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ISSUE 10 December 2011 7 9 10 11 14

Caring for refugees New app trailblazer Medical care for GPs General practices in aspirin study Tips for running a greener practice

Dietary supplements and health risks Results from several large scale studies suggest that some dietary supplements may have adverse health effects. These results have implications for general practice. cited the recent results from the Iowa Women’s Health Study on dietary supplements, and said the results added to the growing concern about the safety of their use in Western society. Professor Wahlqvist said the use of dietary supplements among the “more socio-economically advantaged” was curious because these people “might be expected to out-perform the less advantaged, and indeed they do”, he added, “unless they have unhealthy behaviours.” Professor Wahlqvist said that it appears dietary supplementation has become an unhealthy behaviour, and those people who supplement their diets are usually those who don’t need to do so.

Photo © shutterstock / YaiSirichai

More than half the Australian population take complementary and alternative medicines at some stage in their lives. According to the Australian Self Medication Industry, the sale of vitamins, minerals and herbal supplements in Australia is worth more than $766 million annually. But the US National Institutes of Health argues that those who take dietary supplements often have adequate diets while those who have dietary deficiencies, and who might benefit from supplements, are less likely to take them. Professor Mark Wahlqvist, Visiting Professor at the National Health Research Institute in Taiwan and Zhejiang University in China, and Emeritus Professor at Monash University in Melbourne

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News

Dietary supplements and health risks (Continued) There have been recent studies showing possible risks associated with dietary supplements. Among them is a meta-analysis of randomised studies in the British Medical Journal in 2010, which linked daily calcium supplements – without co-administered vitamin D – to a 30% increased risk of myocardial infarction in women. An analysis of the Selenium and Vitamin E Cancer Prevention Trial (SELECT) in the Journal of the American Medical Association this year found a link between vitamin E supplements and a 17% increased risk of prostate cancer. And results from the Iowa Women’s Health Study published in the Archives of Internal Medicine this year linked multivitamins and iron to premature mortality. The Cancer Council of Australia’s position statement on betacarotene and cancer risk states that studies have demonstrated there is ‘a convincing association between beta-carotene supplements and increased risk of lung cancer in current smokers.’ It also states that ‘beta-carotene supplements are unlikely to have a substantial effect on the risk of prostate and non-melanoma skin cancers.’ These, and other studies, question the common assumption that vitamin and mineral supplementation is always good and fuel concerns that people who are otherwise healthy and have adequate diets risk harming their health by taking supplements. Emeritus Professor of Medicine John Dwyer from the University of New South Wales wrote in the Medical Journal of Australia this year about the trends in integrative medicine. He criticised the increasing role these healthcare methods were playing in the public consciousness and said he knew of no ‘scientific study exploring the motivation for such an approach’.

Photo © shutterstock / Shawn Hempel

Professor Dwyer said it was “terribly important that people be told to talk to their doctor before taking supplements.” The body is extremely parsimonious; it can’t store and doesn’t want to store many vitamins,” Professor Dwyer said. With vitamins, he added, “more is not necessarily good”. Patients are continually subjected to advertising that promotes dietary supplements and with emerging questions about potential ill effects, GPs play an integral role in advising patients. The RACGP Guidelines for preventive activities in general practice (the ‘red book’) state that ‘Vitamin supplementation is not of established value in asymptomatic individuals (with the exception of folate in pregnancy) … and that the ‘prevalence of nutritional deficiency is high in certain groups such as those who are alcohol dependent, and in the elderly living alone and in institutions.’ The guidelines also advise that women planning a pregnancy should take a 0.4–0.5 mg supplement of folic acid per day for at least 1 month before pregnancy and for 3 months after conception. In women at high risk (ie. those with a reproductive or family history of neural tube defects, those who have had a previous pregnancy affected by NTD, those on antiepileptics, or those who have diabetes) the dose should be increased to 5 mg per day.

Published by The Royal Australian College of General Practitioners 1 Palmerston Crescent, South Melbourne Victoria 3205 Telephone 03 8699 0414 Email goodpractice@racgp.org.au www.racgp.org.au/goodpractice

GPs should advise their patients to ‘eat a wide variety of foods including plenty of fresh vegetables, legumes and fruits, plenty of cereals, including lean meat, fish and poultry and to drink plenty of water. Patients should take care to limit alcohol intake and to consume only moderate amounts of sugars. To lower the risk of coronary heart disease, all Australians should consume about 500 mg per day of

... terribly important that people be told to talk to their doctor before taking supplements. The body is extremely parsimonious; it can’t store and doesn’t want to store many vitamins. combined docosahexaenoic acid and eicosapentaenoic acid, and docosapentaenoic acid through a combination of 2–3 serves (150 g) of oily fish per week, fish oil capsules or liquid, food and drinks enriched with marine omega-3 polyunsaturated fatty acids (W-3 PUFA). They should also consume at least 2 g per day of alpha-linolenic acid (a plant based W-3 PUFA that has many health benefits, but does not benefit cardiovascular health as well as marine W-3 PUFA). Patients are also advised to be physically active.’

Professor Wahlqvist said the safest way to achieve optimal nutrient intake is from food, and to include a diverse intake of it in our diet. This is a consistent finding in studies, he advised, and he cited the Mediterranean diet, people of Chinese ancestry and food culture in Taiwan. “The more diverse the diet, the better the survival. This may be seen for small changes in the diet, as with a small daily serving of beans, or a serving of fish a week. With careful food choice these dietary practices are affordable and sustainable – and certainly much more so than buying supplements at inflated prices. Food is too complex to be simulated by pills,” Professor Wahlqvist said. The Heart Foundation provides tips for healthy eating, which reinforce those advised by the RACGP. It recommends eating healthier fats and oils and limiting takeaway food to those containing less sugar, fat and salt. Most importantly, it recommends, along with the RACGP, that we drink ‘mainly water’. The Cancer Council of Australia recommends that people ‘obtain their nutritional requirements from whole foods, rather than individual nutrients in a supplement form’. It also released a comprehensive report in 2007, which stated that ‘foods containing carotenoids were probably protective against lung, mouth,

Resources • Guidelines for preventive activities in general practice. Available at www.racgp.org.au/guidelines/ redbook • SNAP: a population health guide to behavioural risk factors in general practice. Available at www.racgp. org.au/guidelines/snap • NHMRC: Dietary guidelines for Australian adults. Available at www. nhmrc.gov.au/guidelines/ publications/ n29-n30-n31-n32-n33-n34.

staff

Editorial notes

Managing Editor Denese Warmington Editor Sharon Lapkin Features Writer Rosemary Moore Production Coordinator Morgan Liotta Graphic Designer Beverly Jongue

© The Royal Australian College of General Practitioners 2011 All rights reserved. Requests for permission to reprint articles must be made to the editor. The views contained herein are not necessarily the views of the RACGP, its council, its members or its staff. The content of any advertising or promotional material contained within Good Practice is not necessarily endorsed by the publisher.

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pharynx and larynx cancers.’ Although ‘carotenoids in the cells of dark green leafy vegetables and carrots are not readily released in the body’, those in the cell walls of fruit are readily absorbed and the Cancer Council recommends people obtain their carotenoids by eating fruit, rather than taking supplements. Taking supplements may also inhibit the effectiveness of traditional medical treatments. The American Cancer Society warned in 2010 that ‘some oncologists are concerned that vitamin A and other vitamins, that act as antioxidants, may even make chemotherapy and radiation therapy less effective when taken during treatment.’ The RACGP recognises that GPs play a vital role in educating patients about nutrition, not only when treating diseases, but also when providing preventive counselling and advice.

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Reprinted from Good Practice Issue 10 – December 2011

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News

Medicolegal insight Putting patient complaints in context The introduction of the National Registration and Accreditation Scheme has enabled the compilation of national data on complaints involving health practitioners for the first time. The 2010–2011 Annual Report of the Australian Health Practitioner Regulation Agency (AHPRA) revealed there were 8139 complaint notifications made in 2010–2011 across the 10 health professions registered under the scheme. This represented notifications involving 1.5% of all registered health practitioners. About 50% of these notifications were in relation to medical practitioners, who represent 16.6% of all registered health practitioners. Therefore, in 2010– 2011, 4.6% of doctors in Australia were the subject of a notification to AHPRA. Importantly, the relevant National Board determined that no further action was required in 86% of these notifications. Complaints against medical practitioners were most commonly about treatment (39%), professional conduct (25%), communication and information, (9%) and medication (5%). While one medical practitioner in every 20 was the subject of a formal complaint to AHPRA last year, this figure does not include other complaints received directly from patients, either verbally or in writing.

So what does this mean for GPs? Australian Medical Defence Organisation, MDA National, advises that although complaints against doctors may appear to be relatively frequent, in the context of over 100 million general practice consultations each year, very few consultations actually prompt a formal complaint. Regardless, MDA National finds that the receipt of a complaint often comes as an unwelcome surprise to many doctors, and advocates that the anxiety of dealing with complaints can be lessened by having good procedures in place and knowing when to seek assistance.

Why do patients complain? Complaints reflect a patient’s subjective impression of the care they have received and can occur in the absence of any error or

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adverse treatment outcome, but may arise because expectations have not been met. In MDA National’s experience, patients and their families identify the key reasons for complaints as: • wanting an acknowledgment or apology • wanting to obtain information about what happened, and its implications for their health and ongoing medical care • as a way to ensure that whatever happened to them will not happen to anyone else.

SA Fellows reach out to rural practitioners in PNG In September three South Australian College Fellows attended the 47th Annual Medical Symposium, along with a rural and remote medicine workshop, in Papua New Guinea (PNG).

Responding to complaints In MDA National’s experience, the initial response to a complaint will influence whether it will progress any further. Some suggested strategies for dealing with informal complaints are listed below. • Respond promptly and in the spirit of resolution – the provision of a prompt response may lead to a quick resolution of the complaint and less stress for all those involved. A long delay in providing a response will often result in the patient’s view becoming entrenched, making the complaint difficult to resolve. • In providing a response, consider what the patient is hoping to achieve by making a complaint. • Ensure that the patient feels ‘heard’: listen to their concerns, ask questions and paraphrase to clarify. If appropriate, inform the patient what steps have been taken to prevent a similar event from occurring in the future. • If the complaint is from a patient’s relative or other source, ensure you have the patient’s permission before providing a response to any third party. • Keep notes of all meetings, phone calls, correspondence in relation to the complaint and retain these in a file separate from the patient’s medical records. • Before putting anything in writing, or committing to an agreement, contact your medical defence organisation for advice and support. Written by MDA National. This information is intended as a guide only. It is recommended you always contact your indemnity provider when you require specific advice in relation to your insurance policy.

Reprinted from Good Practice Issue 10 – December 2011

Back row: Prof. John Vince (Deputy Dean), Dr Peter Joseph, Dr Magdalene Taune (rural registrar in rural medicine),Dr Terry Francis (registrar in rural Medicine), Emeritus Professor Anthony Radford, Dr Ken Wanguhu, Dr Felix Diaku (registrar in rural medicine). Front: Dr David Mills. (Photo K Wanguhu)

Former RACGP president Dr Peter Joseph, Regional Medical Educator and Rural Censor of the College Dr Ken Wanguhu, and Life Fellow and former Professor of Primary Care & Community Medicine at Flinders University, Anthony Radford, attended the symposium and workshop in PNG. The doctors were invited to the event following discussions with the College about the role it might play in specialist training and continuing education. Dr David Mills, a South Australian Fellow who has been stationed in rural hospitals in PNG for 12 years, established a 4–6 year specialist training program for graduates seeking a career in rural medicine through the medical faculty of the University of Papua New Guinea. The Master of Medicine (Rural Health) structured program is supported by the RACGP, as well as AusAID, and trainees become honorary College members. The program is recognised as the way to redress the dire lack of doctors for PNG’s rural majority. More than 85% of people in PNG live in rural areas, and over 80% of rural medical care is provided by Christian churches that sponsor

all the initial participants in the program. The Papua New Guinea Society for Rural and Remote Health links up doctors serving in the remotest pockets of PNG. Doctors Joseph, Wanguhu and Radford also presented at the symposium. Dr Joseph gave an outline of the ‘Evolution of general practice in Australia’ and Dr Wanguhu spoke on the

The program is recognised as the way to redress the dire lack of doctors for PNG’s rural majority. development of communication technology and medical education. Emeritus Professor Radford, who has undertaken work in the country over the past 50 years, presented an overview of the development of a program in rural medicine for undergraduates, as well as one for interns developed during the 1960s and 70s. In recent years these programs have been eroded and Dr Mills has been appointed to the medical faculty to restore them. At the Rural and remote health

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workshop, Dr Joseph provided an overview of ‘Continuing education in general practice in Australia’ and Dr Wanguhu demonstrated how online technology could provide isolated practitioners with easy access to continuing medical education. Professor Radford conducted a clinical lecture on ‘Skin disease in PNG’. This event was attended by Master of Medicine trainees and several doctors from both church and government hospitals. The attendance by the three Fellows at the symposium and workshop provided opportunities to strengthen the bond between the College and rural general practice in PNG, which it is hoped, may be extended to urban general practice. PNG has produced medical graduates since 1964. The medical course takes 5 years, followed by a 2 year internship. Specialist medical training commenced in 1972, but there was no organisational structure or mechanism for doctors wanting to enter general practice to undertake formal postgraduate training, or specific continuing education. Today, the rural GP in PNG is equivalent to the procedural GP in Australia.

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Practice

Caring for cancer survivors in general practice Five year cancer survival rates in Australia are higher than 60%, and among the highest in the world. The survival rate for many common cancers has increased by 30% in the past 20 years. As cancer survival continues to improve, GPs are likely to play a greater role in after treatment care. With an estimated 750 000 cancer survivors in Australia and an expectation that this will increase by 3% per year, Associate Professor Michael Jefford said projections for cancer survivors in Australia, the UK and the US are ‘enormous’. Associate Professor Jefford – clinical director of the Australian Cancer Survivorship Centre at the Peter MacCallum Cancer Centre and a consultant medical oncologist at Peter Mac, as well as a senior clinical consultant at Cancer Council Victoria and a principal Fellow at The University of Melbourne – said there is no ‘one size fits all’ approach that deals with the needs of cancer survivors after treatment. Not all survivors need ongoing review, Associate Professor Jefford said. People who have been treated for early stage breast or bowel cancer, or early melanoma may prefer to be provided with information about how they can look after themselves and what symptoms to watch out for, which might signify recurrence. Associate Professor Jefford added that ‘It’s not necessarily about moving people from hospital care to primary practice. We need to support people to manage their own health. A part of dealing with aftercare is recognising that lots of people don’t need lots of engagement with the health system but need skills to self manage,’ He also described managing the consequences of cancer and its treatment as similar in some ways to managing a chronic disease such as asthma or diabetes. People need to know how they can monitor their health and stay well.

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Sharing care Supported self-management may not be suitable for all survivors. Some – for example, survivors of childhood cancers – need ongoing review by a team of hospital based specialists. In other cases, a shared care arrangement may be ideal. Shared care – which means a GP, or practice nurse, working according to a patient’s survivor care plan in consultation with the patient’s oncologist – needs to be better defined in cancer survivor care, Associate Professor Jefford said. ‘I think we need to do a lot of work on what shared care means. In maternity care it’s more defined. You know what the outcome will be and the steps along the way.’

Photo © Shutterstock / OtnaYdur

back into the [hospital] system,” Associate Professor Jefford said. Decisions about the best aftertreatment model for each patient will depend on factors such as their preference, where they live and what type of treatment they have had. ‘In the case of someone who has had a childhood cancer and received a bone marrow

We can’t just dump people into primary care and say ‘you’re under the care of your GP now’. We need to make sure that GPs and practice nurses have the information and skills they need. According to Associate Professor Jefford shared care should incorporate the principles of good coordination and communication, ready access to hospital and recognising the GP has an important role in most cancer survivor care. “We can’t just dump people into primary care and say ‘you’re under the care of your GP now’. We need to make sure that GPs and practice nurses have the information and skills they need. Shared care may not be preferred by every GP and every patient; there needs to be some flexibility. Patients need to know their GP has the right information and the right skills, but also know that if there are any concerns down the track there will be rapid access

transplant, there will be impacts on their growth, schooling, sexuality, and so on. It may well be difficult for a rural GP to manage that – they will probably need a multidisciplinary management approach through a long term follow up clinic. There’s clearly a need for risk stratification and individual tailoring,’ Associate Professor Jefford advised.

Hospital-based follow up not always ideal Cancer survivors usually see their oncologist for a regular review, but Associate Professor Jefford said these are sometimes ‘empty episodes’, which have no clear purpose and do not include any formal assessment,

or review of test results.’ He believes these appointments provide some reassurance, but might not address the wide range of survivorship issues. Associate Professor Jefford said that doctors need to ask: ‘Does the process achieve anything? Could we do it better?’ rather than seeing the patient every three months for a chat and a pat on the back. In Australia, unlike the United States where Jefford recently visited, he believes GPs are usually receptive to providing care if they are provided with information on what to look out for, how to manage it and when to pick up the phone. But, he said, from the perspective of oncologists, views of shared care were variable and there is some degree of reluctance to let go of follow up care.

Oncologists need to communicate effectively with GPs In order for shared care to work effectively between GPs and oncologists, Associate Professor Jefford said communication, education, rapid access to the hospital system if needed, shared information and clear roles were important. He and his colleagues trialled faxing information to GPs about the potential side effects of patients’ chemotherapy treatment, including information

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on ‘when to call’. They found it was a simple, inexpensive intervention that increased confidence and managed adverse effects. Associate Professor Jefford said it was unrealistic that GPs should know everything about cancer, as they might have only one or two patients having chemotherapy. He suggested that oncologists provide information about the particular patient, not a textbook on every side effect. Regarding information for GPs on cancer survivorship, Associate Professor Jefford said GP education was not adequate, and that there needed to be more awareness about the issues cancer survivors faced after their treatment was completed. The Victorian Cancer Survivorship Program, funded by the Department of Health, is running a series of pilot programs to look at ways to improve the care of survivors after cancer treatment. Engagement with primary practice is a key requirement in the program. For further information visit the Victorian Department of Health Cancer Survivorship Program at www.health.vic.gov.au/cancer/cancerprojects/survivorship.htm; and the Peter Mac Australian Cancer Survivorship Centre at www. petermac.org/cancersurvivorship.

Reprinted from Good Practice Issue 10 – December 2011

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Review

Escaping Rwanda Leah Chishugi A Long Way From Paradise: Surviving the Rwandan Genocide Publisher: Virago Press, London Published: 2010 RRP: $22.95

Leah Chishugi has written a profoundly insightful and heartbreaking account of her escape through the brutal, bloodied landscape of the Rwandan genocide. As the daughter of wealthy coffee farmers who grew up ‘in a state of more or less perfect happiness’ Leah was not prepared for her unexpected pregnancy at 17 years of age – let alone what followed shortly after. The genocide, which commenced in Rwanda in April 1994, pushed the teenager beyond the edges of human comprehension where, she writes,‘The spirit of death was everywhere.’ With her 6 month old baby boy in tow – whom she believes was the only remaining member of her large family – Leah travels by foot, car and truck through almost 4000 kilometres of life threatening challenges to Uganda, then on to South Africa where she settles briefly. Finally, after enduring the post apartheid violence of Cape Town she flees to the UK where she seeks asylum and a permanent home. Along the way Leah witnesses countless murders, grisly dismemberments and machete wielding Hutu militia, known as the Interahamwe. ‘We all looked like the walking dead’, she writes, as she describes stuffing cotton wool inside her nostrils to ‘squash her nose’ so she looks more like a Hutu than a Tusti. At other checkpoints, Leah is ordered – luckily disguised in traditional Senegalese clothes – to remove her shoes so the Interahamwe can check whether her feet have a Tutsi or Hutu bone

structure. The former, imagined or real, means instant death. ‘Those who killed looked crazy, possessed’ Leah writes. Whenever she comes across killing she hides and consequently witnesses the Interahamwe massacre Tutsi men, women and children. ‘After they ‘killed people’ Leah writes, ‘they ground them into the earth by putting their foot on the dead person’s stomach, in exactly the same way you would crush a cockroach underfoot.’ When Leah isn’t travelling and witnessing the genocide, she is hiding in churches and buildings where the Interahamwe have already done their killing. There she sleeps with piles of rotting corpses their faces distorted in

agony, incomplete with missing limbs and body parts. Along the way Leah picks up a 2 year old boy who is clinging to his dying mother. Her legs are splayed as if she has been raped and her abdomen is bleeding profusely. ‘I’m going to look after your baby for you,’ Leah whispers in her ear. The woman ‘gently closed her eyes so she could die’, Leah recalls. Further along, she comes across twins suckling from their dead mother’s breasts. Leah picks them up too and takes them with her. She breastfeeds the twins, as well as her own baby, on the treacherous journey out of Kigali. Leah’s experiences manifest in deeply rooted fears. She can no longer eat meat and she fears, after seeing so many corpses in the water at Goma, that all water is dirty. And ‘However many times I wash my body it would not be enough’, she writes, to remove the imprint of ‘dead bodies on top of me and underneath me’. Leah also wants to take out her brain and ‘scrub it with a toothbrush to remove all the horrible memories’. When the genocide is over and Leah settles in London with her husband and young son, she is still haunted by guilt for surviving the holocaust. She and her husband do not discuss the past and they avoid all conversations that may lead back to it. She feels no genuine emotion and is ‘overwhelmed by a dark, gaping emptiness.’ Leah articulates her psychological dilemma as a characteristic of her strength. ‘I fought for my life over and over again when it was about to be snatched away from me’, but now that I’m not in danger I don’t ‘know how to live.’ Leah searches for a way to heal. After hearing that other Rwandise people had gone to see members of the Interahamwe in

jail ‘to look into the eyes of the people who had killed their family members and vent their emotions’, Leah decides she too will pursue this course of action. Of the four Interahamwe who broke into Leah’s home in Kigali in 1994 and murdered her family, only one could be located. He was in prison. Expecting a ruthless and staunch enemy soldier – sitting in a bare room, save a table and a few old chairs – Leah is dumbfounded to meet a hunched, broken man. ‘I’m so sorry, so very, very sorry,’ he weeps. ‘How did you kill my family?’ she demands. ‘I didn’t own a gun, so use your imagination how I killed them,’ he tells her. He continued: ‘After I did it I became somebody else ... I was in a trance and it actually felt good at the time to see the blood spurt and have the power over life and death ... I genuinely believed you were all giant cockroaches ... But I woke up and realised what I’d done.’ As he wept and begged forgiveness ‘something extraordinary happened’ Leah writes. Her anger evaporated and was replaced with ‘feelings of sorrow’. The killer had become a small pathetic, shrivelled creature so overwhelmed with remorse that ‘he could barely drag one foot in front of the other.’ ‘That is the first time I have met a dead person who is still breathing and talking,’ Leah said, and consequently – three years after the genocide – she commences her journey towards tangible healing. One built on reconciliation rather than understanding. Leah Chishugi now runs a charity ‘Everything is a Benefit’, which supports the women and children of war ravaged eastern Congo.

Study stresses importance of TIA follow up strategies A study by New South Wales’ researchers has stressed the importance of long term secondary prevention strategies in patients who have suffered from transient ischaemic attacks (TIA). The study found that patients who suffered a TIA subsequently reduced their 1 year survival by about 4%, and their 9 year survival by 20%. The researchers, whose findings were published in Stroke: Journal of The American Heart Foundation, found that for

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patients over the age of 65 years, the outcome was worse. The researchers examined data for more than 22 000 people hospitalised for TIA in New South Wales between 2000 and 2007. Professor Joe Biller, a member of the American Academy of Neurology, told Medscape News that the research was important because it ‘is the first study to review post-TIA for as long as 9 years’. Most studies, he said, had focused on immediate risk in the weeks and months following a TIA. Of all risk factors assessed, congestive heart failure, atrial fibrillation and prior hospitalisation for stroke most strongly influenced survival. Lead author Dr Melina

Reprinted from Good Practice Issue 10 – December 2011

Gattellari (PhD), from The University of New South Wales, said 9 years after a TIA, mortality rates were 20% higher than for those who do not have a TIA. The results suggest better prevention strategies are needed for those who have a TIA. UNSW Conjoint Associate Professor John Worthington, who was involved in the research, said it was time to look at the secondary prevention provided to patients, including those with a distant history of TIA. ‘The brief stroke-like symptoms of transient ischaemic attack’, he said, ‘are a warning of poor outcomes and an opportunity for doctors and patients to intervene before a more deadly event.’ Better management of

Photo © Shutterstock / Neil Rouse

cardiovascular risk factors among those who have a TIA was needed according to Dr Gattellari. ‘These include good blood pressure control, optimising management

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of diabetes and heart failure, giving up smoking, regular exercise, weight control and good management of other risk factors like atrial fibrillation.’

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Global

Caring for refugees

Refugee Health Assessment

Providing care for new Australian residents who come from culturally and linguistically diverse backgrounds can be a rewarding experience.

FIRST NAME

More than 67 000 people entered the Australian community between 2006 and 2011 under the government’s Humanitarian Program. Most of these new residents came from Burma, Iraq, Bhutan, Afghanistan and Congo respectively, with others from Ethiopia, Somalia, Sudan, Liberia and Sierra Leone. While some refugees arrive in good health and readily immerse themselves into their new surroundings, others arrive with serious healthcare needs. Treating patients who have endured physical and emotional trauma requires a unique set of professional skills, as well as the ability to know when and who to refer patients to when their problems require specialist care. In the RACGP’s December issue of check, Multicultural health, a panel of experienced doctors examines the issues faced by GPs when they are presented with patients who may have fled trauma to seek refuge in Australia – and who bring with them health problems not usually seen in the mainstream population. Of the refugees who seek asylum in Australia, one in four has been subject to torture or human rights violations, and almost three out of four have been exposed to traumatic events. Prior to visiting a doctor in Australia, refugee patients might have been forced to flee their homes, and some could have been tortured and sexually assaulted. They may also have witnessed other people enduring violence. They may not speak English and could require the services of a professional interpreter. If the patient spent some time in a refugee camp prior to their arrival in Australia they could have been living in crowded conditions where food and clean water were not readily available and where disease and death were endemic. Health problems common to refugees include post-traumatic stress disorder, depression, psychosomatic disorders, musculoskeletal pain due to torture, hypertension, diabetes, poor oral and dental health, TB, hepatitis, intestinal parasites, STIs, vitamin D deficiency and delayed growth in children. They may also not have received any, or few, immunisations. Dr Catherine Dodgshun, medical editor of RACGP’s check, said that many people also faced a new set of challenges upon their arrival in Australia – such as housing and financial concerns, unemployment, the effects of fragmented education, relationship breakdown and cultural dislocation. Dr Dodgshun said GPs could minimise the barriers to some healthcare issues by accessing interpreter services for their

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patients when necessary. They can also sensitively deal with disclosures of torture and trauma, and utilise various resources to devise catch up immunisation. For GPs caring for refugee patients, best practice according to the RACGP’s check includes: • allocating adequate consultation time • asking a patient if they think their English language skills are appropriate to conduct the consultation in English and engaging the services of a professional interpreter if necessary • pre-registering with the Department of Immigration and Citizenship’s Translating and Interpreting Service • explaining the process of assessment and obtaining consent • being aware of prevailing cultural norms in a patient’s country of origin, but respecting people as individuals with their own beliefs and values, and clarifying individual viewpoints where appropriate • obtaining basic history regarding country of origin, time in refugee camps, immediate health problems, undertakings on visa, past history of chronic disease, operations, injuries and blood transfusions, and medications and allergies • managing immediate health problems • assessing chronic health problems • assessing mental health • assessing women’s health issues • assessing for developmental problems in children • performing a physical examination consisting of blood pressure, height, weight, cardiovascular, respiratory, abdominal, ear, nose, throat, lymph nodes, skin and urinalysis. Undertake with adequate explanation, so as to avoid evoking memories of possible trauma • checking vision and hearing • checking dietary adequacy and dentition • arranging general screening investigations, as well as screening for infectious diseases, worms, nutritional deficiencies, and environmental and genetic issues • providing appropriate catch up immunisation for both children and adults • responding sensitively to disclosures of torture and/or trauma • obtaining social history – family relationships, housing, finances, transport, brief educational and occupational history • referring to specialists and allied health where appropriate • explaining results and referrals • advocating with hospitals, allied health and government authorities if needed

MIDDLE NAME

LAST NAME

FIRST NAME

MIDDLE NAME

LAST NAME

FIRST NAME

MIDDLE NAME

LAST NAME

HOME

WORK

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PATIENT FOR CHILDREN

MOTHER/FATHER/GUARDIAN

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ADDRESS /

DATE OF BIRTH

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Assessment completed by: GP

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Note: This assessment does not need to be completed in a single consultation.

Refugee health assessment template. Available from www.refugeehealthnetwork.org.au/Home/Home.htm

• organising psychological support where appropriate • providing ongoing monitoring of chronic disease. Foundation House, the Victorian foundation for survivors of torture, believes that as well as providing clinical care for refugees many GPs might also be in a position ‘to provide support and information to assist people to access healthcare and other settlement resources’. In a recent report prepared by Foundation House, Promoting refugee health, it was noted that refugees ‘had a higher rate of long term medical and psychological conditions than other migrants’ and they tended to ‘visit health care providers more frequently’. While caring for Australia’s new residents is challenging, and often heartbreaking, Dr Dodgshun said that, “Many GPs who regularly see refugees are inspired by the resilience of displaced peoples and find this area of medicine particularly rewarding.” Resources • Australian Society of Infectious Diseases. Guidelines for the diagnosis, management and prevention of infections in recently arrived

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refugees, 2009. Available at www.asid.net.au/ images/Documents/Guidelines/ RefugeeGuidelines.pdf • Information on a range of medical conditions in multiple languages is available in searchable databases from the NSW Multicultural Health Communication Service, which is available at www.mhcs.health.nsw.gov.au/index.asp and the Victorian Health Translations Directory, which is available at: www.healthtranslations. vic.gov.au/bhcv2/bhcht.nsf • Department of Immigration and Citizenship’s Translating and Interpreting Service telephone number: 1300 131 450. • Request form for TIS National Client Code can be found at www.immi.gov.au/ • World Health Organization’s immunisation schedule is available at http://apps.who.int/ immunization_monitoring/en/globalsummary/ scheduleselect.cfm • Online calculator to help doctors work out catch up immunisation schedules for patients under 7 years is available at www.health.sa. gov.au/immunisationcalculator • The Victorian Transcultural Psychiatry Unit helps support mental health services in working with consumers, carers and communities from diverse backgrounds. Available at: www.vtpu.org.au/resources/ communityprofiles.html.

Reprinted from Good Practice Issue 10 – December 2011

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Technology

Better patient treatment just an app away? Mobile medical apps designed for iPhones and iPads have exploded onto the healthcare market over the past few years, and government regulatory bodies have struggled to keep pace with the development, both internationally and locally. There are two types of mobile medical apps. Those aimed at providing information do everything from counting calories to monitoring fertility and dispensing anatomy and drug explanations. The second, more controversial type of app is marketed squarely at medical practitioners with the aim of assisting them in diagnoses and patient care. Those apps that provide medical information generally fall outside the scope of the Therapeutic Goods Association (TGA), but apps developed for diagnoses and patient care based on clinical analysis of data would likely be categorised in the same way as any other medical software and fall under existing regulatory guidelines, which should be submitted for TGA approval. In the United States a small number of apps have been cleared for diagnostic use by the Food and Drug Administration (FDA). The first FDA approved diagnostic radiology app, which became available for download in February this year, has recently released an updated version. Available from MIM Software Inc, the app, called Mobile MIM, has clearance from the FDA for viewing images and making medical diagnoses based on CT, PET, MRI and SPECT images on iPads, iPhones and iPod touch. FDA chief scientist Dr William Maisal said the app – which was performance tested by a number of radiologists – was important mobile technology that ‘provides physicians with the ability to immediately view images and make diagnoses without having to be back at the workstation or wait for film.’ Welldoc, another US based company, has recently released an FDA approved app called DiabetesManager®. This app not only monitors type 2 diabetes patients’ blood sugar levels, alerts them if its high or low and trends their levels – but it also provides advice to the patient about food

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Reprinted from Good Practice Issue 10 – December 2011

Photo © Shutterstock / Angela Waye

or medication to bring their blood sugar back into line. When the patient keys further information such as cholesterol, blood pressure and medications into the app it is sent directly to the Welldoc server, which analyses it, provides an evidence based treatment and forwards this to the patient’s GP for approval. The process, which needs the patient’s GP to participate, has been touted as an innovation that could vastly change the management of type 2 diabetic patients. In Australia, in early November, the federal Minister for Health and Ageing, Mark Butler, launched a trial of a new mental health app that is specifically aimed at young men. The app, called Work Out, was developed by the Inspire Foundation and The University of Sydney’s Brain and Mind Research Institute. According to Minister Butler, the app ‘allows young men to take part in a “man-friendly” survey that assesses their mental fitness and guides them through a process of setting themselves mental fitness goals.’ The most popular medical app in the United States is reported to be Medscape, which was developed by the respected American organisation WebMD for iPhone and iPad. The iTunes store rates Medscape as the ‘largest, most comprehensive, free medical app for healthcare professionals.’ The app is free of charge and contains listings

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for more than 3200 diseases, conditions and procedures, as well as 2500 images and 150 videos. Medscape’s listing of 7000 drugs and their interactions is encyclopedic. The app is also known for its speed at checking dosages and interactions, although it should be noted that tables and protocols might not be transferable to Australian settings. App Annie, an app sales tracking website, lists the top free medical app in Australia as Sleepmaker Rain. This app contains sound recordings of real rain in light, medium or heavy format. According to App Annie, the most popular paid app sold in Australia currently is St John’s Ambulance First Aid, which provides instructions for common and critical conditions that require immediate first aid. Other free and paid apps listed in the most popular 10 include MIMS, Baby Pregnancy Tracker, Vision Test, Medical Dictionary, Menstrual Calendar and HeartWise Blood Pressure Tracker. Regulating and monitoring the flood of app products and the burgeoning curiosity of purchasers who are downloading them presents difficulties for regulatory authorities both in Australia and internationally, but this hurdle is likely to be overcome promptly as apps for mobile devices are adopted prolifically by consumers.

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Technology

New app trailblazer for patient communication Publisher: Argosy Publishing, Newton, Massachusetts Further information: www.visiblebody.com Price: $29.99 at the Apple app store

Visible Body, a 3D interactive human anatomy atlas app, recently released its updated iPad2 version. The popular medical app can provide GPs with a lightweight, fast and simple method for showing their patients complex anatomy and, at the same time, providing an excellent platform for discussion and explanation. The app received an award for excellence from the Association of Medical Illustrators this year, and the merit of this award can be seen in highly visual, detailed illustrations that launch into 2500 colourful interactive references. The updated version of the app allows viewers to explore definitions of body systems, organs, vasculature and nerves. It only works on iPad2 and is currently rated at four and a half stars by users in the iTunes store. The Visible Body app home screen displays hundreds of thumbnails organised regionally and by anatomical system. When the user taps on a thumbnail, a 3D model of the anatomical structure is launched. To see in-depth definition, the user taps on a particular element of the structure and the app zooms in for an expanded detail.

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Further adjustment can be made by rotating, tilting and zooming into the 3D model. To focus on any particular anatomical element there are fading and hiding features that enable the user to hide distracting details so the viewer can focus on specific features. Visible Body also has the capability to see anatomical structures from any angle and in combination with other structures. It’s possible to identify anatomical structures by name and read definitions of them, as well as display the anatomical hierarchy. The app’s capacity to look at structures from different angles and their placement in relation to neighbouring anatomy is outstanding and these features have been noted by users to be among the app’s most useful. Visible Body replaces the need to use paper and pen when providing anatomical explanations to patients. It allows the GP to focus on the exact area of concern and show the interplay of the structures around it. By manipulating anatomy on the screen, GPs are able to bring to life complex medical concepts for their patients, thereby increasing their quality of patient communication, as well as increasing patients’ understanding of their own medical conditions.

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Reprinted from Good Practice Issue 10 – December 2011

9


GP health

Finding medical care for GPs A substantial number of doctors don’t have their own GP, choosing instead to self diagnose and treat or consult informally with colleagues and friends. Some GPs also act as doctors for family members, often under pressure from relatives who see this as a more convenient and less costly option.

Photo © Shutterstock / Aletia

Numerous studies have shown that doctors are especially poor at seeking help for their own mental health and substance use issues. Adjunct Associate Professor Leanne Rowe, author of a book on doctors’ health, said that doctors usually attend to their ‘physical health needs, but find it difficult to access mental healthcare’. She added that ‘doctors have a tendency to self diagnose and self prescribe, despite the Australian Health Practitioner Regulation Agency’s code of conduct, which gives clear guidance on these matters’. Dr Danielle Clode, who reviewed the RACGP report Conspiracy of silence: emotional health among medical practitioners, wrote that doctors tended not to seek independent medical advice for themselves, and that this increased the risk of ignoring ill health and the likelihood of self-medication, which in turn increased the risk of drug abuse.

A GP for a GP State and territory medical boards advise doctors not to treat themselves or family members. To do so, the New South Wales Medical Board points out, would compromise a doctor’s professional objectivity, could lead to important investigations not being carried out, and might compromise the patient’s autonomy and breach principles of informed consent. The board recommends that all doctors

have their own, independent medical practitioner. But how does a doctor find a GP? Having a doctor who is a colleague, or to whom you refer, could make you a poorer patient. Could you respond honestly to questions about sex, or alcohol and other drug use, or be comfortable having a digital rectal examination or Pap test when the doctor is someone with whom you share dinners or referrals?

GPs need a good doctor they trust, respect and like ... someone who will listen, but is not too close to them and not in awe of them ... According to Keeping the doctor alive (an RACGP publication available online) GPs need a good doctor they trust, respect and like. It should be someone who will listen to them, but is not too close to them and not in awe of them, and who will make their own independent judgments. Adjunct Associate Professor Leanne Rowe added that ‘Informal peer support groups are enormously helpful. Just as executives in high level corporate positions often enlist a ‘coach’ ... it is of great assistance to doctors to see this sort of support. By surrounding

10 Reprinted from Good Practice Issue 10 – December 2011

ourselves with a supportive network, we can weather the inevitable storms in our lives and our careers.’

Treating family members The AMA code of ethics advises that, except in emergency situations, physicians should not treat themselves or members of their immediate families. Depending on the relationship a doctor has with a family member, there is a risk of overtreatment or undertreatment. Writing in the American Medical Association News, pulmonologist Dr Sharon Douglas pointed out that doctors sometimes gravitate to the worst diagnosis when it involves family members. At other times, she said, doctors could underestimate the importance of symptoms when it comes to family because they are so used to routine complaints that are not signs of serious illness. Personal feelings, as well, may unduly influence doctors’ judgment and interfere with a family member’s medical care.

Getting help Beyondblue in its 2010 literature review on the mental health, found that ‘a significant proportion of medical practitioners – including 34% of medical students – reported they would not seek help for depression’. Barriers to seeking help included concerns about stigma in the profession, embarrassment, potential

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impact on career development and concern over being permitted to practise. There are confidential services available for doctors needing help with sensitive issues, and professional organisations – including the RACGP – strongly encourage doctors and medical students needing help with stress, anxiety, substance use or mental health concerns to seek help. Services include: • the GP Support Program, which can provide help to RACGP members with a range of issues including work pressures, managing conflict, anxiety and depression, alcohol and drug issues and traumatic incidents. The program is delivered by IPS Worldwide, an Australian-owned national provider of member assistance programs. The counselling services (face-to-face or by phone) are provided by registered psychologists. The first three consultations are free to all RACGP members registered as medical practitioners. The service is confidential and the RACGP has no knowledge of who accesses the service. Phone 1800 331 626 • doctors’ helplines or advisory services, which are in located in each state and territory, are available at http://ama.com. au/node/3592. Professional indemnity companies may also provide confidential services for issues associated with indemnity claims or professional investigations.

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Research

General practices participate in pivotal aspirin study A 5 year trial involving more than 12 000 participants, 70 years and older in Australia, is attempting to discover whether the benefits of regular low-dose aspirin outweigh the risks for older people. The large scale randomised controlled trial, ASPREE, (ASPirin in Reducing Events in the Elderly) is being led by Monash University in collaboration with the Menzies Research Institute (Tasmania), The University of Melbourne, The University of Adelaide and The Australian National University. ASPREE is also supported by the United States National Institutes of Health and National Institute on Aging, and the National Health and Medical Research Council of Australia. The important study is exploring whether healthy older people could take aspirin daily to extend their life and keep dementia and disability at bay. There is some evidence that aspirin may reduce the risk of heart attack, stroke, vascular events, cognitive decline and certain cancers in people aged over 70 years. Participants in the trial are randomly assigned in the doubleblind placebo controlled study to take either a low dose aspirin tablet (100 mg), or a placebo tablet for 5 years. A number of Australian GPs are participating in the trial and many more will be recruited, resulting in thousands of GP co-investigators. Senior investigator to the study Professor Mark Nelson said that recruiting thousands of trial participants would occur through general practices, underscoring ‘the pre-eminence of primary care’. Professor Nelson, who is Chair of General Practice at The University of Tasmania’s School of Medicine, acknowledged that recruiting 12 500 participants would be challenging. However, ASPREE

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coordinators will be able to identify eligible participants – those without an indication for, or contraindication to, aspirin – thanks to computerised searching of clinical databases. The more efficient search process means the proportion of eligible participants who enter ASPREE is 8 in 10 of those seen in the practice. Professor Nelson said they could ‘make sure that people who are eligible are invited. The efficiency rate is 80–87%, which is very high.’

Too often research done in general practice simply utilises primary care for case finding. We don’t ask the GPs to case find. So far, more than 1100 general practitioner co-investigators have registered for the study and 760 have commenced. The trial aims to recruit the required healthy older participants in Victoria, South Australia, Tasmania, the ACT and regional NSW. More than 4500 have been recruited to date. In addition, more than 6000 Americans will be recruited for the US arm of the study. The trial will be looking at aspirin effects in the group most at risk of dementia and other events, and will include both women and men. The participants will also be followed up annually with health, clinical and other measurements. ‘For a study like this’ Professor Nelson said, ‘we really need to get a representative sample in the community – this is the strength of general practice.’ If a general practice is

interested in becoming part of the trial, ASPREE can organise the recruitment, although some practices may choose to search their own patient records. ‘We have a preference for sending a research nurse into the practice and doing a database search for them. General practices are very busy and we want to have minimal impact – we go in, do the search, print the letters and stuff the envelopes,’ Professor Nelson said. Professor Nelson said that for those practices preferring to search for eligible patients themselves, the ASPREE team was happy to instruct general practices on how to do this. Patient records are not transferred out of the practice, and GPs send invitation letters to patients. The letter includes information about the study and requests that interested people respond by calling an 1800 number. According to Professor Nelson, the trial has had a relatively low drop out rate. The patient information consent form includes the known side effects of aspirin, including bleeding into the brain, or into the gut. Professor Nelson also pointed out the several potential benefits of the trial. ‘It’s an important acknowledgment about the pre-eminence of primary care,’ he said. ‘GPs should be treated as the miners and not the coal. Too often research done in general practice simply utilises primary care for case finding. We don’t ask the GPs to case find.’ While the trial is promoting good public health research, the most significant benefit will be the clarification ASPREE

Photo © Shutterstock / olavs

provides around the risks and benefits of regular aspirin use for older people. ‘The real beneficiary’, Professor Nelson said, will be the public. ‘If we find, for example, that aspirin delays the onset of dementia by 2 years, that’s a great benefit to society.’ The trial provides GPs with a one-off $100 administration fee per randomised subject. Patients see the doctor once,

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and this can be paid for under Medicare since the appointment assesses the patient’s cardiovascular risk. The trial has also built in a program for 40 Category 1 QI&CPD points.

For information on ASPREE visit www.aspree.org, email aspreegp@ monash.edu or phone 1800 728745.

Reprinted from Good Practice Issue 10 – December 2011 11


Faculty news

Rural Health Career Checks The RACGP National Rural Faculty now offers Rural Health Career Checks to students, registrars and GPs. Rural Health Career Checks provide an opportunity for participants to spend 20 minutes face-to-face talking with a respected rural GP about any aspect of their future career in rural general practice. The sessions offer an invaluable opportunity for students and registrars to work through their vocational milestones, pursue goals and opportunities – as well as advance and consolidate training and initial work choices as they embark on a career in rural general practice. The sessions also provide city based GPs interested in rural practice, or looking to diversify to a procedural role, an opportunity to discuss with a rural colleague the endless opportunities and new challenges rural practice offers. Rural Health Career Checks can be held at any RACGP attended event across Australia. For more information, or to find out when Rural Health Career Checks will be available in your area, contact the National Rural Faculty by email: rural@racgp.org.au or freecall 1800 636 764.

Faculty embraces the Torres Strait The RACGP’s National Faculty of Aboriginal and Torres Strait Islander Health visited the Torres Strait in October to learn about primary healthcare challenges, establish relationships and discuss future collaborations.

Brad Murphy and Lauren Cordwell, with Keith Fell, Councillor and Deputy Chair of the TS&NRA Health Partnership and his family at their home on Mabuiag Island

Rural Health Career Checks at GP11 Rural Health Career Checks were offered for the first time at GP11 in Hobart. Twenty one Rural Health Career Checks were undertaken by: • 18 students • 2 resident/interns • 1 practising GP. Feedback received at the GP11 conference was overwhelmingly positive and there was significant interest from external organisations. Formal evaluations were sent to all participants and feedback will be used to shape future sessions and promotion of the Rural Health Career Checks. Feedback received included: “I would be happy to recommend the session to other students in the future.” “I think that this is a wonderful concept, especially for those who are strongly considering a career as a rural procedural GP, such as myself. I felt that I was able to have all my questions answered in an open and honest manner.” “Great initiative. As an intern who has been accepted on a GP training program, to be able to discuss directly with potential registrar supervisors, training options available at the preferred location was priceless. This is a great opportunity for any PGY1/2 who may be interested in a career in rural general practice to get a good overview of what it takes to being/ training as a rural GP. I would happily go again next year.”

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Faculty Chair Associate Professor Brad Murphy, Manager Lauren Cordwell and National Advisor Jill Dixon stayed on Thursday Island, which is the administrative centre. From there they travelled to Horn Island by ferry, where the only airport in the Torres Strait is located, and then they flew out by charter to Mabuiag Island. The group visited the Torres Strait at the invitation of the Torres Strait and Northern Peninsula Area (TS&NPA) Health Partnership. For Dixon, the trip highlighted the costs and logistics involved in travel between islands and the mainland. ‘Flights are often delayed’, she said, and ‘are very expensive and in our case, aircraft were too small to cater for our travelling team.’ The result, Dixon said was that their host had to remain an extra night on the island. The average cost of a flight between Horn Island and the outer islands is $500 each way and some large families have up to 10 members who require transportation. Helicopter evacuations can cost $40 000 in daylight hours and more at night. Associate Professor Murphy, who gave a presentation about the faculty and its

work at a meeting with the TS&NPA Health Partnership, discussed the importance for the college in establishing relationships with the Torres Strait. “We indicated that we were proud that we have two representatives from the Torres Strait on our faculty board”. Associate Professor Murphy said one of the members of the TS&NPA Health Partnership had shared his hope that local people would study medicine and other professions and return to the islands to share their knowledge. Associate Professor Murphy, an Aboriginal man, plays a significant leadership role in building the relationship between the RACGP’s faculty and the TS&NPA Health Partnership. The group also met the CEO and Nursing Director of the Torres Strait and Northern Peninsula Area Health Service District and they toured the hospital. Important issues were identified and discussed regarding the delivery of primary healthcare in the Torres Strait. These included: • difficulties recruiting and retaining staff • significant barriers to telehealth initiatives, including limited resources

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• limited availability of cheap, fresh food – one supermarket chain is the only food supplier on most islands • travel costs and complications • the challenge of TB patients from PNG travelling to Torres Strait islands for treatment • clinical governance issues in clinics on small, remote islands, which have strong systems of local ownership and control • delays in service delivery and suboptimal use of resources, due to complexities of bureaucracy • limited mainland awareness of the Torres Strait, and isolation from professional networks for healthcare professionals • limited access to dentists and other specialists; visits can be prohibitively expensive, sometimes leading to the exacerbation of existing conditions. The national faculty is identifying opportunities for the College to further engage with the TS&NPA Health Partnership and with other organisations working in, or with, the region. These include advocacy, awareness raising, further exploration of telehealth opportunities and identifying research and capacity building opportunities.

Reprinted from Good Practice Issue 10 – December 2011 13


Health

To slip, slop, slap or not

Running a greener practice

With Australians having the highest rate of skin cancer in the world, recent headlines about the potential danger of using sunscreens that contain nanoparticles have alarmed some consumers.

Greeniology 2020: Greener living today, and in the future Author: Tanya Ha Format: paperback, 294 pages RRP: $36.99 Publisher: Melbourne University Press Published: October 2011

The main concern is whether nanoparticles – which are particles smaller than 100 billionth of a metre – are absorbed into viable skin cells where they could cause adverse health effects. The Therapeutic Goods Administration (TGA) issued a statement in 2010, which concluded that the potential for titanium dioxide and zinc oxide – two of the primary ingredients in sunscreen – to cause harm depended ‘primarily upon the ability of the nanoparticles in sunscreens to reach viable skin cells’. To date, the TGA said, ‘the current weight of evidence suggests that titanium dioxide and zinc oxide nanoparticles do not reach viable skin cells’. According to the TGA, the compounds stay on the surface and outer layer of the skin and do not reach viable skin cells. The TGA said it is monitoring emerging scientific literature and will take appropriate action should ‘any tangible safety concerns be identified’. Consequently, it does not believe that sunscreen labels should contain warnings about nanoparticles and it further states that it is not a requirement for labels to ‘declare the size of the active ingredients’. The Cancer Council states on its website, ‘on the best available evidence’ that nanoparticles used in sunscreens ‘do not pose a risk’. The organisation has said it would continue to monitor research. The current position of the RACGP is that SPF+ 30 sunscreen should be used and then reapplied every 2 hours as a protective measure against sun damage. Choice magazine tested 12 sunscreens for nanoparticles and found that four were nano-free, including Cancer Council Classic Sunscreen. Choice is advocating for labelling of nanoparticles on all sunscreens so ‘consumers can avoid them if they’re concerned’. While manufacturers in Australia are not required to list nanoparticles on labelling when included in sunscreens, it is possible to research and identify nanofree sunscreens available commercially if consumers are anxious about any potential ill effects from sunscreen use. SPF 30+ nano-free sunscreens are widely available in chemists and supermarkets. One precaution against skin cancer that is advocated by all authorities is to cover up. A broad brimmed hat, adequate clothing and sunglasses are the best protection against skin damage.

Running a greener, more economically sustainable office is good for the planet, as well as the budget. With increasing electricity, fuel and water prices, the cost of running a general practice is set to rise, so installing equipment and implementing policy that has minimal negative effect on the environment will benefit everyone. And it isn’t just up to the employer to make decisions, employees can also

Printers and photocopiers

Water

• Use print preview to see whether you need to change formatting before printing • Choose the smallest size of photocopier to meet your needs • Choose printers and photocopiers that use recycled content copy paper • Photocopy in batches where possible, since this allows the photocopier to work in its most efficient mode • Choose printers that use recycled toner cartridges • Refer to the RACGP Computer security guidelines for information about correct disposal of e-waste to protect patients’ confidentiality

• Install water-efficient taps and flow restrictors in bathrooms • Put up signs in the bathrooms and kitchens reminding staff and patients not to waste water

Heating, ventilation and air-conditioning • Set thermostats to 18–20°C in winter and 23–26°C in summer • Zone air conditioning and heating so that work areas can be separately cooled and heated, and use timer controls • Have your heating, ventilation and air-conditioning systems regularly serviced • Check that your insulation is adequate and use artificial or natural shade sources where possible

14 Reprinted from Good Practice Issue 10 – December 2011

Transport Make secure space available for staff and patients who want to ride their bikes to the practice

Paper • Hand towels or air dryers? Hand dryers probably use less total energy than paper (although this is disputed) and hand dryers can be recycled – whereas paper towels cannot • If there are large numbers of periodicals coming into the office that nobody reads ask the publisher to stop sending them, or request electronic versions instead • Choose copy paper certified by Good Environmental Choice Australia and the Forest Stewardship Council • Recycle paper products but take care to shred, not recycle, any item that may include personal information about a patient or staff member

Computers • Turn off computer monitors when you shut down the computer – monitors account for most of the power used by a computer • Don’t use screen savers – use password protected sleep mode • Use laptops where practical – they use up to 90% less energy than computers • Look for the energy star symbol when buying office computers • Turn on power management and energy saving features in your computer, but remember to protect security and privacy • Turn off the computer rather than leaving it on standby

If the light’s on

Photo © Shutterstock / haveseen

instigate changes in their workplaces by suggesting ideas and offering to investigate greener policies and practices. Research has shown that most people prefer to work in an environmentally friendly organisation, so planting the seed is often all it takes for others to happily participate in a greener workplace. Award winning environmentalist and ABC television presenter Tanya Ha provides green living advice, tips and ideas for running an environmentally friendly office in her new book Greeniology 2020. We’ve listed some of her most significant suggestions below.

Many appliances can be turned off at the wall over the weekend. Use coloured stickers to identify those that can be turned off, and those that must remain on (such as the fridge, fax and telephone)

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Lighting • Use natural lighting where available and appropriate, but protect patients’ privacy • Use motion censor controls for less-used areas, such as kitchens and bathrooms • Use energy efficient fluorescent tube fittings and light bulbs • Swap incandescent light bulbs for compact fluorescent or LED alternatives

Useful websites • For information about making the transition to green energy visit www.greenpower.gov.au • For certification and advice on environmentally friendly products and services go to www.geca.org.au • For your nearest printer cartridges recycling outlet visit cartridges.planetark.org

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Listings

Check out events in your state at www.racgp.org.au

December IMG study group Tuesday 6 December, 6.30–8.30 pm WA Faculty, 34 Harrogate Street West Leederville, WA The study group is designed for international medical graduates who are sitting the Fellowship exams. It will be run by a medical educator who is also an examiner. Contact Zolly Williams tel 08 9489 9555 email zolly.williams@racgp.org.au

GP Lunchtime Series Wednesday 7 December Tasmania faculty Launceston, Tas Final session in series will commence with lunch at 12.30 pm, followed by a 1 hour expert presentation at 1 pm. The series is free to RACGP members, but nonmembers are warmly welcomed for a nominal fee. Contact Amanda Poljansek tel 03 6278 1644 email amanda.poljansek@racgp.org.au

Psychodynamic principles for GPs workshop Saturday 10 December Seasons, Botanic Gardens Melbourne, Vic Full day workshop about psychodynamic principles and their application in the treatment of common problems via focused psychological therapies, such as cognitive behaviour therapy and interpersonal therapy. ALM component/approved by RACGP QI&CPD program. Approved by the GPMHSC, completion fulfils mental health CPD requirement for registered providers of FPS. Contact Victoria faculty tel 03 8699 0488 email vic.events@racgp.org.au

IMG workshop – workshop 1 Saturday 10 December RACGP College House 1 Palmerston Crescent South Melbourne, Vic Cost: $450 One day workshop is an intensive course to assist IMGs in their FRACGP exam preparations. Available only to practice eligible route IMGs enrolled in the RACGP Fellowship exams, including recipients of the IMG Fellowship Support Grant. For information tel 03 8699 0421 email hop.nguyen@racgp.org.au

IMG study group Tuesday 13 December 6.30–8.30 pm WA Faculty, 34 Harrogate Street West Leederville, WA The study group is designed for international medical graduates who

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are sitting the Fellowship exams. It will be run by a medical educator who is also an examiner. Contact Zolly Williams tel 08 9489 9555 email zolly.williams@racgp.org.au

IMG clinical update session in North Sydney Wednesday 14 December NSW&ACT Faculty, Level 7/12 Mount Street, North Sydney, NSW Designed to assist Australian Medical Council (AMC) candidates with their preparation for the multiple choice question and clinical component of the AMC exams. May also assist candidates aiming to develop their resumes in preparation for seeking a rural medical officer role. Register www.racgp.org.au/facultyeventlinks/NSW1112_16.pdf Contact Susan Jones tel 02 9886 4748 email susan.jones@racgp.org.au

Clinical exam consultation skills IMGs 7 February – 3 April NSW&ACT Faculty, Level 7/12 Mount Street, North Sydney, NSW Cost: $990 Nine week pre-examination course developed for international medical graduates preparing to sit the FRACGP clinical examination. The objective of the course is to improve knowledge of the clinical exam process, and the consultation and cross cultural skills within the Australian patient centred medical context. The course focuses on improving clinical management in mental health, multicultural health, adolescent health and other aspects of medicine. Contact Susan Jones tel 02 9886 4748 email susan.jones@racgp.org.au

March 2012

IMG study group Tuesday 20 December, 6.30–8.30 pm WA Faculty, 34 Harrogate Street West Leederville, WA The study group is designed for international medical graduates who are sitting the Fellowship exams. It will be run by a medical educator who is also an examiner. Contact Zolly Williams tel 08 9489 9555 email zolly.williams@racgp.org.au

February 2012 Pre-exam clinical workshop Saturday 4 February NSW & ACT Faculty, Level 7/12 Mount Street North, Sydney, NSW Workshop providing a detailed tour of the Objective structured clinical examination process, including exam tips and preparation tips. Video vignettes illustrate exam performance and how it can be improved. To register visit www.racgp.org.au/facultyeventlinks/NSW1011_42.pdf. Contact tel 02 9886 4700 email nswact.events@racgp.org.au

IMG workshop – workshop 2 Saturday 4 February RACGP College House 1 Palmerston Crescent South Melbourne, Vic Cost: $450

Medical receptionist course Friday and Saturday 2 & 3 March NSW & ACT Faculty, Level 7/12 Mount Street North, Sydney, NSW The receptionist course covers a range of topics directed at non-medical practice staff to increase their confidence. The course includes a nationally accredited VET qualification and offers participants the opportunity to complete the Statement of Attainment in Basic Emergency Life Support (HLTFA201A) from the Health training package. Contact tel 02 9886 4700 email nswact.events@racgp.org.au

Annual Women’s Health Update Saturday 3 March Melbourne Convention Centre South Wharf, Melbourne, Vic Topics include: thyroid disease in pregnancy, hormonal contraception, PCOS guidelines, gestational diabetes, irritable bowel cancer, relationship counselling and fetal alcohol syndrome. Register www.health.com.au Contact tel 1300 797 794 email info@ healthed.com.au

We are always looking for competent people who are willing to live and work within an international team, share their skills and dedicate their time to support our humanitarian work around the world.

JOIN OUR TEAM www.msf.org.au

One day workshop is an intensive course to assist IMGs in their FRACGP exam preparations. Available only to practice eligible route IMGs enrolled in the RACGP Fellowship exams, including recipients of the IMG Fellowship Support Grant. For information tel 03 8699 0421 email hop.nguyen@racgp.org.au

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msf ad 1 colm.indd 1 Practice Issue 10 – December 17/03/11 11:52 AM Reprinted from Good 2011 15


Good Practice Issue 10. December 2011