BBackstage ackstage ppassass - RACGP Practice/2014/January/February...important to see your GP or...
Transcript of BBackstage ackstage ppassass - RACGP Practice/2014/January/February...important to see your GP or...
www.racgp.org.au/goodpractice
Backstage Backstage passpassMeet Dr John Gullotta, Sydney’s original Rock Doctor
INSIDE
Diabetes alarmExperts warn of coming epidemic
Sexual healthThe internet may be the key to breaking
down barriers around this sensitive topic
Volunteer GPOffering much-needed medical expertise in Nepal
ISSUE 1–2, JANUARY–FEBRUARY 2014
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3Reprinted from Good Practice Issue 1–2, January–February 2014
Published by
The Royal Australian College
of General Practitioners
100 Wellington Pde,
East Melbourne,
Victoria 3002
T 03 8699 0414
W www.racgp.org.au/goodpractice
ABN 34 000 223 807
ISSN 1837-7769
Managing Editor: Kevin Pyle
Editor: Paul Hayes
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Editorial notes
© The Royal Australian College of General Practitioners 2014. Unless otherwise indicated, copyright of all images is vested in the RACGP. Requests for permission to reprint articles must be made to the editor. The views contained herein are not necessarily the views of the RACGP, its council, its members or its staff. The content of any advertising or promotional material contained within Good Practice is not necessarily endorsed by the publisher.
04General Knowledge
Information and events for GPs in
February.
06 Feature Story
Storm on the horizon
Faced with a potential diabetes
epidemic, GPs need to be prepared
for how to best treat their patients.
10GP Profi le
Dr John Gullotta
Sydney’s original Rock Doctor,
John Gullotta is the resident
GP for NSW’s major touring and
entertainment companies.
14International GP
Volunteering in the
Kathmandu Valley
Steve Margolis found taking his medical
skills to Nepal a rewarding experience
he would recommend to other GPs.
18Sexual Health
A sensitive topic
With so many turning to the internet and
social media for sexual health information,
GPs hope it will make it easier to start the
conversation with young people.
22In My Practice
Complete care
Located in one of Australia’s most
multicultural areas, Western Sydney’s
Bridgeview Medical Practice understands
the need for an inclusive approach to
community healthcare.
24Nutrition
Eating together
Getting together to share a meal can have
a number of benefi ts beyond the social.
26Portraits of General Practice
Curiosity and the GP
A healthy sense of curiosity is just what the
doctor ordered for a life in general practice.
06
14
10
ContentsIssue 1–2, January–February 2014
24
18
4 Reprinted from Good Practice Issue 1–2, January–February 2014
Images
Matthew
Norr
is, S
hutters
tock
GENERAL KNOWLEDGE
New GP taxA proposed new Federal Government tax on
patients visiting their GP could jeopardise
equitable access to clinically appropriate
healthcare, according to RACGP Vice President,
Associate Professor Frank Jones.
The new tax, proposed in late 2013 by the
Australian Centre for Health Research in a
submission to the Commission of Audit, would
end bulk-bill visits and see Australians pay a
$6 co-payment for general practice services
as a means of creating Government budgetary
savings. It is estimated the tax could save up to
$750 million over four years.
Jones has urged the Government to seek
proper consultation with the general practice
profession before accepting any proposal. He
warns the tax could have a major impact on the
health of all Australians, as many already delay
seeing their GP for fi nancial reasons.
‘Those with the greatest healthcare needs
often have the least capacity to pay for healthcare
services,’ Jones said. ‘Reducing the Medicare
rebate for all Australians will result in poorer care
delivery and health outcomes for those in greatest
need and ultimately exacerbate inequality.’
Diabetes epidemic382 million people have diabetes globally.
Source: International Diabetes Federation (2013).
Three questions for Dr John GullottaWhat is you favourite aspect of working as a GP?
The variety, seeing patients from all aspects of medicine in one day.
What is the most underestimated aspect of being a GP?
I think the value of a good GP is slipping, which is a shame. I think the more we reinforce general practice
to the younger generation, the more important it is.
Is there one thing you couldn’t do your job without?
A good team. These days, general practice is a team effort and having a good team around you can help
you out. From secretarial staff to practice nurses and the whole team, it’s very important.
Turn to page 10 to read more about Dr John Gullotta.
Western Pacifi c
Southeast Asia
Europe
North America
and Caribbean
Middle East and
North Africa
South and
Central America
Africa
Millions
37m
20m
24m
35m
56m
72m
138m
0 10 20 30 40 50 60 70 80 90 100 110 120 130 140
Turn to page 6 to read more about the current
state of diabetes in Australia and around the world.
5Reprinted from Good Practice Issue 1–2, January–February 2014
Image S
hutters
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What’s in your cough?A new resource from Cancer Australia is designed to encourage
Australians to recognise and act on the symptoms of lung
cancer. The What’s your cough telling you? guide aims to
increase awareness of lung cancer symptoms and reduce delays
in diagnosis. According to Cancer Australia CEO, Professor
Helen Zorbas, the guide provides clear and easily accessible
information about possible symptoms of lung cancer, such as a
new cough that persists for more than three weeks, coughing
blood, a changed cough, or a chest infection that won’t go away.
‘The symptoms of lung cancer can often be vague,’ she said.
‘These symptoms may be due to other conditions, however, it is
important to see your GP or healthcare worker to be sure.’
What’s your cough telling you? is available from Cancer
Australia (www.canceraustralia.gov.au).
RACGP events calendar
February 2014
WA
AKT/KFP Study Group
for IMGs 2014.1
Monday 3 and 10 February,
6:00 pm – 9:00 pm,
College House, Perth.
Contact (08) 9489 9555 or
VIC
CPR Workshop for GPs
Thursday 20 February,
6:00 pm – 9:00 pm, John
Murtagh Centre, RACGP House.
Contact (03) 8699 0488.
VIC
CPR Workshop for GPs
Thursday 6 February,
6:00 pm – 9:00 pm, John
Murtagh Centre, RACGP House.
Contact (03) 8699 0488.
VIC
Clinical Emergency
Management Program
(CEMP) – Intermediate
Friday 21 February,
8:20 am – 5:00 pm,
Ether Conference Centre,
Little Bourke Street, Melbourne.
Contact (03) 8699 0488.
WA
CPR Workshop for GPs
Saturday 8 February,
8:30 am – 10:30 am,
College House, Perth.
Contact (08) 9489 9555 or
WA
Diagnostic Uncertainties
in General Practice
Saturday 22 February,
8:30 am – 5:00 pm,
College House, Perth.
Contact (08) 9489 9555 or
VIC
Sports Medicine
Workshop
Sunday 16 February,
8:45am – 5:00pm, John
Murtagh Centre, RACGP House.
Contact (03) 8699 0488.
VIC
Clinical Emergency
Management Program
(CEMP) – Advanced
Saturday 22 – Sunday 23
February, 8:20 am – 5:00 pm,
Ether Conference Centre,
Little Bourke Street, Melbourne.
Contact (03) 8699 0488.
For further RACGP events please visit www.racgp.org.au/publications/
goodpractice/Book give-awayThe Naked Eye: How the revolution of laser surgery
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Entries close 7 February 2014.
Authors: Dr Michael Lawless and
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RRP: $32.95
Winners of Understanding Type 2 Diabetes:
Fewer Highs, Fewer Lows, Better Health
by Professor Merlin Thomas
T Mettam, M Smith, J Mencel, A Saleh and
J Carter.
6 Reprinted from Good Practice Issue 1–2, January–February 2014
Image S
hutters
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PAUL HAYES
With the number of diabetes cases on the rise throughout the world, GPs and other healthcare professionals need to be well prepared.
The word ‘epidemic’ is not one healthcare
professionals use lightly, but that is how
diabetes expert Professor Paul Zimmet has
been describing the increasing prevalence of
the disease for many years.
‘I think people thought I was a false
prophet,’ he told Good Practice.
With the recent publication of the 12-year
fi ndings of the Baker IDI Heart and Diabetes
Institute’s Australian Diabetes, Obesity
and Lifestyle (AusDiab) study and the the
International Diabetes Federation’s (IDF)
latest Diabetes Atlas, which revealed the
number of people with diabetes throughout
the world is far greater than previously
forecast, he may have been proven right.
One of the world’s foremost voices in
diabetes care and research, Zimmet is
Foundation Director of the International
Diabetes Institute, Director Emeritus of Baker
IDI and serves on the Australian Government
Executive Committee for the prevention of
type 2 diabetes. He also served as the Chair
of the Scientifi c Program at the recent World
Diabetes Congress, held in Melbourne in
December 2013.
Zimmet’s work has seen him travel the
world to research diabetes and he has
Storm on the horizon
FEATURE STORY
7Reprinted from Good Practice Issue 1–2, January–February 2014
believed the disease would be a far-reaching
problem for decades.
‘I discovered in Nauru in 1975, for example,
the highest rate of diabetes in the world;
one-third of all adults. Then we did other
Pacifi c Islands and we saw the same thing.
‘I was predicting there would be an epidemic.’
The numbers are in
While few in the healthcare industry would
have suggested diabetes, whether type
1 or 2, is a minor concern, the numbers
contained in the latest studies proved
startling. According to the Diabetes Atlas,
382 million people have diabetes globally
and, with type 2 diabetes increasing in every
country throughout the world, that number is
set to increase to 592 million – 10% of the
world’s population – by 2035. In Australia,
1.7 million people currently have the disease,
a number that is expected to rise to 2.3
million by 2035. A total of 5.1 million people
died from diabetes-related complications in
2013, with 9500 of those in Australia.
The potential health problems associated
with diabetes are well known and
complications can include heart disease,
stroke, kidney disease, blindness, foot
problems (leading to amputation) and more.
It could be described as a disease with a
‘long tail’, with a reach that extends far
beyond the medical industry.
‘Diabetes is a signifi cant problem in
Australia, not only from the medical point of
view, but it’s a signifi cant factor in relation to
the Australian economy,’ Zimmet said.
According to the Diabetes Atlas, Australia
contributed $10.7 billion to the staggering
worldwide total of US$548 billion spent on
diabetes care in 2013. While the largest
portion of that global spend was in the
US, the Diabetes Atlas revealed that much
of the diabetes footprint covers low- and
middle-income countries, which goes against
the traditionally held view that diabetes is a
‘disease of the wealthy’.
In Australia, large numbers of people with
diabetes, particularly type 2 diabetes, live
in disadvantaged or lower-socioeconomic
areas, where people are less equipped to
deal with the problem.
‘There’s a clear association between
type 2 diabetes and affl uence but, equally
so, there is a high likelihood of diabetes in
socially disadvantaged communities,’ Zimmet
said. ‘It’s poorer education, it’s poorer diet,
it’s the lack of facilities in the community for
exercise. There are demographic factors.’
A question of lifestyle
As the healthcare community continues to
learn more about diabetes, some long-held
beliefs are being challenged. Perhaps the
most signifi cant of these is that type 2
diabetes is predominantly a lifestyle disease
that people bring on through factors like poor
diet, smoking, obesity, inactivity, etc.
Australia contributed $10.7 billion to the worldwide total of US$548 billion spent on diabetes care in 2013
According to Dr Gary Deed, a Brisbane-
based GP and Chair of the RACGP’s
National Faculty of Specifi c Interest
Diabetes, people’s lifestyles are indeed a
factor, but should not been seen as the only
culprit in type 2 diabetes, and reasons for its
prevalence go far beyond a lack of exercise.
‘Certainly, individuals need to take some
responsibility. But often the burden of
responsibility is falling on those people who
can least do something about it. Those who
don’t have economic means to achieve
good health. Those that are racially
fragmented on the edge of our society,’ he
told Good Practice.
‘I think the whole idea that this is the
fault of people sitting in chairs and watching
television is somewhat patronisingly
simplistic.’
Speaking at the World Diabetes Congress,
Zimmet said many of the problems that lead
to type 2 diabetes are, in fact, based in
genetics and are out of a person’s control,
which in turn leads to a generational issue.
‘We’re discovering now that type 2
diabetes … while we say it’s a lifestyle
disease and people aren’t exercising and
they’re eating the wrong foods, it looks like
the actual groundwork for someone getting
type 2 diabetes may actually happen in the
uterus during the mother’s pregnancy,’
he said.
‘It can be a number of factors. It can
be the poor nutrition of mothers during
pregnancy, which starts a vicious cycle
because these changes in the baby can
be intergenerational. Once the change has
occurred, that baby, when it becomes an
adult, has a baby and that baby inherits the
risk,’ he earlier told Good Practice.
Lessons from history
During the World Diabetes Congress,
Zimmet also highlighted the fact his
research has shown large numbers of
people in countries all over the world now
have diabetes after their parents suffered
through a famine decades earlier.
‘With some historical perspective, we
are starting to see trends in the way
environmental disasters such as famine
interact with the genes of a whole population
group. This interaction occurs during
pregnancy, affecting the baby’s risk of
chronic diseases, such as type 2 diabetes,
obesity and heart disease, which can show
up decades later,’ he said.
‘China is the best example. There are now
110 million people with diabetes in China.
Thirty years ago there was virtually none,
but they had a very big famine – the Mao
Famine – in the late 1950s.’
Zimmet was the lead author on a review
paper, Diabetes: a 21st century challenge,
which was published in December 2013 and
outlines the fact modern-day areas currently
experiencing drought and famine may
become future hotspots for type 2 diabetes.
Using research from Australia and the
US, the paper found identifying which
countries are likely to see signifi cant
numbers of people with diabetes in the
future and making these regions a priority
for prevention is critical to stemming the
potential diabetes epidemic of the coming
years. >>
RACGP resourceAn updated version of General
Practice Management of Type
2 Diabetes – Guidelines (the
diabetes handbook) will be
launched in March 2014. The
2014 edition will again be a
joint publication of the RACGP
and Diabetes Australia, but will
include a revamped layout and
new content, designed to make
it a more useful resource for
GPs. The diabetes handbook will
be available in hardcopy and, for
the fi rst time, as an interactive
online version. Visit www.racgp.
org.au/your-practice/guidelines/
for more information.
8 Reprinted from Good Practice Issue 1–2, January–February 2014
Image R
AC
GP
FEATURE STORY
>> ‘Research plays a critical role in helping
us put the pieces of the jigsaw together and,
in doing so, helps to shape our responses to
this most pressing of public health issues,’
Zimmet said.
For Zimmet, previous famines and current
levels of diabetes must act as cautionary tales
for the modern world.
‘It’s a warning to the world,’ he said. ‘In
the Horn of Africa, where there is a famine at
the moment … we may be looking at very big
epidemics of diabetes.
‘We have to learn from history.’
Public policy
According to Sir Michael Hirst, President of
the IDF, former Chairman of Diabetes UK and
Member of the British Parliament, the long
reach of diabetes means governments have a
signifi cant role to play in its treatment.
‘Diabetes is one of these cross-
cutting issues that affects huge areas of
government,’ he said at the World Diabetes
Congress. ‘We [the IDF] are extremely keen
to see diabetes and non-communicable
disease brought into the policy development
of every area of government.’
The World Diabetes Congress saw the
announcement of a number of government
initiatives for diabetes, including the IDF’s
Melbourne Declaration on Diabetes, which
includes signatories from more than 50
parliaments around the world, including
Australia. This ‘Parliamentarians for
Diabetes’ global network has committed
to working to ensure diabetes is high on
every country’s political agenda, paving the
way for preventative work, early diagnosis,
management and access to adequate care for
people living with diabetes.
More locally, the World Diabetes Congress
also saw Australia’s Federal Minister for
Health, Peter Dutton, announce plans for the
National Diabetes Strategy, which will see
the establishment of an expert advisory group
co-chaired by Zimmet and Judi Moylan, Chair
of the Parliamentary Diabetes Support Group.
Dutton said the advisory group will consider
available evidence and consult a range of
stakeholders to shape the development of the
National Diabetes Strategy, informing how
Australian Government spending can be better
targeted to address diabetes management
and prevention, including the challenges from
the increasing incidence of chronic disease.
‘Many of these diseases and associated
complications can be prevented by targeting
shared risk factors such as obesity,’ he said.
‘It is important that doctors and other health
professionals are supported by a system
that enables them to provide patients with
best practice treatment and management of
diseases like diabetes.’
On the front line
Whatever policy plans are put in place or what
numbers come to light from around the world,
it is GPs who carry much of the load in terms
of initial treatment for people with diabetes,
especially those with type 2 diabetes.
Sir Michael Hirst (centre) used the World Diabetes Congress, held in Melbourne in December 2013, to speak about
the need for governments around the world to play a bigger role in fi ghting diabetes and its associated complications.
Statistics contained in the sixth edition of the Diabetes
Atlas highlight a worldwide battle with the disease.
9Reprinted from Good Practice Issue 1–2, January–February 2014
Images
Inte
rnatio
nal D
iabete
s Federa
tion (
Bru
ssels
, B
elg
ium
, 2013),
Paul Z
imm
et, G
ary
Deed
‘At the coalface, general practice has
the central role in the management and
intervention with patients,’ Deed said.
‘General practice not only bears the
burden of larger numbers [of people with
diabetes], but the requirement for complex
care planning, which is required in the
individualised management of people with
type 2 diabetes.’
Deed, one of the clinical editors of the
RACGP’s General Practice Management
of Type 2 Diabetes – Guidelines (see
breakout on page 7), believes GPs play a
fundamental role throughout every stage of
diabetes care.
‘There’s a role right across the spectrum,
starting with health and prevention using
the RACGP’s red book [Guidelines for
preventive activities in general practice] of
guidelines and preventative activities. And,
certainly once diabetes is apparent, using
appropriate management and complication
prevention,’ he said.
‘Because the numbers are so large, it’s the
workforce in the health system that really is
going to be key in addressing these issues.’
According to the Diabetes Atlas, as many
as 175 million people throughout the world
are unaware they have diabetes. While
this is an alarming statistic, Deed believes
a portion of the responsibility falls with
the patients themselves, many of whom
he said may not be not taking the proper
precautions, heeding the warning signs, or
getting the appropriate checks.
‘I suspect it’s not just a GP problem
for not picking it [diabetes] up,’ he said.
‘Some of these people may, in fact, not
be attending other healthcare services for
numerous reasons.’
Deed said it is relatively common for
people to come to see their GP complaining
of various ailments, only to be surprised to
learn they have diabetes.
‘I think an average GP would have those
patients and have memories of patients
like that,’ he said. ‘Patients come in for
fatigue or for other reasons, wanting you to
investigate it. Then, of course, you uncover
that they’ve got diabetes.’
Checks and balances
With that idea in mind, Deed believes GPs
should formulate a fi xed plan of questions
they will ask and what they will look for when
they are presented with a patient they suspect
has diabetes, as well as how they will treat
them should they prove to have the disease.
‘If you single it out using risk tools
and have a checklist in your mind, I think
we will probably discover more of these
people more often,’ he explained. ‘[Then]
try to encourage patients in giving them
evidence-based instructions on what
is necessary. Try to look at things that
patients may be able to do in their own life
and in their own families.’
Regardless of what they learn from
reports and studies like AusDiab or the
Diabetes Atlas, Deed believes GPs are
well equipped to treat diabetes patients
and should rely in their own training and
instincts, rather than getting too caught up
in the statistics.
‘I think it’s important for people to
be aware of [studies], but I don’t want
people to become … disinclined by more
and more information,’ he said. ‘GPs
are well versed in the understanding of
blood-pressure management and lipid
management in all patients, let alone
diabetes.’
Zimmet agrees that while the
modern diabetes epidemic means
doctors and patients need to be more
vigilant, a person’s life does not have
to fundamentally change upon learning
they have diabetes, and the GP has a
signifi cant role in maintaining that healthy
and active lifestyle.
‘If diabetes is well controlled, and blood
pressure’s well controlled, cholesterol
is well controlled [people with diabetes]
can almost expect a normal life,’ he said.
‘The message, of course, is to have your
diabetes well controlled and minimise your
risk of complications.’
With the Diabetes Atlas revealing the
number of Australian diabetes-related
deaths to be relatively low in comparison
to other countries, Deed believes our GPs
and the country’s larger healthcare system
are doing a good job in treating and
managing the disease.
‘I think that’s a refl ection of the whole
of our health system, and our public
health policies,’ he said. ‘Quality general
practice underpins the health system
in this country, and I think we shouldn’t
downplay the infl uence of our colleagues
and their ability to prepare for patients with
diabetes, let alone other chronic illness.
‘Guidelines, good systems, good
consultation and networks of care are key
to underpinning the management of this
illness.’
Professor Paul Zimmet has been predicting a global
diabetes epidemic since the 1970s.
Dr Gary Deed believes GPs have a major role to play ‘at the
coalface’ in the treatment of diabetes.
President of the International Diabetes Foundation, Sir
Michael Hirst has been working to combat the disease
since his son was diagnosed with type 1 diabetes more than
20 years ago.
10 Reprinted from Good Practice Issue 1–2, January–February 2014
Access all areas
PAUL HAYES
Sydney’s original Rock Doctor, Dr John Gullotta is a GP with a very eye-opening client list.
When someone is describing
a life in general practice, a
number of adjectives and
phrases would likely come to
mind: professionally fulfi lling;
intellectually stimulating;
altruistic; diverse; inspiring.
The list goes on. The word
‘glamorous’, however, is
somewhat less likely to used.
Well, at least for most GPs.
Sydney-based Dr John
Gullotta is one of the few
in the industry who could
legitimately use such a term
when discussing his working
life. In addition to his daily life
as a GP in the Sydney suburb
of Matraville, Gullotta is the
go-to doctor for a number of
touring companies and TV
stations in NSW.
‘When the overseas artists
come out or local artists tour, I’m basically
the tour doctor,’ he told Good Practice.
‘Now I am also involved in TV talent shows,
including The Voice.’
Known throughout NSW medical and
entertainment circles as the ‘Rock Doctor’,
Gullotta’s client list features all of the major
Australian promoters and management
companies who are behind some of the
biggest artists to come to Australia, including
the Harbour Agency (Guy Sebastian and
John Farnham), Chugg Entertainment (Elton
John, Dolly Parton, Coldplay), Dainty Group
(Michael Bublé, Il Divo), Frontier Touring
Company (Justin Bieber), Private Idaho
(Delta Goodrem, Human Nature), Nine Live
(One Direction, Olly Murs) and Live Nation
(Pink and Fleetwood Mac). Impressive, to
say the least.
Renaissance man
While such a client list is obviously a little
more dazzling than your average GP’s,
Gullotta is anything but a one-trick pony. In
addition to his work with rock stars and other
VIPs, he is an Adjunct Associate Professor
who owns and operates his own practice,
sits on several medical and pharmaceutical
boards, and teaches medical students.
For his efforts, Gullotta was appointed
Member in the Order of Australia, AM, in
2007 for ‘service to medicine through a
range of executive roles with professional
medical associations and as a general
practitioner, and to the Italian community’.
Gullotta believes it’s the variety in general
practice and the rest of his interests that
keeps him so active.
‘In general practice, it can be anything.
One minute it’s a depressed patient, the next
minute it can be a heart attack,’ he said. ‘I
enjoy it and I wouldn’t change it.’
The son of a pharmacist, Gullotta always
knew he wanted a career in medicine.
‘I was the kid with the doctor bag and
Band-Aids, sticking them on everyone when
I was fi ve,’ he said.
But general practice was not his original
career path. Gullotta initially followed in his
father’s footsteps and earned a pharmacy
degree from the University of Sydney before
going on to graduate from medical school
at the University of Newcastle in 1991.
Following an internship and residency at
the Royal Northshore Hospital in Sydney,
Gullotta moved into general practice with his
own clinic in Matraville, where he has been
since 1992.
‘I am the owner and I’ve got two other
doctors that work with me,’ he said.
‘Basically, I work full-time as a “normal”
GP, then I’ve got all my other roles that
compliment that.’
While many GPs have some of those
‘other roles’ Gullotta mentioned, few see
them rubbing shoulders with major Australian
and international celebrities.
Backstage pass
Having worked successfully in general
practice for several years, Gullotta came to
his role as a GP for performing artists visiting
NSW quite by chance.
‘A friend of mine, Tony Grace Guarrera,
a senior agent with the Harbour Agency,
approached me to see if I wanted to go into
looking after singers and celebrities,’ he
explained. ‘I thought, “Wow, that sounds
challenging and it will complement my love
for music and entertainment”, so I said yes.’
After working with Australian artists for
a few years, Gullotta received another
phone call from a fellow GP and university
colleague, Dr Bill, who offered him the
chance to work with international artists
visiting NSW. He quickly accepted and
Sydney’s Rock Doctor was truly born.
GP PROFILE
10 Reprinted from Good Practice Issue 1–2, January–February 2014
11Reprinted from Good Practice Issue 1–2, January–February 2014
While treating big-name stars can be a
thrilling change from day-to-day general
practice, Gullotta said he is careful to treat
them as he would any other patient. That
said, it’s impossible to escape the reality
of their celebrity status and the fact their
health can potentially have very wide-ranging
effects. There is also the added pressure of
treating a person who may not be used to
being told something don’t want to hear.
‘There is great responsibility. Not only do
you have to look at their health, but you’ve
also got to look after their unique egos and
their psyches,’ he said. ‘So it is a specialised
area and, of course, confi dentiality and
discretion are of the upmost importance.’
While the majority of ailments presented
on tour are what you would expect – ‘upper
respiratory tract infections, sore throats,
voice strain’ – it is easy to forget the life of a
touring artist and their entourage, especially
those with an extravagant stage show, is
very hard on the body and takes a real toll on
all of the performers on the tour.
‘Some major artists can do up to 40 or 50
concerts in succession, with only a few days
in between, and [they are] travelling all over
the world,’ Gullotta said. ‘The actual stress
on the body at that level is immense, with
lowering of the immune system. Then you
can add in the travel [and] being exposed
to germs on aircrafts from fellow travellers,
which may lead to an increased chance of
getting sick.’
In addition, the current wave of musical
nostalgia that has seen many singers and
bands who were popular in the ’70s and ’80s
back on the road means the performers may
not be as spry as they were in their heyday.
‘Some older artists who are touring now
are in their 60s and some even older,’
Gullotta explained. ‘As they get older, they
get the ailments that everyone else gets
when they are older. Some have aches and
pains or arthritis from the years of wear and
tear and stress on their bodies. They might
also present with high blood pressure, high
blood sugars, ankle oedema and heart failure
that, with travel, can get worse.’
Not tonight
Treating an artist for a voice strain or pulled
muscle is one thing, but making the decision
to tell a performer they should not go on with
the show is the biggest decision Gullotta
faces as a tour doctor. And it comes with
serious ramifi cations.
‘That is the most diffi cult thing. The cost
of cancelling a concert is huge,’ he said.
‘Insurance companies are involved … then
we get involved with all the promoters and all
the legal people.’ >>Images
Matthew
Norr
is, John G
ullo
tta
Dr who?While he is certainly a well-known
fi gure in large parts of the NSW
medical and entertainment
industries, Dr John Gullotta still
meets people who are not familiar
with Rock Doctor status.
‘When one of the promoters
invited me to a social function the
other day, he introduced me to a
group of people,’ he said.
‘The promoter introduces me,
saying, “This is Dr John, our Rock
Doctor”. Someone then asked,
“What, is he a geologist?”’
Famous friends
and loads of
memorabilia are
just some of the
perks of being
the Rock Doctor.
11Reprinted from Good Practice Issue 1–2, January–February 2014
12 Reprinted from Good Practice Issue 1–2, January–February 2014
GP PROFILE
12 Reprinted from Good Practice Issue 1–2, January–February 2014
>> While it’s the biggest decision a GP
in Gullotta’s position can make, he has
been forced to pull the proverbial pin on
more than one occasion. But, he said,
making such a decision is about preserving
the health of the performer, as well as the
success of a tour.
‘If the voice isn’t going to plan, we’ve got
two choices: either we cancel tonight and
hopefully they get better because they’ve
got two or three days between shows; or
we risk it and risk the whole lot,’ Gullotta
explained. ‘The artists hate doing that, they
always want to go on. But we’ve got to look
after them and, in some cases, we’ve just
got to make the call where we decide to
cancel it.’
Work of the fi rst order
While he is known to many as the Rock
Doctor, they don’t appoint people Member
in the Order of Australia for looking after
rock stars and their entourages. Gullotta
has been heavily involved in medical politics
and a number of other healthcare pursuits
for many years.
While his political positions are far too
numerous to name in their entirety, Gullotta
served as President of the Australian
Medical Association (AMA) in NSW
between 2004 and 2006 and as a member
of the AMA Executive Council from 2007
to 2009. He was also President of the
Eastern Suburbs Medical Association from
1999 to 2004, a member of the RACGP
NSW Faculty Executive Committee from
1993 to 1995, Foundation Secretary of the
South Eastern Sydney Division of General
Practice, and Chair of the Federal AMA
Therapeutics Committee.
Gullotta also maintains his pharmacy
registration and serves on several
pharmaceutical advisory bodies, including
as a member of the Poisons Advisory
Committee of the NSW Health Department
and the Medicines Australia Code of
Conduct Committee.
In addition to his political life, Gullotta also
takes time out to teach medical students at
the University of Sydney, an experience he
still fi nds invaluable.
‘It helps with your thinking and I
enjoy passing on knowledge to the new
generation,’ he said. ‘It always challenges
… and stimulates you mentally. It also
keeps you up to date.’
If that wasn’t enough, Gullotta’s Italian
heritage sees him do a lot of work within
that community.
‘I speak Italian and I am the doctor for
the Italian consulate,’ he said.
‘And I’m involved in … the Italian
[community], helping people that need
medical pensions and things like that.
That is usually done pro bono because
they can’t afford the fees.’
It was this sort of selfl ess work, which
also includes chairing the AMA NSW
charitable foundation, that culminated in
Gullotta’s Order of Australia.
‘That was a great honour, and very
humbling,’ he said.
Regardless of the awards he receives
or the celebrities he treats, Gullotta is
fi rst and foremost a GP. He still
appreciates that every day in general
practice can be different from the last
and loves the relationships he forges
with his patients through the years, even
if they do remind him just how long he
has been in the business.
‘I am now seeing kids that I
immunised having babies,’ he said. ‘I’m
now thinking, “Oh my god, I’m getting
old”.’
Images
John G
ullo
tta
Regardless of their high profi les, Dr Gullotta
said he is careful to treat the VIPs the same
way he would treat the patients at his practice in
Matraville, Sydney.
14 Reprinted from Good Practice Issue 1–2, January–February 2014
Volunteering in the Kathmandu Valley
INTERNATIONAL GP
15Reprinted from Good Practice Issue 1–2, January–February 2014
STEPHEN A MARGOLIS
For Australian GP Steve Margolis, taking his much-needed medical skills to Nepal proved a fulfi lling and educational experience.
Approaching the later stages of our respective
careers in education and medicine, my partner
Valmae and I were looking for opportunities to
give something back to those less fortunate.
With many years of experience working with
Aboriginal and Torres Strait Islander people,
and having lived and worked in the United
Arab Emirates, we looked for locations where
our skills and experience might provide the
greatest benefi t to those most in need.
With English our only language, and
personal safety a signifi cant consideration,
Nepal became our destination of choice, a
country of dramatic and stunning scenery
which is bearing witness to a burgeoning
populace and rapid urbanisation, but with
limited resources and much of its population
living in poverty.
We started by approaching DocTours, a
Sydney-based company that organises volunteer
placements for professionals in countries with
areas of need. Our destination was on the
fringes of the rapidly expanding urban centre
of Kathmandu Valley, where the population has
risen from 1.6 to 2.5 million in the last 10 years.
Mindful that personal connections are
crucial for volunteering across cultures
and languages, we decided to undertake a
two-week preliminary/exploratory trip, which
allowed Valmae to meet with teachers and me
to meet with doctors.
Through DocTours, we met our Nepalese
hosts, Bijuli, Sunita and Phillip Timila, from
Banepa, a town of about 20 000 located
an hour (through some rather hectic traffi c)
southeast of Kathmandu. Bijuli has been
supporting volunteers in his district for 10
years and has strong connections across
health and education.
The health service around Banepa mostly
consists of village-based primary care
delivered by health workers, the community-
based Scheer Memorial Hospital (similar
to an old-style Australian country hospital)
and Dhulikhel Hospital, the district teaching
hospital of Kathmandu University.
Although undergraduate medical education
is now well established in Nepal, graduate
education programs have only recently been
established. Most of the doctors are trained
in countries other than Nepal and bring a
broad and varied range of experience to
clinical practice. Through Bijuli’s personal
connections, I had the privilege of working
closely with the Scheer Hospital team across
a range of inpatient and outpatient services,
as well as a shorter experience at the
Dhulikhel Hospital.
On rounds
Each morning at Scheer would begin with a
joint meeting of all medical staff, where the
overnight admissions would be discussed,
often followed by an education session. Ward
rounds would follow and I usually chose to
participate, only missing out when I was in the
operating theatre.
Around 25 inpatients made for lengthy
rounds and provided a powerful insight into
the health challenges faced by the community.
Grinding poverty, limited education and few
medical options combine to see most patients
present to hospital very late in the course
of their disease. Although hypertension,
ischaemic heart disease, chronic obstructive
pulmonary disease (COPD) and, to a lesser
extent, diabetes are all very common, few
people have access to, or are compliant with,
outpatient medication. As a result, many
presentations to hospital are the outcomes
of these diseases, including myocardial
infarction, stroke and pneumonia.
Few [local] people have access to, or are compliant with, outpatient medication
Infectious disease is also a major challenge,
with tuberculosis and typhoid common
causes for admission, with septicaemia
(mostly from pneumonia), requiring inotrope
support, occasionally presenting. Surprisingly,
attempted suicide by organophosphate
poisoning is also quite common.
Dr Angela, the sole physician at the Scheer
Hospital, welcomed my participation in her
ward rounds, taking time to translate key
points in the dialogue for me, allowing me to
examine the patients (with their consent) and
discussing each person’s condition. Clinical
acumen is uppermost because the range
of investigations and treatment options is
limited by availability and cost. However, late
presentation and advanced disease means
physical signs are often quite pronounced
compared to the Australian clinical setting.
Counting the costs
Patients in Nepal must pay for all treatment,
often upfront, and there is no insurance.
While these costs are admittedly very low by
Australian standards, they represent a major
expenditure for people who earn an average
of US$540 per year.1 >>
Image V
alm
ae Y
pin
aza
r
16 Reprinted from Good Practice Issue 1–2, January–February 2014
Images
Valm
ae Y
pin
aza
r
INTERNATIONAL GP
>> Simple tests, including full blood
count, electrolytes, renal function, blood
cultures and liver function are available at
Scheer, as are plain X-rays and ultrasound,
with echocardiography (excluding Doppler)
available once a week. CT scans are available
at a location 30 minutes away, but cost
US$200.
Medication choices vary depending on
availability from suppliers, but most that
are relatively cheap and commonly used
can be provided. I was interested to note
that patients request and receive almost no
analgesia, meeting the cultural norm of the
population serviced by the hospital.
In addition to the traditional male and
female wards, there is also a three-bed
high-dependency unit with contemporary
bedside monitoring, but no access to blood
gas analysis.
Ward rounds at Scheer are followed by
breakfast in the cafeteria and the rest of the
day is fi lled with outpatient clinics. The clinical
content of medical outpatients is similar to
Australian general practice, with a number
of chronic disease management issues,
including monitoring of disease conditions and
compliance with medications both prominent.
I also visited the hospital’s very busy
obstetric unit, which sees 5–10 deliveries
per day. Most patients delivering at Scheer
receive antenatal care, helping to keep
the C-section rate to around 15%. The
government co-funds these obstetric
services, which demonstrate high standards
of care with good clinical outcomes.
However, a high national perinatal mortality
rate (27 in 20111) is due to the large number
of women not receiving antenatal care and
delivering at home unsupervised, which
occurs despite national government programs
to support and promote antenatal care and
hospital birthing units.
Operations at Scheer are conducted at a
high standard. Modern anaesthetic machines
donated in 2012 allow safe and effective
anaesthesia for patients who often have
high levels of comorbidity and associated
complications. The skilled surgeons provide
a range of acute and elective operations,
including laparoscopic cholecystectomy,
vaginal hysterectomy and internal fi xation of
fractures. Visiting international teams also
provide specialised procedures; a cleft palate
team from Japan was visiting during our stay.
Inpatient care
Although my principal attachment was to
Scheer, I also visited the Dhulikhel Hospital,
10 minutes further west from Banepa.
Above left: Severe poverty and poor education often combine to see Nepalese patients often present at hospital very late in the course of their disease. Above right: Despite its limited
resources and rapid urbansiation, Australian GP Steve Margolis found Nepal a country of great beauty and culture.
Contacts
If you are interested in visiting
Banepa and offering your services,
useful contacts include:
Karin Eurell, DocTours, Sydney
(02) 9967 8888 or
Bijuli Timila, Banepa, Nepal
+977 9841543982 or
Scheer Memorial Hospital,
Banepa, Nepal
www.scheermemorialhospital.org
Dhulikhel Hospital, Dhulikhel, Nepal
www.dhulikhelhospital.org/
Baylor International Academy,
Banepa, Nepal
www.baylor.edu.np
Esa Memorial School, Banepa, Nepal
www.scheermemhosp.org/School.asp
17Reprinted from Good Practice Issue 1–2, January–February 2014
This large and more modern hospital offers
a greater range of services, including an
intensive care unit (ICU), neonatal intensive
care unit (NICU), and a formal emergency
department. I spent one day working with the
sole emergency department consultant and
two days with the paediatric team.
With Nepal in the early stages of
developing a pre-hospital care system, and
emergency medicine not currently recognised
as a special discipline, the inpatient
specialty teams are closely involved in the
management of patients in the emergency
department. Trauma, infections and the
complications of pregnancy and chronic
disease are the most common presentations.
A larger range of investigations is available,
but no CT.
Clinical problems faced by the inpatient
paediatric unit include multiple infectious
diseases similar to those seen in adults,
including tuberculosis, typhoid, hepatitis
A and pneumonia. Some children I saw
appeared small and undernourished,
consistent with marasmus or kwashiorkor.
The very modern and well-equipped NICU
provides continuous positive airway pressure
(CPAP) and ventilation for small, premature
and septic babies.
Learning opportunities
Universal education has a very short history in
Nepal. In 1951, there were only about
10 000 students attending school, primarily
children of the ruling classes. But through
successive governments and policy changes,
the number had grown to 7 800 000 by
2010. This large increase has taken place in
a country beset by poverty, isolated villages
and very poor infrastructure, and the current
literacy rate of the Nepalese population is
estimated to be 60%, with around 90% of all
children attending primary school.
One of the consequences of such rapid
expansion of education is the critical shortage
of qualifi ed teachers; approximately half of the
country’s educators have no formal teaching
qualifi cations.
I volunteered in two private schools
while I was in Nepal, both of which have
an emphasis on teaching in English. The
Esa Memorial School is part of the Scheer
Hospital and has 60 students, ranging from
early childhood (2–3 years) through to Year 5.
Unlike Australian schools, the children stay in
their assigned rooms while the teachers rotate
through each grade.
The subjects covered are similar to those
in Australia, including English, maths, science
and social studies. Nepalese is also taught.
I gave support to the teachers in the
classroom, engaged in conversational English
with the older students, helped take English
lessons, played singing games with the
younger students and did some one-on-one
work where I could see a need.
The Baylor International Academy has an
Early Childhood Care and Education facility
that was established in 2010 and caters for
children aged 2–5. This is more like a typical
Australian early-childhood centre, with a
single teacher responsible for their own group
of students.
I worked with an older group of students
in the two days I spent there. I joined in with
their songs, helped with reading and writing,
conversed in English, did some one-on-
one work with a young boy, and generally
supported the teacher where I could.
The Nepalese children and teachers are
very welcoming and appreciative of any
skills brought to the classroom, and it is
not necessary to be a teacher in order to
volunteer in this environment. Conversations
conducted in English with the children and
teachers go a long way towards improving
their English-language skills, and any interests
in music, art, dance and drama that could be
shared would be most welcome.
Both schools have very few resources
so creating educational resources would be
another volunteering opportunity. The only
thing required is a joy of being with children.
Offer your services
Nepalese health and education providers
welcome doctors and teachers from Australia
who wish to assist with their programs. The
options range from shorter orientation-style
visits through to being a staff member over a
period of weeks or months.
Options for living arrangements include
daily commuting from a range of hotels in
Kathmandu (your choice), local district hotels
and guesthouses, or home-stay with Bijuli
and his family. Although taxis and buses are
readily available and very cheap over short
and long distances, road conditions are poor,
which makes for long travel times.
Valmae and I both thoroughly enjoyed
our brief visit to Nepal and plan to return
for a more extended stay, when we hope
our contribution can be more substantial.
Australian-trained GPs have much to offer
Nepalese healthcare services and, depending
on your training, experience and interests,
this could include village-based primary care,
hospital-based consulting or procedural
practice.
Reference
1. Unicef. Available at www.unicef.org/infobycountry/
nepal_nepal_statistics.html [Accessed December 2013].
education inNUTRITION
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A sensitive topicBEVAN WANG
With the internet now a key source of sexual health information for young people, GPs hope it will make it easier to start the conversation in a clinical setting.
For people of any age, talking t o a GP about
matters of sexual health can be uncomfortable.
No matter how easy the doctor–patient
relationship, people are still likely to feel
awkward when raising such a sensitive and
potentially embarrassing topic. When it comes
to younger Australians and their GPs, research
has found they are increasingly reluctant to
raise the issue at all.
According to The youth worker’s role in
young people’s sexual health: A practice
framework, from the Australian Clearinghouse
for Youth Studies, many young Australians
are hesitant to seek sexual health information
from their GP due to the perceived stigma,
embarrassment, lack of interest, and apathy,
and they are largely going online to have their
questions answered.
Similarly, a 2013 study from the University
of Melbourne looked at the sexual health
relationship between 31 young male students
aged 16 –25 and their GPs and found the
young men are getting their sexual health
information predominantly from the internet,
largely because they do not feel comfortable
bringing it up with their GPs
Dr Sarah Latreille, key author of the
University of Melbourne research, believes
that with so many young people going
online for their sexual health information,
questions around the accuracy of the
material remain.
‘They [participants] all got most
of their sexual health information
from the internet and most of
them knew it could be unreliable,
but because it was easy the
benefi ts outweigh that,’ she told
Good Practice.
Colin Batrouney, Manager
of Health Promotion at the
Victorian Aids Council (VAC),
agrees. He believes that as
more young people turn
to the internet, it is
important for organisations like the VAC to take
more responsibility in ensuring the information
available on their websites is accurate.
‘There is so much misinformation on the
internet and it is very easy for people to be
misinformed around sexual health issues,’
he said. ‘In terms of the work we do, and
the responsibility that we carry in relation to
health promotion, it is very important that our
message around sexual health and wellbeing is
correct. It was very important for us to provide
people with the right information and, in that
sense, we make sure that what we are saying
is in accordance with health professionals.’
Many young Australians are hesitant to seek sexual health information from their GP ... and are largely going online to have their questions answered
Despite the prevelance of potentially
unreliable health information online, there
are ways of making sure specifi c websites
are valuable. Health On the Net Foundation
(HON) is an online organisation designed to
‘encourage the dissemination of quality health
information for patients and professionals
and the general public’. Websites that are
HONcode-certifi ed comply with a code of
practice to provide accurate health information.
As more people turn to use the internet for
health information, it is hoped initiatives like
this will ensure they access quality information.
Online world
The internet, especially social media, is gaining
recognition as a valid platform for health
communication and education. The ability to
reach and connect individuals, regardless of
time or place, makes its reach enormous.
SEXUAL HEALTH
18 Reprinted from Good Practice Issue 1–2, January–February 2014
Image S
hutters
tock
19Reprinted from Good Practice Issue 1–2, January–February 2014
Image S
ara
h L
atr
eill
e
‘All these health promotion tools like
Facebook, Twitter and YouTube are at our
disposal and we have to learn to harness it
and use it,’ Batrouney said.
‘Anything that we can use, we will use
to keep the conversation alive with young
people and the population at large. That is a
very important message.’
Social media has allowed users to create
profi les and connect with friends, long-lost
relatives, companies and organisations, and
even celebrities. A 2013 nationwide survey
by the Australian Communications and Media
Authority (ACMA) found that 97% of 14 –15-
year-old and 99% of 16 –17-year-old internet
users reported using social media.1
With more than half of the 12 million
Australian Facebook users aged 18 –34,2,3
Batrouney believes the ability to target this
audience makes sites like Facebook one of
the most effective ways of communicating
sexual health information to young people.
‘It is important that we fi nd a way to
use social media to further the health and
wellbeing of young people,’ he said.
One of the advantages of social
media is that users are not only receiving
information, but are also actively engaging
in the communication of it. It is this type of
online interaction, where people engage
in discussions and share fi les related to
issues they know are relevant to them, that
Batrouney believes is vital in successfully
providing sexual health information via these
online outlets.
‘There is no point in just providing the
information unless you actually provide people
with a context entry point into the information
so that they can actually see how it might
relate to them or their lives,’ Batrouney said.
Being Brendo
With the average YouTube visitor accessing
the site 11 times per month, 4 and 89% of
Australian Facebook users watching videos on
the website,5 many organisations are looking
to capitalise on this market.
With that kind of reach in mind, the VAC
launched an online soap opera targeted
at people aged 16–29. Available on
Facebook and YouTube, Being Brendo is a
Melbourne-set show that follows the lives of
four gay housemates and tackles issues like
homophobia and sexual health.
Having racked up 86 webisodes, Being
Brendo now has more than 7500 Facebook
fans who regularly contribute to and post on
the show’s page.
‘The ultimate purpose is to engage an
online audience around issues related to
sexual health and health and wellbeing,’
Batrouney said. >>
Dr Sarah Latreille said while young people will discuss
sexual health if it’s raised by their GP, they are reluctant
to bring it up themselves.
20 Reprinted from Good Practice Issue 1–2, January–February 2014
SEXUAL HEALTH
Images
X-M
ach
ine P
roduct
ions
>> Much of the success of Being
Brendo, Batrouney believes, can be
attributed to the show’s ability to connect
with its audience through humour and
entertainment.
‘By creating a drama that also included
comedy, we believe that the audience would
not only get invested in the characters, but
also understand the issues that they are
facing, particularly in HIV transmission and
sexual health,’ he said.
‘People can get on the Facebook page
or YouTube channel and be engaged in the
drama and be able to laugh and cry with
the characters. That has been the most
successful aspect of the campaign, where
we have been able to insert health promotion
messages in there through the Trojan Horse
of drama, entertainment and comedy.’
Talking with GPs
As the fi rst point of medical contact for most,
GPs have a signifi cant role to play in the
sexual health of young people. But while they
are a trusted source of information, research
shows many young people are becoming
unwilling to raise the often diffi cult issue of
sexual health with their GP.
‘Most of them [young people] said if their
GPs brought it up, they would be happy to
talk to them about it. They just don’t want
to do it themselves,’ Latreille said. ‘They
either did not have the confi dence to bring
it up with their GP or health professional, or
they believe it’s a taboo topic and they are
wasting their GP’s time.’
Batrouney believes that regardless of
the advancements of online information,
GPs provide an environment that cannot be
replicated outside of the clinical setting.
‘We can be out there campaigning, but
GPs still play an incredibly important role,’
Batrouney said. ‘They have to be there to
offer a full sexual health screen and provide
a safe environment for those individuals so
that they can set up a regular relationship
and a testing pattern around sexual health
with their GPs.’
The RACGP encourages all GPs to follow
suggestions outlined in its Guidelines for
preventive activities in general practice 8th
edition (the red book), which recommends
sexual health screening for those aged
15 –29.
Batrouney hopes that as sexual health
promotions on social media like Being
Brendo continue to be more infl uential,
young people will feel more comfortable
discussing sex with their GPs. However, he
also points out that the onus is also on GPs
to ensure they make discussions around
sexual health as comfortable as possible.
‘If GPs are able to normalise the whole
aspect of being able to talk about sex,
sexual practice and sexual health with
young people, then the whole fear aspect
and barrier around fear or discomfort or
embarrassment towards sexual health can be
removed,’ he said.
References
1. Australian Communications and Media Authority, 2013.
Like, post, share: Young Australians’ experience of
social media. Available at www.acma.gov.au/~/media/
mediacomms/Report/pdf/Like%20post%20share%20
Young%20Australians%20experience%20of%20
social%20media%20Quantitative%20research%20
report.pdf [Accessed December 2013].
2. Facebook hiring in Australia to service 12 million
active users. Available at www.brw.com.au/p/
tech-gadgets/facebook_hiring_in_australia_to_
YQKB6Cl4SxoAqJV2VoIJdJ [Accessed December
2013].
3. Achievers Group. Facebook for Business. Available at
www.achieversgroup.com.au/articles2/Learning-Library-
60-Seconds-with-Achievers-Group-Nick-Jerrat-Volume-
5-Issue-8-Facebook-for-Business [Accessed December
2013].
4. Nielsen. Australian Online Landscape Review. Available
at www.nielsen.com/content/dam/corporate/au/en/
reports/2013/nielsen-au-online-landscape-review-
may-2013.pdf [Accessed December 2013].
5. Australian Communications and Media Authority.
Digital Australians – Expectations about media content
in a converging media environment: Qualitative and
quantitative research report. Available at www.acma.gov.
au/webwr/_assets/main/lib410130/digital_australians-
complete.pdf [Accessed December 2013].
Available on Facebook and YouTube, the Victorian Aids Council’s Being Brendo is using social media to directly target
young Australians on matters of sexual health.
22 Reprinted from Good Practice Issue 1–2, January–February 2014
IN MY PRACTICE
Complete careBEVAN WANG
Western Sydney’s Bridgeview Medical Practice understands the need for a holistic health approach for the community.
Leaving your home for a new country is not
an easy undertaking. Add in the inability to
communicate in your own language and
fl eeing from your possibly war-torn homeland,
and health and wellbeing may not be too high
on your priority list.
One of the most multicultural areas of
Australia, Western Sydney is home to a
large portion of Australia’s Sri Lankan Tamil
community. Working with the Department
of Immigration, Bridgeview Medical Practice
is essential in treating many of the asylum
seekers and refugees in the area. As one of
the practice principals, Dr Thava Seelan, told
Good Practice, improving the health outcome
of the Tamil community is a key mission of
the clinic.
‘Since the civil war in Sri Lanka [in 1983],
lots of Tamil refugees have been coming to
this area and we believe that good health
communication will result in a better health
outcome for them,’ he said.
The ability to service the community in
another language is important to the practice
and, according to Dr Shanthini Seelan, makes
the potentially daunting experience of going
to see a local doctor much more comfortable
for people in the Tamil community, especially
when they are new to Australia and their
English is limited.
‘The population of the subcontinent is quite
high here and their literacy is quite low. Some
of them are new arrivals and they are fi nding it
diffi cult to fi nd their feet. Talking in a language
that is familiar to them will be much more
benefi cial to their wellbeing,’ Shanthini said.
In recognition of this type of approach to
patient health and wellbeing, Bridgeview was
awarded the RACGP’s 2013 NSW General
Practice of the Year Award.
One-stop shop
Along with the third practice principal, Dr
Lumina Titus, Thava and Shanthini work
alongside fi ve other GPs, as well as registrars,
medical students, nurses, specialist doctors
and allied health professionals to ‘provide
personalised, holistic medical care’ for the
practice’s 12 000 patients.
Working closely with their allied health
partners, the trio believes that as primary care
continues to evolve, practices need to be able
to adapt and expand to meet the needs of
their patients.
‘Primary care provision has changed a
lot and those days of just seeing a patient
and giving them some medication are over,’
Thava said. ‘Lots of patients with chronic
diseases need allied health all the time, like
physiotherapists, dietitians, diabetic educators
and even chemists.’
Recipient of the Primary Care Infrastructure
Grant from the Federal Government in
2010, Bridgeview is now made up of six
consulting rooms, a physiotherapy room, four
treatment rooms, a boardroom, auditorium,
four purpose-built consulting rooms for allied
health services, a chemist and a chronic
disease management clinic.
‘We feel that if we can have everything
under one roof, when a patient comes in they
can see their doctor and their allied health
providers and everyone in the one time,’
Shanthini said. ‘By providing an atmosphere
where they can get everything done at relative
ease, it works very well for them and for us.
The outcome is extremely favourable.’
Better than a cure
According to Titus, one of the most effective
and cost-effi cient ways of practising
preventative medicine is for GPs to conduct
comprehensive health assessments. Patients
who attend consultations will be asked
targeted questions to detect diseases or the
relative risk of getting a particular disease.
‘Doing the health assessments, we actually
get the whole system reviewed with the
patients and we can actually address the
issue. We can prevent the diseases before
they are present,’ she said. ‘Depending
on the risk factors, we can deal with the
factors and can refer them to allied health
professionals to try to minimise that risk.’
Additionally, Shanthini discussed the
need for more practices to make use of the
Australian Diabetes Risk Assessment Tool
(AusDrisk) in patients aged 40–49 in order
to test their likelihood of contracting diabetes
in the next fi ve years. By implementing this
tool, the practice was able to introduce many
patients into intervention programs.
23Reprinted from Good Practice Issue 1–2, January–February 2014
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‘If we get someone with a very high risk
of diabetes, we can go in at the opportune
moment and get them into intervention
programs,’ she said.
‘We can consider sending them off to the
dietitian or organising a lifestyle modifi cation
program, keeping a close eye on them and
making sure that their risk factors are reduced
and removed.’
In keeping with the practice motto, ‘caring
for the community’, the doctors believe their
role is not just within the four walls of the
clinic, but is also about building awareness
and educating local people.
‘We try to reach out to the community
in any way and work closely with charities,
organisations and schools to promote health
education and get the community thinking
about risks,’ Shanthini said.
Managing chronic diseases
According to Shanthini, diabetes is the most
common chronic disease seen at Bridgeview.
She said treating these patients is a team
effort that requires primary care and allied
health cooperation.
‘We have 574 [patients with diabetes] and
each and every single one of them needs
care,’ she explained. ‘Together with our
allied health partners, they can get their feet
checked, their eyes done, [get] a dietitian to
review them and an exercise physician to see
to their exercise program.’
By repeating this process every three
months, chronic conditions can be better
managed and patients are able to live
more comfortably.
In addition, having GPs and allied health
professionals connected on the same e-health
system enables the sharing of information that
can be utilised throughout the whole practice.
‘When they go through their monthly checks
with all the other allied health providers,
whatever the allied health providers do will be
uploaded on the system so that everything is
there for us to see,’ Shanthini said.
While the GPs, nurses and allied health
professionals all play their own vital role in
the management of chronic diseases,
Shanthini believes health professionals
can only do so much and real progress is
ultimately up to the patients themselves.
‘What we have to say is, “Look, it’s not
something that we can do ourselves, you
have to come on board as well so we can
help you.” This way, the patients are a major
partner in the process,’ Shanthini said.
Thava said following this process has
already shown to result in healthier patients.
He believes compliance and health have
improved as a result of providing holistic
care in a single location, as evidenced in the
practice’s patients with diabetes.
‘The health outcome is really good,
actually. And we have proven it already with
our diabetic patients’ HbA1c, the indicator
of blood glucose level. Over 65% [of our
patients] are under control, whereas the
national level is only at 45%,’ he said.
My workplaceGood Practice asked Dr Thava
Seelan how the practice works.
What is the most important
role of your practice?
Bridgeview is totally dedicated to
caring for the community on many
levels. We sincerely hope that our
holistic health services, promotion of
community awareness and continued
involvement can bring about
important and powerful changes in
the health sector.
What is your practice’s
greatest challenge?
The myriad problems we face on a
daily basis. For example, as primary
care physicians we deal with physical,
psychological and social illnesses all
in the same consult and have
to formulate a reasonable and
sensible form of management. This
can be daunting and satisfying at the
same time.
How does your practice keep
up with developments relating
to public health?
As primary care physicians, public
health is second nature to us and
we are fortunate to be able to work
closely with WentWest, the Western
Sydney Medicare Local, who provides
unfailing support and guidance.
Top: Bridgeview practice principals Lumina Titus, Thava Seelan and Shanthini Seelan (L-R middle) proudly receive their
RACGP 2013 NSW General Practice of the Year Award. Above: With consulting, physiotherapy and treatment rooms,
Bridgeview allows patients to access a number of services under one roof.
24 Reprinted from Good Practice Issue 1–2, January–February 2014
NUTRITION
Eating together SOPHIE BLACKMORE
The benefi ts of sharing a meal with other people can go far beyond the social.
Food is a fundamental requirement for life.
Our very survival depends on the proteins,
fats, carbohydrates, vitamins and minerals it
provides. According to Maslow’s Hierarchy of
Human Needs, a psychological theory that
fi rst appeared in the 1943 paper, A Theory of
Human Motivation, and grades different levels
of peoples’ needs, food sits alongside shelter,
sleep, sex, air and water as one of our basic
physiological needs.1
But how food is eaten can transform it from
a basic physiological necessity into something
far more psychological, even spiritual. Eating
food with a group of people has been shown to
provide not only physical advantages, but also
important emotional and social value.
Happy together
The physical benefi ts of people eating
together have been well documented.
Research shows that when families enjoy
meals together they tend to eat better, with
more fruit and vegetables and fewer fried
foods and soft drinks.2 When families share
a meal at least fi ve times a week, evidence
suggests the adolescents in those families
reduce tobacco and alcohol use, and show
improved mental health.3
It is clear there is a lot to be gained from a
shared meal other than what the nutrients in
the food provide our bodies.
People eating together provides security
and a sense of belonging and, during stressful
and challenging times in particular, regularly
shared meals create a safe and comforting
haven for adults and children alike. Our basic
human desire to belong and be loved is fed
and satisfi ed by this shared ritual.
Acclaimed chef and kitchen-garden
advocate, Stephanie Alexander, beautifully
25Reprinted from Good Practice Issue 1–2, January–February 2014
Illust
ratio
n J
ulie
Sm
ith; Im
age S
hutters
tock
sums up the importance and power of the
shared meal in this quote on her website: ‘In
many cultures, eating together around a table is
the centre of family life. It is the meeting place,
where thoughts are shared, ideas challenged,
news is exchanged and where the participants
leave the table restored in many ways.’4
Shared history
People getting together to eat dates back
as far as recorded human history and every
culture has its own unique way of sharing
meals. One common thread, however, is that
that the dinner table is a place of signifi cance,
where people meet, spend time together
and share their stories. This universal ritual
works to ensure the cohesion and health of a
community.
It all begins during the making of the meal.
There is time and cost spent in planning the
meal: buying or growing the food; cooking
and serving the meal; and each person
making themselves available to sit down
together.
None of this has to be complicated and it is
nicely illustrated in the iconic 1997 Australian
movie, The Castle, when the Kerrigan family
sits down for dinner.
Family patriarch Darryl looks at his plate
and adoringly asks his wife, Sal, ‘What do
you call them?’ Sal blushes and responds,
‘Rissoles. Everyone knows that.’ Darryl
replies, in awe, ‘But it’s what you do to ’em.’
The importance is not so much what we
cook, but that we have prepared something
signifying we care about the people we made
it for.
Who does the cooking?
The cooking of a meal involves the creation
of a nurturing environment from which we all
benefi t tremendously, namely the shared table
that ensures we eat quality food. There is a
sense of love and belonging, a safe haven to
recharge our batteries and go back out into
the world all the better for it.
While this has traditionally been seen as
a woman’s role, that is no longer the case.
Cooking and sharing meals is something we
should all be comfortable with, if only for our
survival, health and relationships. Anyone
can do it by applying a few basic skills: shop
intelligently; budget wisely; cook healthily; and
keep it simple. You have a kitchen, a fridge
and a stove, so have a go. They’ll love you for
it (even if they don’t show it).
But that’s what ritual is all about – following
the rules of culture without expecting
acknowledgement. This way we contribute
toward survival and quality of life in body, mind
and spirit.
References
1. Maslow AH. A Theory of Human Motivation.
Psychological Review. 1943;50(4):370–96.
2. Rockett H. Family dinner: more than just a meal. J Am
Diet Assoc. 2007;107(9):1498–1501.
3. Sharing meals with family. Indicator overview. VicHealth
Indicators Survey. Available at www.google.com.au/url?
sa=t&rct=j&q=&esrc=s&frm=1&source=web&cd=1&c
ad=rja&ved=0CCkQFjAA&url=http%3A%2F%2Fwww.
vichealth.vic.gov.au%2F~%2Fmedia%2FIndicators%2
FOverview%2520sheets%2F16%2FVH_IO_Sharing%
2520meals%2520with%2520family.ashx&ei=-ialUoW
eK4jriAeRjoHIDA&usg=AFQjCNFCAnpezgZVYNDktn
5wlpPPYvPKtw&bvm=bv.57752919,d.dGI [Accessed
December 2013].
4. Kitchen Garden Foundation. Available at www.
kitchengardenfoundation.org.au/about-us [Accessed
December 2013].
Sophie Blackmore is an accredited
practising dietitian and registered
nurse with more than 25 years of
practical experience in healthcare.
She has also written two books
and is the founder of Education in
Nutrition, an organisation providing
professional development to
Australian dietitians.
PORTRAITS OF GENERAL PRACTICE
26 Reprinted from Good Practice Issue 1–2, January–February 2014
Image R
AC
GP
JOHN MURTAGH
A healthy sense of curiosity isn’t just a feature of general practice, it’s a necessity.
‘Curiosity is the hallmark of scholarship and
science, but it is also the hallmark of service.
Curiosity is not confi ned to the research
laboratory; it is obligatory at the bedside
as well. Only by being curious as to basic
mechanisms, with a genuine regard for who
is ill, how did they become so, and why this
disorder or that sign or symptom, can one
become and remain a competent physician.’
George A Perera, Journal of Medical
Education, 1963.1
As GPs, we are in an ideal position to
satisfy the curious side of our professional
art. In fact, the close relationships we forge
with patients and their families demand it. But
such curiosity is different to inquisitiveness
or voyeurism, or even being nosey. It’s about
problem solving.
House calls
A number of years ago, I had several
appointments with a pleasant, seemingly
reserved woman who was living with anxiety
and depression, and complained about her
indifferent, critical and unsupportive husband.
The image she presented of this man was
quite different to the person I knew. I felt
concerned for this lady and was curious about
the real nature of her husband.
Soon after, I was undertaking a house call
next door to the lady’s home. I thought I would
visit to see how she was responding to her
anti-depressants. As I approached the door,
I could hear a tirade of abuse being directed
at her husband. I thought about leaving, but
decided to go ahead with the social visit.
I had been curious about the relationship
between this lady and her husband, but
now I felt I had a clearer picture. At her
follow-up visit, I gently confronted her about
what I overheard. It opened a new world and
provided a real baseline for counselling.
Home visits like this can be a goldmine for
this type of information. Family relationships
are not necessarily what you picture in the
consulting room.
Stay interested
Soon after I fi rst entered practice many years
ago, a family sought my opinion about their
17-year-old son, who had seen many doctors
but none who could provide an answer for
his apparent intellectual disability, which had
manifest itself as poor school performances.
My curiosity was piqued and I read
the pediatricians’ letters many times and
asked colleagues about this boy, but
could never put my fi nger on the problem.
It had bothered me for years when, one
day, the cause was revealed – Fragile X
syndrome, a genetic condition that causes
intellectual disability, behavioural and
learning challenges and various physical
characteristics.2 I certainly hope I recognise
the next case I encounter.
Forty years ago, I was asked to repair
a third-degree tear in a small woman who
had delivered a large baby. My curiosity and
the fact I was concerned about my work
following such a poor obstetric result saw
me maintain a keen interest in the outcome.
Twenty years later, the lady visited me and
informed me that, yes, all functions were
normal.
‘Why do you ask?’ she said.
‘Just curious,’ I replied.
Curious similarities
In 1974, two farmers I was treating presented
with lymphosarcoma, which I considered to
hardly be a coincidence. When another, and
yet another, presented with the same ailment,
I was very curious about the circumstances
surrounding these patients.
I wondered if it was due to exposure to
a herbicide spray now known as ‘agent
orange’ and decided to report the matter
to the relevant health authorities. After
an investigation, I was told there was ‘no
fi rm evidence for an association’ with the
herbicide. However, I am still wondering – it
was during the Vietnam War and seemed to
make a lot of sense.
On another occasion, a 40-year-old
married woman presented with dysuria and a
vaginal discharge; a gonococcal infection. My
curiosity turned to her husband, who was a
travelling salesman. I suggested the husband
come and see me and, while he didn’t
appear, the lady’s bachelor neighbour did, and
presented with dysuria and discharge.
Counselling can be diffi cult in general
practice. Curiosity isn’t.
Reference
1. Perera G. By Way of Curiosity. J Medical Education
1963;38(1):44–45
2. The Fragile X Association of Australia. Available at
http://fragilex.org.au/ [Accessed December 2013].
Curiosity and the GP
Professor John Murtagh is one Australia’s best
known and most loved GPs. A best-selling
author for McGraw-Hill, his books are translated
into 13 languages. He is the recipient of many
awards and honours and became a Member of
the Order of Australia in 1995.