Do people see service gaps? Undue complexity? Unreasonable costs? These community feedback sessions contribute to the future planning of primary health services to be delivered.

The PHNs were set up in 2015 after a largely critical review of their forerunners, the Medicare Locals, bodies whose very name confused the public. Many thought it was where you took your bills to get the Medicare refund. Today’s PHNs have considerably less profile: Julie Sturgess is often asked what the organisation she runs actually does. The answer is a lot, working behind the scenes to improve primary health care, and create seamless journeys for patients between the community and acute care providers, notably the State-funded Local Health Districts - two of them in this PHN’s footprint, Tweed to Port Macquarie - and private hospitals. The collaborative aim is to deliver a safer and smoother ‘patient journey’ through our often-complex health system, reducing duplication and unnecessary calls on the precious health dollar. Despite contrasting geography and seemingly different demo-

In addition, “Both have pockets of significant advantage and great disadvantage.” Conscious that health services do not operate in a social vacuum, Ms Sturgess commented on the high cost of local housing, both for purchase and rent, and how this can stress all aspects of people’s lives, including lifestyles and health care. A new report shows that six of regional

It also seeks to promote healthy lifestyles, hence its ‘Healthy North Coast’ branding, and to enable all residents to actively manage their own health, make informed decisions about their healthcare needs, and get the type of healthcare they need, where and when they need it. The goals may be easy to define, but the challenge is in the delivery. It is a task that Julie Sturgess, qualified nurse and former practising RN, both recognises and looks forward to tackling.

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Many doctors in the house

sonal stressors ranging from exam anxiety through to frequent patient mortality… “We see a lot of suffering, we need formal systems to support us.” Striking a parallel with going into a procedure with a rusty scalpel, Dr Barker added, “If we’re not well, we’re in trouble.”

by Robin Osborne As a lay attendee (one of only two) at the NoRDocs Unconference I am in no position to comment on the clinical veracity of the presentations delivered in the packed six hours that it ran. As the presenters were acknowledged experts in their diverse fields, I can only assume that they spoke with authority and made significant contributions to the knowledge base of the audience, including us two ‘NCAs’ who, perhaps surprisingly, found most of the sessions understandable.

goers - would one prefer ‘Tom Keneally in conversation’ or ‘Gareth Evans with Kerry O’Brien’? (examples from this year’s Byron Writer’s festival) . Or in the Unconference, GP Dr Zewlan Moor from Byron Bibliotherapy on the healing power of reading, or neurologist Dr Bob Lodge on the timely topic of cannabis in medicine, and how Australia has been slow to address the relevant issues? Clearly, one can’t be in two sessions at once, although unlike, say, the writer’s festival, we do have free access to all Unconference sessions through videos to be posted on the GPSpeak website. Well done, organisers.

Beginning his talk on shared medical appointments (SMA) with a cartoon showing a gut-bulging patient saying, “It’s me knees, doc”, Dr Andrew Binns said that when he started as a local GP in 1979 around 20 per cent of his patients suffered chronic disease. Now he estimates it is around 80 percent. The impediment to the wider use of SMAs, already popular in the UK and North America, was, in a word, “Canberra” he said. “We have made a number of representations to politicians and the department [Health], and received reassuring words, but no sign that SMAs will be supported through the MBS.” Amongst the various sessions addressing

That said, certain things stood out in the presentations I could attend, and some controversy attaches to them. The demise of the nationally acclaimed North Coast GP Training two years ago was “a real tragedy”, in the words of Nick de Marco, standing in for Dr Chris Jambor who had recently experienced a significant accident.

Dr Jane Barker - Caring for ourselves and each other Certainly, the reception that all speakers received was extremely positive. The frustration, of course, was how to resolve the dilemma facing all ‘festival’ 6|

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This project remains on the back burner, ready to be re-ignited should the federal government not be fully satisfied by the centralised provider chosen to take over this vital training role. The new arrangements have been widely criticised, and if there are to be changes, North Coast GP Training is well prepared to step into the breach. “Doctors in trouble are falling through the cracks,” said Dr Jane Barker speaking of the need to better help both medical students and practising doctors who face per-

Dr Bob Lodge - Cannabinoids in Neurology


Northern Rivers Doctors Group ‘Unconference’ how the Australian healthcare system might do things better, with the USA’s much criticized system being a frequent reference point, one stood out - for me, as an NCA on the basis that it ticked a number of boxes in addition to the medical. Dr Arthur Proudfoot is a local GP of Canadian extraction whose work has a significant focus on Aboriginal communities. Like one of the Unconference coordinators, Dr David Guest, who spoke on cyber security, he is somewhat of an “IT geek”, and with a colleague has developed an e-health professionals directory known as GPReferral.com The aim of the project, launched at the Unconference after an intense development period, is to provide an updated database of health professionals, public and private surgeons, allied health, diagnostic services etc - to whom GPs can refer their patients.

Dr Andrew Binns - The squeeze on the 15 min consultation and addressing this issue using shared medical appointments.

This service, which will be supported by subscriptions from non-GP providers, is both a fine example of the innovation that the federal government extols, and a local initiative. The most surprising thing is that no one has done it before. The same could be said for the NoRDocs Unconference - the Northern Rivers has an increasingly strong reputation for the quality of its medical services and the dedication of its practitioners. Bringing them together for collegial and educational exchanges is long overdue. It is highly likely to be the first, not the last, gathering of this kind. The day ended with two ’lightning talks’, a conference version of speed-dating where presenters were allowed four minutes to put their case. The first was Boyoung Kim, a recent medical graduate supported by the University for Rural Health, whose Lismore headquarters hosted the Unconference. Being able to discuss patients’ issues with senior clinicians was a marked difference from the more formal protocols observed in the big cities, Dr Kim said.

Dr Louise Imlay-Gillespie - Understanding Iron

The second was Sharyn White, then acting Director of the North Coast Primary Health Network, my co-NCA, who, in addressing her given theme of The Yellow Brick Road, explained the complex workings of the region’s primary care co-ordination tool, HealthPathways. It was a whimsical yet meaningful ending to a Saturday well spent. Dr Arthur Proudfoot - Northern Rivers Health Directory

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I'm losing my patients by Dr Hilton Koppe When I was a final year medical student in 1981, I did an elective term in USA. While I was there, I was introduced to “The House of God”. This irreverent novel about the life of interns and residents in a big teaching hospital became my bible for my first years as a doctor. I have continued to find some of the “Laws of the House of God” to be helpful as I navigate the rocky path of being a human being and a doctor. “The aim of good medical care is to do as much of nothing as possible,” and “If you don’t take a temperature, you’ll never find a fever” have been particularly helpful signposts in general practice. But the law which I have tried to follow most closely is “Always remember, the patient is the one with the disease.” As someone with a tendency to over empathise, holding these simple words in my mind has been extremely helpful. But as another law states, “They can always hurt you more,” and sometimes, despite my best efforts to remember who is the patient, I become fond of the people I care for. Dare I say it, but there are times when I think that I may have fallen in love with my patients. Not in an inappropriate romantic way. But to love them as I might a friend or a neighbour. I have known some of my patients for over 20 years. I am not a robot. I do have feelings for them. Over the last decade or so, I have learnt a simple way of managing uncomfortable or disturbing feelings that arise from my work. The sort of feelings or thoughts which might keep me awake at night. Or as I have sometimes said to my registrars, “the sort of patients I take home to bed” (in a purely metaphorical sense, of course). I write stories. About my thoughts. About my feelings. About our conversations. About my reactions to their suffering. Much to my surprise, I have found writing in this way to be extremely helpful. It seems to whisk the uncomfortable thoughts or feelings away, taking them out of my heart or mind and transforming them onto the page or the computer screen. Challenging patients become interesting people. Difficult situations become opportunities for reflection and learning. It’s like magic. Most of my patients are elderly, one of the rewards of having worked in this area for so long. And they are dying. Not because of poor treatment or lack of care, but because 8|

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they are old. Recently, three of my patients died in quick succession. It made me wonder what the future held for me and my other patients. This thought kept pestering me. It wouldn’t leave me alone. Until I wrote a story about it. And here it is: .............................................................. The blank death certificate sits in front of me. Housed in its bland beige pad. No matter where a life starts, where it journeys, the Medical Certificate of Cause of Death is the concluding punctuation mark on a person's medical narrative. I approach the completion of the death certificate with reverence. My final task in the care of a patient. A moment to pause. To reflect. To say goodbye. To honor their life within the rigid confines of a bureaucratic document. This ritual is becoming increasingly frequent. As a GP in a rural area for thirty years, my patients have grown older with me. Despite medicine's advances and my best efforts, they are dying. It is their time. As my wise grandmother taught me before she died, Mein lieber Gott vergisst niemanden. My dear God forgets no one. I'm losing my patients. Just last month, I lost three.

♥♥♥ Lilly was an elegant matriarch. She was my oldest patient. Each of her frequent visits to me ended with her gently touching my arm and saying Bless you, Hilton. I had cared for her husband Don before his death. Now it was Lilly's turn. Her heart was failing. I hope that one night I will go to sleep and wake up dead. Like Don did, she once told me. Her wish came true a few weeks ago. Who is going to bless me now?

♥♥♥ Len had been a child during the bombings of London during the war. I had once ruined his Christmas by advising that he go to hospital to have a heart pacemaker inserted. He would have died without it. He wasn't ready for that. The pacemaker kept him going for another decade. Not

always easy years. But better than the alternative, as he’d say. Len was a poet. Each visit to me was accompanied by the gift of a poem, from when the muse was upon me. The last time I saw him he told me that he was feeling better than he had for years. Another gift. He woke up dead a few days later.

♥♥♥ Reg's children and grandchildren were patients of mine. When Reg moved to our town with his wife, they became my patients too. Reg was a lovable rogue with a wicked sense of humor. He was fiercely independent and loyal to his wife, who had advancing dementia, constantly shielding her from interfering do-gooders. Reg dropped dead at home without warning. Out of sight beside his bed. It took two days for his family to discover what had happened, as in his wife's mind, he was just having a long session at the pub. I am haunted by the memory of seeing him lying face down on the floor, so very very dead. I finish writing the death certificate. I walk out to greet my next patient. The waiting room is full. Many familiar faces look my way. I am troubled by a nagging thought. A persistent pestering question. I wonder who will be next? .............................................................. Dr Hilton Koppe has been a GP in the Northern Rivers region since 1988. He has combined medical practice with teaching medical students, doctors-in-training and experienced clinicians. Hilton would be happy to hear from anyone interested in exploring how writing can be helpful in maintaining a sense of balance and purpose in work. Email contact hiltonkoppe@gmail.com


To market, to market by David Guest To market to market went my PHN when somebody threw a tomato tha'd b'en all soft and squishy; ‘twould not hurt the skin But alas, I'm afraid, this was wrapped in a tin July 1st 2018 marked the first day of the next phase in the North Coast Primary Health Network’s transition to a commissioning body. The transition began two years ago and the latest development sees a major change to the organisation’s structure. In line with the Coalition's philosophy of competitive markets PHNs are gradually devolving their activities through a tendering mechanism to external parties. The government believes this has worked well in telecommunications, aged care and disability services. It brings market forces to bear on the provision of human services of all types. The core activities of the PHNs, as defined by the government, fall into six key areas:Mental Health, Aboriginal and Torres Strait Islander Health, Population Health, Health Workforce, eHealth and Aged Care. However, the Minister for Health, Greg Hunt, has also added a seventh category, Alcohol and Drugs. The Department is focusing on addressing patients’ needs while minimising waste within the system. The key activities are: • Engage patients and carers as active partners in decisions about their health and wellbeing. • Ensure service and funding models are based on best practice to maximise patients’ health improvement, service safety and quality, and allow flexibility. • Deliver efficient health care, eliminating waste and duplication. • Ensure potentially avoidable hospitalisations are minimised. • Facilitate integration and coordination of patient care across care settings and support health care professionals to work as multidisciplinary teams. • Encourage all primary health care professionals to work to their full scope of

practice. • Support the collection, reporting and use of primary health care outcome. These are laudable aims but as always the devil will be in the detail. It is to be hoped that a market approach to service delivery will bring about the necessary changes within the system in a more timely manner. A threshing machine soon sorts the wheat from the chaff. The NCPHN has already made significant strides in some of these areas. It continues to gather extensive data about our community to better target health issues specific to our region. It also has an active eHealth program, with the promotion of the My Health Record, the development of the Orion Rhapsody system for hospital - community care - primary care coordination and support for improved data transfer in the Tweed Valley from general practice to the hospital. The Winter Strategy is in full swing for its second year. It aims to keep high risk patients healthier and out of hospital over the winter months. It has used techniques to help patients become more active in their care by monitoring their illness and empowering them to take timely action in response to early indicators of clinical deterioration. The major change for general practitioners in the current biennium is the transfer of continuing medical education activities to external parties. Support for local clinical societies, the Women in Medicine group and the Northern Rivers General Practice Network has been withdrawn and the NCHPH Executive and Board are considering the best model to deliver continu-

ing medical education, particularly in the areas that are government priorities. Commissioning is an unfamiliar concept to most clinicians but those wanting to be involved in education will have to structure themselves into an entity that can bid for these contracts. It may be a steep learning curve. Commissioning has been a boon to governments around the world for over 30 years and has provided great value to those societies, however it is not without problems. In the June 2, 2018 Saturday Paper Mike Seccombe looked at the issues with commissioning human services in Australia and the UK in his article Privatisation by stealth. He quotes a UK expert:“Long experience – and in this country we now have several decades of experience in the provision of things like employment services – suggests that competition between service providers tends to drive down costs. The greater problem is that it also drives down the quality of the services provided.” Another commentator with extensive experience in the field notes:“If you use simple tender processes for the delivery of complex services, you inevitably over time drive down the price, you endanger the commercial viability of the contracting organisations, and you diminish, incrementally, the quality of the services.” The model to be adopted by the North Coast Primary Health Network is eagerly awaited by many, but not without some trepidation.

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Getting us moving Canberra has released a 10-year plan to make Australian sport cleaner and more competitive, and to reduce the population’s inactivity by 15 per cent. Robin Osborne runs through the National Sport Plan known as “Sport 2030”. In late July the federal government launched the 71-page “Sport 2030” roadmap for how sport and physical activity might best be planned and administered over the next decade. Perhaps unsurprisingly, most media focus was on strategies aimed at achieving sporting excellence (gaining more Olympic medals, finding the next Cadel Evans etc), safeguarding the integrity of sport (doping and sports gambling), and strengthening Australia’s sports industry (e.g. the future of the AIS et al). Far less prominent, although arguably much more important for the health of the population, was the attention paid to the section (the first in the report) headed Building a More Active Australia, summarised as “More Australians, more active, more often”.

and premature mortality, the report says two-thirds of adults and one-quarter of children are overweight or obese. A simple yet dramatic example of how much things have deteriorated is that in a 1.6 km run the average child in 2015 would finish 250 metres behind an average child from the 1980s. The “Movement for Life” strategy is Cadel Evans in Surhuisterveen 2011 Tour de France. CC by 2.0 Author: Michiel Jelijs

aimed at encouraging everybody, whether sport inclined or not, to become more active over the coming years: “The Australian Government will partner with sporting organisations and other physical activity providers which have a national footprint to deliver programs that encourage inactive people to undertake more physical activity.”

communities can access their facilities in a move to “unlock school gates”. At the other end of the age spectrum, the government will encourage – by supporting accessible networks in workplaces, aged care services and retirement villages, and sports/recreation centres –Australians aged 65+ years (only 25% of whom currently meet exercise guidelines) to adopt and incorporate physical activity into their everyday lives. This would help prevent and reduce the impact of chronic conditions, reduce the risks associated with falls and increase overall physical and mental health. In an age of high sugar consumption and proliferating fast food it remains to be seen how successful these well-intentioned counter measures will be. Although it is hoped that by 2030 some 15 per cent more Australians will be undertaking at least 150 minutes of moderate to vigorous activity each week, there is no mention of how appropriate eating would help our fitness.

This includes people with a disability, the homeless and Meanwhile, the media continues to show marginalised, those from culfar more interest in the quest for sporting turally and linguistically diverse excellence and the titillation of match communities, low-medium fixing and sports doping. It can only be income households, Indigenous hoped that the ‘unsexy’ goal of making evpeople, regional and remote reseryone fitter and healthier will not be outidents, and females. Water safety stripped by a focus on high profile sports and swimming (“A skill for life”) people and assorted dodgy practices. are features of the overall strategy, and yoga Physio Alex Roberts guides Feros Care residents through an exercise routine at Byron Bay pool. is one of the activities depicted, highThat said, the target seems unambi- lighting that the govtious: the aim is to reduce inactivity – or ernment is also looking put another way, to increase activity – by “beyond sport” to idenjust 15 per cent in ten-plus years from now. tify and engage with “innovative physical activNoting that “The physical and mental ity providers who may benefits from being active at all stages in deliver appropriate “para person’s life are clear,” Sport 2030 says, ticipation outcomes”. “Despite this, as a nation we are moving Starting the young on less than ever.” the exercise path is a As a result we are getting weightier and key part of the strategy, sicker by the year, even from an early age. with tactics to include Adding that physical inactivity costs the promotion of physiUniting Caroona Goonellabah, aged care facility’s Red Hot Australia an astounding $13-plus billion cal literacy and encourMummas practice seated tap dancing every week and regularly each year in health care, lost productivity aging schools to ensure perform concerts for residents, families and staff. 10 |

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Exercise and sports are good therapy Whatever our ability, it pays to keep moving, as Mark Liberatore explains. The proven benefits of exercise A range of up to date research indicates that structured exercise prescription can lead to the following outcomes:

People living with disabilities like cerebral palsy are often encouraged to participate in weekly therapy interventions from a very young age. The goal of such interventions include reaching milestones, improving gross and fine motor skills, mobility, communication and daily living activities. When combined, these therapies help to increase the social and community participation of the individual, which can have profound benefits on emotional and psychological well-being.

place outside of education time, resulting in children and teens not always receiving the same level of access to exercise and sport related activities as their developing peers. This can lead to a more sedentary lifestyle and, as a consequence, the development of lifestyle related chronic health conditions. The NSW Department of Health recommends children and teens complete at least 60 minutes of moderate to high intensity physical activity per day to obtain optimum health. But it is well documented that those

“It is well documented that those living with disabilities rarely achieve even close to 30 minutes of recommended physical activity per day”. Despite the significant benefits of focusing on therapy related goals, it often takes

living with disabilities rarely achieve even close to 30 minutes per day.

Increased muscle strength and endurance

Improved coordination and balance (leading to reduced falls risk)

Improved resting heart rate, blood pressure and blood sugar levels

Better maintenance of healthy weight ranges (BMI specific)

Increased emotional wellbeing due to social nature of activities

Reported improvements in self confidence

In order to prevent health related complications, it is essential that children and teens of all abilities are provided with the opportunity to access exercise and sport related activities. Cerebral Palsy Alliance specialises in delivering services to people living with disabilities. They run a range of programs using specialised equipment such as Race Running and Boccia, encouraging children and teens to find a sport they enjoy. They have professionals such as physiotherapists, occupational therapists and exercise physiologists who not only provide expert support, but also have the skills to link in with mainstream sporting organisations and institutions who have the desire and skills to appropriately support these types of clients. Cerebral Palsy Alliance (CPA) is an organisation that has been providing therapeutic supports to babies, children, teenagers and adults living with cerebral palsy and other neurological and physical disabilities for over 70 years. CPA’s patient centred approach to service delivery means the organisation has a deep understanding of client needs, particularly around the strong therapeutic value of exercise and sport. Mark Liberatore is Manager- Health & Well-being (Cerebral Palsy Alliance) & ESSA Accredited Exercise Physiologist . Photos courtesy of Cerebral Palsy Alliance

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New Clinical Guidelines for the treatment of Opioid Dependence in NSW Dr Bronwyn Hudson is the founder and principal GP at the Yellow Gate Medical Clinic in Bangalow. She specialises in addiction medicine and runs an outpatient opioid treatment program. In good news for the medication assisted treatment of opioid dependence (MATOD) in general practice, the recently updated NSW Clinical Guidelines: Treatment of Opioid Dependence 2018 provide a number of measures that make treating opioid dependence in the community more practical and flexible. The new guidelines aim to increase access to MATOD by expanding the role that GPs play in opioid replacement therapy. The guidelines also place a greater reliance on non-government organisations as well as community pharmacies. The guidelines allow for unaccredited prescribers to increase the number of patients they can support. For methadone, unaccredited medical practitioners can apply to the Pharmaceutical Regulatory Unit (PRU) to prescribe for up to 10 low

risk patients (increased from 5) who are being transferred from an accredited prescriber. For buprenorphine and buprenorphine-naloxone, unaccredited prescribers may be authorised to prescribe for up to 20 patients. The guidelines also allow for non-accredited prescribers to initiate non-high risk patients in primary care settings. This means that patients can not only bypass waiting lists but can be treated in their local community, negating the need to travel to their nearest public clinic for initiation. The 2018 guidelines introduce a riskbased case management model that differentiates between low risk patients that can be effectively treated in the community and those who have complex treatment needs that are best cared for in the specialist treatment sector. The use of buprenorphine in the treatment of opioid withdrawal and opioid dependence is evidence based and supported by a Cochrane review. General practitioners are uniquely placed to support patients in

Dr Bronwyn Hudson recovery from opiate dependence. This may, or may not, include replacement therapy. The new guidelines, make prescribing in a general practice setting easier. For support in prescribing, please contact your nearest public Opioid Treatment Clinic. Other useful contacts include the Alcohol and Drug Information Service (1800 422 599) and the Drug and Alcohol Specialist Advisory Service (1800 023 687). The new guidelines, along with all relevant information for prescribing can be found on the OTP in NSW website.


Cricket charity bats for kids with disabilities Lords Taverners began long ago and far away when a group of cricket-lovers who congregated at the Tavern at Lord’s Cricket Ground in London resolved to give a sporting chance to young people whose circumstances, physical and economic, inhibited them from experiencing a fuller life.

dancing and playing in a playground, walking, riding and water exercise, all of which do not rely on complicated skills or instructions. Older children with physical disabilities may enjoy sport such as wheelchair basketball. Drawing on this knowledge, Lords Taverners supports a range of school-based activities focused on mixed sports activities such as cricket skills - not surprisingly - indoor soccer, boccia, golf and basketball. Instruction is provided by well-qualified coaches, and the activities have proved immensely popular with students, families and participating schools.

In time their inspiration has come to resonate in such distant settings as Lismore’s Wilsons Park Special School, Biala Special School in Ballina, Casino High School and annual sports camps in Corndale. In these and other locations the LT’s Northern NSW branch, formed in 1982, has been actively involved in boosting the fitness and community engagement of hundreds of young people experiencing disabilities or social disadvantage.

Lords Taverners is funded by membership subscriptions, local donations (tax deductible) and a range of special fundraisers. These include dinner and speaking engagements fronted by high-profile figures such as Pat Cash, wheelchair champ Kurt Fearnley and author William McInnes.

According to the Australian parenting website a healthy

lifestyle can help children with a disability to make the most of their abilities - “Getting into nutritious foods and fun activities can become a great part of daily life for everyone in the family.”

Research shows that children with disabilities are less likely to take part in physical activity and more likely to have poor nutrition, leading to health issues, lower levels of fitness and obesity.

It is seen as important to choose simple activities that do not demand complex skills and have few rules. Open-ended activities, in which there is no one right way to do things, will let children participate at their own level. These include moving to music,

The club is also a strong supporter of Our House, the accommodation facility for patients undergoing regular treatment at Lismore Base Hospital, and supports undergraduate students at local universities SCU and UNE who otherwise would not have been able to pursue further education. It is now expanding its work into helping girls and women to pursue their goals in chosen sports and activities.

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considered for investigation of OSA if they are symptomatic or there is a clinical suspicion for OSA.

CPAP Traps

A good screening tool

Dr Joe Churton North Coast Respiratory and Sleep Clinic Queensland Sleep

The STOPBANG questionaire. S: Loud snoring T: Tired, fatigued or sleepy in the day O: Observed apnoeas P: High blood Pressure B: BMI>35 A: Age>50 N: Neck size: 43cm men, >41cm women

OSA – Who should I test?

G: Gender is male

Testing, need for treatment and method of treatment come back to 2 main principles: OSA - Patient symptoms

All of these impact a patients daytime function. It is usually these factors that a patient will seek help for. OSA - Cardiovascular risk

• EEG, nasal and mouth flow, oximetry, thoracic and abdominal bands, leg movements, position sensor.

Advantages: • Own bed • No need for private health insurance

Disadvantages: • Loss of signals • Reliant on patient following instruction • No scope to assess complex sleep disordered breathing • Not observed by technician • Unable to perform treatment studies

• EEG, ECG, nasal and mouth flow, oximetry, thoracic and abdominal bands, leg movements, video, sound meter, decibel meter, transcuta-

S: Snoring T: Tired O: Observed Apnoeas P: High Blood Pressure B: BMI> 35 A: Age > 50 N: Large Neck (♂ 43cm♀ 41cm) G: Gender Male Score ≥ 5 is high risk

CPAP Therapy

CCF CVA/TIA AF Resistant HTN

Symptoms of OSA or Comorbidities requiring treatment of OSA

Is the patient eligible for Enable No

Diagnostic Sleep study: Home or In-lab

Weight Reduction : Diet and Exercise (in All)

APAP not indicated for COPD or Complex Sleep Disordered Breathing

APAP Trial or In –lab CPAP study

2 month therapy trial

Postural Manoeuvers (for supine only OSA) Mandibular Advancement Splint (mild to moderate OSA)

• Able to detect complex sleep disordered breathing. • Disadvantage • Different bed • Private coverage may be required.

• Patient symptoms • Cardiovascular risk – OSA as a risk factor for future cardiovascular events • The severity of OSA and the presence of oxygen desaturation will guide therapy.

Treatment options • Weight reduction • Positional Manoeuvers • Mandibular advancement splints (MAS) • Provent, Nasal clips, Rhino device, Magic rings • Surgery

CPAP Pitfalls 1) Not trying before you buy

• In Lab study - generally as inpatient with a technician present.

Patients with these conditions or are high risk of these conditions, should be

• Patient is observed and can be assisted. Less loss of information and artefact than a home study. • Better accuracy for position due to video.

Again we come back to the main principles:

Home study

How to test?

• CCF and Cardiovascular disease • Resistant HTN • Previous CVA or TIA • AF

• Advantages • More accurate • More information

OSA - Who to treat?

OSA- How to test? • Patient goes home with device fitted

• Cardiovascular risk • OSA - Patient symptoms • Somnolence • Fatigue • Snoring • Choking arousal • Broken/fragmented sleep • Nocturia • Morning headaches • Accidents and near misses behind the wheel

neous CO2 (if desired), arm movements (if desired).

2) Not shopping around 3) An over reliance on the data 4) Forgetting about the mask View video of talk (password required)

1) AHI>30 (Severe) 2) AHI > 20 and either Pulm. HTN, CCF, CVA, Resistant HTN or Central Sleep Apnoea 3) Hypoventilation 4) O2 Desaturation Index >30/hr

Yes

3 day APAP Trial or In –lab CPAP study

1 month CPAP trial Download demonstrates use of >4 hrs/ night for >70% of nights

In Lab study mandatory if: 1) COPD 2) On Supplemental O2 3) Waking O2 <92% 4) Hypoventilation 5) BMI > 45 6) CCF 7) Opiate use 8) Neuromuscular disease 9) EtOH abuse 10) Other significant sleep disorder 11) Significant Psych Issues

Purchase Review by sleep physician, application sent, device delivered 2-3 months later.


Medicine has become acutely chronic by Dr Andrew Binns

Population Pyramid Australia

In 1979, when I started in GP practice, some 80% of my patients presented with an acute problem. Now I estimate the same quantum has one or more chronic diseases. The Medibank scheme started in 1975 (it became Medicare under Hawke in 1984) and the standard consultation was described and given a monetary value. The descriptor basically said take a history, examine the patient, investigate as appropriate, implement a management plan, provide appropriate preventive health care and document this record on the one or more presenting health- related issues.

But when it comes to preventive care the team is often giving out the same advice no matter what chronic disease presents. For example, there are virtually no chronic diseases where there is evidence to support resting.

There are virtually no chronic

On the contrary there is mounting evidence to support increased exercise, not just for the metabolic diseases but also for chronic diseases such as cancer and dementia. Research keeps coming in that supports exercise as being beneficial. Other lifestyle issues such as a good diet, adequate sleep, smoking cessation and alcohol moderation also rate highly as preventive health measures.

diseases where there is evidence to support resting. Fair enough for a sore throat or ‘flu like’ presentation but what about the patient with one or more chronic diseases, who is likely to have multiple medications and many complex physical and/or psychological health issues? The allotted consultation time of up to twenty minutes to manage all this often falls short. It is true that the situation is getting worse because of the ageing population, however we also need to factor in the baby boom bulge – not just the abdominal girth issue but the population bulge. This has resulted from the significant post-WW2 ‘populate or perish’ baby boom promoted by the government in the interests of the economy and defence. Then add in the immigration push that was promoted for the same reasons. This all adds to the pressure and expectations of general practitioners as the gate keepers of the health system funded largely through the Medical Benefits Scheme. An acknowledgement of this compounding pressure has been the development of chronic disease systems that involve the team approach with allied health professionals as well as medical specialists.

The so called share medical appointments (SMAs) or group visits provide the framework for improving efficiencies in patient education and empowerment for self management of their chronic disease(s).

allied health professionals for such groups. SMAs complement one-to-one consultations and are different from purely educational sessions in that the GP’s presence adds clinical expertise as well as helping to motivate the group. Positive group dynamics are important and the facilitator is also a key to achieving this. There is a need to find innovative ways to improve efficiencies for coping with the increasing demands of managing chronic and complex disease in general practice. Motivation for bringing about lifestyle change is vital for preventive health care, and in a standard consultation the need for diverse clinical input often outstrips the time available.

SMAs involve a group of patients with chronic disease(s) - not necessarily the same - sitting in a talking circle with an allied health professional who provides facilitation for one and a half hours. A doctor comes in for one hour during that period to add weight to the advice on bringing about lifestyle change and providing motivation. There can be a so-called “programmed SMA” for people with like illness, for example diabetes, chronic pain, obesity, or a more general group who can bring up any topic they like. Currently, the GP time is often funded through the standard consultation for each person in the group and this is compatible with the current descriptor. There is no specific Medicare item number for GPs or

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or contact us by email editor@gpspeak.org.au

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- Tips for your tax return Before we sit down with you to go over your tax return, certain information will be needed. These days pre-filling takes care of a lot of the “paperwork”, and if you wait until mid-August the ATO’s systems will be able to provide most of the information from employers, banks, government agencies and other third parties. However, to be thorough, before coming in for your tax appointment here are the sorts of information needed to enable us to complete your tax return •  •  •  •  •  •  • 

Payment summaries Bank statements Shares, unit trusts or managed fund statements Buy and sell investment statements Records from your rental property Foreign income Private health insurance policy statement

Income that must be declared Below is a list of common types of income that must be declared on your tax return. •  Employment income •  Super pensions, annuities and government payments •  Investment income (including interest, dividends, rent and capital gains) •  Business, partnership and trust income •  Foreign income •  Income from the sharing economy (for example Airtasker, Uber or Airbnb) •  Other income, including compensation and insurance payments, discounted shares under employee share schemes, some prizes and awards. Check with TNR if you are unsure.

Deductions When completing your tax return, you’re entitled to claim deductions for some expenses, most of which should be directly related to earning your income (called “workrelated expenses”). A deduction reduces your taxable income, and means you pay less tax. To claim a deduction for work-related expenses: •  you must have spent the money yourself and not been reimbursed •  it must be directly related to earning your assessable income •  you should have a record to substantiate your claim. Below is a list of the things you may be able to claim. •  Vehicle and travel expenses •  Clothing, laundry and dry-cleaning expenses •  Gifts and donations •  Home office expenses •  Interest, dividend and other investment income deductions •  Self-education expenses •  Tools, equipment and other equipment •  Other deductions

Please contact TNR if you have any queries from above information or if you have other queries regarding preparing for your tax return.

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Saving paper with secure medical communication by Dr David Guest The principles of secure communication using public key encryption were uncovered 40 years and have been implemented in medical communication in Australia for over 25 years. The details of the process, asymmetric encryption, are well described and cryptography is an increasingly important area of computer science. Online explanations abound and vary from the very technical to the overly simplified. The latter appearing trivially so at times. Most end users merely want to know that their communication is secure and that the padlock in their browser or email client means something. While the technology is freely available, the implementation has proven too difficult for most users to perform on their own. Large companies buy commercial solutions or devote internal departments solely to this issue. In the Australian medical scene a number of commercial secure messaging organisations provide this service. The Federal Department of Health also runs these systems for Medicare billing, the My Health Record and online web access. By design these systems are incompatible. While this has the effect of limiting damage from a cyberattack, it does put an increased burden on medical practices in maintaining multiple encryption clients on their own servers. The general public is increasingly familiar with secure internet interactions and commerce. Online banking, travel and accommodation are routine. Online publica-

Dr David Guest - Options for securely communicating with patients tions and entertainment have shut down newsagents, libraries, newspapers and cinemas. Federal and State governments prefer online communication with the public for cost and efficiency reasons. The passage of the Notifiable Data Breaches (NDB) scheme in February 2018 put medical practitioners in a difficult spot. While wanting to increase online communication with their patients they face increased penalties if there should be cyber theft of their patients’ data. In recent times some solutions have become available for use by individuals and small businesses. These solutions are web based and can overcome the difficulty of creating keys for public key encryption. They also address the security issue of

stolen passwords by implementing two factor authentication. For several years medical software has allowed practices to retain patients’ email addresses and mobile phone numbers for SMS messaging. Secure practice to patient communication is now a reality by combining these technologies. Many patients will be familiar with these techniques through their online banking experience. A financial transaction is not completed until a pin code sent separately by SMS is entered by the customer into the confirmation box on the web page. In the case of secure email communication, the practice sends the patient an email link that takes them to a secure website. The patient visits the link and can decrypt the communication and any associated attachments by using a pin number that has been sent to them by SMS. All encryption and decryption is done at the end points, the practice’s and the patient’s browsers. The system is also suitable for transferring large attachments such as a complete electronic medical record between surgeries. It is faster, more accurate and more secure than any of the off line alternatives. No system is foolproof but new technologies that are both simple to use and cryptographically secure provide a welcome alternative to printing the entire patient record.

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Novel prescriptions by Dr Zewlan Moor

Indeed, bibliotherapy is enough of a hot topic in the UK to warrant its own conference in September 2018. Titled “The Book as Cure: Bibliotherapy and Literary Caregiving, from the First World War to the Present,” it will be hosted by The Open University and the Institute of English Studies, University of London. The conference aims to look at the legacy of wartime bibliotherapy through an “interdisciplinary dialogue about the curative power of reading during and after the war.” Some questions they hope to address include: “In what ways does the legacy of First World War bibliotherapy remain active in contemporary policy-making in the charity sector, and in work with veterans and settled refugees?”

I remember reading in an interview that Dr John Murtagh, the doyen of General Practice in Australia, said that he used to keep a list of all the masquerades up on the wall behind his patient’s head, so that he would not miss an important diagnosis. Once he had satisfied himself that he had excluded these and any other organic causes of the symptoms, he was free to sit with the patient and help them realise what it was that truly ailed them. I do think that certain sorts of doctors get certain sorts of presentations. I have always been the sort who attracts psychosocial problems. That used to stress me, but now I’m trying to see it as my superpower. Indeed, I’m attempting to “lean in” to this superpower by opening a new private practice, called Byron Bibliotherapy. History of Bibliotherapy in Hospitals and Institutions Bibliotherapy is a term that comes from the Ancient Greek biblio, meaning book, and therapy, meaning healing. Aristotle compared reading to a sort of healing for the soul. In times past, small libraries have adjoined hospitals and their books have been read to or by patients, in an attempt to touch their souls while they were physically healing. In the 19th Century, bibliotherapy was seen as an integral part of inpatient rehabilitation, and was termed “moral therapy.” By the early 20th Century, advances in medical diagnosis meant “moral therapy” declined. After the Second World War, the rise of medical education saw the hospital and asylum library take on more of a curatorial and educative role for medical staff, rather than a therapeutic one for patients. Some hospital librarians remained passionate about their therapeutic roles, running story hours and book clubs. One such librarian was Sadie Peterson Delaney, who worked with African American veterans in a United States repatriation hospital after both World Wars. Since then, bibliotherapy has been used as a therapeutic model with various population groups, including at-risk youth and prisoners. For such marginalised groups, studies have shown a clear benefit for treating depression. Group members were introduced to stories from literary greats, such as Dickens and Shakespeare. The readers 18 |

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Bibliotherapy in Schools became part of an “interpretive community” that dealt with more complex issues. This allowed more discussion, insight and awareness than the usual problem-solving techniques. Researchers and participants reported that among this group of depressed patients, calming of agitation and mental anxiety was frequently observed (Billington, 2011, cited in Yontz-Orlando). Bibliotherapy in the Community Bibliotherapy is big in the UK and there have been a lot of studies looking at its efficacy. This is likely in the context of the the public funding model of the NHS its emphasis on Evidence-Based Practice. It has been taken up in the UK with the enthusiasm expected of a cost-effective form of therapy that can be offered during the waiting period for more traditional psychotherapy. Various programs have demonstrated significant improvement in mental health outcomes, including the Read Yourself Well project delivered via the public library in East Ayrshire, Scotland. This treatment plan was directed towards self-referrals and welfare agencies. One hundred and fourteen people participated in the study, which consisted of a pre-intervention and 3-month post-intervention written assessment (MacDonald, Vallance, & McGrath, 2013). The first such program was Books on Prescription in 2003. It offered a list of cognitive-behavior therapy (CBT) readings. It benefited good readers and highly motivated patients, however suffered from a limited list of resources and no supportive follow-up (Brewster, Sen, & Cox, 2012).

Good teacher-librarians and teachers have probably always tried to reach at-risk children by offering them support, referral to a counsellor or perhaps a resource that might help them. Many librarians have lists of books that might resonate with certain children. They often present these in a non-threatening manner on leaflets or bookmarks around the library. Bibliotherapy in Australia The School of Life in Melbourne and Sydney offers bibliotherapy sessions in-person and via Skype. The Central West Library service In Orange, NSW have partnered with the Centre for Rural and Remote Mental Health to offer a Books on Prescription service. The Handbook of Non-Drug Intervention (HANDI) Project Team has published “Bibliotherapy for Depression” in the Australian Family Physician. It is indicated for patients with mild to moderate depression, with a reading age above 12 and a positive attitude towards self-help. The books are mainly self-help and CBT. Byron Bibliotherapy As I mentioned above, I started Byron Bibliotherapy in late 2017 in an attempt to “lean in” to my calling in mental health. I’ve always spent a large proportion of my day dealing with anxiety and depression, which I think is quite common for female GPs. Sometimes I have suggested specific novels to my patients, and they have often reported that they have been helpful to them. So Byron Bibliotherapy was born to help those people, and to combine my passion for books with my medical practice.


- a Doctor’s perspective on Bibliotherapy I’m not too fazed by the lack of evidence about bibliotherapy. I’m definitely a proponent of evidence-based medicine. However, I do recognise that humans are funny creatures. We often act illogically and in direct opposition to what is best for us. As GPs we’re all aware of this in the context of non-adherence with treatment regimens. As humans, we’re all aware of this in our difficulty losing the last 3kg, or our struggles with procrastination or salary-sacrificing to superannuation. There is currently not much data on the effectiveness of bibliotherapy. There is one study on long-term follow-up of cognitive bibliotherapy for depression (Smith et al). However, there is also a dearth of data for much best practice in medicine. I take heart from Murtagh himself saying that, “For the everyday nitty-gritty problems of general practice, recommended treatments include those that have worked effectively for myself and my colleagues” (Murtagh, xv). In the future, I would like to be involved with research into bibliotherapy as an intervention. In terms of matching patients up with books, I am an avid but slow reader. Like most medical graduates though, I am adept at recognising what I don’t know and when to call for help. Instead of calling a MET call, in bibliotherapy I call for help from specialist professionals. Booksellers, librarians, writers and publishers are all a wealth of information. I also rely on specialist amateurs: keen reader friends and fellow book club members. I am aware of the potential negative aspects of bibliotherapy for certain patients. Like all psychotherapies, there needs to be a therapeutic relationship first and foremost. It is contraindicated for some patients with severe mental health issues such as psychosis. In these situations, I feel my general practice background and further mental health training have prepared me to recognise when and how to refer to more suitable care. There is also the issue that is brought up very eloquently in this article in The Horn Book. Teacher Librarian, Maeve Visser Knoth, discusses all the times when suggesting a book would be inappropriate. For example, it might be too much soon after your mother is diagnosed with cancer. However, inoculating your children through reading about difficult issues before they happen can be helpful by en-

abling them to rehearse a difficult situation. I like this idea a lot. Just as I’m committed to vaccination in an Anti-Vax region, I’m happy to think the articles on my website might suggest enough emotionally complex books to help inoculate people against what life throws at them. I passionately believe in the benefits of bibliotherapy as described by Alex (1993, cited in Maich and Kean): awareness that others have faced similar problems; knowledge that alternative solutions to problems exist; development of a freedom to talk about problems; growth of problem solving skills; further development of a positive self concept; relief of emotional or mental stress; development of honesty in self image; growth of interests beyond just the self; and fostering of a better understanding of human behaviour. If you have a patient or loved one who is at a crossroads, who may be reluctant to see a psychologist, or even a “worried well” patient who is suffering, I’d love to see them! Gift certificates are also available. Programs: A Novel Prescription: Program includes: • a pre-consultation questionnaire • a 45-minute individual consultation • a Novel Prescription, emailed one week later. In-person consultations are $220. They may be eligible for a Medicare rebate of $132.75 (Item 2725) under a Mental Health Care Plan. Video-consultations are available and cost $180. There is no Medicare rebate available for video-consultations.

on a case-by-case basis. (Costs are based on a consulting rate of $60-70/hr, which is extremely good value for a medical practitioner.) A Hero’s Journey: For those at a transition and interested in a more intense 3-month program, structured around narrative theory. For more information about bibliotherapy, or to suggest collaborations, please contact me via the contact page on my website, https://byronbibliotherapy.com/ or email hello@byronbibliotherapy.com References • Berthoud, E. & Elderkin, S. (2013) The Novel Cure. Penguin. New York. • MacDonald, J. J., Vallance, D. D., & McGrath, M. M. (2013). An evaluation of a collaborative bibliotherapy scheme delivered via a library service. Journal of Psychiatric & Mental Health Nursing, 20(10), 857-865. • Maich, K. & Kean, S. (2004) Read Two Books and Write Me in the Morning: Bibliotherapy for social emotional intervention in the inclusive classroom. TEACHING Exceptional Children Plus, 1(2) Article 5. • McCloskey, T. (1998). Bibliotherapy for Beginners: An Annotated Bibliography. Current Studies in Librarianship, 22(1-2), 20-33. • Murtagh, J. (2007). John Murtagh’s General Practice (4th ed). McGraw-Hill, Sydney. • Smith, N.M., Floyd, M.R., Jamison, C.S. and Scogin, F. (1997). Three-Year Follow-Up of Bibliotherapy for Depression. Journal of Consulting and Clinical Psychology, 65(2), 324-327. • Robertson, R., Wray, S. J., Maxwell, M., & Pratt, R. J. (2008). The Introduction of a Healthy Reading Scheme for People with Mental Health Problems: Usage and Experiences of Health Professionals and Library Staff. Mental Health in Family Medicine, 5(4), 219-228. • Yontz-Orlando, J. (2017) Bibliotherapy for Mental Health. International Research in Higher Education Vol. 2, No. 2; 2017. doi:10.5430/irhe.v2n2p67

Graphics: Zoë Collins — hellozoecollins.com.au

Dr Zewlan Moor

MBBS/BSc(Med)/BA(Hons1)(Eng Lit) UNSW FRACGP

Follow-up consultations may be arranged

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The Physicians Exam: Putting Lismore on the national stage by Dr Louise Imlay-Gillespie

In 2016 I started work at Lismore Base Hospital after moving from Royal North Shore Hospital in Sydney. Having been involved in teaching and education, particularly at the resident and registrar level, I was keen to get involved in a similar scene in Lismore. It didn’t take me long to track down my old supervisor from my time as a trainee registrar in Lismore, Dr Adam Blenkhorn, who had been evolving the Basic Physician Training program over the years at Lismore. One of the key milestones he was keen to achieve was to run the national Physicians exam locally. This was no mean feat, but with the support of the new Department of Medicine, this aim is being achieved. The physician clinical exam takes place once a year and is run over the last two weeks in July. Candidates begin preparation for this exam 18 months prior to it, undertaking rigorous training both on the job and academically. They work as the ward registrar rotating through relevant medical specialties, gaining skills and knowledge, whilst being responsible for the patients under their team and on the ward. Simultaneously they begin their studying, dedicating most evenings and the majority of their weekends to the task, that is of course when they’re not on overtime shifts. They will often spend two weeks away at a dedicated course focused on only medicine and much of their finances are contributed towards focused courses to help them achieve their goal. In the year I passed my exam I had spent over $20k on dedicated activities. By March of the following year they are expected to have achieved a peak of knowledge that is adequate to see them achieve a pass in the written papers and move on to the clinical exam. This is another challenge entirely… Between March and July candidates apply themselves to the task of honing their clinical skills to the sharpest point. 20 |

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The 2017 Trial Examination: Examiners and Candidates No physician ever achieves a greater level of knowledge and broad clinical skill than immediately after successfully achieving passes in both of these exams. For the clinical exam, candidates must go interstate to a hospital they have not worked at previously. To avoid biases they need to be a ‘blank slate’ to the examiners. This involves its own sense of terror: they have to travel out of town for the most important date in their career so far, with all of their clinical equipment. Will the plane be delayed? Will they allow neuro tips through airport security (yes)? Will they be able to find the hospital? What if they can’t find good coffee in the morning? This is a terrifying exercise, but it is designed to give the candidate every opportunity to pass on neutral territory. All candidates are equal in this examination. The clinical exam requires candidates to review two ‘long case’ patients and four ‘short case’ patients. A long case is a complicated patient with multiple active issues. An example might be a patient with cardiomyopathy with worsening renal failure and a new PE who is diabetic. A review undertaken of long case patients and their outcomes post exam and their estimated two year mortality rate was 30%. Candidates are expected to review the history and examination of these patients with no notes or results and within an

hour be able to synthesise a comprehensive summary of their issues, along with a detailed problems list and solutions. The short case takes a different approach. Candidates have seven minutes to examine a patient on a specific system (i.e. cardiovascular) and using physical examination skills alone be able to report the relevant positive and negative signs that correlate to their provided diagnosis. Again patients often have rare or unusual diagnoses. Charcot-Marie-Tooth, HOCM, Muscular dystrophies are common fare in this part of the exam, along with more standard cases of Rheumatoid arthritis, Parkinsons and Aortic Stenosis. So, over two weeks at the end of July, all around Australia and New Zealand, these clinical exams are held. Around Australia more than 3000 people are involved in running these exams, including patients, candidates, examiners, administrators and volunteers. The highly trained National examiners are included on every examination panel to ensure a standard is maintained. The remainder of the examining panel is made up of local examiners who are from the region but have an interest in participating. The local examiners have spent time observing the exam in other centres and have been monitored acting as a preliminary examiner before being accepted. Every year all of the examiners attend a cont on P21


Paediatric bowel training by Dr Ian Lennan

told me, “put your finger in it, or put your foot in it”!! If in doubt it comes to examination under anaesthetic. Since 1 in 5 with these problems are diagnosed late, it is often with weaning the breast feeds, then cometh the hour!! Passage of huge calibre bowel motions suggest the anus works. To help a child with constipation for any reason, stool softeners are preferred and a teaspoon of brown sugar in milk is as good as any till the baby has teeth. Perhaps Actilax is preferred on the basis of taste in the first years of life, Parachoc before school, Osmolax in primary school, as the slightly salty tasting Movicol, preferred by teenagers and adults, if often knocked back by younger children.

Poo too quick, too slow, the foundation of a paediatrician’s life! It all starts at birth. Although 97% of babies pass meconium by 48 hours of age, this cannot be relied on to diagnose the congenital anal abnormalities, as breast fed stools are a sloppy, seeded mess and will sometimes (?20%) just go whistling through a congenital anal stricture, 1 in 5,000 birth (? 1 every 3 years at Lismore Base Hospital). Meaning 20% of these rely on primary health care diagnosis. Hirchsprungs is similar, 1 in 5,000 births. A gentle little finger rectal examination will diagnose these. Some old fella once

“Potty training”, getting those bowel motions in the toilet, is often achieved later for boys but usually by age 3. You need an empty rectum filling to achieve sensation with a change in pressure. With a continually full rectum, “sensation” is lost. The anus will dilate with rising rectal pressure, on reflex, hence the collection of problems with soiling, full rectum, no sensation (Ï didn’t know I need to go”, is often very honest), the smell, the mess, the shame of soiling, the blame, the anger, the frustration, I personally find just a little sad!, and is very common. The first treatment is to introduce hope! It’s imperative to allay parent’s fears about long term stool softeners, and reassure them about their safety. A dilated hollow organ is a weak one, so I stress to families

The Physicians Exam session ‘calibrating’ to ensure consistency. If we now go back to 2016 with Adam discussing plans to run the Physician exam locally we can understand just what that request meant. It is not merely providing the College with an examination centre. It is not just about allowing more candidates to be examined. It is about participating in a national event. The pinnacle of physician training in Australia. It is about Lismore having something to offer on that national scene and inviting people to come and view that.

that to empty the bowel is to make it stronger, hence long term stool softeners strengthen the bowel, they don’t “wreck it”. I try to explain the preference for “top end” treatment, with oral medications, reserving “bottom end” treatment, enemas, for emergency relief only. To make bowel training all fun is the challenge, see Dulwich Centre’s excellent “Story of a sneaky poo”. With soiling the treatment is to sit and push for one minute per year of age, three times a day and record this in a diary. Parachoc make a cheap practical diary to record progress, a tick in the diary for sitting, a sticker of bowel motion in the toilet. Firstly asking the child to sit and push, three times a day, after breakfast, afternoon tea and dinner, so it’s all at home, not at school. So off we go, happy bowel training, oi!

continued from P20 So where are up to in this endeavour? In 2017 and 2018 we ran a trial exam for four candidates from Prince of Wales Hospital, Sydney. We provided interesting and challenging patients for the candidates and the exam was well received. In order to proceed with running the formal exam in July, however, we need local examiners to become qualified. To date I, along with Dr Adam Blenkhorn, Dr Venkat Manickavasagam, Dr Joe Churton and Dr Joe Gormally have been accepted as local examiners, with more to train in the future.

integral in our ability to aim high with this project and a key part of that was the provision of a Medical Education Support Officer, Mrs Stacey Casagrande, who will provide project leadership to help us with this goal. The main goal is to maintain and enhance the medical care for the community through the development of a high quality local education and training facility for Physician Training. We aim to run Lismore Base Hospital’s inaugural Physician Examination in 2019.

The new Rural Training Hub has been

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Warmest welcome for UOW long stay medical students The Lismore, Grafton and Murwillumbah hubs of UCRH have welcomed 18 University of Wollongong (UOW) Phase 3 medical students for their 12-month rural clinical placement. The longitudinal placement offered by UOW enables senior medical students to develop extended clinical competence and achieve a range of professional development objectives, including greater understanding of and appreciation for the complex personal and professional demands of rural clinical practice. Students will participate in multifaceted interactions with patients and their families, clinical teachers and other health care professionals through their placements in our local hospitals, community centres, Aboriginal medical services and general practice clinics. These rural based learning opportunities provide rich experiences into their medical journey and evolving notions of professional identity as rural practitioners.

At a welcome dinner on their first evening, some students were able to meet their GP preceptors. This also provided an opportunity for the new cohort to network and reconnect with UOW medical elective and pre-internship students as well as UOW Graduate Medicine graduates who are currently working at Lismore Base Hospital. The majority of the new UOW Lismore Hub students have strong ties to rural Australia, and all students are very keen to engage with the local community and join in community based groups such as sporting teams in their down time.

graciously welcomed students, supervisors and staff to his home for a most enjoyable evening of introductions, storytelling and laughter. The evening rounded off with marshmallow toasting and the students expressed appreciation for a great introduction to the rural life in ‘Murbah’. It was obvious that this group is raring to go – to maximise learning opportunities while making a positive contribution to our communities. We are set and excited for a great year ahead.

Grafton students with a spectacular Clarence Valley vista view from their backyard. Murwillumbah students share the warmth around a bonfire

UOW Lismore Hub students visiting Westpac Rescue Helicopter Service on their first Regional Academic Day Lismore Hub students during their first week participated in a range of activities including a clinical skills session with FACEM and medical educator Dr Charlotte Hall, their first Case Based Learning (CBL) session with UOW’s Lismore Hub Regional Academic Leader Dr Jane Barker, and orientations to Lismore, Ballina and Byron hospitals.

Murwillumbah UCRH Hub welcomed eight new senior UOW longitudinal (12 month) medical students on Monday 16th July. The first week comprised of tours of both Murwillumbah District Hospital and Byron Central Hospital, including the Tuckeroo (Mental Health) Unit, introductions and presentations by the Nurse Unit Managers, Indigenous cultural awareness immersion training, medical records training and practical compliance sessions in PPE, CPR, scrub competency, aseptic technique and IV therapy. Orientation week activities provide the students with the necessary groundwork to begin their placements on various wards in local hospitals and GP practices. UOW medical students were welcomed to the Murwillumbah Hub with a roaring bonfire and scrumptious BBQ dinner. UOW Regional Academic Leader Dr John Moran

Grafton Hub welcomed four UOW senior medical students in July. The students enjoyed a diverse and thorough first week of activities, designed to welcome and orientate them to the Clarence Valley region. They immersed themselves in two days of orientation and practical competencies at Grafton Base Hospital, led by UOW Regional Academic Lead Alastair McInnes, then travelled to Grafton CBD, Maclean and Yamba to visit their general practice placements. They met various clinicians, staff and locals and were offered valuable advice about how to get the most out of their year in the Clarence Valley, both professionally and personally. Students have already visited our beautiful beaches and plan to explore more of the area during their stay. All University of Wollongong long and short stay medical training placements are supported in collaboration with the North Coast University Centre for Rural Health.


Doctors join push to recognise Indigenous rights Medical bodies including the AMA and the Colleges of General Practitioners and Physicians are putting their weight behind moves to see practical changes in the way Aboriginal and Torres Strait Islander people are treated in the health, child protection and criminal justice systems. Pressure is also being exerted on government to give greater recognition to the views of Indigenous people from around the country. These issues were featured prominently at the National Indigenous Incarceration Conference (NIIC), held in Kingscliff in June 2018 and attended by a wide range of mainly Aboriginal and Torres Strait Islander speakers and delegates, both national and local. Australia is heading towards one in two of the prison population comprising Aboriginal prisoners by 2020. In 1992, the ratio was one in seven. Amongst the alarming statistics was the revelation that since 2004 the number of Aboriginal Australians in custody has increased by 88 per cent, compared to a 2 per cent increase for non-Aboriginal Australians. Moreover, Australia is heading towards one-in-two of the prison population comprising Aboriginal prisoners by 2020. In 1992, the ratio was one in seven. Senator Patrick Dodson, a respected Indigenous leader has said, “The vicious cycle remains the same. Indigenous people are more likely to come to the attention of the police. Indigenous people who come to the attention of police are more likely to be arrested and charged. “Indigenous people who are charged are more likely to go to court. Indigenous people who appear in court are more likely to go to jail. Indigenous youth now comprise over 50 per cent of juveniles in detention. The statistics speak for themselves and the cold fact remains an indictment on all of us” The NIIC participants passed two recommendations, advocating for: 1. A national review of out-of-home care Acknowledging the high rate of removal of Aboriginal and Torres Strait Islander (ATSI) children into out-of-home care and the way this frequently leads on to contact with the juvenile justice system and adult incarceration, the Commonwealth Government should establish a national inquiry into child protection laws and processes

affecting ATSI children. The conclusion aims to promote justice reinvestment through a redirection of resources from incarceration to prevention, rehabilitation and support in order to reduce reoffending and the long-term cost of incarceration of ATSI peoples. 2.Raising the age of criminal responsibility from 10 to 15 years This would bring Australia into line with other countries - the European average is 14 years. Other reasons cited are the protection of children’s rights, the limited ability of doli incapax (i.e. of 10-14 year olds not knowing their behaviour is wrong rather than just being naughty or mischievous) and issues of mental illness and cognitive impairment. A low minimum age of criminal responsibility adversely affects Indigenous children who comprise the majority of children under the age of 14 years who come before youth courts in Australia and are sentenced to either youth detention or community based sanction. The NIIC strongly endorsed the Uluru Statement from the Heart, produced after exhaustive preparation, consultation and discussions in Central Australia, but unceremoniously dismissed by Barnaby Joyce (“That idea just won’t fly”), and soon afterwards by PM Turnbull. The statement can be read here. Conference attendee Dr Andrew Binns, a Lismore GP involved with providing primary care to Indigenous people in an Aboriginal Controlled Health facility, said the event was “a time to listen, learn and reflect”. The Uluru statement from the Heart has three main calls:

1. to give a First Nations voice enshrined in the Australian Constitution 2. Makarrata, which means bringing the community together after a struggle, and 3. truth telling of the sixty millennia history of Australia. “There are many health reasons why this statement is important on health grounds alone,” Dr Binns said. “This has been stated by Croakey, the Australian social journalism project that connects health and social service professionals, academics, community members, policy makers and others with the aim of improving health and health equity.” Croakey gives five reasons why the Uluru Statement should be endorsed on health grounds. The site notes, “Paying attention to the social determinants of health is particularly important if we are to close the health and life expectancy gap between Indigenous and non-Indigenous Australians.

“In particular, racism, social exclusion, disempowerment and intergenerational trauma have been identified as important factors that need to be addressed before we will see real improvements in the lives and health of Aboriginal and Torres Strait Islander people.” These are well worth reading. “I was enlightened by this conference and have a better understanding of the challenges before us, Dr Binns said. “The self determination message from the speakers was loud and clear. There is so much we non-Indigenous health professionals can do to become more culturally aware of the serious plight of our Indigenous community and support them with our clinical skills as well as politically.”

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Book Reviews pinprick would be much less daunting for patients, especially those who needed frequent testing.

Reviewed by Robin Osborne

Bad Blood John Carreyrou Picador 339pp There are many surprises in this expose of how IT health company Theranos conned billions from American investors and put countless patient lives at risk by claiming to have invented a miniaturised, multitest blood analysis technology. How could so many large investors, along with retail customers such as Walgreens and Safeway, have flocked to support a company whose testing was so minimal, and whose products simply didn’t work? The secret, if such it is, lies in the charisma of the company’s founder Elizabeth Holmes, exceptionally bright and self confident, socially well-connected and ruthlessly ambitious. In the over-heated atmosphere of Silicon Valley start-ups, she was hailed, not least by herself, as the female Steve Jobs, playing the part to the hilt, wearing black outfits and seeking to model her ‘miracle’ devices on the iPhone. In theory the Theranos innovation lay in extracting a pinprick of blood, two at most, from a patient’s finger, conveying it over wi-fi or cellular links to the lab, and providing rapid results from a bevy of tests - HIV to Zika virus, Mexican swine flu, herpes and blood clotting, you name it. No one could match such technological wizardry and thanks to the PR spin everyone wanted to buy in. Holmes’s motivation, apart from easy profits, lay in her self-confessed haemophobia. In speeches to medical audiences and interviews to fawning media she spoke of hating to see a syringe drawing blood - a 24 |

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The Theranos technique was so simple it could be performed by untrained staff in pharmacies, hence Walgreens’ involvement to the tune of $140 million. It was set to revolutionise blood diagnostics… America today, tomorrow the world! As Wall Street Journal reporter John Carreyrou details, the personalising of this story lies at its core, and he will “leave it to the psychologists to decide whether Holmes fits the clinical profile [of sociopath]”. This is generous of him, for soon after he embarked on his investigation he encountered the company’s vicious legal attempts to silence him and ruin his reputation. In time they went gunning for all his sources, even pressuring Rupert Murdoch, the paper’s owner, to veto the story. Murdoch was one of the high profile investors, apparently blinded to Holmes’s deception by her charm, and had put $100 million into Theranos. To his credit, he expressed confidence in the editorial team, and refused to act. When Theranos was about to sink he sold back his stock for $1.00 - “so he could claim a big tax write-off on his other earnings,” Carreyrou writes. Among supporters of the entrepreneurial Holmes were the Clintons and Barack Obama, while Board members included the current US President’s Defense Secretary, retired general James (‘Mad Dog’) Mattis, Henry Kissinger and another former Secretary of State George Shultz whose grandson Tyler, a sometime Theranos staffer, became a whistleblower about faked lab results. Despite massive and disgraceful family pressure he told the author that the assays supposedly using blood pricked from fingertips actually came from venous samples analysed by a mainstream company. Elizabeth Holmes’s co-conspirator in this decade-long corporate fraud was Indian born Ramesh ‘Sunny’ Balwani, nearly

twenty years her senior, a bullying and paranoid manager - and in time, her lover - whose scientific knowledge was far outstripped by his liking for Lamborghinis, blue Gucci loafers and telling staff “You’re fired!” Staff attrition was chronic, morale was rock bottom, and every dismissal or resignation - often resulting in being marched off the premises by security - was met with the forced signing of non-disclosure agreements. One reads with delight that the company collapsed catastrophically, with Holmes and Balwani continuing to face litigation and possible criminal prosecution. The extent of clinical impacts is not known, although many patients are engaged in legal action. The sorry saga highlights yet again that if something seems too good to be true, it probably is.


Reviewed by Robin Osborne

How to Change Your Mind Michael Pollan Allen Lane/Penguin 465pp The ‘high priest of LSD’, Dr Timothy Leary casts a long shadow over this exhaustive study of mind altering compounds despite being dismissed early on as a washed-up psychologist who had less influence over the potential value of psychedelics than he claimed. The Berkley, California based academic was by no means the first to realise the effects of ‘acid’. That was down to the chemist Albert Hoffmann who, in 1938, thirty years before Leary et al discovered tripping, inadvertently absorbed LSD-25 in his lab and after lying down on a couch in his home reported perceiving “an uninterrupted stream of fantastic pictures, extraordinary shapes with intense, kaleidoscopic play of colors.” Writes Pollan, whose previous works include the acclaimed The Botany of Desire, “Thus unfolds the world’s first LSD trip, in neutral Switzerland during the darkest days of World War II. It is also the only LSD trip ever taken that was entirely innocent of expectation.” For many years LSD was being dispensed, researched and used by creatives (Aldous Huxley, Bob Dylan, John Lennon, Mick Jagger…), politicians and bureaucrats, the CIA, Church leaders, Robert Kennedy’s wife and myriad others - often not covertly. At a conference in 1979 attended by participants in the first wave of psychedelic research, including Leary, old timers considered the question of whether mistakes had been made. One quipped, “There was a mistake made: nobody gave it to Nixon!” Thirteen years earlier, when “the whole project of psychedelic science had collapsed”, Santoz pharmaceutical withdrew it from circulation. By then the research findings and users’ experiences showed

that LSD does not lead to addiction and causes no physical harm, assuming that ‘trippers’ are properly supervised. Later, and to this day, it was found that Hoffmann’s extract from ergot mould (which attacks rye) can help with addressing addictions such as nicotine and alcohol, and improving end-of-life experiences for the terminally ill. Chapters are devoted to the neuroscience surrounding the ingestion of LSD and psilocybin mushroom extract, and their use in treating certain psychiatric and mood disorders, including depression, and end-of-life anxiety. Whatever the misgivings of the author regarding Leary, and he’s not alone, his index references outnumber those for Hoffmann by ten-to-one. Pollan deeply regrets that in portraying LSD as the ideal recreational drug Leary sabotaged its therapeutic acceptance for decades. However, he concedes that the professor of psychedelics played an important, and valuable, historical role, not so much contemporaneously but from his “enduring contribution… by turning on a generation - the generation that, years later, has now taken charge of our institutions [“Steve Jobs often told people that his experiments with LSD had been one of his two or three most important life experiences’] - he helped create the conditions in which a revival of psychedelic research is now possible.” Many figures have contributed to the psychedelic story, and Pollan has identified most of them in his lengthy research. Not content to present the story at arm’s length, or report others’ experiences, he embarked on a series of trips himself, noting that, by his late 50s, he had never taken psychedelics.

in somewhat New Age settings, are much what one might expect to hear - “The mushroom teacher helps us to see who we really are,” said mushroom Mary - and provided him with insights he regarded as valuable. The third trip, on 5-MeO-DMT, derived from the smoked venom of the Sonoran desert toad, resulted in a rapid, horrendous, out of body high that caused him to think, “Is this what death feels like?” He didn’t know “what to think of this last trip.” While these experiences have gained his book the most media attention, the real merit is his charting of how these extraordinary substances have travelled a path from potential therapeutic value through recreational use and subsequent banning to an increased recognition that they could help address many conditions. But there seems no role for 'The Toad’!

His accounts of LSD and psilocybin, both

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Dr Dominic Simring

Dr Anthony S Leslie

VASCULAR AND ENDOVASCULAR SURGEON

VASCULAR AND ENDOVASCULAR SURGEON

B.Sc. (Med) M.B.B.S (Hons) F.R.A.C.S (Vasc) Provider No: 2382248J

BSc, MBBS, FRACS Provider No: 253312LL

24 Hour Advice Hotline 0401 175 995 A single telephone number has been established to put you directly through to one of the Vascular Surgeons at:

Coastal Vascular Group 24 hours a day, 7 days a week for any patients about whom you have a question or need advice.

Rapid Referral Service Any patient in whom an urgent opinion is sought can be seen on the very next consulting session with either of the Vascular specialists.

Contact details: - Ph: (02) 6621 9105, (02) 6621 6758 Fax: (02) 6621 8896 WEB: - www.coastalvascular.com.au EMAIL: - info@coastalvascular.com.au CONSULTING LOCATIONS: Lismore – Level 2 Suite 4, St Vincent’s Specialist Medical Centre, 20 Dalley Street Ballina – John Flynn Specialist Suites, 79 Tamar Street Casino – North Coast Radiology, 133-145 Centre Street Grafton – Specialist Suites, 146 Fitzroy Street Glen Innes – East Avenue Medical Centre, 39 East Avenue Armidale – 3/121-123 Allingham Street Inverell - St Elmo Medical Practice, 27 Oliver Street Tugun – Suite 2B, John Flynn Medical Centre, 42 Inland Drive


Splendid response to chlamydia testing A chlamydia testing program at the recent Splendour in the Grass festival near Byron Bay met with a positive response from patrons, with more than 1000 young people attending the NSW Health ‘VIP zone’ to contribute urine samples.

including infertility. The good news is that chlamydia is easily cured by a single dose of antibiotics. It is important to see your doctor or sexual health clinic to get tested and treated. Franklin John-Leader, Manager, North Coast HARP Health Promotion and Prevention Programs said, “Music festivals are a great opportunity to reach people aged between 15 and 29 to improve awareness of safe sex behaviours and to help normalise STI testing and the process was simple and easy.”

The zone provided participants with a clean toilet, phone charging and the opportunity to freshen up their make-up, according to Marty Janssen from the NSW STI Programs Unit. He said the ‘Down to Test’ "It's easy as peeing in a jar. team collaborated with the People think it's so complicatPositive Adolescent Sexual ed and cumbersome. But it’s Health (PASH) Consortium simple and we want to norFestival goers emjoying the PASH chocolate wheel at Splendour in the Grass and the North Coast HIV and malise testing." Related Programs (HARP) to enhance the range of sexual health promoYoung people aged 15-29 have the “The best way to prevent Chlamydia is tion services available to festival goers. highest rates of chlamydia, with notifica- the correct and consistent use of condom tion numbers continuing to rise. There were when having sex. Always use condoms with 28,000 chlamydia notifications among new or casual partners. If you are treated people living in NSW in 2017.w for chlamydia but your sexual partner is not, you could be re-infected”, he said. “Many people who are infected with the bacteria do not have symptoms but can still Previous research at a Northern Rivers transmit it,’ Marty Janssen added. music festival showed an alarmingly low rate of proper condom usage, with many “Chlamydia can affect the urethra, cervix, people not using them at all, and a high rectum, anus, throat, and eyes. If left unnumber reporting malfunctions such as treated, it can cause long-term damage, breakage or slippage. “Young people with a negative result were contacted by SMS, while those with a positive result were contacted by a sexual health nurse from NSW Sexual Health Info-Link to inform them of diagnosis, and arrange treatment. “We have been able to contact over 90% of those with a positive result at the initial four festivals,” Mr Janssen added. Results from the earlier festivals showed a chlamydia positivity rate of between 3-5 per cent. “The program’s aim is to increase STI testing in young people by improving positive attitudes and social norms for STI testing among higher risk young people,” Mr Janssen said. “So far the program’s evaluation has shown over 25% improvement in positive attitudes and social norms for STI testing, as well as 30% increase in young people’s intention to test in the next 12 months.”

Sexual health physicians and peer educators at 'Down to Test'

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The rise of antibiotic resistance The leading causes of death in 1900 were infections: pneumonia, TB and diarrhoea/ enteritis. While sulphur antibiotics were developed first, the discovery of penicillin in 1928 lead to its widespread use by the 1940’s, resulting in a significant change in epidemiology of disease throughout the 20th century with a sharp drop in infant and child mortality and a near 30 year increase in life expectancy by the late 1990’s. Resistance to antibiotics has occurred for every antibiotic agent that has ever been used. Antibiotic resistance is not a manmade phenomenon but rather a reflection of natural selection and evolution; widespread antibiotic use, however has led to the rapid emergence of resistance bacteria.

by Dr Sarah Coghill Prior to the widespread development and use of antibiotics, some bacterial infections, such as bacterial endocarditis and meningitis, were almost uniformly fatal.

There are concerns that we have entered into the ‘post-antibiotic era’. Antibiotic resistance leads to the loss of effective antibiotics and hence undermines our ability to treat or manage infections or infectious complications; this in turn leads to the use of antibiotics that are potentially more

toxic, less effective or more expensive. Patients with resistant infections are more likely to die, experience longer hospital stays and have delayed recuperation. It has been estimated that by 2050, more people will die of resistant organisms than cancer. Some of the significant contributors to the development of antibiotic resistance include: overuse of antibiotics, inappropriate prescribing, extensive use of antibiotics in agriculture and livestock and a lack of new antibiotics being developed. Suboptimal antibiotic prescribing has been shown to occur in both the community and hospital setting with previous antibiotic surveys finding that >20% of prescriptions in hospitals are non-compliant with guidelines and >20% considered to be inappropriate prescriptions. Reducing antibiotic resistance can be achieved by vaccination, improving precont on P29


Data Transfer ReFormed Paper, paper, everywhere

The form is a little clunky to use but is undergoing constant revision in the light of continuing experience. A new version seems to pop up every few weeks.

And there’s smudging of the ink Paper, paper, everywhere

The form will prompt for missing data and cannot be lodged until all required fields are completed. Additional data can also be added from the electronic health record or other patient data held locally, if required.

It’s time to change, you’d think. Everybody wants your data. Each organisation has its own form they want completed. It’s time consuming and expensive for staff to do it, so they pass it off to the customer. It’s the modern way. The client does the work and you take the money. This approach has also been discovered by insurance companies, specialists, hospitals and government departments. It is being increasingly applied to general practitioners. We are now being asked to complete paper based forms for numerous groups and fax them off. This is time consuming, frustrating and prone to error, (not to even mention the issue of doctors’ poor handwriting!) Having completed the form at the practice it is often scanned into the electronic health record (EHR) for archival and legal reasons. It is fiddly getting the form into the correct area of outgoing correspondence in the EHR and a poor scan image can further degrade the readability. The scan is also several orders of magnitude larger than text based requests which over time adds to the data management problems of the practice manager.

Technology can help. It has revolutionised modern business practices. Completing forms online saves time and reduces errors compared to the old days of transcribing paper based data. Over the last year the medical messaging company, Healthlink, in conjunction with NSW Roads and Maritime Services (RMS), has found a solution that suits all parties. Nowadays the yearly Fitness to Drive medical examination form can be lodged online. Once the patient’s file is opened in the EHR the Healthlink menu allows you to select the required form, which is prepopulated with the patient demographics. The RMS knows clients by their driver’s license. Entering that pulls down a new form that is pre-populated with data the RMS holds, such as previously reported medical conditions.

The rise of antibiotic resistance scribing practices, antimicrobial stewardship programs, improving diagnosis and diagnostic tools, prevention of transmission of bacterial infections and the development of new and novel antimicrobials. We can improve our prescribing practices by using antibiotics less and using them more prudently; specifically, using the narrowest-spectrum agent where possible, treat infection – not contamination or colonisation, and following the Australian Therapeutic Guidelines. Specific things we can do to improve our prescribing include: not treating asymptomatic bacteriuria as this does not reduce the development of symptomatic

UTI’s or their complications and results in a higher prevalence of antibiotic resistant strains (shown in women with UTI’s). Community acquired pneumonia is over-diagnosed frequently leading to unnecessary antibiotics – which are often too broad or given for too long; recent evidence suggests that treating for 5 days of antibiotics is just as effective as more prolonged courses. Overall, shorter courses of antibiotics are better – all randomised controlled trials comparing short with longer course therapy has found short courses just as effective. Further reading on his topic can be found at: Spellberg B. The new antibiotic mantra – ‘shorter is better’. JAMA Intern

Once the form has been successfully received at the RMS end, an immediate acknowledgement is sent back. The form with this receipt acknowledgement at the top can be printed for the patient’s own records. The process is a little slower for the GP than the paper version but it stops errors in data input, saves scanning, and allows for the retention of a legible copy in the appropriate section of the patient record. It is more convenient for patients since they no longer have to attend Services NSW in person. How-tos for several common EMRs are available on the Healthlink website as are some explanatory videos. The system uses the ADURO specification for medical data exchange. More widespread use of this technology has the potential to greatly facilitate and improve the transfer of required medical data between health practitioners.

cont from P28 Med. 2016;176(9):1254-55. Dr Sarah Coghill is an Infectious Diseases Physician at Lismore Base Hospital specialising in infectious diseases which encompasses antibiotic resistance and all things infectious! "I’ve recently moved to the Northern Rivers and commenced work at Lismore Base Hospital in February of this year after working in both Queensland and Victoria. I live in Ballina with my husband and large dog and enjoy horseriding and the beach."

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Advanced Care planning and My Health Record documents are accessible to healthcare providers when they are needed. This access is vital to ensure that ACDs are implemented as intended by the patients who make them.

With funding from the National Health and Medical Research Council of Australia, we have been conducting research on the My Health Record. To understand more about one of the documents within the record, we recently reviewed the legal and ethical issues surrounding Advance Care Directives (ACDs) in Australia, and considered implications for storage in the My Health Record. There are many legal and ethical issues relating to Advance Care Planning (ACP) and Advance Care Directives in Australia, and both doctors and patients navigate complex legal issues relating to legal capacity to make decisions, and either create or identify the validity of an ACD. ACP holds opportunities and benefits for those who engage with the process, and an Advance Care Directive gives individuals the chance to determine the care they will receive in the future, when they are no longer able to express those wishes. Patients may be empowered by the opportunity to control their own care, and the ACD can reduce the risk of receiving unwanted or burdensome medical proce-

dures. The ACP process may also reduce family conflict arising from different motivations or opinions among family members on appropriate medical care. However, legal and ethical barriers exist that may limit implementation of ACDs. One of the key barriers identified in the literature to date is that people generally lack awareness and knowledge of the legal nature, purpose, and benefits of ACP. This poor knowledge could affect people who would benefit from having an ACD, as well as health professionals who are responsible for decisions relating to implementation of the Directive. The My Health Record provides an accessible means of storing ACDs so that these

Recently, we completed several interviews with Australian lawyers in relation to their views on the My Health Record. Now we really want to find out the views of GPs within this research, in ways that are not too time consuming and that maintain confidentiality. With the system moving to an Opt Out system it is really important that we discover the barriers to and facilitators for use of the My Health Record, and the views and experiences of GPs as key health professionals in the process. GPs, Practice Nurses and Practice Managers who wish to participate confidentially in our research and share their views can complete a very short, ethically approved survey online, by going to https://www. surveymonkey.com/r/MyHRMedical Bronwyn.Hemsley@UTS.edu.au Professor Bronwyn Hemsley Ph.D., B. Ap. Sc (Speech Path), CPSP, FSPAA


Why I love being a HANDI-man by Dr Dan Ewald Following up on the NoRDocs Unconference, where local medicos presented on things they are passionate about, the following is an introduction to the Handbook of Non-Drug Interventions I have been part of the editorial/ writing group for HANDI since 2013, and have learned much from it.

by patients and are often without the side effects commonly associated with medication.

Why a handbook of non-drug interventions?

HANDI is a formulary of evidence-based non-drug treatments that addresses the gap in availability of non-drug intervention by compiling them into a single online formulary. Each entry includes details of treatment, similar to a pharmacopeia, plus handouts and video links showing how interventions are performed. Inclusion in HANDI involves a 2-step process: 1. Evidence review presented to the committee (minimum of one high quality RCT plus other supporting evidence, usually a systematic review of RCTs)

It is estimated that half of the myriad clinical trials conducted each year globally are for non-drug treatments. However, effective non-drug interventions are less well known, less well promoted and less well used than their pharmaceutical counterparts.

2. If sufficient evidence is presented, then HANDI entry is drafted for review and useful resources are added. Often Dr Dan Ewald - Handbook of Non-drug Intervention additional work is required to get the detailed treatment protocol from the reClinicians require a precise description searchers. of treatments for safe recommendation to The HANDI group is chaired by Prof patients. However, getting the ‘prescrip- Paul Glasziou, a leading expert in evidence I like to practice evidence based medition’ correct – dose, duration, monitoring based medicine, from whom I have learnt cine to the best extent I can. This involves – is not as straightforward as it is for phar- much about the EBM process. We have pro- knowing the evidence and negotiating with maceuticals. The adequacy of treatment de- duced over 60 reviews of effective non-drug the patient about how this fits with their scriptions in trials and systematic reviews interventions relevant to general practice values and preferences. The work helps to tend to be worse for non-drug treatments: and have rejected many more where the ev- keep me up to date, particularly for treatonly 30% of them are directly replicable, idence was insufficient. The effective treat- ments that may involve allied health. compared to 66% of drug treatments. ments are presented in the HANDI web site We aim to add 15 new topics each year, As a result, health professionals often by the RACGP. and keep them regularly reviewed. If you resort to drug-based treatments as a first HANDI is now a Medline listed publica- are aware of an evidence based non-drug point of call when there may be alternatives tion and has had around ten million hits intervention that you think would fit the that are just as effective, might be preferred from around the world. bill, do let me know.

Diabetes pen and hep C drug listed on PBS announced.

The federal government has approved the listing of new diabetes and hepatitis C medications on the PBS, helping patients save thousands of dollars a year.

Ryzodeg is the first diabetes pen to contain two types of insulin. “A basal insulin called insulin degludec, which has a long blood sugar lowering effect and a rapid-acting insulin called insulin aspart, which lowers blood sugar soon after you inject it. Patients would normally pay around $930 per year for Ryzodeg.”

Hepatitis C Referring to the hepatitis C drug Maviret, local MP for Page Kevin Hogan said, “Without the listing, patients could pay more than $50,000 per course of treatment for this medicine. Maviret works by stopping hepatitis C virus from multiplying and infecting new cells. It belongs to a class of new treatments which provide a cure for well over 90 percent of people treated.” In addition Hepatitis Australia has been allocated $1.0 million to continue educa-

tion and awareness activities to improve hepatitis C testing and treatment uptake. Insulin treatment for diabetes “People living with both type 1 and 2 diabetes will also be able to more easily regulate their blood sugar levels with the August 1 listing of Ryzodeg on the PBS,” Mr Hogan

These two new listing on the PBS will now mean patients will pay a maximum of $39.50 per script for these medications, or just $6.40 per script for concessional patients, including pensioners. Mr Hogan said the Coalition Government has now subsidised more than $9 billion worth of new medicines.

GPSpeak

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GPSpeak Spring 2018  

Spring and new beginning in primary health on the NSW North Coast

GPSpeak Spring 2018  

Spring and new beginning in primary health on the NSW North Coast

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