Pr int Post Approved PP 299436/00041

November2006

C a n b e r r a D o c t o r i s p r o u d l y b r o u g h t t o y o u b y t h e A C T A M A

Volume 18, No. 8

Woden 6282 2888 Deakin 6214 1900 Tuggeranong 6293 2922 Civic 6247 5478 A member of the I-Med Network

Dr Jeremy Price | Dr Iain Stewart | Dr Suet Wan Chen | Dr Malcolm Thomson | Dr Fred Lomas | Dr Paul Sullivan | Dr Ann Harvey

SEASON’S GREETINGSIn recognition of your support, NCDI has made donations to:

World Vision Salvation Army MS Society ACTWe wish you a Merry Christmas and a happy and safe New Year.

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2 N o v e m b e r 2006

Some Parking SanityThe other morning I was

called to Delivery Suite as one ofmy patients was ready to deliverher baby. When I entered theroom I noticed that her husbandwas absent and I jokingly askedwhether his stomach was a bitweak – only to be told that hehad gone to top up the parkingmeter. Fortunately he did returnjust in time to see his new familymember arrive safely. This is anappalling state of affairs!

I was pleased to hear thatsome sanity has entered the paidparking story and that ACTHealth will now relax the rules sothat patients who are delayedbecause of medical treatmentsare not subject to parkinginfringements.

The next step would be toallow free parking after 6pm,when there are ample parkingspaces. Have I previously men-tioned a multistorey car park atCalvary is urgently needed?

General PracticeWe are looking to restructure

our GP Forum to include moreACT AMA GP members. TheForum has always addressed thecutting edge and top of mindissues in general practice and Iam keen that the re-vamped GPForum should continue this tra-dition so that we can better rep-resent our local GPs to supportand advocate on their behalf toour local and federal politicians.In particular, it would be nice tobe able to address the issues of adiminishing workforce and theinequity of status between cityand outer metropolitan practices.

VMO NegotiationsThe lawful bargaining period

for VMO contacts terminated on1 November 2006. ACT AMAwas able to achieve a rise of 1.1%

on the baseline contract rates, aswell as a guaranteed minimum4% rise each year. Both of thesewill be quarantined from thearbitration process which willtake place to determine the out-standing matter as I mentionbelow. There are now no out-standing core-contract issues forsessional VMOs and the individ-ual VMO must make a personaldecision regarding renewingtheir contract. If there is no lapsein contracts the VMOs will alsogain a 5% continuity bonus, andhave their workload guaranteedand for those affected the transi-tional allowance will remain – asper the previous contract condi-tions.

There was no agreementfrom government to our claim toincrease fee for service contractsa further 15% to bring rates inline with the 120% (plus) ofCMBS that Veterans Affairs isnow paying. There will now bearbitration for this matter only,and ACT AMA will prepare acompelling case for the arbitra-tion and will draw on the expert-ise resident within the AMA fam-ily when preparing the case. Thisis another example of the benefitof being an AMA member – itsexpertise is available to you – andcontract negotiations such asthese are core business for theAMA. We are hopeful that thiswill be resolved in as short a timeframe as possible. However, ACTHealth have guaranteed to “backpay” contract holders to 29November 2006 irrespective ofwhen the decision is finallyhanded down.

2007 –Why wouldn’t you?

A female patient of mine saidthe other day that she reluctantlycame to see me as a male doctor,because the last male doctor had

been ‘too rough’. Putting on mybest bed-side manner I was ableto complete the examinationwith minimal discomfort. I sub-sequently found no major abnor-mality and discharged her backto her local GP, whereby sheasked if she could return in 2years for her next Pap smear.

What was the point of thatanecdote? I keep on hearing fromformer members that theyresigned in the past because ofsome terrible policy or deed thatFederal or local AMA perpetrated(or didn’t perpetrate). Or that theAMA is a specialist organisation,or conversely is a GP organisa-tion or that it doesn’t represent x,y or z, and so won’t join. I havebig shoulders, but I get a littletired of being responsible for thesins of the past – real or imag-ined, Federal and/or local! Iknow a lot of you feel passionate-ly about medicine – don’t just bean armchair expert, get involvedas a member – YES YOU!

From a purely economic per-spective the AMA brand dis-counts would virtually pay foryour membership (especially theCommonwealth Bank’s merchantEFTPOS terminal discount, andthe tax deductibility status ofmembership). In 2007 we will beoffering discounts by a numberof local retailers for local AMAmembers only – watch forupcoming details. The ACT AMAVALUES your membership!

I have also heard various col-leagues say that they belong tothis GP organisation or thatVMO association, and thatbelonging to AMA is unneces-sary. I beg to differ, and wouldemphasise that the AMA is amembership organisation and isonly able to lobby local and fed-eral politicians because of ourmembers. The AMA is a hugefamily with considerableresources and political clout and

remains the only independentrepresentative organisation forthe profession. So, don’t sit onthe sidelines – get involved andmake a difference!

I would therefore encourageALL readers to join the AMA in2007, by completing theenclosed membership form orgoing online.

More 2007The ACT AMA Council has

been a hive of activity and iskeenly plotting strategies for2007 which include: an earlyannual AMA dinner, intern ori-entation week, welcoming recep-tion for our new cohort of med-ical students, Family Doctorweek, and lobbying the ACTGovernment to participate in thelong term care scheme. This isnot an exclusive list – just a sam-pler!

The Doctor in Trainingforum will have its first meetingin November and we are in theprocess of establishing ourIMG/OTD forum. I shouldn’tneed to explain the necessity ofthese two important fora. If youfill the criteria for membership ofeither of these two for a please letChristine Brill know if you wantto be involved.

PhilanthrophicChallenge

For those who read theKenya article in the last CanberraDoctor you would be aware thatformer local Canberra GP Dr JoeRadkovic is requesting an ultra-sound machine to assist in hisdifficult and under-resourcedwork. To that end I am pleased toconvey that National CapitalDiagnostic Imaging and Canb-erra SIVF have already made sig-nificant contributions to thefund. I challenge other col-

leagues to contribute by sendinga cheque to ‘OR34 KorogochoSlum Maternity Clinic – Dr JoeRadkovic’ c/o ACT AMA. I wouldbe very happy to mention othersignificant contributions in thenear future.

Federal IssuesThe Federal AMA met in

Canberra from 3-4 November.Electronic health is laggingbehind in Australia, and majorareas of concern include elec-tronic communication betweenhospitals and GPs, and GPs andspecialists.

An important resolution waspassed supporting long term carefor children under age 18 whohave permanent disabilitiesrequiring more than 2 hours ofpersonal care/day and for adultswho are permanently injured as aresult of serious and rare medicalcomplications or accidents. I ama strong believer in the social jus-tice of this initiative, especiallyfor those children with cerebralpalsy. The next step will be to getpolitical support. Certainly ACTAMA intends to lobby our localgovernment to support this ini-tiative.

I would like to wish all readers ameaningful Christmas, and look

forward to meeting you at an AMAfunction in 2007.

Dr Andrew Foote.

ACT AMA President’s letter

A small group of Canberradoctors recently attended afundraising cocktail party, organ-ised by the ACT AMA and host-ed by President, Dr AndrewFoote and Mrs Foote, to benefitthe Medical Benevolent Assoc-

iation. The Association providesa counselling service and finan-cial assistance and is available toevery registered practitioner inNSW and the ACT. The eveningraised $4000 for this worthwhileaid organisation which supportsdoctors and their families duringtimes of need.

Dr Liz Rushbrook, an MBABoard member and Canberra-based medical officer with theNavy spoke of the work of theMBA and told the attendees that,“MBA currently assists just under300 persons in NSW and ACT.About 25% of these are doctors,the remainder are doctors’ part-ners, children or other family.This translates to assisting about 5 doctors (directly or indirectly) in 1000. Inrecent years support to the totalvalue of $450 000 per annum has

been provided. Assistance is pro-vided in the form of direct finan-cial assistance (65%), socialworker assessment and support(20%) and essential administra-tion costs (15%)

The beneficiaries of MBAinclude those that are:� Mentally and physically ill;� The bereaved;� The separated/divorced; and� Those that have temporarily

or permanently lost theirright of practiceMBA council does not allow

the cause of an individual’s needystate to influence the decision ofwhether or not to help”.

Dr Rushbrook pointed outthat MBA NSW is overseen by abody of 20 councillors (all regis-tered Medical Practitioners) whogive their services on a voluntarybasis. A full time social worker is

employed to accept calls, provideassessments and practical careand advice (initial and ongoing asrequired). Since 2005, a part timeadministrative assistant hasensured timely processing of nec-essary administrative documentsand services. Professional servic-es are outsourced as required.

Dr Rushbrook said that, “theMBA aims to help doctors andtheir families exist and emergefrom times of trouble to self-suf-ficient status. MBA provides:� Confidential counselling and

support� Funds for basic life necessi-

ties including accommoda-tion, food, clothing, school-ing/university basics (textsetc). MBA often pays formortgages (for limited time)because we have found thatif beneficiaries lose their

houses, rent will cost evenmore. We do not restorehigh-flying lifestyle. We arenot too shy to insist thatexpensive cars be exchangedfor more economical modelsbefore we accept someone asbeing truly in need;

� Provision of advice aboutavailability of other assis-tance programs such asDoctors Health AdvisoryService, CommonwealthSocial Security and Disabilityschemes,

� Social Worker: Mrs MDoughty AM.“MBA derives income from

donations from the medical pro-fession – generally throughannual and Christmas appeals(direct mails outs to registereddoctors). Donations come fromdoctors via the NSW branch of

Medical Benevolent Association to receive $4000 from

Dr Ian Pryor and Mr Nevin Agnew(Minter Ellison) at the cocktail party.

3N o v e m b e r 2006

Eight months left to take advantageof the tax free regimeIn previous articles we looked at 3 opportunities, betweennow and 1 July 2007(this is the date most of the federal budgetsuper reforms comeinto effect) so as tomaximise your longterm wealth throughsuperannuation.

The 3 opportunities we pre-viously mentioned are:

1. Using the one off oppor-tunity to contribute up to $1million post tax contributionsbefore 1/7/07 (before a$150,000 cap of these contribu-tions are introduced)

2. Last chance to use supercontributions to offset largecapital gains on the sale of otherassets

3. Final opportunity tomaximise the tax efficiency ofyour super

We have found that manypeople still understate or don’tcomprehend the value of theseopportunities, particularlynumber 1 and to a lesser extent

number 2. From now until1/7/07, the word should bespread, particularly to thosenearing retirement, to reviewyour overall financial strategyor risk missing out.

The government knowshow attractive super will bepost 1/7/07 from a tax point ofview. Generally, they willreceive no tax revenue fromeither the member, or from thesuper fund, whilst the fund ispaying a pension. A completelytax free entity! Compare this toa 30% tax take through compa-nies and trusts, or as high as46.5% for assets held in yourown name.

Hand in hand with the taxfree entity proposal is the con-tribution limits though. Thegovernment must limit howmuch a taxpayer can contributeto this tax regime after 1 July2007, otherwise it would be tooattractive. The post tax contri-butions limit of $150,000 perannum was originallyannounced as effective immedi-ately from Budget night.

During the submission peri-od there was a protest votehowever, as some “pre-retirees”had planned to sell large assetsand place the proceeds intosuper just prior to retirement.At the same time, most were

also planning to offset any capi-tal gains tax using a deductiblesuper contribution (number 2).The new contribution limitssuddenly prohibited this activi-ty. As a result of the backlash,the government conceded andhas allowed a $1 million dollarcontribution window until July.Beyond July, the $150,000 perannum limit will apply.

The proposed limits from1/7/07 will also have significantconsequences for some medicalpractitioners. A very popularstrategy in the past has been forthe self managed super fund toacquire a business premises(usually the building where thepractice is run), by way of anin-specie contribution. Thefund then leases the buildingback to the practice. Under thenew contribution limits, veryfew funds will be able to acquirethe business premises in thisway, unless of course they actbefore 1/7/07.

The key message is thatwhether retired or preparing toretire, the decisions you makenext eight months are likely becritical to the wealth you willenjoy in your retirement years.Now is the time to review yourprospective retirement.

Our advice…get advice.

AMA which kindly includes anappeal for donations with itsannual membership renewalnotice, as does the ACT AMAwith additional donations from Local Medical Associa-tions, Divisions of GeneralPractice, Medical Staff Councils,Annual Reunions and othermedical bodies.

“Over the past 5 years, indi-vidual donors have exceeded1200, with the average donationbeing approximately $100-150.A large proportion of currentincome comes from the MBAinvestment portfolio. This iswhere donations and bequests in“excess” of need over past yearshave been invested for use in thefuture. Over recent years, it hasbeen this income that has “keptus afloat” in terms of meetingthe needs of beneficiaries. (One

bequest for $300,000 in 1993has made an enormous differ-ence).

“MBA exists to help those ofour profession who require it. Inorder to protect yourself andyour family, MBA recommendsthe following:� Life insurance� Income protection insurance� Review your lines of credit –

availability, care in over-extending credit limits/expo-sure

� Social life – Take time forfamily, spouse, leisure

� Substance abuse. Awareness,limiting risk, accessing assis-tance

� AVOID Self treatment – GETA GP

� Keep documents “up todate” – wills, financial docu-ments, legal documents (see

www.mba.nsw.org.au for“Take Care” advice)

� Referrals – self, colleague,AMA, NSW Medical Board,DHAS, Family members,other social workers; and

� Initial point of contact is oursocial worker Ms MaryDoughty 02 94197062. MBA thanks you for your

support, now and in the future”.

Background to the MBAThe Medical Benevolent

Association (MBA) was foundedin 1896. Initially it was a groupof doctors who themselvesassessed and advised needy doc-tors and their dependants. As thedemands upon the service grewmore complex, the group app-ointed an almoner (1941) toprovide assessments and dispas-sionate counseling. Increasingnumbers and complexity ofcases led to the engagement of apart time social worker (1947).Over time, increasing workload

has made this an essentially fulltime role.

Today, MBA’s charter is toassist medical practitioners ofNSW and the ACT and theirfamilies during times of need.The interpretation of “their fam-ilies” includes partners, childrenand other moderately removeddegrees of relationship. In fact,the MBA constitution allowshelp to any person determinedby the Council as being “necessi-tous”. This broad definition ofwhom we can help allows MBAto obtain/retain tax deductiblestatus for donations to us.

In 1859, the original AMAset up a benevolent fund. ThatAMA became defunct in 1869.

MBA NSW began its life in1896 as the Medical BenevolentFund of NSW, made up of agroup of thoughtful doctors whowished to provide “money help”for members of the professionand their families as the needarose. It was set up as an inde-

pendent body which became theMedical Benevolent AssociationNSW in 1926 and a registeredcompany in 1936. It became aregistered charity in 1957. In1977, it gained tax deductiblestatus for donations made to theAssociation.

Thank you to all who sowillingly gave to support thework of the Medical BenevolentAssociation. If you were unableto attend and wish to send adonation, please make yourcheque payable to the MBA andyou can send it to the ACT AMAat PO Box 560 Curtin ACT 2605.Donations are tax deductible.

The event was generously sup-ported by Minter Ellison,

Lawyers, Medfin, King Financialand American Express as well as

Dawn Drifters, De costiseafoods, Bungendore Wood

Works and International SportsPhotography.

Canberra doctors

General advice disclaimer:Information provided in this arti-cle is for general purposes only &the application of its contents tospecific situations will depend

upon the personal circumstancesinvolved

Information is current as of 06October ‘06 & subject to changeWhilst King Financial Services

believes that the information con-tained in this presentation is cor-

rect, no liability for errors oromissions is accepted

AssistingCanberra Doctorsand their families too!

The Medical Benevolent Association is an aid organisation which assists medical practitioners, their spouses and children during times of need.

The Association provides a counsellingservice and financial assistance and isavailable to every registered medicalpractitioner in NSW and the ACT.

The Association relies on donations toassist in caring for the loved ones of your colleagues.

For further information please phone Mary Doughty on 02 9419 7062

4 N o v e m b e r 2006

The protected “bargaining period”for VMOs terminatedon 1 November 2006, following a lengthyprocess that hasengaged both VMOsand their bargainingagents.

Core contract conditions(other than the percentageCMBS increase), are accept-able in the view of the ACTAMA. Modest changes havebeen applied to the new con-tracts which have been agreedby all parties to the negotia-tions. There is no reason, inthe view of the ACT AMA,why VMOs should not extendtheir contracts pending resolu-tion of the remaining matter atarbitration.

ACT Health has guaran-teed that any arbitratedincrease will be “back paid” to29 November, 2006 and anycontractors who renew orextend will not jeopardisetheir guaranteed workload,transitional allowance or con-tinuity bonus. At the conclu-sion of the arbitration, individ-ual VMOs will be able to makethe decision to take up a con-tract or to decline. VMOs willmake this decision in the lightof the result of the arbitrationand their own practice andpersonal pressures.

The ACT AMA has keptVMOs informed of progress onthe negotiations and soughtfeedback from its membersduring the process and so

VMOs know that it was appar-ent early in the negotiatingprocess, that ACT Healthcould not agree to an increaseequal to 120 percent of the2005 CMBS for fee for servicecontract holders and offeredearly arbitration of this matter.In any event, any unresolvedmatter required under thelaw applying to VMO con-tracts is subject to arbitration.For further information visitthe ACT AMA websitewww.ama-act.com.au and lookfor the VMO “Hot Spot”.

At a meeting almost liter-ally at the 11th hour, the ACTAMA successfully negotiatedfor an increase in the floorprice to 105 percent of the2005 CMBS and ACT Healthagreed to an equivalentincrease of 1.1 percent for ses-sional contract holders inreturn for “goodwill”. (Fee forservice contracts were former-ly at 103.9 percent of the 2005CMBS). Both contracts willattract a 4 percent indexationin July each year. ACT Healthhas provided guarantees thatthese will be preserved in thenegotiation process and thatany rate arbitrated must beeither equal to or more thanthese rates.

The ACT AMA is prepar-ing its case for arbitration andwill argue for an increase to120 percent of the CMBS.VMOs are invited to submittheir arguments for thisincrease to Christine Brill,executive officer, at ACT AMAby email: execofficer@ama-act.com.au or by fax to 62730455. The ACT AMA hasengaged VMOs throughoutthe process and intends toremain inclusive.

VMO contracts to go to arbitration

AMA President, DrMukesh Haikerwal, saidtoday that the require-ments of the 457 visa foroverseas trained doctors(OTDs) must bestrengthened.

The AMA call comes on theback of recent announcementsthat the health sector is now thebiggest user of temporaryskilled migrants with 457 visas.

Dr Haikerwal said if theStates and Territories can’t gettheir act together and adoptconsistent OTD assessment andsupport standards, then theCommonwealth should streng-then the 457 visa requirementsfor OTDs to ensure that theAustralian health system gainsmaximum benefit from the con-tribution being made by OTDs.

The AMA believes thatstronger 457 visas would assistmoves, led by the AMA, toadopt consistent national stan-dards and processes for assess-ing OTDs – a development thatwould ultimately result in OTDsstaying and working for thelong term.

“It’s a two-way street,” DrHaikerwal said.

“We have to ensure thatOTDs working in Australia havethe necessary qualifications,

skills and experience to work inour health system and to main-tain patient confidence.

“But we also have to ensurethat these doctors are properlyeducated and mentored in themedical practice, language, andsocial and cultural facets ofbeing a doctor in Australia.

“Unless we urgently imple-ment consistent national stan-dards, the Federal Government’sefforts to implement standard-ised assessment, training, super-vision and support processes forOTDs will fail.

“The States and Territorieswould continue to do their ownthing based on short term polit-ical expediency rather than longterm benefits for patients andthe health system.

“The Federal Government,though, can send a strong mes-sage to the States by strengthen-ing the 457 visa requirementsfor doctors,” Dr Haikerwal said.

The AMA is calling on theGovernment to implement thefollowing new requirements fora 457 visa for OTDs: � OTDs’ skills and qualifica-

tions must be assessed bythe relevant Medical College

� employers sponsoring OTDsmust provide the OTD withaccess to a formal orienta-tion program about theAustralian health system

� the employer must ensurethat the OTD is providedwith any supervision and

training as determined bythe College assessment

� the employer must providethe OTD with a mentorwho holds qualificationsrecognised in Australia andwho is established inAustralian medical practiceCurrently, Temporary Bus-

iness (Long Stay) visa (subclass457) are available under arr-angement for: � sponsorship by Australian

or overseas businesses:Businesses unable to meettheir skills needs from with-in the Australian labourforce can sponsor personnelfrom overseas on a tempo-rary basis, to work inAustralia for up to 4 years.

� Labour agreements: This isa formal agreement negoti-ated between the AustralianGovernment and employers,including industry oremployer associations.

� Invest Australian SupportedSkills agreements: For over-seas companies that plan toestablish their headquartersfor the Asia-Pacific region inAustralia; and

� Service Sellers. For repre-sentatives of overseas sup-pliers of services negotiat-ing, or entering into, agree-ments to supply their serv-ices in Australia.

457 visa requirements must bestrengthened for OTDs

Book for review:A reviewer is wanted for the new revised and updated edition ofDr Christopher Green’s “Toddler Taming – The guide to your child’sbehaviour from one to four”. If you are interested in reviewing thisfor “Canberra Doctor” readers, please contact Linda McHugh inthe ACT AMA Secretariat on 6270 5410.

PLEASE CUT OUT & PASTE INTO YOUR DIRECTORY

GENERAL SURGERYCHONG, Guan Head and Neck, Endocrine surgeries 6262 1200 Suite 18, John James Medical

Centre, 175 Strickland Crescent, DEAKIN ACT 2600OBSTETRICS AND GYNAECOLOGYGALLAGHER, Elizabeth Private obstetrics, private and public general gynaecology. 6282 2033 Suites 3-5, John James Medical Centre, 175 Strickland Crescent,

Special interest in pelvic floor prolapse, colposcopy and outpatient LLETZ DEAKIN ACT 2600

HEATON, Roger 6285 1873 Suite 9, John James Medical Centre, 175 Strickland Crescent, DEAKIN ACT 2600

PLEASE REMOVE FROM YOUR DIRECTORY

NEPHROLOGY FALK, Michael

CORRECTIONS: The ‘Canberra Doctor’ Specialist Directory

✁

5N o v e m b e r 2006

ACT Minister for Health,Ms. Katy Gallagher MLA andMs. Julie Tongs, Chief Exec-utive of Winnunga Nimm-ityjah Aboriginal MedicalService, have recently jointlylaunched a new range ofresources for palliative careand dealing with grief and lossfor Aboriginal and TorresStrait Islander peoples.

The new resources includ-ed a brochure, poster andworkbook developed by ACTHealth and aimed at raisingawareness of palliative careoptions, and a series of broch-ures developed by Winnungaand the community on ‘Griev-ing our Way’.

“While the ACT Healthpalliative care resources aim toincrease awareness in theAboriginal and Torres StraitIslander communities of thepalliative care services avail-able in the ACT, they also aimto increase the cultural appro-priateness of palliative careservices for Aboriginal peo-ple,” Ms Gallagher said.

“The resources will pro-vide guidance to mainstreampalliative care workers on cul-tural beliefs and needs whenthey deliver care to Aboriginaland Torres Strait Islanderclients.”

“National figures from pal-liative care services and re-

search within Aboriginal andTorres Strait islander commu-nities indicate that very fewpeople from these communi-ties access palliative care sup-port.”

“Hopefully, these resourc-es can open up the valuableand wide-ranging palliativecare services we have toAboriginal and Torres StraitIslanders from the ACT andaround the district,” MsGallagher said.

Funding for the projectwas made available by theAustralian Government Dep-artment of Health and Ageingas part of a project to raiseawareness of palliative carepractice principles in Aborig-inal and Torres Strait Islandercommunities.

Ms Gallagher said theresources had been developedthrough wide community andgovernment consultation andincluded Ngunnawal Abor-iginal Corporation, WinnungaNimmityjah Aboriginal HealthService and areas of ACTHealth.

The launch was part of atwo-day workshop dealingdeath, dying and grieving inour community – a palliativeapproach for Aboriginal andTorres Strait Islander peoples.

New palliative careand grieving resources Prevocational medical

educationThe 11th National Forum

on Prevocational MedicalEducation was held in Adelaideat the beginning of November.

One common theme washow to cope with the "tsunami"of medical graduates fromAustralian medical schools like-ly over the next few years. Iss-ues of concern include tellingfull fee paying students thatthey may not be guaranteedpostgraduate training placesand whether private hospitalsshould be able to contract toteach postgraduates and subjectto what types of quality assur-ance programs.

Emergency medicinefacilities in Iraq

An article in the BMJ (2006;333; 847) has highlighted thelack of adequate emergencymedicine facilities in Iraq whereit is estimated that

terrorist violence has killed14,338 civilians between Janu-ary and June 2006.

Federal court injunctionMerck Sharp and Dohme

has won a Federal Court in-junction delaying market entryof generic forms of its high salesvolume osteoporosis drugFosamax.

It is hoped that proposedamendments to patent laws in

Australia (facilitating 'spring-boarding' or pre-marketing useof brand-name data by genericcompanies) may limit such'evergreening' actions (Pharmain Focus 6-12 Nov 2006)

Exclusivity of new phar-maceutical products

In a recent edition of theNew England Medical JournalAlastair Wood defends his sug-gestion that data exclusivity ofnew pharmaceutical products,now offered for about five yearspost marketing approval for allallegedly 'innovative' drugsregardless of their communityvalue, be only offered to thosethat can prove they are moreeffective than current therapies.He writes "It is eye-opening toreview the list of the 10 top-sell-ing drugs and recognize howfew of them show any evidenceof superiority over genericdrugs, even though billions ofdollars are spent on them. Thisis truly an indictment of ourprescribing practices." (NEJM2006; 355 (19) 2046)

US supreme courtdeclines to overturnfederal court judge-ment

Another article in the NEJMdiscusses the recent LabCorpCase where the US SupremeCourt declined to overturn a

Federal Court judgement whichupheld a patent over a methodof diagnosing a vitamin defi-ciency on the basis of homocys-teine levels in blood. The Amer-ican Medical Association andthe American Heart Associationhad opposed the decisionbecause physicians who areuncertain whether a new treat-ment has patent protection maynot feel free to adopt it, soinhibiting the distribution ofmedical knowledge.

Dr Thomas Alured FaunceBA LLB (Hons) B Med. PhD.Lecturer ANU Law Faculty(Health Law, Ethics and Human Rights)Senior Lecturer ANU Medical School(Chair: Personal and ProfessionalDevelopment)Project Director, Globalization and HealthCentre for Governance of Knowledge andDevelopment, RegNet, ANUPh: (02) 6125 3563

Bioethics from the Journals with Dr Thomas Faunce

The AMA fought longand hard to remove a sig-nificant level of the redtape and complexitiesrelated to the old EPCitems to deliver the newchronic disease manage-ment items. While theyare not utopia they dorepresent a real improve-ment evidenced by thevery significant uptake ofthe items by generalpractitioners.

The Government listened tothe AMA on this issue and alsolistened when it raised issuesaround access to a variety ofhealth checks.

The intent of the healthassessment and care planningitems is to enable GPs to providecomprehensive and continuingcare to patients who have, or areat risk of, chronic illness. To thisend the AMA ensured the inclu-sion in the MBS of a requirementthat these services be providedby the patient’s “usual GP” orpractice.

Anecdotal evidence suggests,however, that the definitionaround the patient’s “usual GP”or practice may be misunder-stood or being interpreted loose-ly by some practices. In the past12 months, the AMA hasreceived increasing complaintsfrom doctors who are findingthat their ability to provide vitalcare to their patients is beingrestricted. These GPs are discov-ering that they are unable to givetheir regular patients a healthassessment or develop a careplan because these services havealready been delivered throughanother practice. Member GPshave questioned the motivesbehind the enthusiasm withwhich some GPs, who do nothave regular contact with apatient, utilise these items.

There is little doubt that theGovernment is also questioningsome practices in this area aswell. While the Government andAMA share a strong view thatmeasures may be needed to tidyup practices which devalue theintent of the items such measuresshould not compromise accessfor the genuine “usual GP” orpractice to treat their patientsand provide access to high quali-ty ongoing care through use ofthese items.

The AMA urges doctors pro-viding these services to be aware

of the requirement that the itemsbe delivered by the patient’s“usual GP” or practice and con-sider whether they will be caringfor the patient over the next 12months before using these items.The first question that should beasked is whether providing thisservice is “good” for the patient.

The AMA intends to workwith the Government in pursu-ing compliance with the require-ment for this service to be deliv-ered by the patient’s usual GP inorder to ensure this care remainsreadily available to patients.Contact and consultation withAMA members suggests thatappropriate measures aimed atcurbing practises that do notcomply with the spirit and intentof the items and the “usual GP”requirement in the MBS will besupported and welcomed.

We have been advised thatMedicare Australia is planning toconduct an audit of the chronicdisease management items nextyear and this may help highlightthe true extent of this problem.Where the service and billing areprovided in good faith by theusual GP, in the interests of goodpatient care, GPs have nothing tofear from this audit.

By Julia Nesbitt, Director ofGeneral Practice & e-Health,

Federal AMA

THE ‘USUAL GP” – An AMA WIN

6 N o v e m b e r 2006

AMA President, DrMukesh Haikerwal, calledon State and TerritoryGovernments and publichospital administrators tourgently review rosteringand work practices forhospital doctors after anAMA survey revealed thatalmost two-thirds of public hospital doctors areworking unsafe hours.

The AMA Safe Hours Audit2006 has found that 62 per centof Australian hospital doctorsare working unsafe hours – clas-sified as high risk or significantrisk – with one doctor reportinga continuous unbroken shift of39 hours.

The survey is the first sincethe groundbreaking AMA SafeHours Audit of 2001.

Dr Haikerwal said the 2006survey exposes work practicesthat contribute to doctor fatigueand stress levels that ultimatelyimpact on the quality of care andpatient safety in the public hos-pital system.

“All Australian governmentsmust take a close look at theresults of this survey and urgent-ly put in place measures to dra-matically improve the work con-ditions and work practices fordoctors,” Dr Haikerwal said.

“Fatigue and stress are tak-ing their toll – we have to stopoverworking our medical work-force, which is already becominga scarce resource.

“Our junior doctors allcome up through the hospitalsystem and we cannot risk turn-ing them off medicine or forcingthem out of the full-time work-force.

“Things have improvedmarginally since the last survey,but reform of hospital workpractices is too slow and incon-sistent across the country.

“The public hospital systemis a major and vital pillar ofAustralian health care, and is thefirst port of call for manyAustralians seeking medical careand treatment.

“We must not let our publichospitals and the doctors whowork in them fall into neglect.

“Safe hours for doctorsequals safe hours for patients,”Dr Haikerwal said.

Conducted in May 2006, theaudit tabulated responses frommore than 550 public hospitaldoctors of all ages from all Statesand Territories.

The on-line survey collecteddata on the hours of work, on-call hours, non-work hours, andsleep time experienced by doc-tors working in the public hos-pital system over a full workingweek.

The most stressed disciplineis surgery, where 85 per cent ofdoctors fall into the significantrisk and higher risk categories.

There are minor improve-ments over the AMA’s 2001 sur-vey results, where 78 per cent ofrespondents fell into the signifi-cant risk and higher risk cate-gories.

Some other indicators showsigns of improvement. Forexample, for doctors in the high-er risk category the longest con-tinuous period of work fell from63 hours to 39 hours.

Doctors had more full daysoff work during the audit weekand more opportunities for mealbreaks when working.

But in the AMA’s view, shiftsof 39 hours are no more accept-able than 63-hour shifts.

Even doctors in the lowerrisk category are working shiftsof up to 18 hours.

The average of total hoursworked in the 2006 audit weekwas the same as in 2001. How-ever, the longest hours worked byindividuals during the auditweek actually went up – to 91(from 86) and 113 (from 106) for

the significant risk and higherrisk categories respectively. Thisindicates that the riskiest workpatterns are still commonplace.

Dr Haikerwal said that inany other industry or profession,these ‘improved’ figures wouldbe cause for deep concern andimmediate remedial action.

“We now have awarenessand recognition that the old cul-

ture of onerous hours has tochange for the good of doctorsand their patients.

“Translating this into prac-tice remains a challenge.

“The AMA’s National Code ofPractice – Hours of Work, Shift-work and Rostering for HospitalDoctors should be adopted by allStates and Territories as anabsolute minimum.”

This coming year will seeACT Health welcoming thirdand fourth year medical studentsinto full time clinical placements.The program involves learning atthe patients’ side in the contextof four rotations, including gen-eral practice, surgery, medicineand paediatrics. Compulsorycontact hours stand at approxi-mately 20 hours per week with asuggested further 20 hours of selfdirected learning. However, thereare currently no clear andenforceable limits to ensure thatstudents will not work in excessof the hours required, therebyrendering them and theirpatients susceptible to the conse-quences of fatigue and burnout.

In Australia, working hoursfor doctors are largely unregu-lated. In comparison, mandato-ry work hour limits were set inthe USA by the AccreditationCouncil for Graduate MedicalEducation in 2003. This policystates that a trainee should notwork in excess of 30 consecu-tive hours and no more than an80 hour week, and one day outof seven the trainee should befree of all work duties. In theUK, work days have been limit-ed to 13 hours and a 58 hourworking week.

The Australian MedicalAssociation is currently review-ing its policy on the hours youngdoctors work through the nationwide safe hours survey. The cur-rent policy states that working inexcess of 14 consecutive hoursplaces doctors at increased riskof fatigue; however the policydoes not formally restrict thesehours. Unlike the strategies soonto be in place in Australia forpractising doctors, universitiesare yet to consider regulatingmedical student training hours.

Research has shown thatfatigue caused by long workinghours can impair the judgementand competence of medical per-sonnel, resulting in negative con-sequences to both patients anddoctors. A study by Arnedt, 2005looked at the neurobehaviouralperformance of residents afterheavy night call vs after alcoholingestion. Heavy night call wasdefined as a month of 90 hourweeks with overnight shiftsevery 4th or 5th night vs bloodalcohol levels of 0.04 percentafter one month of 44 hourweeks of daytime shifts. Arnedtand colleagues reported thatboth sleep deprivation and alco-hol consumption impair a per-son’s reaction time, attention,

judgement, control and drivingability. Fatigue has been reportedto contribute to work placeerrors, lack of time spent withpatients, impaired communica-tion and failure to complete casenotes appropriately.

Extended work hours alsoincrease the likelihood of percu-taneous injury to physicians by61 percent compared with non-extended work hours as reportedby Czeisler et al 2006. The studyalso reported that 64 percent per-cutaneous injuries were due tolapses of concentration and 31percent were due to fatigue.Although medical studentsshould be considered ancillarystaff, they do share responsibili-ties in patient care. Beingplagued by fatigue and sleep dep-rivation can lead to adverseeffects on patient care and stu-dent learning and safety.

Both physical and emotionalexhaustion lead not only to med-ical mishaps but also to psychi-atric morbidity and the commonwork place issue of burnout.Historically the intern year hasbeen associated with high levelsof depression, anxiety andburnout. Willcock et al. 2004,stated that 26 percent of finalyear medical students from the

University of Sydney sufferedfrom somatic symptoms, anxiety,insomnia, social dysfunction anddepression, collectively referredto as psychiatric morbidity. Theprevalence increased significant-ly during internship to 70 per-cent. Considerable increases inemotional exhaustion and deper-sonalisation were also reported.

Psychological distress canalso result from an inability toachieve often unrealistic idealsby exhausting one’s physical, andmental resources. Many medicalstudents enter their degree withaltruistic ambitions and heroicfantasies of healing the sick. Inorder to achieve these ideals,many students develop compul-sive type A personalities whichfurther contribute to theirpropensity to over-extend them-selves. In addition to the person-al characteristics discussedabove, junior doctors face thehistorically perceived rights ofpassage dictating arduous dutyschedules. Unfortunately this oldschool of thought is still har-boured by some senior medicalphysicians placing further pres-sures on students to be availablearound the clock and emulatetheir supervisors’ work ethic. Inlight of the literature discussed itis clear that the current culture of

the profession leads to dangerousoutcomes for both patients andyoung doctors.

Medical student work hourreforms must be addressed bymedical schools, and policies putin place to limit hours spent inthe hospital. Strategies that maybe developed include: settingtime limits for hours on duty,compulsory rest periods, morestructured timetabling, and edu-cating students on the impor-tance of self-regulation regardingsafe work hours and mental well-being. Student duty hoursshould be regulated and moni-tored taking into account theeffects of fatigue and sleep depri-vation on learning and patientcare. In general, medical studentsshould not be required to worklonger hours than interns andresidents. Although it is ulti-mately the responsibility of theindividual, universities shouldenforce mandatory regulations tostop those students who can’tstop themselves. � This has been written by 2nd

year ANU medical students,Elizabeth Coyle andGiovanna Zuccala.References can be obtainedfrom the authors.

Continued on page 7

Sensible hours and safe students save lives: Unregulated training hours for medical students

AMA SAFE HOURS AUDIT 2006 Hospital Doctors still working long and stressful hours

7N o v e m b e r 2006

AMA Position StatementEmployment of MedicalStudents in Hospitals(2006)

The AMA understands thatin some states, during theirundergraduate university course,some final year medical studentshave been employed inappropri-ately to fill medical workforceshortages.

The AMA believes that med-ical students are not substitutesfor any type of Medical Officerand they should not be utilised tofill gaps in the medical work-force.

In particular, the AMA isconcerned about reports that stu-dents employed in hospitals havebeen left without supervision andare undertaking tasks thatrequire medical practitioner reg-istration.

The AMA believes that therole of medical students in hospi-tals and other clinical settingsshould be focussed on learningrather than fulfilment of employ-ment obligations and tasks.

It is inappropriate for med-ical students, by default or other-wise, to be performing the role ofMedical Officer or undertakingtasks which require a registeredmedical practitioner. Allowingsuch a situation to arise placesstudents – and potentiallypatients – at risk and raises med-ical indemnity and legal issuesfor the students, their supervi-sors, the hospital and the univer-sity. It may also place at risk thefuture medical registration of thestudent. It imposes an unfair andinappropriate burden of respon-sibility on students, their medicalsupervisors and other hospitalstaff.

The AMA does not opposethe employment of medical stu-dents by hospitals, as there arecircumstances where medicalstudents are employed success-fully by hospital departments inappropriate roles (eg pathologyassistant or orderly).

The AMA believes that theemployment of medical studentsby hospitals in any capacityshould only occur when stu-dents:� are employed in appropriate

job classifications (notMedical Officer) and are notundertaking work that wouldotherwise be part of theirclinical training;

� are performing duties com-mensurate with their level ofskill, knowledge and qualifi-cations;

� do not undertake tasks thatrequire medical practitionerregistration;

� have clear job descriptionsdetailing what is expected ofthem in the workplace andthat these are strictlyadhered to;

� are appropriately supervisedand trained for the work theydo;

� are paid appropriately forwork performed; and,

� have adequate indemnityinsurance with the employertaking full medico-legalresponsibility for all theiractivities.It should also be ensured that

the:� employment arrangements

do not impact on the abilityof the student to meet thelearning objectives of theirmedical degree; and

� hours of employment do notencroach on time needed forlearning activities.Proposals for employment of

medical students, and any exist-ing employment situations,should be assessed against thesecriteria.

ACT Health to implement e-rosteringusing AMA safe hoursnational code of practice as guide

The AMA and the ACT AMAhave written to Health Minister,Katy Gallagher, urging her to acton the findings of the AMA SafeHours Audit 2006, which isavailable in full on the AMA web-site at www.ama. com.au

ACT Health have engagedwith the ACT AMA as it pro-gresses its implementation of anelectronic rostering system. Thefirst phase of the design of thissystem is underway with theengagement of CSIRO to conductresearch and draft mathematicalalgorithms that will inform thedevelopment of the e-Rosteringsystem. A catalyst for this newinitiative is the recognition thatrostering is largely fragmentedand therefore substantial ineffi-ciencies and irregularities dooccur. Examples of these for doc-tors include excessive overtime,and difficulty in achieving leavealignments with submitted timesheets and approved leave appli-cations.

The AMA’s National Code ofpractice – Hours of Work,Shiftwork and Rostering forHospital Doctors will helpinform the same and responsibleshift practice the e-rostering sys-tem will establish.

The AMA has available formembers copies of the AMAsNational Code of Practice,Doctor’s Guidelines for Imple-menting Flexibility and Manage-ment Guidelines for Imple-menting Flexibility and these canbe obtained by phoning theSecretariat on 6270 5410.The report on the recent audit isalso available on request or fromwww.ama.com.au

A bank that provides a special offer for Australian Medical Association (NSW/ACT) members. Which bank?

The Commonwealth Bank is pleased to make a special offer to Australian MedicalAssociation (NSW/ACT) group members for the following merchant services.

Merchant Service Fee Credit Debit Minimum MSFCredit Card Turnover$0 – $100,000 0.81%* $0.15 N/A$100,001 – $250,000 0.76%* $0.15 N/A$250,001 – $500,000 0.71%* $0.15 N/A$500,001+ 0.66%* $0.10 N/A*Additional 0.22% charge effective 1st January 2007 on all International Visa (Visa ISA) and International MasterCard (MasterCard CBTA) transactions

General Fee Type EFTPOS PLUS EFTPOS LITEMonthly Terminal rental $29.70 $16.50Fee Type Amount DetailsJoining fee Waived Per facility Administration fee $24.00 Per facility per annum Chargeback processing fee $27.50 Per chargeback Stationery On order Per order

Authorisations KeyAuth authorisations* Free Per itemPre-authorisations $0.15 Per item Voice authorisations* $2.90 Per customer assisted call* Only applicable during downtime or terminal malfunction.

If you would like to take advantage of any of the above offers please contact the ACT Branch of the AMA on 02 6270 5410 or reception@ama-act.com.au for an application form.

Note – You do not have to be a Commonwealth Bank customer to take up this offer.Important information. Applicants for this offer consent to their name and merchant identification beingprovided to the Australian Medical Association (NSW/ACT)group to confirm their membership and eligibilityfor the offer. Full terms and conditions available on application. All fees and charges are inclusive of Goodsand Services Tax (GST). Fees subject to change without notice. If more than 5% of your credit transactionsare on international and/or commercial credit cards, or if more than 7% of your credit transactions are handkeyed into your terminal, then the MSF stated above may be reviewed.Commonwealth Bank of Australia ABN 48 123 123 124. V0906

New Qantas Club membershiprates for AMA members

The AMA has renegotiated special Qantas Club membership rates for members

of the Association. The discounts available are currently the best offered to any

professional organisation.The new rates are:

1 year membership $265 OR 2 year membership $465One off joining fee $200 (all rates are inclusive of GST)

For further information or an application form please contact the ACT AMA secretariat on 6270 5410 or download the application from from the Member’s Only section

of the ACT-AMA website www.ama-act.com.au

Sensible hours…continued

AMA Position Statement on General Practiceand Public Hospital IntegrationThe AMA is calling onState and TerritoryGovernments and publichospital administratorsto urgently introduceprocesses to better moni-tor and coordinatepatient care as thepatient moves from thecare of their GP in thecommunity to hospitalcare and back to theirGP’s care, ensuring thereis continuity of involve-ment from the GP.

AMA President, Dr MukeshHaikerwal, said recently that formost Australians their GP is theprimary health care provider.

“To ensure the best possiblehealth care for patients throughperiods of illness or treatment,we must ensure continuity of

care from the GP and the spec-trum of other health care serviceproviders involved, and elimi-nate any disruptions.

“One of the most commonexamples of loss of continuity iswhen patients are admitted topublic hospitals.

“To assist public hospitaladministrators provide continu-ity of care, the AMA has adopteda Position Statement on GP-Public Hospital Integration thatsets out simple steps to keep apatient’s GP involved in thehealth care process and use theirknowledge to help care betterfor patients, minimising the riskof disruption.

“Efficient integration of gen-eral practice and public hospitalcare can lead to improvedpatient health outcomes throughbetter clinical management,improved continuity of care, andfewer re-admissions.

“Clear and timely communi-cation is the key.

“GPs and hospitals can bothlearn to better communicatewith one another for the benefitof their patients.

“It is up to the State andTerritory Governments and theirhospital administrators to devel-op and implement practical sys-tems that allow hospital doctors,nurses and other carers to keepthe patient’s GP in the loop.

“This is not a big ask of thehospitals.

“Hospital doctors and GPsare very busy and the systemcurrently works against themcommunicating with each otheras often and for as long as theywould wish.

“There must be streamliningof processes and systems to sup-port good communication.

“With a growing trendtowards earlier hospital dis-charge and for more care to beprovided in the community, it isvital that a patient’s transitionthrough the health system ismonitored by their GP.

“Most long-term manage-ment of chronic and complex ill-ness is now provided throughthe primary health care systemled by GPs.

“The AMA believes it is vitalthat hospitals and GPs discuss a

patient’s pre-admission state andtogether plan for their dischargeat an early stage.

“This can help prevent prob-lems such as doubling up ontests, adverse drug reactions andinteractions, or medicationerrors.

“Proper integration betweenGPs and public hospitals is animportant quality and safetyissue,” Dr Haikerwal said.

Some of the initiatives setout in the AMA PositionStatement on General Practiceand Public Hospital Integrationinclude:� Public hospitals to be com-

pelled to provide dischargesummaries to each patient’sGP as a condition of thatpatient’s discharge

� Public hospital accreditationto require the provision oftimely, detailed and legibledischarge summaries to GPsfor every patient; and

� GPs to provide comprehen-sive referral letters to hospi-tals

Refer to www.ama.com.au forfurther information.

8 N o v e m b e r 2006

A News Magazinefor all Doctors

in theCanberra Region

ISSN 13118X25

Published by the ACT Branchof the AMA Ltd42 Macquarie St Barton(PO Box 560, Curtin ACT 2605)

Editorial:Christine BrillPh 6270 5410 – Fax 6273 0455

Typesetting:DFS Design GraphixPO Box 580, Mitchell ACT 2911Ph/Fax 6238 0864

Editorial Committee:Dr Ian Pryor – Chair/EditorDr Jo-Anne BensonDr Keith BarnesMrs Christine Brill –Production ManagerDr Ray CookDr John DonovanDr Jeffrey LooiDr Tracy SohDr Peter WilkinsMs Gemma DashwoodMr Stefan Baku

Advertising:Lucy BoomPh 6270 5410 – Fax 6273 0455Email accounts@ama-act.com.au

Copy is preferred by Email to execofficer@ama-act.com.au oron disk in IBM “Microsoft Word” orRTF format, with graphics in TIFF,EPS or JPEG format.

Next edition of Canberra Doctor –February 2007

DisclaimerThe Australian CapitalTerritory Branch of theAustralian Medical AssociationLimited shall not be responsi-ble in any manner whatsoeverto any person who relies, inwhole or in part, on the con-tents of this publication unlessauthorised in writing by it.The comments or conclusionset out in this publication arenot necessarily approved orendorsed by the AustralianCapital Territory Branch ofthe Australian MedicalAssociation Limited.

Thanks to JohnDonovan’s “CanberraDoctor” article printedin the July 2006 edi-tion, and a faint memo-ry of a particular soapadvertisement from TVdays gone by, thewords ‘Tahiti soundsnice’ sent me recentlyin the direction ofFrench Polynesia.

Like John and CaptainCook, I also headed for Moorea.Though the thought of bumpinginto Keith Urban or some otherOzzie notable on Bora Bora wasenticing, I did my pre-travelresearch of travel brochures,Lonely Planet and blog sites anddecided that Moorea had thebest combination of relaxationand adventure.

And what a good choice itwas! Due to heavy bookings Iended up with my third accom-modation choice, but thatturned out to be a bonus. Myover-water bungalow at theMoorea Pearl Resort was spa-cious, private and had unre-stricted views and access to thelagoon. It came complete withTahitian TV, otherwise knownas a glass bottomed floor,through which you could watch

the tropical fish (and stray skindiver). It was even more satisfy-ing to watch the storms eachevening pass by our perfectweather lagoon on their way toBora Bora.

The island only had its oneroad sealed eight years ago, soyes it operates on island time,but when the hardest decision ofthe day is whether to get in thewater or to eat, who needs awatch? One meal at the resortthankfully was enough incen-tive for me to dust off that highschool French and use the localphone book. There are numer-ous quaint little fine French cui-sine restaurants on the islandthat provide minibus transportdoor-to-door at no charge.

But what about the horseriding? Yes, this was one reasonfor picking Moorea. Half dayrides set out from the centre ofthe island near Cook’s Bay, butonly if there are four or moreriders. So if you intend on doingthe same, book early and haveenough days on your itineraryto find enough people whowant to ride. I readily filled infive days swimming with andfeeding stingrays, kayaking andscuba diving with big sharks(not just reef sharks; reef sharksare a bit like zebra in Africa –exciting when you see the firstone, then they’re so numerous itbecomes ‘ho hum, another one’– but you still take care!).

Well I found that August/September is a good time for

riding in Tahiti – no flies, nomozzies and least chance ofrain. The horses were wellgroomed and responsive. Aswith most riding, it afforded anopportunity to access the ‘backcountry’ and vantage pointsunavailable to vehicles; plentyof tropical flowers, volcaniccliffs and pineapple groves. Thesecond half of the trail ride pro-vided an opportunity for theexperienced riders to canter offand make our own way homewhile the owner stayed backwith the less experienced riders,including the men wearingshorts (another bonus of for-ward planning – taking jodh-purs to a tropical zone!). Nohelmets were provided, and thiswas disconcerting for me as acity slicker who has seen onetoo many patients with ridinginjuries. The owner spoke someEnglish, but once again I wasthankful that those years recit-ing French verbs had not beenin vain.

All in all a good trail rideand the best holiday I’ve had

yet. You don’t have to be a hon-eymooner to enjoy Moorea, butthere really is no catering forchildren. The horse trail ridingon Moorea is a lovely feature yetto find a popular market, andgiven the number of honey-mooners decked out in boardshorts, I think it will be a hid-den secret for a long time yet.

Jo-anne Benson is Hon Secretaryof the ACT AMA and a memberof the “Canberra Doctor”Editorial Committee.

JBs Horse tales

As a service to our GPs,we will publish thissummary of issuesreported in the weeklyGP Network News pro-duced by the FederalAMA in each issue ofCanberra Doctor. AnyGP wishing to receivetheir own weekly copy ofGP Network News,should email reception@ama-act.com.au orphone 6270 5410 andgive contact details.

Mental health packageundervalues the role ofGPs

The Federal Governmentlaunched a new mental healthpackage recently, which isdesigned to make it easier forpatients to seek help throughgeneral practice and other healthprofessionals such as psycholo-gists and allied health workers.While the AMA welcomes theGovernment’s financial commit-ment to mental health care, it isvery concerned that the packageundervalues the role generalpractitioners play in providingmental health care to Australians.

AMA President, Dr MukeshHaikerwal said the initiative hasthe potential to improve patientaccess to psychiatrists and psy-chologists in team-based care,but the Government has failed tounderstand that GPs are the mainsource of expert care for patientswith mental illness and that theyare the first place turned to forimmediate, urgent care, as well aslong-term management.

Instead of supporting GPs inthis role the package is puttinghurdles between patients and theGP care they need, risking its via-bility. “We have warned that apackage that offers so much willbe less effective without propersupport for the role of GPs, DrHaikerwal said.

“The Government is under-valuing the role of GPs in mentalhealth, and has failed to recog-nise the unique skills and experi-ence that GPs have in this area,”Dr Haikerwal said. “The Govern-ment wants to impose complexrequirements on GPs, includingcompulsory extra training.”

“They are also seeking tointroduce Medicare rebates forpatients who see GPs for mentalhealth care, that are lower thanthose applicable to services fromother health practitioners.Higher Medicare patient rebateswould be available for patientswho saw a psychologist with nomedical training and limitedexperience, for instance, whichhighlights the inequity of thepackage. This demeans highlytrained, qualified and experi-enced GPs. GPs provide ongoingholistic care for patients with amental illness and this careshould be valued accordingly,”Dr Haikerwal said.

The AMA will continue tolobby the Government for chang-es to the package. Importantly thepackage represents yet againacknowledgement by Govern-ment of the shortcomings of thecurrent attendance item structure.

MBS Compliance – Item10993 – Immunisationby GP Practice Nurse

Medicare Australia hasadvised the Department ofHealth and Ageing that they haveidentified a number of GPs whoare claiming item 10993 for anyinjection provided by a practicenurse. The Department has askedthat we draw to the attention ofGPs that Medicare Australiaintend to seek recoveries whereMBS item 10993 is being claimedfor injections that do not comewithin the definition of animmunisation provided in theGeneral Medical Services Table.GPS need to be clear that it isonly the administration of vac-cines on the Australian StandardVaccination Schedule and vac-cines in the Australian Immun-isation Handbook 8th edition2003 that are covered by item10993.

Latest MBS BookOn 1 November the new

Medicare Benefits Schedule Bookcame into effect. Under thisSchedule the Medicare patientrebate has increased by 2%. TheAMA does not believe this is inline with increases in expensesfaced by general practice, such asstaff wages. The failure of the MBSto keep pace with practice costswill make it increasingly difficultfor GPs to bulk bill their patients.

GPs should take time toexamine the additions to theMBS Book as there are a signifi-cant number of new items con-tained in this edition.

General Practice Nurseitems expansion

The AMA has supported theintroduction of items designed torecognise the contribution nursesmake to patient care in generalpractice. Some of the most recentadditions to this suite of itemswere only made available to ruraland remote areas of Australia.These were the general practicenurse cervical smear items. TheGovernment was also proposingto make new items for practicenurses taking a cervical smearand preventive checks accessibleonly by patients in these areas.

The AMA argued thatpatients around Australia wouldbenefit from the Governmentmaking every practice nurse itemavailable to all general practices,regardless of their geographicallocation.

Therefore, the AMA is verypleased that the Federal Govern-ment listened to this plea and hasextended these items so they canbe used by general practices any-where in Australia. General prac-tice nurses can now provide cervi-cal smears and preventive checksto patients and those patients willreceive a rebate from Medicare nomatter where they live.

Primary Health CarePosition Statement

The AMA Federal Councilhas adopted a Position Statementon Primary Health Care, whichwas developed by the AMA Coun-cil of General Practice (AMACGP) in consultation with grass-

roots GPs around Australia. AMAPresident, Dr Mukesh Haikerwal,said the Position Statement setsout practical measures to assistgovernments to develop soundprimary care and general practicepolicies to ensure patients contin-ue to have access to quality afford-able health services.

Dr Haikerwal said primaryhealth care is the foundation ofany health care system, and inAustralia general practitionersare integral to the successfuldelivery of all the elements ofprimary health care. “The AMAbelieves quality primary healthcare requires a team approachthat allows patients to gain accessto care from all the health profes-

sionals they will encounter in thehealth system to address theirindividual health concerns. Butfor patients to benefit from pri-mary health care, there must be aleader and co-ordinator of thecare team – and that leader has tobe the GP.

“The merits of GP-led med-ical care are widely documentedand benefit patients in all parts ofAustralia every day. We urge allgovernments to commit to theprinciples of quality primaryhealth care and acknowledge thekey role of GPs in providing andcoordinating that care,” DrHaikerwal said.The position statement can beviewed at www.ama.com.au

9N o v e m b e r 2006

News from the AMAs GP and e-health department

1 0 N o v e m b e r 2006

ACT Health “management plan” forpandemic influenza released for commentACT Minister forHealth, Katy Gallagher,recently released thedraft ACT Health“Management Plan” forPandemic Influenza.

Ms Gallagher said the Planoutlined how the health sectorwas preparing, and drewtogether what the residents ofthe ACT may need to knowabout that planning effort, for apossible future outbreak ofpandemic influenza.

“It also explains how peoplecan protect themselves and oth-ers from infection, with muchlocal information,” she said.

The Plan, which is intendedto complement the AustralianHealth Management Plan forPandemic Influenza 2006(AHMPPI), has been developedin consultation with the ACThealth sector and the ACT Influ-enza Pandemic Action Comm-ittee (ACTIPAC). Established in2004, ACTIPAC consists of ACTHealth and other key govern-ment and non-government agen-cies, including the ACT AMA.

“ACTIPAC is central to thecurrent agenda of planning andresponding to an influenzapandemic, recognising that theconsequences of such a pan-demic could go beyond thespectrum of health and includesocial and economic issues,”Ms Gallagher said.

“ACT Health is specificallyseeking input from communitymembers and groups on the use-fulness, accuracy, relevance andcomprehensiveness of the Plan.”

“The feedback received willbe used to review and improvethe Plan.”

Ms Gallagher urged interest-ed groups and individuals tocomment on the draft Plan,which is available on theInternet at www.dhcs.act.gov.au/engagement/ or www.health.act.gov.au/publications. Comm-ents will be received up to 24December 2006.

Comments can be forwardedto the ACT AMA for inclusion inits feedback or can be forwardeddirectly to ACT Health.

Australian hospitalsmust plan for pandemic

In a recent article in theMedical Journal of Australia,biosecurity and health special-ists have warned that Australianhospitals must plan for the pos-sibility that crucial infrastruc-ture such as power and tele-phones may fail in the event ofan influence pandemic.

In a special influenza pan-demic supplement, Mr RalfItzwerth, a medical sociologistfrom the National Centre forImmunisation Research andSurveillance of Vaccine Preven-table Diseases, and ProfessorRaina MacIntyre, an influenzaexpert from the University ofSydney, said it is unclear howmany hospitals have drawn updetailed and comprehensiveplans for pandemic or disastermanagement.

Mr Itzwerth and colleagueshave put together a checklist offactors that hospitals shouldconsider in planning for aninfluenza pandemic.

“Pandemic planning forhospitals and the health sectorneeds to consider not onlyhealth-related strategies, butalso the broader systems uponwhich hospitals depend – bothinside and outside the healthsystem,” Mr Itzwerth said.

“Securing critical infra-structure is an overarchingrequirement for all hospitals,and requires a whole-of-gov-ernment approach.”

While it is obviouslyimportant to plan for back-upmedical staff in the event of apandemic, Mr Itzwerth said‘back office’ operations andexternal services are equallycritical to maintaining continu-ity of service.

“Essential infrastructureservices outside hospitals maybecome unavailable or get dis-rupted,” he said.

“These include power, tele-phones, mobile phones, emailand paging services, water, andgarbage removal.

“For a hospital, supplies offood, pharmaceutical products,medical gases and other con-sumables would have to beadded to the ‘essential’ list.”

Hospital staff working inpay offices, human resources, ITand building management alsokeep hospitals running, he said.

“It is hardly conceivablethat a complex and sensitivestructure like a hospital, at atime when it is overburdenedwith a surge of critically illpatients, could maintain any ofits core functions without someor all of the infrastructure serv-ices,” he said.

The article and supplementcan be accessed in full atwww.mja.com.au

General Practitionersvital in event of pandemic

Australia’s GP workforcewould have to be redistributedto cope with a major influenzapandemic, general practiceexperts said in the same issue ofthe Medical Journal of Australia.

As part of the special influ-enza pandemic supplement,

Sydney GP Dr Nick Collins andcolleagues outlined key strate-gies that GPs need to considerin planning for a pandemic.

“Some areas of Australiaare well supplied with GPs, butworkforce shortages are recog-nised in some rural and outermetropolitan regions,” Dr Coll-ins said.

“A redistribution of clinicalsupport to bolster local num-bers will be required, and islikely to be one of the con-tentious issues of pandemicplanning.”

Some of the measures DrCollins and colleagues suggestGPs consider now includetraining staff, preparing to col-lect data to assist in future dis-ease outbreak planning, andimplementing infection controlmeasures such as replacingwaiting room magazines andtoys with masks and gowns.

“Training, protection, re-muneration and indemnity are

important areas of concern forall groups,” Dr Collins said.

“GPs are old hands at deal-ing with uncertainty in clinicalpractice. However, when thisuncertainty is coupled with anx-iety, lack of clear informationand limited awareness aboutstrategies to manage the range ofpossible scenarios, the outcomeis more likely to be chaotic.

“The more certain webecome of our abilities to act ina pandemic situation and thecloser to agreement we are onhow the best outcomes can beachieved, the more likely weare to engage in rational deci-sion making and play a clearand key role in maintainingand protecting the health of theAustralian public.”

The full article, includingrecommendations for GPs’ pan-demic planning, can be access-ed at www.mja.com.au

The Medical Journal of Aust-ralia is a publication of theAustralian Medical Association.

Photo reproduced with permission of Australian medicine.

On October 9 2006, I andfour other medical students fromthe ANU flew to Brisbane for the“Standing Strong Together forAboriginal and Torres StraitIslander Health” conference, pre-sented by the National Aborig-inal Community ControlledHealth Organisation (NAC-CHO), the Australian Indigen-ous Doctors’ Association(AIDA), the Royal AustralianCollege of General Practitioners(RACGP), the Australian Collegeof Rural and Remote Medicine(ACRRM) and General PracticeRegistrars Australia Ltd (GPRA).

Our travel and attendance atthis conference were kindlyfunded by the RACGP and pro-vided an opportunity for us tofocus on a range of Indigenoushealth issues. These includedpreventative health priorities inIndigenous health, Medicareclaiming in Aboriginal medicalservices, counselling skills, man-agement of endemic diseases inAboriginal communities, teach-ing and research in Indigenoushealth, and models of best prac-tice, as well as recruitment andsupport of GP workforce in In-digenous health.

Throughout the day a num-ber of presentations were made;most painting a depressing pic-ture of the present state ofIndigenous health in Australia.However, one truly inspiringstory was told of the establish-ment of a renal dialysis centre inKintore (also known by its tradi-tional Aboriginal name, Walun-gurru). This concerned a remoteIndigenous community in theNorthern Territory located500km west of Alice Springsnear the Western Australia bor-der, which allowed peopledependent on dialysis to returnhome to country.

With the permission ofSarah Brown, Manager of the

Western Desert NganampaWalytja Palyantjaku Tjutaku(which literally translates to“Making Our Families Well”),this is the story of the Yanangupeople’s success in bringingrenal dialysis to Kintore.

Renal disease withinIndigenous communities is sub-stantially worse than in non-Indigenous communities. This isprimarily the result of type 2Diabetes Mellitus. In Kintore therate of end stage renal disease isthirty times the national average.

Previously all patientsrequiring dialysis had to travel toAlice Springs. This resulted in alarge proportion of the commu-nity moving away for treatment,causing rifts in families and inthe community. This had seriousconsequences as a number ofcommunity elders were nolonger present to give guidancein daily affairs. There was a senseof loss to community and familylife in Kintore as well as to thoseon dialysis in Alice Springs, whogenerally felt dislocated andlonely as a result of being sepa-rated from their family and com-munity, and losing their connec-tion to the land. Many viewed amove to Alice Springs as a one-way ticket, with no prospect ofcure and many returning toKintore only to die.

Zimran Tjampitjinpa wasone Kintore community mem-ber who moved to Alice Springsfor dialysis. It was his dream toreceive treatment at home andremain there. Mr Tjampitjinpainspired the idea of sellingAboriginal art to raise money fora dialysis unit in Kintore. As aresult large collaborative workswere painted by men andwomen from Kiwirrkurra (inWestern Australia) and Kintore.Art dealers and collectors fromaround Australia also donatedpaintings. In 2000 Sothebys

helped to auction the paintingsat the Art Gallery of NSW.According to Tim Klingender,Director of Aboriginal Art,Sothebys Australia, “Our inten-tion was to raise $400,000, andwe raised $1.1 million”. Thismoney meant the community’sgoal was achievable, but theystill had to decide on how best todo this.

Sadly, Zimran Tjampitjinpadied shortly after the auctionand was not able to see the reali-sation of his dream, however, thedevelopment of the dialysis cen-tre was carried forward by deter-mined members of the Kintorecommunity despite minimalsupport from the AustralianGovernment. The FederalHealth Minister at the time, DrMichael Wooldridge, said kid-ney dialysis “is something no-one in the world has ever beenable to make work in the desert.I understand that the people ofKintore want it, but there areenormous difficulties because itwould be a world first if itworked” (Alice Springs News,February 2001). In the words ofSarah Brown, Dr Wooldridge’scomments “were like a red rag toa bull” and strengthened thecommunity’s resolve to bringdialysis to Kintore.

Between 2000 and 2004, thecommunity of Kintore workedextremely hard to develop amodel that would suit the com-munity. Initially they wanted tobuild a Remote Renal Unit, butthey decided the massiveexpense involved would be pro-hibitive, a problem exacerbatedby lack of resources and infra-structure available to the remotecommunity. Ultimately, theydecided that the facility shouldenable “Self-Care” dialysis –where patients could be trainedto manage their own dialysis. A“Reverse-Respite” system was

also implemented, allowing peo-ple who could not be trained forself-care dialysis to return homewith assistance. The Kintoredialysis centre opened inSeptember 2004.

The $1.1 million was used topurchase two dialysis units. Onewas established in the primaryhealth clinic at Kintore and thesecond in Alice Springs, in arented house. The NT govern-ment eventually committed tohelping Kintore by providingfunding for two full-time renalnurses. The Commonwealthgovernment, through a sharedresponsibility agreement, pur-chased the rented house in AliceSprings to enable a permanentunit to be set up and also pro-vided a vehicle to transportpatients from Alice Springs backto their communities.

Now, community memberswho are in Alice Springs for dial-ysis are able to return home forup to three weeks, four times ayear. Amy Nampitjinpa was thefirst Kintore Community mem-ber to return home when thedialysis centre opened in 2004.There are currently thirtypatients who are able to return toKintore and receive dialysis.

Already this initiative hasproved to have significant finan-cial as well as health, culturaland personal benefits. The Co-operative Research Centre for

Aboriginal Health estimated that$113,000 per year of taxpayermoney is saved due to reducedhospital care following misseddialysis and through a drop inemergency evacuations by air.Sarah Brown reported that thepresence of the dialysis centre inKintore has increased the oppor-tunities for screening and earlyintervention, which will eventu-ally decrease or delay the devel-opment of end-stage renal dis-ease. There are obviouslyimmeasurable benefits in thewellbeing and stability of thisremote community.

This is a rare story of hopeand success in Indigenoushealth. The key to the success inKintore may lie in the fact that itwas a community-driven initia-tive, developed by the communi-ty for the benefit of the commu-nity. As Sarah Brown stated inBrisbane, “It gave them theopportunity to develop theirown model of care.”

Sarah Brown is more thanhappy to be contacted for furtherinformation about the WDNW-PT or their activities. They arealways in need of donations andsupport. Ph: (08) 8953 0002,Email: wdnwpt@bigpond.net.au

By Julia Parmeter a second yearmedical student at the ANUMedical School

1 1N o v e m b e r 2006

“Back to Country” – An Inspiring Story about IndigenousHealth in Kintore, Northern Territory

Woman receiving dialysis at the Kintore Dialysis Centre.

1 2 N o v e m b e r 2006

This address was givenby Emeritus ProfessorMiles Little, Centre forValues, Ethics & the Lawin Medicine, Universityof Sydney, Sydney, NSWat the 2006 Pink RibbonDay breakfast held inCanberra on 23 October2006.

There is a rich narrative liter-ature that has been written orspoken by women with breastcancer and by the people whocare for them at home, telling oftheir experiences, of theirencounters with doctors andother therapists. Much of whathas been written is frankly criti-cal of the attitudes and commu-nication skills, particularly ofdoctors. I want to examine thenature of the complaints thatpeople make against doctors andsometimes other members oftherapeutic teams, and to pleadfor an interchange of under-standing between consumers andproviders of medical services. Ipropose to use as my main exam-ple the narrative of a carer,which, with particular elo-quence, distinguishes the heart-felt and legitimate perceptions ofthose who feel dissatisfied. Thecase is not even one of cancer. Itis one in which a tragic deathtakes place, but it is the experi-ence of the relationshipsthroughout the illness that con-cerned the writer. The point tome is that any serious illness –not just cancer, not just one thatends tragically – sensitizes every-one concerned to the words andattitudes of all the othersinvolved.

In November 2005, in theAustralian Internal MedicineJournal (the IMJ), Professor PaulKomesaroff of Melbourne pub-lished a paper written by thewidow of a patient who died afternearly 5 months in intensivecare. It was a deeply movingaccount of a drawn-out terminalillness and its aftermath thatindicted the doctors and the hos-pital because during the terriblelast hours of the patient’s illness“not one doctor approached me.”The hospital offered no formalnotification of his death, “no clo-sure of his case, no summation ofhis medical history.” Even hisprivate cardiologist, whom hetrusted, made no contact after hisdeath. “Why”, asked the anony-mous author, “is it so difficult toacknowledge the passing of a val-ued individual, a valued client?”

This paper was an intenselypersonal, articulate, engagingand compelling piece that fittedinto a familiar pattern, that of agrieving carer with a terriblegrievance. It had a clear rhetori-cal purpose. It was meant toengage us on a moral level, it was

meant to make us angry, we weremeant to share the frustration,disappointment and even con-tempt that were so clearly centralto the author’s experience. Thestructure and content of this andsimilar pieces tends to follow asimilar pattern. Due deference isusually paid to the technical skillof the medical staff. Often, there’sacknowledgement that informa-tion is passed on during the ill-ness. The presence of doctors isacknowledged on their dailyrounds and during medicalcrises. What is primarily criti-cized is the failure of doctors toacknowledge the “person withinthe patient”. And, when it’s rele-vant, writers also deplore thelack of “closure of the case”, thefailure of doctors and their hos-pital system to recognize “thepassing of a valued individual, avalued client.” I might add thatpatients who survive oftendeplore the failure of individualsto recognise the presence of avalued individual, a valuedclient. It doesn’t take death tobring out this failing. Illness isquite enough.

This kind of narrative piecedates back a long way. Un-fortunately, it seems to have littleimpact on the way that doctorsthink and practise. I can think ofat least five reasons for this, andmost of them make me very sad.

First is the residual paternal-ism that’s the legacy of all thelearned professions. If you readabout eighteenth, nineteenth andearly twentieth century doctors,you’ll find that they told peoplewhat to do and expected to beobeyed. Regard for autonomyand the consumer’s rights are rel-atively recent. Consumerism hasdone something to redress theimbalance between the medicalprofession and the people it caresfor. It’s expressed in the IMJ arti-cle when the author uses theword “client” to describe her latehusband.

Second is the lack of anyforum for the exchange of viewsbetween ‘consumers’ and‘providers’. The IMJ approach ischaracteristic of the consumernarrative tradition because it fea-tures the consumer’s strongly feltargument, but offers no chancefor readers to hear the narrativesof the providers. Even when doc-tors write about their bad med-ical experiences, they don’t seemto ask their physicians or sur-geons to explain or justify theirperceived shortcomings. I’llcome back to this, because it’simportant.

Third, a narrative deals witha singular experience, personallyperceived and personally inter-preted. That, after all, is whatnarrative is. Thus, a narrativegives us insight into what thisperson experiences, rather thanproviding us with a way tounderstand the experiences ofthe many with whom doctorsmust deal. I’ve been berated bythe wife of a recently dead uni-versity professor who was a

friend and patient of minebecause my condolences wereimpertinent – how could I haveknown, she asked, what he was‘really like’? What does that anec-dote teach us? Does that meanthat we should never offer con-dolences? Or does it mean thatpeople differ in their needs andwishes at times of great grief andanger?

Fourth, the current privileg-ing of narrative tends to makeus conflate individual percep-tions with objective truth. Thereis profound truth in narratives,but it is personal truth. Genera-izations and unexpected in-sights can be drawn from manynarratives together – that is howrigorous qualitative researchusually works. Reading a mov-ing narrative adds to our store ofintuitive insights, makes usaware of issues that mightn’thave been obvious. But, asanalysis of airline disasters hastaught us, each individualepisode is unique. It’s from pat-terns and recurrences that welearn how to change policy.

Fifth – and saddest – con-sumer narrative generally dealswith moral issues, and moralissues still rank in importancewell below science, policy, eco-nomics and practice conditions.Despite all the fuss that has beenmade about medical ethics sinceWorld War II, the medical pro-fession still holds back fromtranslating ethical concerns forrelationships and communica-tion into anything that works inpractice.

The author of the IMJ articleproposed that “the answer lies inbetter education and communi-cation.” I fear that this is simplynot true. For many years now, anumber of universities havestressed the importance of med-ical communication, and taughtthe subject in the medical cours-es. They have also taught ele-ments of psychology, explainingsuffering and grieving to impres-sionable students, and they havestressed the importance ofhuman relationships. There areusually sessions devoted to‘breaking bad news’. Courses inthe medical humanities areincreasingly popular. Teaching‘communication skills’, however,achieves very little – make eyecontact, come down to the phys-ical level of the patient, practisean empathic look, and so on.These were not the performancesthat the IMJ author was missing.She was looking for somethingmuch more basic – a fundamen-tal, innate respect for the worthof her husband and the meaningof his life. I’m afraid that timealone, and the experience of thesuffering of many people –including one’s own suffering –can teach this, and then only tosome people. It’s not a wisdomgiven to all. Formal educationcan help, but it helps most thosewho need it least.

Finally, we need to askwhether some kind of educationneeds to reach carers and friendsas well as doctors. Pellegrino andThomasma –both Catholic the-ologians as well as doctors – haveargued for medical duties to bematched by duties of patientsand their carers. This is anunfashionable line of reasoningthat will no doubt anger many,but it’s an interesting and chal-lenging issue that deserves seri-ous discussion. Public expecta-tions of medicine have becomeincreasingly unrealistic, partlybecause of media persuasion,partly because of societal changeand partly because of the claimsmade by the profession itself.Doctors have been expected tostep into the roles of miracleworkers, priests and counselors,to be physicians, psychologistsand social workers, to be super-human in their insights. Theseare fearsome demands to make ofpeople who, in the long run, areonly human.

What might be more helpfulthan formal education would bethe creation of opportunities forbilateral representation of theperceived problems, some way ofallowing both consumers andproviders to lay out their experi-ences before one another in a civ-ilized and well moderated way.We now know a lot about con-sumer perceptions. We knowmuch less about medical percep-tions. Medical people aren’tintrinsically evil or insensitive,but they’re very reserved aboutoffering their narratives to pro-vide insight for others. Outsiderscan scarcely appreciate what itmeans for a physician or surgeonor nurse to know that when onetragic episode is closed by death,there are others waiting to bemanaged, other cases thatinvolve the still living and theirfamilies. This doesn’t excuseinsensitivity, but the depth andbreadth of that responsibilityneeds to be shared and mutuallyacknowledged by all the partiesinvolved in delivering andreceiving health care. And thereis no forum in which this trans-action can take place.

What we need, then, I sug-gest, is an ongoing forum wherepatients, carers and those whodeliver health care mightexchange and share their experi-ences. Isolated narratives are notthe answer. We need a dynamicprocess, the construction of adiscourse between all those whoare involved. We sometimes for-get that the clinic is the settingfor distress that’s felt by thewould-be healers, just as it’s feltby carers and patients. Listen toSue, the Nursing Unit Managerof a Cancer ward, trusted andrevered for her empathy and carefor patients and their families:

‘You are dealing with thepublic’, she says. ‘You are goingto get some that just love youand some that just hate you. Andwe do get that mix, which is real-ly frustrating, even when you

bend over backwards for somepeople sometimes it is still notenough, and I find that incredi-bly upsetting.’

If the medical professionreally values its relationshipswith the community that itserves, it needs to get involved ina dialogue with that community.And it needs to break with tradi-tion, and to speak more freelyand openly about the realities ofits own distress. This is Jon, amuch loved and respected oncol-ogist, speaking about an angry,bereaved relative of a cancerpatient who died:

‘He had’, says Jon, ‘a lot ofunfocussed anger about every-thing that had happened, and hewas just non-specifically angry,you know, as you would be. Andhis anger found a focus – me –and a focus was what was need-ed…That’s why people are sued,I believe. Unfocussed anger thatfinds a focus… and that left ascar.’

Let me close with the wordsof Max, code name for one ofAustralia’s foremost surgeons,whose words capture the chaosthat is cancer treatment, and thevulnerabilities of both patientsand doctors. Max begins:

‘Further down the track it’s adifficult time, because you aremeeting people at their most vul-nerable. They have been slashed.They have been mutilated. Theyhave been humiliated. They areput in a strange bed in a strangehouse, in strange pyjamas. Theirbodily fluids are around them.They have got nursing staff, youknow, who may or may notappear to care for their needs.Doctors who may or may notappear to be concerned abouttheir needs. Food that smellsbad, tastes bad, looks bad.Trolleys. People coming in andout, cleaning the machines.Interns who walk in and out,sucking blood out of them,puncturing their veins. Oncol-ogists talking about recurrentcancer; people next door vomit-ing…; showers that are shared byfour different people – it’s like azoo. And in the middle of that,you are trying to establish a rap-port … a human rapport in diffi-cult circumstances.

And therein, ladies and gen-tlemen, lies our problem –‘human rapport in difficult cir-cumstances’. It is certainly aproblem we need to discuss, andto keep discussing until we allunderstand one another better.

This talk was based on a writtenpaper originally published as:Little, M. (2006). "On being bothprofessional and human' – aresponse." Internal MedicineJournal 36: 319-322.References available on request toCanberra Doctor.

"Patients and Doctors – how to misunderstand one another"

1 3N o v e m b e r 2006

During VMO contractnegotiations, CalvaryHospital physiciansraised concerns at whatthey regarded as a glar-ing inequity in the ACThealth system, whichsees TCH well resourcedand Calvary – havingalmost as many A&Epresentations – beingdisadvantaged by amaldistribution of staff,resulting in serious staffshortages and reductionin services. This in turnimpacts on the physicianVMOs who work in thehospital.

Calvary Hospital – indeedany hospital – should strive tobe a “centre of excellence”whatever the services provided.These services should be deter-mined by community need andfor this to occur adequate fund-ing is fundamental. Accordingto Dr Terry Gavaghan, thismeans technologically up-to-date facilities, appropriate lev-els of nursing and medical staff,experienced medical and otherallied staff with high levels ofsupervision for training juniormedical staff.

This short article does notaddress funding and any otheragreements which may be inplace between ACT Health andCalvary Hospital, but is intend-ed to highlight the issues from aVMO perspective. The politicalissues are not commented on –only in as much as politiciansdetermine the budgets and to adegree therefore the serviceswhich can be funded. No com-ment is made on disciplinesother than general medicine andobstetrics.

Three of the four VMOphysicians at Calvary Hospitalhave contracts expiring inDecember 2006. And three outof the four celebrated 50th birth-days some time ago and there isgeneral concern among thegroup at the lack of youngphysicians looking to work inCanberra; and whilst thisremains the burden falls onthese committed long-servingdoctors.

Dr Gavaghan, a VMO physi-cian at Calvary public hospital,told “Canberra Doctor” that“there were major obstacles togood health care delivery inCanberra and that unless some-

thing was done, this would onlydeterioriate further. This wouldbe tragic, in his view, given theimportance of Calvary Hospitalto the large catchments ofBelconnen and Gungahlin –both of which were expected toexpand, rather than contract.There was no doubt that CalvaryHospital was the “hospital ofchoice” for many patients andcertainly the VMOs at CalvaryHospital are equally committedto the hospital. That said, how-ever, unless the hospital was bet-ter resourced it was likely that itwould be downgraded to a “sec-ondary hospital” for elective sur-gery only and a VMO hospital,rather than a “tertiary hospital”in its own right. The A&Edepartment had about 48000presentations each year com-pared with 53000 at TCH, but itis treated as a back-up hospitalby ACT Health and funded onlyas such. If Calvary is not betterresourced, it is likely it will notbe able to service the ever-expanding needs of the north

side of Canberra with “state ofthe art” facilities and servicesand staff”, Dr Gavaghan com-mented.

Dr John Hehir, an obstetri-cian at Calvary hospital said thatCalvary obstetricians provide"first on call" cover for three outof seven nights and provide "oncall" services seven nights aweek. There was a shortage ofobstetricians but no shortage ofgynaecologists and because ofthe number of deliveries therewould be insufficient to justifyaccreditation of a training posi-tion. This shortage of obstetri-cians was in part the result of themedical indemnity “crisis” a fewyears ago. He also reminded thatACT Health committed to fund24 hour resident cover as part ofthe 2003 contract negotiations,but this has not been forthcom-ing. Dr Hehir considered that

the senior staffing level was ade-quate, however, urgent attentionwas required for junior cover ateither the accredited or unac-credited registrar level. Obstet-rics and gynaecology is a partic-ularly high-risk specialty and 24hour registrar cover would pro-vide added patient safety forobstetric calamities such asshoulder dystocia, cord prolapseand massive post-partum haem-orrhage. He also said that therewas an inappropriate use ofmedical expertise when resi-dents were tied up for hours inpaperwork – a clerical function.Dr Hehir said that they weredoing approximately sixty dis-charge summaries in any givenweek.

Dr Gavaghan commentedthat it had not been able to gaina “front door” admission to thehospital for some years – with allhis patients being admittedthrough A&E. He also said thatCalvary Hospital doctors per-formed in excess of 1500 endo-scopies annually; these are notdoctor driven procedures, but aresponse to community demandand good diagnostic and preven-tative health imperatives.

Both Dr Hehir and DrGavaghan said that they couldearn more money in their pri-vate practices, but both had acommitment to Calvary Hosp-ital and to their public patients.In return, they wanted fair com-pensation and a commitmentthat Calvary Hospital would beresourced by ACT Governmentto provide a high level and com-prehensive service to the com-munity it served.

Dr Gavaghan said that ICUand CCU were poorly fundedand as “backup” for TCH, it wasimportant that they be wellresourced and because of thislack of resource funding, staffwere under considerable pres-sure.

Dr Gavaghan said he waslooking at the big picture – withtoo few graduates coming intothe profession, too few specialtyand sub-specialty trainees, anageing medical (and nursing)workforce and a reliance onoverseas trained doctors, the pri-vate vs public patient mix – andregretted that he could not see abright future for medicine inCanberra unless these issueswere addressed. Under theTerritory-wide agreement Cal-vary junior staff were rotatedthrough both TCH and Calvary;however, if TCH was under-staffed then Calvary did notreceive the promised staff – com-promising patient care and plac-ing unreasonable demands onthe existing staff. By way ofexample, Dr Gavaghan pointedout that despite a comparablenumber of presentations atCalvary A&E, Calvary staffing

was considerably less than thatof TCH. He believed there werein the order of seven emergencymedicine physicians at TCH andonly two at Calvary for a not toodissimilar number of presenta-tions. Dr Gavaghan also drewattention to the fact that therewas a general roster only, no subspecialty rosters so that thephysicians were required tocover all aspects of care, whereasTCH had rostered cover acrosseach of the sub specialties.

In relation to the futuremedical workforce, Dr Gava-ghan lamented the fact that theANU Medical School Calvarycampus had no lecture theatre,no tutorial rooms and limitedaccess to computers for stu-dents. This was unacceptable, inhis view, for student teaching inthis technologically advancedage – making Calvary Hospitalnot only appear, but in reality be,second rate in this respect. Hecompared Calvary to TCH withits plethora of tutorial and meet-ing rooms, as well as lecture the-atres and the co-located ANUMedical School. Calvary JohnJames Hospital’s new clinicalservices building at Deakin hada “state of the art” lecture the-atre, but none at the main hospi-tal at Bruce. He also commentedthat there was no common roomfor doctors to meet with col-leagues over coffee and that thisexchange at the semi formallevel was fundamental to patientcare, and learning.

Dr Gavaghan believes thatTCH is also under-funded andbecause of this under-funding“Calvary Hospital has to bear thebrunt of the large number oftimes in any week that Canberrahospital is placed on by-pass.By-pass means that for any peri-od of time, TCHs throughput iscompromised, the Hospitalrefuses to accept any furtherattendances in the A&E depart-ment and all presentations dur-ing that time are directed

towards Calvary. There is littlethought given to the fact that atany one time in an area such asthe Division of Medicine, theremay be ten or twelve physicianson call at TCH, to suddently goon bypass to Calvary where onlyone physician is on call and ofcourse applies across all disci-plines and all specialities andsub-specialities. It also applies toa hospital which is funded for180 beds or so versus a hospitalthat is funded for six or sevenhundred beds. The number ofregistrars on call in the specialtyof medicine is only one com-pared to ten or twelve in theprincipal hospital. The issue ofby-pass is becoming more andmore a problem and puts a veryinequitable load on Calvarywhich tries to back-up serviceson the south side as well.Recently, Canberra Hospital wason by-pass for nearly three daysin the week, but very frequently,at least seven or eight timesevery week the whole of TCH ison by-pass for any admissions orA&E attendances and all ofthese people end up beingreferred to Calvary.”

Calvary Hospital is accord-ing to both Drs Hehir andGavaghan, a “great place towork”, with VMOs being regard-ed an important part of the team,embraced for their skills andexpertise and treated well by thehospital management.

Calvary Hospital physicianand obstetric VMOs remaincommitted to the hospital andtheir patients but are concernedthat it will cease to be the won-derful place it is – for patientsand doctors – unless some of theissues above are addressed.Fundamental will be a demon-strated commitment to fundCalvary Hospital to continue tobe the centre of excellence itstrives to be across a range ofdisciplines.

Dr Terry Gavaghan.

Calvary VMOs concerned at inequity in the health system whichleaves Calvary Public Hospital and its patients disadvantaged

Dr John Hehir.

1 4 N o v e m b e r 2006

Pathologists mark 50 years of service to Canberra region

Canberra pathologists willmeet at Old Parliament House onNovember 16th to celebrate the50th anniversary of the establish-ment of the Royal College ofPathologists of Australasia(RCPA).

“We don’t bear much resem-blance to TV pathologists inshows like ‘Silent Witness’”, saysCanberra Hospital pathologistDr. Chris Hemmings, who tookover as Honorary Secretary of theRCPA on November 10th. “Mostof us are more likely to be busyidentifying the cause of a urinarytract infection, monitoring some-one’s diabetes or diagnosing can-cer, than solving a murder.”

Something in the region of 2million.pathology specimens,including cervical smears, tissuebiopsies, blood and urine tests(among others) are processed inCanberra each year, and approxi-mately 450 autopsies are per-formed. In addition to their diag-nostic duties, ACT pathologistsare involved in a number of localand national committees relatingto pathology and public health,as well as participating inresearch and in undergraduateand postgraduate teaching. Aswell as the Foundation Dean ofthe ANU Medical School, immu-nologist Professor Paul Gatenby,numerous other Canberrapathologists hold teachingappointments at the MedicalSchool, and provide regular edu-cation sessions for GeneralPractitioners and other medicalspecialists and trainees. In addi-tion, pathologists contribute sub-stantially to a number of multi-disciplinary groups involved inthe care of various diseases, suchas the Canberra Sarcoma Group,the Canberra Melanoma Group,Breast Screen ACT/SE NSW, andthe SE NSW/ACT ColorectalCancer Treatment Project.

Several local members takean active role in College affairs,including examination of candi-dates for admission to fellowhip,and various office-holders withinthe College are domiciled inCanberra. Dr. Hemmings says “Ifanything, the ACT is dispropor-tionately well represented inCollege affairs. Canberra pathol-ogists take an active role in thewider practice of pathology at a

number of levels, and I believethe Canberra community is wellserved by this branch of medi-cine. There are a lot of dedicated,hard-working doctors here whostrive to maintain a high level ofservice to their patients, eventhough we never meet most ofthem, and many don’t even knowwe exist.”

History of pathologyservices in the ACT

Until 1948, pathology testingfor the Canberra region was per-formed in Sydney. With theopening of the CanberraCommunity Hospital (laterknown as Canberra Hospital andlater the Royal CanberraHospital), a local pathology serv-ice grew out of a public healthlaboratory that had opened in1937 in Civic. They serviced thelocal general practitioners andsurrounding regions includingYass and Wagga Wagga, and postmortems were contracted out togeneral practitioners. In 1959 DrTed Macarthur was appointed todo surgical pathology, mycologyand autopsies (for both the hos-pital and the police). By 1964,60% of all hospital deaths werereferred for autopsy. The forensicautopsy caseload increased from55 in 1960 to 220 in 1980.

By the early 1950’s the work-load had increased such that thelaboratory needed to expand,and was moved to the Institute ofAnatomy, in what is now theNational Film and SoundArchive. With completion of hos-pital extension in 1965, the labo-ratory facilities were moved tothe Canberra Hospital. The labo-ratory was first accredited forFRCPA training in 1968, initiallyin anatomic pathology and sub-sequently in other disciplines.With the arrival of ProfessorPeter Herdson in 1991, the num-ber of registrar training positionsdoubled. Professor Herdson wasinstrumental in the establish-ment of the pathology museum,which now bears his name.

By the late 1960’s moveswere afoot to combine publichealth and clinical pathologyservices in a central laboratory,which was finally opened at theCanberra Hospital (then knownas Woden Valley Hospital) in

1976. Dr Jocelyn Farnsworthremained at Canberra Hospitalperforming frozen sections,whilst the other pathologistsmoved to Woden. The ensuing30 years have seen furtherexpansion of the laboratory, par-ticularly in electron microscopy,cytogenetics, molecular patholo-gy and immunology services.Today ACT Pathology, based atthe Canberra Hospital, employsmore than 200 staff and providespathology services, includingautopsies, to the public and pri-vate sectors in Canberra and thesurrounding region. Drs Hallamand Jain from ACT Pathologyalso perform coronial autopsiesfor the region. In 1991 DrsBennett and Jain from ACTPathology established CanberraAspiration Cytology, a privateFNA biopsy service.

The first private pathologyservice in Canberra was estab-lished by Dr Barry Moran in1967, servicing general practi-tioners and the John JamesMemorial Hospital whichopened in 1970. In 1981 DrFarnsworth established the sec-ond private pathology practice inCanberr, which was subsequent-ly sold Drs Barratt and Smith in1987. This laboratory moved toQueanbeyan and subsequentlymerged with Dr Barry MoranPathology to form CapitalPathology in 1996. CapitalPathology provides pathologyservices to Canberra and theregion, including Jindabyne,Cooma, Bega and Merimbula.

Today the ACT contingent ofthe RCPA represents some 28currently practicing pathologists,most of whom are employed byACT Pathology (based at TheCanberra Hospital), or CapitalPathology (based in Deakin). Inaddition, there are currently 12trainees studying for admissionto fellowship, and some privatepathology services are providedby Symbion Mayne LavertyPathology. With thanks to "Pathology,Professional Practice and Politics:A History of the Royal College ofPathologists of Australasia 1981-2006" which was published by theRCPA this year to mark theJubilee. (Eds Conyers, MacLeod,Muller & Raik)

In response to the annou-ncement by MDAV and UNIT-ED that the organisations haveagreed to merge in early 2007,MDA National CEO, Mr PeterForbes commented that themove is a positive step for themedical indemnity industry.

Mr Forbes has previouslycommented in the media thatconsolidation in the medicalindemnity industry has beenconsidered desirable by both theFederal Government and theFederal AMA. This merger will

reduce the number of doctorowned insurers from 5 to 4,resulting in more streamlinedindemnity choices for theAustralian medial profession.

“A reduced number ofproviders will address some ofthe confusion in the market bypresenting Australian doctorswith a smaller field of indemnityinsurers with clear differentia-tion in products and benefits”,said Mr Forbes.

MDA National will continueto build on its success to date by

concentrating on its core busi-ness of delivering appropriatelypriced medical indemnity insur-ance to Australia’s doctors.

Mr Forbes commented that“it is important that the mergerof the mutal organisations willrequire the consent and supportof the members of both groups.It will need to be evident thatany merger is in their best inter-ests.”

“Clearly, to obtain membersupport, it will need to bedemonstrated that the cost of

both membership and medicalindemnity premiums will bereduced and that there will be anincrease in the standard of serv-ice-delivery which their mem-bers are entitled to”.

While confirming that thereis certainly no financial driverfor MDA National to consider amerger, Mr Forbes stated that “ifan opportunity arises we wouldcarefully consider the option onthe proviso that it adds to ourmembers’ security and benefits.Recent analysis conducted by

our professional advisers hasindicated no such option existedat that point”.

Canberra GP, Dr Ian Pryor, amember of the UMP Medicaladvisory council said, “Thismerger creates an efficientopportunity to extend the bene-fits of scale to members ofUnited and MDAV. It enablesUnited to maximise thoseadvantages of its strong marketposition to increase its presencein the Victorian sector”.

MDA National responds positively to the MDAV/UNITED merger announcement

Children aged 0 -18years of age can accesstherapy services foradvice and recommen-dations. Referrals can bemade directly by fami-lies by telephoning thetherapy administrator atthe Centre – which islocated in Spence.

The therapy team consistsof a therapy administrator,physiotherapist, speech path-ologist and occupational ther-apist.

The 'Equipment Loan Pool'has been a success story withsubstantial support from theCanberra community contrib-uting money to purchase specif-ic pieces of expensive equip-ment to be pooled and used bychildren and their families whoattend the Centre. Many piecesof equipment that are recom-mended by therapists are be-yond monetary reach for fami-lies and the establishment ofthe 'Loan Pool' has been a boonfor all.

The Spastic Centre com-menced offering therapy servic-es to children with cerebral

palsy and associated conditionsin 2004. The Spastic Centre, anon-government organisationwill receive over $700,000 toassist children and their fami-lies in the ACT.

The Centre is located at theMt Rogers Community Centre,Crofts Crescent, Spence and thetherapy administrator, GilianCoady can be contacted on tele-phone 6258 8723, or by fax to6258 5847

CP helpline 1300 30 29 20 CP register (02) 9975 8239 Website:www.cpregister-aus.com.au

Spastic Centre assistschildren and families

1 5N o v e m b e r 2006

Medical Treatment Act introduced into legislative assembly

Children aged 0 -18 yearsof age can access therapyservices for advice andrecommendations.Referrals can be madedirectly by families bytelephoning the therapyadministrator at theCentre.

The therapy team consists ofa therapy administrator, physio-therapist, speech pathologist andoccupational therapist.

The 'Equipment Loan Pool'has been a success story withsubstantial support from theCanberra community contribut-ing money to purchase specificpieces of expensive equipment tobe pooled and used by childrenand their families who attend theCentre. Many pieces of equip-

ment that are recommended bytherapists are beyond monetaryreach for families and the estab-lishment of the 'Loan Pool' hasbeen a boon for all.

The Spastic Centre com-menced offering therapy servicesto children with cerebral palsyand associated conditions in2004. The Spastic Centre, a non-government organisation willreceive over $700.000 to assistchildren and their families in theACT.

The Centre is located at theMt Rogers Community Centre,Spence and the therapy adminis-trator, Gilian Coady can be con-tacted on telephone 6258 8723,or by fax to 6258 5847.CP helpline 1300 30 29 20CP register (02) 9975 8239website: www.cpregister-aus.com.au

Spasstic centre assistsThe various propertymarkets are behavingexactly as they shouldand for those whounderstand the“Property InvestmentCycle” this offersexcellent opportunities.

Like all commodities, pro-perty is subject to strong andpredictable cyclical fluctua-tions. These cycles apply toboth capital prices and rentalreturns. It is important toappreciate though that capitalprices and rental returns cycleat different times but pro-foundly influence each other.

A brief explanation of theproperty investment cycleshould aid in understandingand moreover begin to high-light the opportunities provid-ed to astute investors.

After a period in stagnationof construction activity excessdemand starts to emerge. Ashortage of rental propertyleads to rises in rental returns.Higher rental returns attractnew “yield seeking” investorsinto the market. This increaseddemand causes prices to beginto rise and with it activity in themarket. This phase of the cycleis known as “The Upturn”.

After the upturn the marketenters “The boom”. This phaseis driven by the entry of specu-lative investors attracted by therising prices and hoping to takeadvantage of the prospect offurther price rises. The entry ofeven more investors into themarket fuels further price risesas demand begins to outstripsupply. Developers tap into theincreased demand and bringmore property to the market. Atthe peak of the boom prices andactivity overshoot realistic lev-

els and property becomes over-valued. Rental yields havingfallen to unsustainably low lev-els as rises in prices have sub-stantially outstripped the grow-th in rents.

The excess of stock leads toan over-supply and this coupledwith poor rental returns due tohigh prices leads to a withdraw-al of investors from the market.Property is now overvalued andnew investors do not enter themarket. As a result sales vol-umes fall and building activitydrops off accordingly. “TheBust” has arrived and the mar-ket activity slows as investorslook for other opportunities.

After the bust buildingactivity is subdued below thelong term level of new dwellingsrequired. “The Stagnation”phase is characterised by a grad-ual reduction in excess housingstock created during the boomand sets the stage for the nextupturn in activity. Investors aretypically hesitant to re-enter themarket after the earlier bust andthis leads to an undersupply ofproperty resulting in excessdemand creating the conditionsfor the next upturn.

The market today is dem-onstrating the characteristics ofbeing in the early Upturn Phasewith rising interest rates puttingadditional pressure on supplyand increasing the demand forrental as first home buyers arepriced out of the market. Rentsare rising rapidly and thoseinvestors who are able to recog-nize the next growth opportu-nities will be well positioned totake maximum advantage of thenext boom. At the same timethe continued growth in rentswill rapidly reduce the holdingcosts for investors entering themarket at this time.

(copy supplied by Geoff Proud,Park Heath – see advert page 10)

The medical treatmentdirection bill, tabled inthe ACT LegislativeAssembly, will protectpatients' rights in theTerritory, ACTAttorney General,Simon Corbell, saidwhen tabling the Bill.

"The direction, known for-mally as the Director of PublicProsecutions Direction 2006 No.

2, has been issued to ensure thatthe ACT Medical Treatment Act1994 remains effective despitethe enactment of the Comm-onwealth Euthanasia Laws Act1997. The new direction is castin the same terms as a directionmade in 1998, and is intended toreplace the 1998 direction.”

Mr Corbell said the directionwould protect the right ofpatients to provide instructionsin advance regarding the with-drawal or withholding of med-ical treatment. The directionwould also protect the right ofpatients to appoint a decision-maker to make decisions about

medical treatment on theirbehalf, through the use of apower of attorney.

“The direction requires theDirector of Public Prosecutionsnot to pursue a prosecutionagainst a health professional forthe death of a patient in circum-stances where the health profes-sional follows, in good faith, theinstructions set out in anadvance directive, or instruct-ions given by a person exercisinga power of attorney, regardingthe withdrawal or withholdingof medical treatment,” he said.

“The Director of PublicProsecutions is also directed not

to pursue prosecutions againsthealth professionals who pro-vide pain relief in good faith to aperson diagnosed as being in theterminal phase of a terminal ill-ness where an incidental effect ofthe pain relief appears to havebeen the hastening of death.

“Recent events promptedinquiries about whether the cor-rect processes were followed inmaking the 1998 direction. Thenew direction re-instates theeffect of the previous direction,and is made in the same terms asthe previous direction.”

Under the Director ofPublic Prosecutions Act 1992,

the Attorney General has theability to issue directions to theDirector of Public Prosecutionsabout the management of par-ticular categories of prosecu-tions. Given the importance ofmaintaining the decision-mak-ing integrity of the Director ofPublic Prosecutions, suchdirections can only be of a gen-eral nature, rather than refer-ring to a specific case, and canonly be made following properconsultation with the Director.Both of these conditions havebeen met in relation to themedical treatment direction.

What’s happening withresidential property?

Completed form should be returned to the ACT AMAby fax 6273 0455 or by post to PO Box 560, Curtin, ACT 2605.

APPLICATION FOR AMA MEMBERSHIP✁

1 6 N o v e m b e r 2006

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phone: 6253 3399www.canberracuresclinic.com.au

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As a GP you are invited to choose freelyyour own sessions. Stay as long as youenjoy the sunny lifestyle. Surrounded by

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General Practitionerfor Sunshine Coast

Rob APATHY Clinical NeuropsychologistAllied Health Care provider

~ Neuropsychological Assessment ~ Sleep and Breathing Disorders ~ Biofeedback, Psychophysiology.

The "Waterfront", 63a Strayleaf Cres, Gungahlin ACT 2912Telephone 02 6262 2628 ~ Mobile 0434 051 042

DR GEOFFREY SPELDEWINDE Consultant in Rehabilitation & Pain Medicine15 NAPIER CLOSE Phone: 02 6282 6240DEAKIN, ACT 2600 Fax: 02 62825510

SPINAL PROCEDURES – x-ray guided Best-Practice:• ZYGAPOPHYSIAL and SACROILIAC JOINTS

(diagnostic, therapeutic and RADIOFREQUENCY NEUROTOMY)• TRANSFORAMINAL EPIDURALS• SYMPATHETIC BLOCKS etcINTENSIVE CONSERVATIVE TREATMENT, by direct referral:• PHYSIOTHERAPY – Musculoskeletal & Neuro-physio specialists• REHABILITATION EXERCISE THERAPY• REMEDIAL MASSAGE• PSYCHOLOGY – Medicare rebate now available

Female VR or traineeGP early 2007 for friendly

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conditions flexible.

6295 3072 or 0416 014 518

GP POSITIONAvailable

ATTENTIONProceduralists/InvestorsExpressions of interests are invited to invest in a standalone/doctor owned Day Surgery and Professional Suites.

Would suit plastic surgeons, gastroenterologists, opthalmologists, dermatologists, orthopaedic surgeons,dermatologidsts, oral surgeons, urologists and gynaecologists.

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PO Box 5244, GARRAN ACT 2605

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Fully accredited, established family practice. Partner retiring soon.Full-time or part-time VR general practitioners required withopportunity to join partnership if suitable.Purpose built rooms. Busy practice with excellent medical staff,nurses, practice manager & reception staff.Please phone Eleanor on 6249 1823 or 6257 4086

PLAN NOWFOR A

JOURNEYINTO THEAFTERLIFEStep through into the

world of the Gods in anACT AMA private viewing

of the new exhibition

EgyptianAntiquities from

the Louvreat the National Gallery

of Australiaon Friday evening,16th February 2007

Immortality, mystery andbeauty in a collection ofmore than two hundred

objects from the Musée duLouvre, Paris.

More details about the function,including cost,in the next Canberra Doctor

Dr Stewart Mayis very pleased to announce that

Dr STUART MILLER FRACP FJFICM DA(UK)

SLEEP MEDICINE PHYSICIANwill be joining his practice in January 2007

For appointments please call 6282 4955 fax 6285 1608Canberra Sleep Laboratory, 2 Geils Court DEAKIN ACT

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Sharp AR-151 digital photocopier

Excellent condition, serviced regularly.

$400 ono

Ph: 6273 3102

FOR SALE