BBackstage ackstage ppassass - RACGP Practice/2014/January/February...important to see your GP or...

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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

E [email protected]

W www.racgp.org.au/goodpractice

ABN 34 000 223 807

ISSN 1837-7769

Managing Editor: Kevin Pyle

Editor: Paul Hayes

Writer: Bevan Wang

Graphic Designer: Beverly Jongue

Production Coordinator:

Beverley Gutierrez

Publications Manager: Susan Muldowney

Advertising enquiries

Kate Marie:

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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

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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.


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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

[email protected].

VIC

CPR Workshop for GPs

Thursday 20 February,

6:00 pm – 9:00 pm, John

Murtagh Centre, RACGP House.

Contact (03) 8699 0488.

VIC


Thursday 6 February,

6:00 pm – 9:00 pm, John


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


Saturday 8 February,

8:30 am – 10:30 am,


Contact (08) 9489 9555 or

[email protected].

WA

Diagnostic Uncertainties

in General Practice

Saturday 22 February,

8:30 am – 5:00 pm,


Contact (08) 9489 9555 or

[email protected].

VIC

Sports Medicine

Workshop

Sunday 16 February,

8:45am – 5:00pm, John


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

has unshackled the human eye

Having evolved over thousands of years, modern-day work,

study and lifestyle factors are said to be causing the quality

of our eyesight to deteriorate. The Naked Eye looks at the

history of laser-eye surgery and the advancements it has made

in improving vision. Written by renowned ophthalmologists

Dr Michael Lawless and Professor Gerard Sutton, the book

follows these eye surgeons in their work all over the world and

offers a jargon-free insight into everything you ever wanted

to know about laser vision correction. If you would like to win

one of 10 copies of this book, please email your name and

postal address to [email protected].

Entries close 7 February 2014.

Authors: Dr Michael Lawless and

Professor Gerard Sutton

Format: Paperback, 192pp

Publisher: AKA Publishing

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.


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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


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.


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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.


Images

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Paul Z

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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.


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



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.



GP PROFILE


>> 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.


Volunteering in the Kathmandu Valley

INTERNATIONAL GP


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


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

[email protected]

Bijuli Timila, Banepa, Nepal

+977 9841543982 or

[email protected]

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


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


Image S

hutters

tock


Image S

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‘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.


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.


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.


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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.


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


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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


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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.

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