Agent of social change

INSIDE
Leaders of general practice
A closer look at the GP15 award winners
Doctor–patient boundaries
Maintaining ethical relationships
Nutrition and older patients
The healthy weight range and older people
ISSUE 10, OCTOBER 2015
Agent
of social
change
The RACGP’s 2015
Rose-Hunt Award
winner Max Kamien
has spent his medical
career in service of
those most in need
www.racgp.org.au/goodpractice

Contents
Issue 10 – October 2015
04
Your College
RACGP news and events for October.
06
Rose-Hunt Award
Agent of social change
Emeritus Professor Max Kamien’s
career in general practice has allowed
him to advocate for some of the world’s
most vulnerable populations.
10
GP of the Year
Comprehensive approach
The holistic and collaborative
nature of general practice suits
Dr Kean-Seng Lim’s methods of
delivering healthcare.
06
18
General Practice of the Year
Progressive practice
GPs at Western Australia’s Collie River
Valley Medical Centre believe general
practices can evolve to best meet the
needs of their patients.
20
Brian Williams Award
Rural pathway
A close relationship with the local
community is one of many reasons
Dr Ken Wanguhu loves rural
general practice.
22
Conference for General Practice
Full list of award winners from GP15.
12
General Practice Supervisor
of the Year
Leading the way
Medical educator Dr Cathy Milligan hopes
registrars at her rural practice can develop
an extensive range of skills.
14
General Practice Registrar of the Year
Support system
Dr Ashlea Broomfi eld has dedicated
much of her time in general practice to
advocating for her fellow registrars.
16
Rural Registrar of the Year
One of the team
Dr Hannah Visser believes the GP is one
of many links in the chain of Aboriginal
and Torres Strait Islander health.
10
14
23
Ethics in General Practice
Boundary crossings
Maintaining appropriate doctor–patient
boundaries.
24
Nutrition
BMI and older people
Does the healthy weight range
apply to older patients?
26
Financial Planning
Value of trusts
In the fi rst of a new series of columns,
fi nancial planner Terry McMaster examines
the advantages structuring a general
practice business as a trust.
12 18
Published by
The Royal Australian College
of General Practitioners
100 Wellington Parade
East Melbourne
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T 03 8699 0414
E goodpractice@racgp.org.au
W www.racgp.org.au/goodpractice
ABN 34 000 223 807
ISSN 1837-7769
Editor: Paul Hayes
Writer: Bevan Wang
Graphic Designer: Beverly Jongue
Production Coordinator:
Beverley Gutierrez
Publications Manager: Jenni Stiffe
Advertising enquiries
Kate Marie:
T 0414 517 122
E kate.marie@racgp.org.au
Editorial notes
© The Royal Australian College of General Practitioners
2015. 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.
We recognise the traditional custodians of the land and
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Cover image Jeremy McCready
Good Practice is printed on PEFC certifi ed paper,
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Reprinted from Good Practice Issue 10, October 2015
3

YOUR COLLEGE
Benjamin Whittaker:
‘I General-ly Practice good study habits! #punny’
Student
winners
Jessie Ling:
‘A cool day in the offi ce #Antarctica #retrieval’
Danielle Todd:
‘GP fi ts into my life like it
fi ts into my handbag’
Lawrence Ling: ‘My daily medicines!’
The successful entrants into the RACGP’s
‘Win a trip to GP15’ Facebook competition
included one general practice registrar and
four medical students from around Australia,
all of whome won their way to last month’s
Conference for General Practice in Melbourne.
The prize package for Jessie Ling
(Tasmania), Katie Drewett (Queensland),
Danielle Todd (Victoria), Lawrence Ling
(Queensland) and Benjamin Whittaker
(South Australia) included return fl ights to
Melbourne, four nights’ accommodation and
entry to GP15.
The Facebook competition allowed
participants to post a photo and accompanying
caption in answer to the question, ‘How does
general practice fi t into your daily life?’. The
RACGP was overwhelmed by the positive
response to the competition, with the number
and quality of entries surpassing expectations.
Visit the RACGP’s Facebook page
(www.facebook.com/TheRACGP) to view
the full gallery of entries.
Katie Drewett: ‘The best of both worlds! #jugglingact’
Management of moderate acute pain
and the role of combination analgesia
This learning activity explores the assessment and
management of acute pain in general practice, and
discusses the role of combination analgesia.
To access the learning program go to gplearning.racgp.org.au
and sign in with your current RACGP username and password.
This educational program was funded with an educational grant from Aspen Australia 2
4 Reprinted from Good Practice Issue 10, October 2015

September 2015
Vision for general
practice and a sustainable
healthcare system
Images Jessie Ling; Danielle Todd; Lawrence Ling; Katie Drewett; Benjamin Whittaker
New vision
The RACGP’s Vision for general
practice and a sustainable
health system (the Vision) was
offi cially released by President
Frank R Jones at last month’s
Conference for General Practice in Melbourne.
The Vision outlines the RACGP’s plans to better
support the delivery of quality, sustainable and effective
primary healthcare, designed to meet the needs of
Australia’s patients, GPs and governments.
‘When the right system is in place to look after
people in the community, serious conditions such as
heart disease and diabetes can be prevented and
the severity of illnesses can also be reduced through
improved management,’ Dr Jones said.
Much of the direction of the Vision was shaped
by RACGP member feedback, which proved vital to
its development.
‘Our new funding model has been developed by
grassroots GPs who know what the issues are and
what needs to change to make a system better for their
patients,’ Dr Jones said. ‘The current funding model for
primary healthcare is not focused on the patient.
‘Our new model will deliver quality, patient-focused
care that will reap long-term benefi ts for communities.’
Visit www.racgp.org.au/vision for more information.
www.racgp.org.au Healthy Profession.
17908 RACGP Vision for general practice and a sustainable health system.in d 1
Expert Committee chairs
President Dr Frank R Jones announced the new chairs of the RACGP
Expert Committees (RECs) at last month’s Conference for General
Practice in Melbourne:
• Dr Nathan Pinskier – eHealth and Practice Systems
• Dr Beres Wenck – GP Advocacy and Funding
• Dr Kay Atkinson – Pre-Fellowship Education
• Dr Janice Bell – Post-Fellowship Education
• Dr Evan Ackermann – Quality Care
• Prof Tania Winzenberg – Research
• Dr Mike Civil – Standards for General Practices
RECs provide Council with information and advice on general practice
issues and oversee the implementation of initiatives developed in
accordance with the RACGP’s strategic plan.
‘Each elected chair has been chosen for their strong community and
professional networks across the health sector, as well as their ability to
monitor trends and recommend suitable innovations into RACGP programs
and to provide critical advice to the RACGP Council,’ Dr Jones said.
‘The chairs represent and refl ect a deep knowledge of general practice.’
Visit www.racgp.org.au/yourracgp/organisation/committees/racgpexpert-committees
for more informa tion.
Healthy Australia.
RACGP events calendar
October 2015
NSW
CPR course for GPs
Wednesday 7 October,
7.00–9.00 pm, RACGP
House, North Sydney
Contact 02 9886 4700 or
nswact.events@racgp.org.au
VIC
Career speednetworking
event
Saturday 17 October,
12.30–4.00 pm, RACGP
House, East Melbourne
Contact 03 8699 0488 or
vic.events@racgp.org.au
VIC
Perform CPR –
a workshop for GPs
Tuesday 20 October,
6.00–8.00 pm, RACGP
House, East Melbourne
Contact 03 8699 0483 or
vic.qicpd@racgp.org.au
NSW
Embracing
boundaries series
Wednesday 21 October,
4.00–9.30 pm, Harbourview
Queens Wharf, Newcastle
Contact 02 9886 4700 or
nswact.events@racgp.org.au
NSW
CPR course for GPs
Wednesday 21 October,
4.00–6.00 pm, Harbourview
Queens Wharf, Newcastle
Contact 02 9886 4700 or
nswact.events@racgp.org.au
NSW
CEMP intermediate
workshop
Friday 23 October,
8.30 am – 5.00 pm, Sydney
Boulevard Hotel, Sydney
Contact 02 9886 4710 or
nswact.cemp@racgp.org.au
WA
Emergency skills
training ALM
Saturday 24 October,
8.30 am – 5.00 pm,
College House, Perth
Contact 08 9489 9555 or
rachel.patterson@racgp.org.au
NSW
CEMP advanced
workshop
Saturday–Sunday 24–25
October, 8.30 am – 5.00 pm,
Sydney Boulevard Hotel,
Sydney
Contact 02 9886 4710 or
nswact.cemp@racgp.org.au
QLD
CEMP advanced
workshop
Saturday–Sunday
31 October – 1 November,
8.30 am – 5.00 pm,
Queensland University of
Technology, Brisbane
Contact 07 3456 8944 or
janet.lindsay@racgp.org.au
For further RACGP events please visit
www.racgp.org.au/education/courses/racgpevents
Reprinted from Good Practice Issue 10, October 2015
5

XXXXX SE-HUNT XXXXXX AWARD ROSE-HUNT AWARD ROSE-HUNT AWARD ROSE-HUNT AWARD ROSE-HUNT AWARD ROSE-HUNT AWARD ROSE-HUNT AWARD ROSE-HUNT AW
Universal
practitioner
BEVAN WANG
Emeritus Professor Max Kamien’s
career in general practice has allowed
him to advocate for some of the
world’s most vulnerable populations.
The Rose-Hunt
Award
The Rose-Hunt Award is the RACGP’s
highest accolade.
The award was a gift to the
RACGP from the UK’s Royal College
of General Practitioners (RCGP) in
commemoration of two of the RCGP’s
founding members, Dr Fraser Rose
and Lord Hunt of Fawley (the fi rst
Honorary Secretary).
The Rose-Hunt Award is given to
an RACGP Fellow or member who, in
the opinion of Council, has rendered
outstanding service in the promotion of
the objects of the RACGP by individual
patient care, organisation, education,
research or any other means.
Outstanding service may be over
a period of 10 years or a substantial
and signifi cant contribution to general
practice over a shorter period.
The inaugural Rose-Hunt Award
was presented to one of the RACGP’s
founding fathers, Dr William Arnold
Conolly, in October 1974.
6 Reprinted from Good Practice Issue 10, October 2015
Certain Australians will likely always
be synonymous with their profession
– Don Bradman and cricket, Banjo
Paterson and poetry, Cate Blanchett
and acting. When people think about
who is associated with general practice,
especially in Western Australia, few
could look past Emeritus Professor Max
Kamien, an RACGP Life Fellow who
has dedicated more than fi ve decades to
Australian and international medicine.
Dr Kamien’s lifelong devotion to
the general practice profession, and
his passion for medical education and
Aboriginal and Torres Strait Islander
health are just some of the reasons
he was awarded the RACGP’s 2015
Rose-Hunt Award. But this accolade
was far from his fi rst.
Dr Kamien was presented with the
Australian and New Zealand Association
of Medical Education Award for
Research in 1995, the Louis Ariotti
Award for Rural Health Research in
2000, named a Western Australian
Citizen of the Year in 1998, made a
Member in the Order of Australia for
his services to medicine, particularly in
medical education, Aboriginal health
and rural medicine, in 1999, and was
Dr Kamien became one of the oldest
doctors to work on polar expeditions
when he started at the age of 70.
a Western Australian fi nalist in the
Australian of the Year Awards in 2009.
But receiving the Rose-Hunt, the
RACGP’s highest honour for a career
in general practice, holds a special
place for Dr Kamien.
‘When one is in his 80th year, the time
for recognition of any achievements has
usually long passed, so the Rose-Hunt
Award was completely unexpected. It is
nice that someone thinks highly enough
of me to go to the considerable trouble
of putting in a nomination for me,’ he
told Good Practice. ‘I put a fair bit of
effort into whatever I do, but I don’t
expect to get any recognition for it.’
Dr Kamien’s involvement with the
RACGP began when he sat on the
Western Australia Faculty Board from
1977–88. He later became the Western
Australia state archivist, Corlis Fellow
and Provost and is now Chair of the
National Archives Committee.
‘I was fairly late to the RACGP. I
was 40 years old before I joined,’ he
said. ‘As I got older, I put my hand up
and said that I would be interested in
being the state archivist because I had
an interest in medical history. Then
they were searching around for a wise
Images Max Kamien

old man to be the Provost, so I said I would
do that as well.
‘I have really enjoyed working with the
Western Australia Faculty, particularly the staff
members. I go in fairly regularly just to remind
them of what a good job they are doing.’
Early beginnings
Dr Kamien grew up in Perth during the
Second World War and was accepted into the
academically-selective Perth Modern School
during his secondary years. Despite the lack
of a medical school in his home state, he
remained determined to pursue his dream of
a career in medicine.
‘Because Western Australia did not have a
medical school, those who wanted to study
medicine had to move to South Australia,’
Dr Kamien said. ‘When I fi nished my fourth
year of medical school in Adelaide, the
Western Australian medical school had just
begun so I transferred back to Perth.
‘Those were the golden days of the
medical school. There were more teachers
than there were students, which enabled
me to form really close relationships with
many of those teachers. And I still maintain
relationships with many who are still with us.’
Dr Kamien graduated from medical school
in 1960 and completed his residency at
Fremantle Hospital and Melbourne’s Royal
Children’s Hospital. He then embarked
on three years of travelling and practising
medicine in some of the more far-fl ung
corners of the world.
‘I went to Papua New Guinea for a year,
worked as a volunteer locum for the Save the
Children Fund in South Korea and Jordan,
and I had a stint with the Red Cross in Nepal,
working with Tibetan refugees.’
It was during this time of international travel
that Dr Kamien met his future wife, Jackie.
‘I was in Israel administering anaesthetics
in a hospital when I decided I needed to
learn Hebrew in order to converse with my
patients,’ he said.
‘I was at the bottom of the class in
the language school and the teacher put
me with the lady who was the top of the
class. We ended up getting married and
she has been teaching me and our three
children ever since.’
When his travels ended, Dr Kamien settled
in the UK with the intention of training and
working towards becoming a physician.
‘I couldn’t get a job because, at the time,
my travels made me seem quite unreliable,’
he said. ‘Eventually, I got a job in child
psychiatry. After that I got very good jobs and
I had a really good time learning in England.
‘I ended up completing diplomas of
psychological medicine and child health and
was one of 50 candidates from a fi eld of 750
who passed the Royal College of Physicians
of London exam. It was the only exam that
I ever topped.’
While Dr Kamien was working in
gastroenterology at the Royal Postgraduate
Hospital in London in 1969, a psychiatric
research position in the New South Wales
town of Bourke became available. A remote
town with a large Aboriginal population
situated approximately nine hours north-west
of Sydney, Bourke is where Dr Kamien kickstarted
his Australian general practice career.
‘The very fi rst day that I was in Bourke,
I went to the Bourke Aboriginal Reserve
where the fi rst child that I saw had
kwashiorkor, a protein-defi ciency disease,’
he said. ‘Gradually, I became the GP for the
Aboriginal community.
‘I could see that just being their doctor was
really not enough. I wanted to do more and
I came up with the idea of being a doctor who
was also an agent of social change.’
General practice advocacy
Dr Kamien has been credited as a pioneer
who introduced a number of different
services to the people of Bourke, including
inexpensive housing and various types of
specialist care. When he fi rst arrived in
Bourke, Dr Kamien found that up to quarter
of the Aboriginal children had trachoma, a
bacterial infection of the eye.
‘I went to Sydney looking for an architect
interested in low-cost housing with hot
water and protection from fl ies. I was also
looking for an eye doctor and I found Fred
Hollows,’ he said. ‘He came up to Bourke
several months later and it was in a little
place called Enngonia, 100 km from Bourke,
that he thought up the idea of a National
Trachoma Campaign.
‘This morphed into a worldwide organisation
[the Fred Hollows Foundation] that has
reduced blindness in over a million people.
The saying “from little things big things grow”
could not be truer than when applied to the
Fred Hollows Foundation.’
Dr Kamien believes GPs’ advocacy role
should extend beyond the walls of the
practice and encourages more young doctors
to get involved with health initiatives in
their community.
‘One of the ways I thought about getting
rid of infective skin disease among the
Aboriginal population in Bourke was to get
the kids into a chlorinated swimming pool,’ he
said. ‘But Aboriginal kids back then did not
go to the swimming pools because they felt
discriminated against.
‘So I decided to start a water polo
association for Aboriginal kids and they then
went to the swimming pool. I really thought
this is one direction that general practice
ought to explore.’
Dr Kamien left Bourke after 3.5 years
to be with his ill mother in Perth. He soon
got his fi rst taste of academia when he was
appointed a senior lecturer in medicine at the
University of Western Australia. >>
Dr Kamien met his wife, Jackie, while working in a hospital in Israel early in his healthcare career.
Reprinted from Good Practice Issue 10, October 2015
7

XXXXX SE-HUNT XXXXXX AWARD ROSE-HUNT AWARD ROSE-HUNT AWARD ROSE-HUNT AWARD ROSE-HUNT AWARD ROSE-HUNT AWARD ROSE-HUNT AWARD ROSE-HUNT AW
Dr Kamien’s history of advocating for disadvantaged populations throughout his career has seen him help people in various corners of the world, including testing for and treating
malaria in Papua New Guinea (left) and working with Tibetan refugees in Nepal (right).
>> ‘In comparison with Bourke,
teaching hospital medicine was pretty
tame,’ he said.
‘It was predictable because you had 15
beds. Five were people with diabetes, fi ve
had alcohol problems, four were waiting for
aged care accommodation and, once every
three months, there would be a patient that
required real diagnostic acumen.’
Medical education
Growing up in Perth, Dr Kamien aspired
to be a secondary school teacher who
specialised in English, physics and tennis.
His own educators, however, encouraged
him to pursue other career objectives.
‘My teachers took me aside and told
me that they didn’t think I’d do very well
as a teacher because I would have a lot of
trouble with the educational department,
and vice versa,’ he explained. ‘I saw a
vocational guidance counsellor and he put
me through a whole lot of tests and told
me I was totally unsuited for medicine, but
engineering was my forte.
‘I ended up going against his advice and
enrolled in medicine – and probably saved
Western Australia from a few tragedies as
a result of collapsing bridges.’
Despite choosing medicine over his
initial aspirations of the classroom,
medical education has always been a
signifi cant aspect of Dr Kamien’s career
and it remains something about which he
is deeply passionate. He believes more
medical training should be conducted
in general practice, where it can benefi t
patients and students.
‘I just enjoy medical education. No one
had to tell me to do it and I enjoyed that
8 Reprinted from Good Practice Issue 10, October 2015
sort of relationship,’ he said. ‘I was aware
that since most medicine occurs in general
practice that is where some more medical
education should take place.’
Dr Kamien was appointed Chair
of General Practice and Head of the
Department of Community Practice at the
University of Western Australia in 1976.
‘In those days general practice was
not accorded the status of an academic
discipline. Community practice was to
be the new university-based discipline.
It was to include general practice, social
medicine, epidemiology, the sociology
of medicine and medical anthropology,
and so on,’ he explained. ‘It was sort
of a catch-all and I thought that would
really suit me.
‘I saw it as an extension of my
explorations into the doctor as an agent
of social change.’
Dr Kamien’s much-anticipated
Report of the ministerial inquiry into the
recruitment and retention of country
doctors in Western Australia (also known
as the Kamien Report) was published in
1987 and played a major role in policies
around general practice in WA’s rural and
remote communities.
‘The report found that a student’s
chances of getting into medical school
from a rural high school were close
to nil, and the chances of getting in
as an Aboriginal person were nil,’
Dr Kamien said. ‘My recommendations
for affi rmative entry of such students to
medical schools were widely resisted. But
they have been proven to be right and
the action of taking people [into medical
school] has produced excellent doctors,
many of whom have gone into rural
medicine and taken up leadership roles.’
Personal pursuits
While many people choose to slow down
past the age of 65, Dr Kamien was 70
when he became one of the oldest doctors
to have worked as a medical offi cer on
polar expedition boats in both the Arctic
and Antarctic, something he went on to do
on seven occasions.
‘I have always been interested in polar
exploration and that is sort of a retirement
thing that I took up,’ he said. ‘Most of the
medical people who go on these boats
are young doctors training in emergency
medicine, but most of the passengers are
closer to my age and they don’t always
form a relationship with the young doctors.’
Another of Dr Kamien’s long-held
interest lies in writing. His literary pursuits
fi rst began when he became the editor
of the University of Western Australia’s
medical student magazine, The Refl ex. He
has published more than 200 academic
papers and 400 commentaries over the
course of his career and continues to write
for Australian Doctor.
‘I write a lot about the things I do
and see because I need a level of
self-deprecating humour to sustain me,’
Dr Kamien said. ‘Good general practice
is a hard discipline. I enjoy the long-term
relationships with patients and families. I
also enjoy the lateral thinking that is often
needed to help them solve their problems.
‘I tell medical students and young
doctors that medicine is a serious business,
but it can also be a lot of fun. If there was a
second life, I would do it again.’
Images Max Kamien

The good GP never stops learning.
Royal Australian College of General Practitioners
racgp.org.au

GP OF THE YEAR GP OF THE YEAR GP OF THE YEAR GP OF THE YEAR GP OF THE YEAR GP OF THE YEAR GP OF THE YEAR GP OF THE YEAR GP OF THE YEAR GP OF THE
Comprehensive
PAUL HAYES
The holistic and
collaborative nature of
general practice suits
Dr Kean-Seng Lim’s
methods of delivering
healthcare.
10 Reprinted from Good Practice Issue 10, October 2015
Following two years in the hospital system,
Sydney’s Dr Kean-Seng Lim, the recipient
of the RACGP’s 2015 GP of the Year
Award, came to the conclusion that the
patient and healthcare diversity of general
practice made it the specialty for him.
‘After doing a variety of hospital
rotations, including paediatrics, psychiatry,
general medicine and surgery, I decided
that general practice was where I really
wanted to be,’ he told Good Practice.
‘I found hospitals to be very “partialist”
environments that didn’t always take
a holistic view of patients and
their health or their social
nature. The focus was on
the single illness that the
patient came in with.
‘General practice is
where you have the
greatest capacity to
make a difference to
someone’s life. We
are seeing patients
not just for a single
episode, but on multiple occasions
throughout their life.’
Dr Lim received his medical degree
from the University of Sydney in 1991
before undertaking his residency in the
Hunter Region of New South Wales.
He has worked at the Mt Druitt Medical
Centre in the western suburbs of Sydney
for the past 20 years, where he is able
to offer the holistic, collaborative care
that has appealed to him since his
days as an intern.
‘I have a keen interest in the evolution
of the general practice model and our
practice has been strongly infl uenced by
the RACGP’s 2012 paper on the general
practice of the future [A quality general
practice of the future],’ he said. ‘I am
supported in my day-to-day work by our
practice team of doctors, admin staff,
practice nurse, pharmacist, dietitian,
exercise physiologist and psychologist,
who all play an integral role in helping me
provide what I like to think of as more
comprehensive care for our patients.
‘A good team allows us to be better
doctors and adds to the joy of the
work we do.’
Changing environment
Dr Lim’s primary special interests are
nutrition and lifestyle, subjects that have
driven signifi cant areas of his work outside
of the consulting room.
‘That interest is what has led to my
involvement with the SALSA [Students
As Lifestyle Activists] program, which
was established about 11 years ago,’
he said. ‘The SALSA program is
a peer-led education program
where we train
Images Kean-Seng Lim; AMA

approach
Year 10 students to be peer leaders, to take
on the role of educating Year 8 students in
the context of having lessons embedded into
their PDHPE [Personal Development, Health
and Physical Education] curriculum.
‘The purpose of the program is to
encourage behavioural change in the way of
improvement in diet, improvement in lifestyle
and reduction in poor health behaviour, such
as screen time, junk food, consumption of
juices and soft drinks.’
SALSA has now grown from a single
participating school to more than 20. The
idea for the program came about after
Dr Lim and other GPs in Mount Druitt,
following several years of treating overweight
and obesity in general practice, came to
understand the relative limitations of short
sessions with patients.
‘We realised that managing obesity
and other lifestyle problems was very
diffi cult in the context of day-to-day
consultation, and we have much diffi culty
addressing wider issue of the obesogenic
environment,’ he said.
‘The SALSA program gives us the
opportunity to intervene at a wider cultural
level, and by this I’m referring to actual
school culture. Having a peer-led education
model, you not only infl uence the leaders
and each peer group, but as those peer
leaders in Year 10 go on to become Year 11
and Year 12 students they actually start to
infl uence the whole school culture.
‘Culture in any organisation, in my
mind, is paramount when it comes to
sustaining any sort of change. So we really
have the ambition of nothing less than
changing society.’
Dr Lim sees the model presented by the
SALSA program as a more organic way
of getting a positive nutrition and lifestyle
message across.
‘The model of healthcare is very interesting
and works in a whole lot of subtle ways,
including the fact that a lot of the teachings
do not have to be made directly through the
lessons themselves, but can actually be a
change of infl uence by role-modelling by
the students, who are peer leaders, and the
infl uences they have on their peers and
their family.
‘The next stage from here is to move
on to infl uencing the broader school
community by going to the parents, the
grandparents and others who are part of
that extended community.’
Future of general practice
Training the next generation of GPs through
medical education plays a signifi cant role in
Dr Lim’s career. He is a general practice
supervisor with the Western Sydney GP
training organisation WentWest, and a guest
lecturer at the University of Western Sydney
School of Medicine.
‘I have been training general practice
registrars and medical students for many
years now. It is part of what I see as an
important role for GPs,’ he said.
A good team allows us to
be better doctors and adds to
the joy of the work we do
‘Part of my belief is that GPs have a
responsibility to leave the system better than
when we entered it and part of that involves
training the new generation of doctors, from
medical students through to registrars.’
Beyond the people who will populate
it, Dr Lim believes much of the future
of the general practice profession lies in
the digital world.
‘eHealth has certainly been one of
my other big interests, pretty much right
from the beginning of my general practice
career,’ he said. ‘Information management
and information technology is a real game
changer when it comes to what we can do
in general practice.’
Dr Lim feels the availability of these
new tools will allow GPs to better serve
an ever-growing patient population.
Dr Lim’s wife Sonia is also a GP. ‘When I am having
trouble I always ask myself, “What would Sonia do?”,’
he said.
‘More and more of the work we do
in general practice is chronic disease
management, and more of the patients
we see are suffering from more complex
diseases and the interactions of those
conditions,’ he said.
‘In the general practice of the future
we will be doing more proactive
population-based care, which is the sort
of work that’s very diffi cult to do without
having very good data on your patient
population and management.
‘So information management and
technology – eHealth technology and
health informatics – is vital for what we will
need to be doing in general practice now
and into the future.’
When refl ecting on his present position
in the industry, namely the RACGP’s GP of
the Year, Dr Lim shies away from individual
praise, preferring to see the award as the
culmination of the work he has done with
many GPs and healthcare professionals in
what is a very collaborative profession.
‘I’m going to steal from Michael
Crampton – the GP of the Year Award
winner from last year – in that I see it as
accepting an award on behalf of all of the
good work done by so many others that
doesn’t get recognised,’ he said. ‘It is
very nice to be recognised and I am very
grateful to the RACGP.
‘I hope that it will make me a better
doctor.’
Reprinted from Good Practice Issue 10, October 2015
11

XXXXX PERVISOR XXXXXX OF THE YEAR SUPERVISOR OF THE YEAR SUPERVISOR OF THE YEAR SUPERVISOR OF THE YEAR SUPERVISOR OF THE YEAR SUPERVISOR OF THE YEAR SU
Leading
the way
PAUL HAYES
Medical educator Dr Cathy Milligan
hopes registrars at her rural practice
can develop an extensive range of skills.
For Western Australia’s Dr Cathy Milligan,
quality medical education can provide almost
as much for the supervisor as it does for the
general practice registrar. As the recipient
of the RACGP’s 2015 General Practice
Supervisor of the Year Award, Dr Milligan
certainly understands the two-way nature of
the learning process.
‘Registrars are good with the protocols
and practices and they keep you on your
toes,’ she told Good Practice. ‘They will
often ask about things you haven’t thought
about for a while, so we can add to that
knowledge together or we can go away and
do our own research.
‘That is a really positive aspect of the
relationship – bouncing off each other, both
sides bringing different skill sets.’
Medical educator
A GP and director at Margaret River Surgery,
Dr Milligan has been based in the south-west
of WA for the last 19 years. After obtaining
her medical degree from the University of
12 Reprinted from Good Practice Issue 10, October 2015
Western Australia, she undertook several
different rotations as a junior doctor in major
hospitals in and around Perth, followed
by a year of anaesthetics training in the
UK, before starting a career in Australian
general practice.
‘I work as a procedural GP, involving family
practice, plus obstetrics, anaesthetics and
emergency medicine, as well as women’s
health,’ she said.
Medical education has been part of
Dr Milligan’s career ever since she started
in Margaret River Surgery, with the practice
taking medical students and general
practice registrars as long as she has
worked there. The ability to train and work
with eager young doctors helps Dr Milligan
stay energised and up-to-date in her
work as a rural GP.
‘It’s nice to be in touch with the next
generation of doctors coming through
because they bring a freshness and a quality,
and you get to understand how they work
and think,’ she said. ‘Plus, they are always
fresh from the major hospitals so they’re
pretty sharp with their protocols.
‘We [GPs] can share our experience
and it’s really nice to watch the registrars
use their existing skills that blossom in the
environment down here in Margaret River,
which is different from the tertiary hospitals.’
According to Dr Milligan, that different
environment provided by a rural healthcare
setting, in which patients often prefer to have
their needs met locally rather than having
to travel to see a specialist, provides the
general practice registrars at Margaret River
Surgery the opportunity to develop a broad
variety of skills.
‘Because Margaret River is more in a
rural and remote setting, we have limited
specialist support. We are it in a town with a
population of about 8000–9000 people,’ she
said. ‘Of course, our specialist colleagues
are on the phone down the road and we can
always contact them for help and advice,
but we largely work on our own and I think
that develops a special skill set of crisper
Image Western Australian General Practice Education and Training

judgement, deciding whether you can help
this person or whether you need to transport
them elsewhere.’
While Dr Milligan does acknowledge those
decisions, coupled with patients’ desires to
avoid travel, can place some pressure on young
doctors, she believes the independence helps
to build their confi dence and is ultimately very
benefi cial for their training.
‘They have to be fairly confi dent and be able
to work autonomously,’ she said. ‘Although
they are supervised, the supervisor is not
always on site with them. That said, they are
always supported.’
With a total of 12 GPs offering services
including obstetrics, anaesthetics, minor
treatment room procedures, women’s and
men’s health, mental health, palliative care,
geriatric care, immunisations, diabetes
education, and more, general practice registrars
who come to Margaret River Surgery have
access to a wealth of experience.
‘As a group practice we can help the
registrars with all of our different expertise,
so I think it’s a great experience for them,’
Dr Milligan said.
Special interests of obstetrics, anaesthetics,
women’s health and emergency medicine
have proven extremely valuable in Dr Milligan’s
rural healthcare setting. Another of her
special interests, however, tends to stand out
from the rest.
Dr Milligan is a keen pilot and her love of
aviation was one of the key motivators behind
her obtaining her qualifi cation as an aviation
medical examiner.
Like any good
relationship, you get more
out of being a supervisor
than you put in
‘That involves a study course which
heightens your awareness of the special
medical issues in the cockpit and in aviation
generally. CASA [Civil Aviation Safety
Authority] licences you to examine commercial
and general aviation pilots,’ she said.
‘It’s not my core business, but I’d probably
do a couple each month. Of course, the
consultations are extremely long, mainly
because we exchange stories regarding our
incredible fl ying feats – some of which may
even have an element of truth.’
Best advice
As a long-time general practice supervisor,
Dr Milligan understands the fact that some
GPs may be somewhat hesitant to take on
the responsibilities that come with the role.
But her advice to anyone considering
becoming a supervisor is simple.
‘Don’t hesitate – it’s a great job,’ she
said. ‘People might feel overwhelmed by
the thought of the commitment, but once
you’ve settled into it that time commitment
is nothing huge.
‘The registrars will be an asset to your
practice. The patients like the young ones and
they’re very understanding of the fact that
they are training registrars.
‘And like any good relationship, you will get
more out of it than you put in.’
Dr Milligan described being named the
RACGP’s 2015 Supervisor of the Year as a
‘surprise’, but she is extremely happy to have
had her work acknowledged in such a way.
‘I haven’t really come to terms with it yet,’
she said. ‘It’s an honour to be recognised for
the work I’m doing. There are lots of other
doctors out there who are equally deserving,
but I am grateful that this was my year to be
voted. I’m very proud.’
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Reprinted from Good Practice Issue 10, October 2015
13

REGISTRAR OF THE YEAR REGISTRAR OF THE YEAR REGISTRAR OF THE YEAR REGISTRAR OF THE YEAR REGISTRAR OF THE YEAR REGISTRAR OF THE YEAR REGISTRA
Support system
PAUL HAYES
Dr Ashlea Broomfield
has dedicated
much of her time in
general practice to
advocating for fellow
registrars.
Dr Broomfi eld said the
General Practice Registrar
of the Year Award represents
all of the healthcare professionals
who have helped inspire
her career.
14 Reprinted ed
from Good dP
Practice eI
Issue su
10, October r2
2015
They say the good GP never stops
learning. For Dr Ashlea Broomfi eld,
recipient of the RACGP’s 2015
General Practice Registrar of the Year
Award, it was an early learning experience
that saw her embrace general practice
after considering physician training as a
hospital-based specialist.
‘When I fi rst went into medicine I wanted
to do general practice. That was my ideal,’
she told Good Practice. ‘But then I got a
little bit carried away with the interest in
the specialties and the hype and glamour
associated with being a hospital-based
specialist in a particular fi eld. For a little
while there I moved away from wanting
to do general practice until I started
doing my clinical year and experienced
general practice.
‘I noticed the difference between
the trainees in specialty/hospital-based
or FRACP [Fellowship of the Royal
Australasian College Physicians] programs
and the general practice trainees.
‘I also did a PGPPP [Prevocational
General Practice Placements Program]
placement and realised that general
practice was well supported, with good
education and a lot of autonomy, and
you’re treated like an equal team member
in the general practice environment. So I
decided to go back down that route.’
In training
Following medical studies at the University
of New South Wales (UNSW) in Sydney,
Dr Broomfi eld moved to Coffs Harbour on
the NSW north coast to attend the UNSW
Rural Clinical School (RCS).
What was supposed to
be a one-year stint in
Coffs Harbour turned
into a more
permanent move after Dr Broomfi eld’s
positive experiences at the Coffs Harbour
Hospital and the RCS.
From there, Dr Broomfi eld’s efforts in
training and working on behalf of other
registrars started to develop.
‘I got on the GP training program
with North Coast GP Training [NCGPT]
and worked in Grafton, Woolgoolga and
Toormina in NSW. Within the fi rst couple
of months of being a registrar I was
asked to be the Registrar Liaison Offi cer
[RLO] with NCGPT,’ she said. ‘I have
now been working as an RLO for more
than 12 months.’
This RLO position with NCGPT sees
Dr Broomfi eld work closely with doctors
in training from all over Australia.
‘Part of our role is to liaise with any
registrars who are having issues in their
practices and then advocate for them to
their training provider or their practice,’
she said. ‘They come to us with a
variety of issues.’
According to Dr Broomfi eld, some
of those issues include remuneration,
teaching methods, patient load,
communication within their practice,
personal issues, contracts, exam support
and preparation, and more.
‘We have a varied role which changes
throughout the year depending on the
needs of the registrars,’ she said. ‘There’s
a lot to learn initially, but after that it’s a
role that’s nice to do because you’ve got
a lot of people across the country who
experience the same issues and it is good
to be able to help them out by utilising the
network of RLOs.’
Dr Broomfi eld was also named Chair
of the General Practice Registrar Medical
Educator Network (GPRMEN) earlier this
year. A sub-committee of General Practice
Registrars Australia, GPRMEN is designed
to help registrars with a passion to teach,
supporting them in their roles within
training providers.
‘The GPRMEN is a committee that
basically aims to promote positions as
registered medical educators [RMEs]
to general practice training providers and
Image Ashlea Broomfi eld

make sure that’s ongoing. Then to
support RMEs through a variety of different
ways – networking, educational events
and general support with each other,’
Dr Broomfi eld said.
Online support
Her role as GPRMEN Chair also allows
Dr Broomfi eld to further another of her
interests in general practice, helping registrars
and experienced GPs in the process.
‘At the moment I am trying to move
the GPRMEN a bit more onto online and
social media platforms. Lots of medical
educators are disconnected all over
Australia so I’m trying to get them together
so they can connect, interact and share
resources,’ she said.
‘We also had a slot at the recent General
Practice Training and Education Conference,
where we talked about how best the
GPRMEN network can support RMEs and
new medical educators in their positions in
terms of what they need for education and
what the network might be able to do in
regards to helping them.’
An active social media participant,
Dr Broomfi eld understands the potential
advantages this ever-evolving medium offers
healthcare professionals, particularly those in
more isolated settings.
‘A lot of GPs across Australia might work
in solo practices or practices with only a few
GPs. Or they might fi nd that extra-curricular
work they’ve got to do before or after work
means they are just consulting in their own
room then leaving for the day, which can
be quite isolating,’ she said. ‘Social media
provides a platform to get involved with other
GPs and talk about issues related to the
workplace or wellbeing, and to get support
from other doctors.
‘It also allows you to see any new or
updated information, as well as a variety of
different information options.
‘Lots of GPs have varied levels of special
interest and varying degrees of expertise in
different areas, so in interactive forums where
you can discuss cases you get a lot of input
from people who are experts in their fi eld and
get up-to-date information on assessment,
diagnosis and management.’
Dr Broomfi eld’s digital expertise has also
been put to use in her role at NCGPT, where
she helped develop an online resource for
fellow registrars.
‘As part of my role as an RLO at NCGPT
I was asked to be involved in setting up
the resource area on their online learning
platform, so I used all the resources I already
had stored on my own computer to update
them,’ she said. ‘All of those resources were
uploaded to the “Resources for registrars”
section of NCGPT’s online learning platform.’
Dr Broomfi eld is honoured, if admittedly
a little surprised, to be named the RACGP’s
2015 General Practice Registrar of the Year.
‘I am very humbled to win the award and
was very honoured by the people from my
regional training provider who put forward the
nomination for me,’ she said.
‘There are so many doctors and registrars
out there who do so much for their community
and medicine in general, and for education
and the promotion of general practice. I’m
inspired by other people around me and that’s
why I do a lot of the work I do, because of
so many inspirational people I’ve seen in
general practice.
‘It’s so nice to be given this award but, at
the same time, there’s so many other people
out there who are doing so much good work.
I wish I could give the award to all those
people as well.’
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Reprinted from Good Practice Issue 10, October 2015
15

RURAL RESGISTRAR OF THE YEAR RURAL RESGISTRAR OF THE YEAR RURAL RESGISTRAR OF THE YEAR RURAL RESGISTRAR OF THE YEAR RURAL RESGISTRAR OF THE
One of the team
PAUL HAYES
16 Reprinted from Good Practice Issue 10, October 2015
Dr Hannah Visser believes the GP is one of many
links in the chain of Aboriginal and Torres Strait
Islander health.
Dr Hannah Visser, the RACGP’s 2015
Rural Registrar of the Year, was exposed to
rural healthcare from a very early age when
she was growing up.
‘My mum is a rural GP back in Germany,
so I grew up with an old school practice
on the ground fl oor and we lived on top of
it. My mum is a 24/7 GP,’ Dr Visser told
Good Practice.
As a result, rural general practice has
always been Dr Visser’s goal throughout
her healthcare career.
‘You are a part of the whole community
and it’s about continuity of care,’ she said.
‘The care you provide is broader because
access to some resources is more diffi cult
in the rural setting, so you have to provide
more services. You make more clinical
decisions and usually treat the patient there
and then.’
After completing her medical studies in
Germany, Dr Visser lived and worked in
several places before settling in her current
location in the Northern Rivers region on
the north coast of New South Wales.
‘I did my university studies in Germany
and during this time did a lot of travelling.
I fi rst went to Sydney for my internship in
2004 and then spent six months in South
Africa, working in a township hospital,
before coming to Australia again in 2006,’
she said.
‘When I came back to Australia I went to
the Sunshine Coast [Queensland] and did a
year at Nambour Hospital.
‘Then I moved to Melbourne for a year,
then to Newcastle for a year, then back to
Melbourne. I then moved up to the north
coast of NSW three years ago and have
been there ever since.’

Images Hannah Visser
That fi nal move to the north coast of NSW
saw Dr Visser take a position at the Bulgarr
Ngaru Medical Aboriginal Corporation Casino
Clinic, an Aboriginal medical service (AMS)
that offers medical and dental services,
chronic disease management, mental health
services and health education programs
covering substance use, sexual health and
lifestyle management.
‘My biggest passion is working with the
communities with limited or no access to
services. That has always been my main
interest,’ Dr Visser said. ‘After being in the
hospital system for most of my other time
in healthcare I found myself wanting to do
Aboriginal health, and now that I am doing
it I will never do anything else.’
Team approach
Dr Visser’s time at Bulgarr Ngaru Casino
has helped her develop a new approach to
healthcare, one in which the GP is one of
several people involved in its delivery.
‘I have been here mostly full-time for the
past 2.5 years and I have really had great
access to the community. They have been
very welcoming of me and I really enjoy
working as part of a team,’ she said. ‘Working
in Aboriginal health services is different than
working as a mainstream GP; you can often
be in situations where you might be the GP
but you’re not calling the shots.
‘The team of Aboriginal health workers
will help you with cultural things or an
understanding of what’s going on with the
situation of people’s lives in the community,
which helps you make your treatment plan or
approach people differently.
Above: Dr Visser and her family have settled into life
on the north coast of NSW. Left: Dr Visser appreciates
the support of many people in the delivery of Aboriginal
and Torres Strait Islander health services.
‘Basically, service delivery is just a
bit different because you’re guided by
your team members.’
Dr Visser has used her expanded
knowledge base about the role of the GP in
Aboriginal and Torres Strait Islander health to
help other registrars working at AMSs.
‘I recently gave a talk to registrars at North
Coast GP Training – we have a meeting with
all the new registrars working in AMSs in
the region – and I said, “It’s not about your
agenda, it’s really about the agenda of other
people around you”.
‘You try to work your health message
around that and make it work and see what
the best chance is that it’s actually been
taken up or followed,’ she said.
In Aboriginal and Torres
Strait Islander health you
are often more than a
doctor – you are also a
liaison officer, social worker
and advocate
Dr Visser’s international background has
also proven to be something of a benefi t
when communicating with Aboriginal and
Torres Strait Islander patients.
‘Cultural understanding is very, very
important in the Aboriginal health setting,’
she said. ‘I’ve always thought, with my
German background, I could just ask very
straightforward questions – tell me about
this or that – because obviously I don’t
know the history that well. So I could still
get very interesting stories and cultural
background explained to me.’
That ability to develop a clearer cultural
understanding has allowed Dr Visser to
tailor her healthcare approach accordingly,
offering Aboriginal and Torres Strait
Islander patients services that are more
appropriate to their needs and desires.
‘Aboriginal and Torres Strait Islander
peoples have a different understanding of
health, or often different priorities,’ she
said. ‘For example, if they have to go to a
funeral today, you need to discharge them
from the hospital, or they are not going to
the hospital even if you think, as a doctor,
they really do have to. So you have to kind
of negotiate plans around that.
‘It’s very important to give Aboriginal
and Torres Strait Islander patients the
choice to decide what they think would
work best for them. I think a lot of it is
about empowerment.’
Broader scope
Research is another of Dr Visser’s
healthcare passions outside of the
consulting room. She is currently
undertaking a project on population health
with the University Centre for Rural Health,
working with and teaching students
from the Sydney University, Western
Sydney University and the University of
Wollongong, with her work funded by the
Department of Health.
‘I’m doing an academic term at the
moment, which is 1–1.5 days of research
and another day of teaching per week,’
she said. ‘Working in the Aboriginal
community got me to realise about
population health. We can treat little things
and give antibiotics and we can do this and
do that, but there is also the broader aspect
of what’s behind it. That’s what led me to
have some ideas about research projects we
can do to change policies and practice and
improve the health of the people.’
Dr Visser loves the holistic yet constantly
varied nature of her role as a rural registrar,
particularly working with Aboriginal and
Torres Strait Islander peoples.
‘I think it’s nice to see different
generations and have the continuity of
care of rural general practice,’ she said.
‘And with Aboriginal health, you do more
than just the doctor role; you are a liaison
offi cer and social worker and advocate. You
have a few roles.’
Regardless of the specifi cs, Dr Visser
recommends that those considering
working in an Aboriginal and Torres Strait
Islander community never lose sight of
the fact their a pproach to healthcare must
remain fl exible.
‘You have to be very open and able to
be guided by the community and what their
needs are, and broaden your skills as much
as possible,’ she said.
Being named the winner of the RACGP’s
2015 Rural Registrar of the Year Award is
a lot to take in for the usually reserved
Dr Visser, but being recognised by others in
her profession means a lot to her.
‘I really appreciate it,’ she said. ‘It’s an
appreciation and recognition of the work
that I do and my compassion towards the
community that I work in, and the research
that I’m doing.’
Reprinted from Good Practice Issue 10, October 2015
17

GENERAL XXXXX XXXXXX PRACITCE OF THE YEAR GENERAL PRACTICE OF THE YEAR GENERAL PRACITCE OF THE YEAR GENERAL PRACTICE OF THE YEAR GENERAL PRACITCE OF THE
Progressive practice
BEVAN WANG
GPs at Western
Australia’s Collie
River Valley Medical
Centre believe
general practices
can evolve to best
meet the needs of
their patients.
Please note: Collie River Medical Centre was also
profi led in the August 2015 issue of Good Practice.
Teaching is a central feature of the Collie River
Medical Centre healthcare philosophy.
18 Reprinted from Good Practice Issue 10, October 2015
Australia’s population demographic has
changed signifi cantly in the last two
decades and general practice has been
working to keep up.
Western Australian GP Dr Peter
Wutchak, practice principal at Collie River
Valley Medical Centre, believes it is crucial
that individual practices are able to develop
and cater to the requirements of their
patient population.
‘General practice has really evolved quite
a lot because we are looking to meet the
needs of our community,’ Dr Wutchak told
Good Practice. ‘GPs are now more involved
with chronic health initiatives through things
like general practice management plans,
mental health plans and other health checks.
‘It means that we are involved with the
acute side of a patient’s care, but we can
also put preventive steps in place to stop
negative health outcomes from occurring.’
Collie is a mostly industrial town
approximately two hours south of Perth with
a population of around 7000. Collie River
Valley Medical Centre has been providing
holistic general practice care ever since it
fi rst opened its doors in 1998.
‘We are quite balanced with our patient
demographic,’ Dr Wutchak said. ‘We have
young children and families, some of whom
are associated with the main industries
of the town. We also have a fairly even
demographic, right through to the elderly
people who are usually retired miners and
their families, who have lived in the town all
of their lives.’
Collie River Valley Medical Centre’s
dedication to and involvement with its
community, as well as its commitment to
medical education, are just some of the
reasons it was named the RACGP’s 2015
General Practice of the Year.
‘We are extremely pleased to have won
the award,’ Dr Wutchak said. ‘The entire
staff has been energised by this recognition
for what we feel was some pretty hard work
over the last 5–10 years.
‘We defi nitely see it as a team effort,
from the receptionists through to all of the
nurses and doctors who have been part
of the practice.’
Community engagement
Collie River Valley Medical Centre’s key role
in the occupational health and safety of its
community is one of many ways it has grown
according to patient needs.
‘In an industrial town, it is almost impossible
to divorce from occupational health,’
Dr Wutchak said. ‘We decided to expand
into this area because there was always a
need for injured workers to get treated and
they don’t necessarily want to have to travel
away from home to get that treatment.
‘We built on what was already a strong
relationship with local industries to make it
more encompassing, to allow for companies
to have one point of call for their medical
needs. So the workers are well supported,
no matter what they come in with.’
In addition to primary care, the practice is
also involved with the emergency department
at the Collie District Hospital.
‘We provide 24/7 coverage. One of our
doctors is available at all times to attend
to any emergency department problem,’
Dr Wutchak said.
‘The emergency department is staffed
by nurses who have had training in an
emergency setting and we support them in
all aspects of that.
‘We like it when we have a good
relationship between our practice and the
emergency department because it makes
everyone’s job easier. Also, patients can
get quality services in a timely fashion and
everyone involved feels like they are on
the same page.’
Dr Wutchak believes that he and fellow
practice principal Dr Jan Van Vollenstee
have helped the practice remain engaged
with the Collie community, something
for which he has consistently strived
throughout his career.
‘The practice’s engagement with the
town is incredibly important to us,’ he said.
‘If you take a more aloof approach, where
you basically set up a general practice clinic
and expect the patients to come and receive
whatever service you are prepared to deliver,
then you are going to be limited.
‘If you really want to provide an allencompassing,
strong general practice
Image Western Australian General Practice Education and Training

service in a rural community, you need to
engage with the community and with the town.’
Staff members from Collie River Valley
Medical Centre can often be found at school
functions, local workplaces, sports grounds
and other community events to further enhance
this relationship.
‘Over the last three years we’ve had a stand
at the local agricultural show where we promote
skin cancer checks, which we do for free.
We also take names and arrange follow-up
calls,’ Dr Wutchak said. ‘We are showing that
we want to get involved with the community
and that we feel like we are actually part of
the community.
‘The benefi t of doing that is that the patients
see you as more than just a doctors’ clinic.
They see you as the health resource for the
community, a business that has a real fi nger
on the pulse, particularly in regards to the
health of the town.’
Procedural practice
While Dr Wutchak’s time at Collie River Medical
Centre originally started as a general practice
registrar, the affi nity he developed for the
town and practice has seen him stay on for a
further 17 years.
‘I did my advanced general practice term
in Narrogin [WA] for my procedural skills,
obstetrics and anaesthetics, and felt that I had
the skills needed to be a rural GP,’ he said.
‘I really wanted to be at Collie River Valley
Medical Centre because it was somewhere
I could still practise my procedural skills,
as well as the general practice that such a
vibrant town needs.’
Medical education now takes up a large
part of Dr Wutchak’s role at the practice.
He sees this as one of the most important
aspects in his career.
‘I have found that training has helped me
to be a much better doctor,’ he explained.
‘The ability to understand my knowledge and
skills, plus the ability to then impart that on to
someone else, has helped me to grow.
‘Teaching really helps in that it keeps
you current and dynamic because it helps
to bring fresh and enthusiastic people into
your practice. If you keep an open mind,
your ability to develop as individual clinicians
and teachers will help the practice to
grow as a whole.’
Procedural work has been at the heart
of Collie River Valley Medical Centre since
it fi rst opened, providing the community
with obstetrics, anaesthetics and minor
surgery procedures.
‘A community like Collie is too small to
get access to regular visiting specialists,’
Dr Wutchak said. ‘Most of our patients will
have to travel for any procedural skills if we
don’t provide them.
‘Collie, like many rural communities
in Australia, relies on its local practitioners
to provide those skills that people in the
community need.’
Dr Wutchak encourages general practice
registrars and medical students to consider
taking on a procedural skill, especially if they
are thinking of moving to a rural or remote
part of Australia.
‘We really need to be encouraging the next
generation of GPs to take up at least one skill
because most of the communities that don’t
have easy access to specialist services or a
hospital need it,’ he said.
‘We certainly give our registrars the
opportunities to take on procedural skills
if they are interested. We want to get the
registrars who leave our practice to have
some degree of experience with minor
procedures because that’s what rural general
practice is about.’
Reprinted from Good Practice Issue 10, October 2015
19

XXXXX IAN WILLIAMS XXXXXX AWARD BRIAN WILLIAMS AWARD BRIAN WILLIAMS AWARD BRIAN WILLIAMS AWARD BRIAN WILLIAMS AWARD BRIAN WILLIAMS AWARD BRIA
Rural
pathway
BEVAN WANG
A close relationship
with the local
community is one
of many reasons
South Australia’s
Dr Ken Wanguhu
loves rural general
practice.
Dr Wanguhu was surprised and fl attered to
receive the 2015 Brian Williams Award.
20 Reprinted from Good Practice Issue 10, October 2015
The RACGP’s National Rural Faculty
(NRF) commemorates the work of the
late Dr Brian Williams, a long-time rural
advocate and former Director of the WA
Centre for Remote and Rural Medicine, by
recognising an outstanding rural GP whose
mentoring and support enables other
rural GPs to dedicate themselves to their
patients, family and communities.
South Australia’s Dr Ken Wanguhu
was surprised when he was named the
2015 recipient of award.
‘I can’t get over it,’ he told Good
Practice. ‘I would like to know who
nominated me because it is very, very
fl attering. I did not expect it and I am a bit
overwhelmed, to be honest.’
Growing up in Kenya, Dr Wanguhu’s
altruistic nature meant he was often looking
to help those in need, and he always knew
he wanted to be involved in medicine and
practise as a doctor.
‘It is one of those things that I always
wanted to pursue since I was a child
because I always thought medicine and
health were interesting,’ he said. ‘I looked at
the doctors around me when I was growing
up and I just really admired all the work that
they did and I wanted to help people.
‘The doctors in my village were an
important part of the community and we
looked up to them.’
After trying his hand at a number of
specialities areas – anaesthetics, obstetrics,
surgery and emergency medicine –
Dr Wanguhu decided he did not want to
commit to a single area of medicine.
‘When I tried all these specialities
I realised that it was not something that
I wanted to do for the rest of my life,’ he
said. ‘Nothing really made me think that
I could do this or that particular speciality
because I always wanted to do something
more substantial and more holistic.
‘The reason I got into general practice
is because I can do a little bit of everything
and there are fewer restrictions around
that. I choose what I want to specialise in
and work towards that.’
Community care
After practising medicine in South Africa,
Somalia and Kenya, Dr Wanguhu took the
opportunity to move to the South Australian
town of Waikerie, two hours north-east
of Adelaide. Waikerie is a small rural
community in the SA’s Riverland region with
an estimated population of 1635.
‘I immigrated to South Australia from
South Africa for family reasons. After
getting married, I wanted to bring up a
family in a safer environment with fewer
risks, particularly for personal security and
health. Australia provided a most suitable
place for that,’ Dr Wanguhu said. ‘I also
wanted to work where I would be able to do
procedural work because I was interested
in that, and I also wanted somewhere
that I could call home and become part
of the community.
‘I came out to Waikerie almost 15
years ago without knowing much about
the community or the place. There was
an attractive job opportunity available that
I was interested in. Needless to say, it
Images Ken Wanguhu

Clockwise from below left: Dr Wanguhu has been a member of the NRF executive board as Rural Censor since 2013;
his passion for medical education sees Dr Wanguhu consult with medical schools in various locations, including Papua New
Guinea; the Wanguhu family has become part of the community in the SA town of Waikerie.
worked well all round. Since then, the Waikerie
folks have looked after us and been really
good with us coming into the community.’
Much of Dr Wanguhu’s attraction to rural
Australia was due to the ability to practice
holistic medicine in communities where it
was most needed.
‘Rural general practice allows you to do
a great range of things that you would not
always be able to do in metropolitan regions,’
he said. ‘For example, I get to be involved
with obstetrics because I can form great
relationships with the patient before she’s
pregnant, know her family and friends, assess
her when she’s in labour and put in the
epidural, and either attend the delivery or do the
c-section if there are any complications. Then I
get to look after the baby.
‘I have patients I delivered who are now
14 or 15 and I am looking forward to being able
to deliver their babies down the track.
‘It is just an absolute privilege to be able
to go on that journey with the patients and
the community.’
Dr Wanguhu fi rst got involved with
the RACGP as an international medical
graduate (IMG) and became the NRF
Rural Censor in 2013.
‘The NRF has always been a big part
of my professional life because, like me,
a lot of IMGs are in areas of need which
are generally rural, so the NRF has a
big membership of IMGs,’ he said. ‘The
NRF was probably the fi rst faculty that
realised it needed an IMG representative
and I was approached as one of the early
representatives.’
Dr Wanguhu believes it is important for
GPs to take a leading role in helping to
determine Australia’s healthcare policies.
‘The thing is that doctors often hate
politics. We just want to take care of our
patients and move on,’ he said. ‘But what
some people may not realise is that you don’t
decide what you are going to be paid or
have any say as to what is going to happen
in your profession, whether it is training or
location of students and resources, without
touching on politics.
‘You shouldn’t leave these things solely to
the politicians because you need to inform
politics to base its decisions on the people
who actually live in the community and work
in the fi eld and know what it is all about.’
Imparting knowledge
Dr Wanguhu’s interest in medical education
began when he was studying for his RACGP
Fellowship exam and realised that resources
for IMGs like himself were somewhat limited.
‘When I came to Australia, there was very
little in the way of support for IMGs sitting
the Fellowship exams, which are crucially
important for IMGs,’ he said. ‘After I got
my Fellowship I thought about it and really
wanted to do something to help the people
who are coming into the country.
‘I had always enjoyed teaching, well before
I came out to Australia, but being able to help
my fellow IMGs was probably what prompted
me to really step up my efforts and is what I
am most enthusiastic about.’
According to Dr Wanguhu, properly
equipping GPs with procedural skills
necessary to best help their community is
one of the signifi cant challenges for rural and
remote general practice in Australia.
‘There really are a lot of things that we are
asking of these procedural GPs when they
come to rural general practice because the
range is just so wide,’ he said. ‘It is important
that we have the systems in place for medical
students who want to practice procedural
skills and who want to move out into country
areas to do that work.
‘You need procedures such as obstetrics
in the community because it is hard for a
pregnant woman to have to travel hours to get
the medical help she needs.’
Educating and empowering the next
generation of GPs is especially important
to Dr Wanguhu.
‘To all the medical students and general
practice registrars, I tell them that they cannot
get a more fulfi lling job,’ he said.
‘It is amazing because if they have the right
mentor they will almost always come out of
the experience saying that’s what they want
to do. There is nothing better than to be
immersed in rural general practice, to really
get into it then decide if it is for you.
‘It is a great feeling to be able to give these
students a chance and a taste of rural general
practice, and to really build them up to take
over from us when we retire.
‘And, as we strive to educate, equip and
encourage our profession, it is important that
we tie this to the family relationships that
count the most for all of us.
‘I have found that the supportive
environments in which that is practised
mean that rural general practice, which by
its very nature is rigorous and demanding of
time and energy, provides a unique comfort
for the family.
‘Rural general practice provides a real
sense of everyone being in it together.’
Reprinted from Good Practice Issue 10, October 2015
21

GP15 AWARD WINNERS GP15 AWARD WINNERS GP15 AWARD WINNERS GP15
RACGP Academic Session Awards 2015
Rose-Hunt Award
Emeritus Professor Max Kamien,
Western Australia
Honorary Fellowship
Dr Frank Moloney, New South Wales
Mr Neil Greenaway, Victoria
National Faculty of Aboriginal and
Torres Strait Islander Health
‘Standing Strong Together’ Award
Ms Sue Pinckham and Dr Liz Marles,
Bungee Bidgel Aboriginal Health Clinic,
New South Wales
National Rural Faculty (NRF) Medical
Undergraduate Student Bursary Award
Ms Maureen Krasnoff, Western Australia
Brian Williams Award – NRF
Dr Ken Wanguhu, South Australia
Monty Kent-Hughes Memorial Medal
Dr Daniel Edge, South Australia
(2014.2 examination cycle)
Dr Meredith Stewart, Western Australia
(2015.1 examination cycle)
RACGP Foundation Research Awards
• RACGP/MDA National Best General
Practice Research Article in Australian
Family Physician (AFP) Award:
Ms Jessica Orchard, New South Wales
• RACGP Family Medical Care Education
and Research (FMCER) Grant:
Dr Penelope Burns, New South Wales
• RACGP Rex Walpole Travelling
Fellowship: Dr Louise Stone,
Australian Capital Territory
• RACGP Family Medical Care Education
and Research (FMCER) Grant and
RACGP PWH Grieve Memorial Award:
Associate Professor Clare Heal,
Queensland
• HCF Research Foundation/RACGP
Research Grant 2015:
Associate Professor Paresh Dawda,
New South Wales; Associate Professor
Christopher Pearce, Victoria
• RACGP/Diabetes Australia
Research Grant: Associate Professor
Peter Schattner, Victoria
• Therapeutic Guidelines
Limited/RACGP Research Grant:
Professor Danielle Mazza, Victoria
General Practitioner of the Year Award
Dr Kean-Seng Lim, New South Wales
General Practice Supervisor of
the Year Award
Dr Cathryn Milligan, Western Australia
General Practice Registrar of
the Year Award
Dr Ashlea Broomfi eld, New South Wales
Rural Registrar of the Year Award
Dr Hannah Visser, New South Wales
General Practice of the Year Award
Collie River Valley Medical Centre,
Western Australia
Join your colleagues and celebrate at
the HESTA Primary Health Care Awards
Tuesday 10 November 2015, Plaza Ballroom, Melbourne
Tickets on sale now at hestaawards.com.au
Discounted price for group bookings.
$
30,000 in prizes to be won! * *Proudly
Follow us:
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See phcawards.com.au for details
22 Reprinted from Good Practice Issue 10, October 2015

ETHICS IN GENERAL PRACTICE
Boundary crossings
SARA BIRD
Maintaining
appropriate
doctor–patient
boundaries.
Doctor–patient
boundaries
According to Good medical practice: A
code of conduct for doctors in Australia
(the Code), ‘patients trust their doctors
because they believe that, in addition to
being competent, their doctor will not
take advantage of them and will display
qualities such as integrity, truthfulness,
dependability and compassion’.
Section 8.2 of the Code states: 4
professional boundaries are
integral to a good doctor–patient
relationship. They promote good
care for patients and protect
both parties. Good medical
practice involves:
• maintaining professional boundaries
• never using your professional
position to establish or pursue
a sexual, exploitative or other
inappropriate relationship with
anybody under your care. This
includes those close to the
patient, such as their carer,
guardian or spouse or the parent
of a child patient
• avoiding expressing your
personal beliefs to your patients
in ways that exploit their
vulnerability or that are likely to
cause them distress.
This article is provided by MDA National. They
recommend that you contact your indemnity
provider if you need specifi c advice in relation
to your insurance policy.
What would you do if one of your patients said
they could not afford the medications you have
prescribed to treat their acute illness? Would
reaching into your pocket for the $30 to pay for
their prescriptions be an inappropriate boundary
crossing in the doctor–patient relationship?
This case was discussed by a leading US
family physician and researcher in 2013
when he found himself reprimanded for
‘unprofessional boundary crossing behaviour’. 1
What ethical and professional concerns arise
in this type of situation?
Boundaries
Professional boundaries defi ne the expected
and accepted physical, psychological and social
limits of the relationship between a doctor and
their patient. At times, it can be diffi cult to
defi ne these boundaries.
Transgressions include boundary ‘crossings’,
which are departures from usual professional
practice that are not exploitative and can be
supportive of the therapy. On occasion, a
boundary may be consciously crossed with the
intention of assisting a patient’s management.
Boundary ‘violations’, on the other hand, are
transgressions that are harmful, or potentially
harmful, to the patient and their therapy.
The distinction between ‘crossings’ and
‘violations’ involves judgement about whether,
and to what degree, a patient has been
exploited and/or coerced, and the harm
caused to the patient and their relationship
with the doctor.
Boundary violations are unethical because
they exploit the doctor–patient relationship,
undermine the trust patients and the
community have in doctors, and can cause
profound psychological harm to patients and
compromise their ongoing clinical care.
Balancing benefits and risks
Many highlight the ‘slippery slope’ concept in
boundary dilemmas. 2 While this model may
assist in grasping boundary violations, it does
not provide a good understanding of the larger
area of boundary crossings. The slippery
slope model maintains that crossings are likely
to lead to violations and stresses vigilance
in managing these interactions, preferably
by refraining from a boundary crossing in
the fi rst place.
The US family physician was concerned
that strict interpretation and application of
boundaries can discourage doctors from caring
for and about patients, and risks encouraging
detached, arm’s length, uncaring relationships.
Strict rule-based decision making in
boundary dilemmas, combined with the
slippery slope model, can confuse doctors
and discourage boundary crossings that are
benefi cial to patients.
A graded risk model for boundary dilemmas
provides a framework for ethical decision
making, outlining elements to consider before
crossing a boundary:
1. The potential harm to the patient and the
doctor–patient relationship.
2. The potential benefi t to the patient and the
doctor–patient relationship.
3. The presence, absence or degree of
coercive and exploitative elements in the
boundary crossing.
4. The doctor’s motives and intentions.
5. The doctor’s aspiration to professional
ideals.
6. The context of the boundary crossing.
Doctors are encouraged to be alert to
situations in which boundaries may be crossed,
and to have a framework and strategy to
manage such situations. This may include
discussing it with a colleague or other adviser.
Balancing professional boundaries and your
duty to make the care of patients your fi rst
concern can be complex. But caring for and
about patients and establishing meaningful
therapeutic relationships is at the heart of
healing and our professional satisfaction.
Fears about crossing boundaries may
inadvertently inhibit the care we provide.
Considering the likely benefi t or harm by using
a graded risk model can assist in maintaining
our professional responsibilities and values.
References
1. Schiff G, Gordon D. Crossing Boundaries – Violation or
Obligation? JAMA 2013;310(2):1233–34.
2. Galletly CA. Crossing professional boundaries
in medicine: the slippery slope to patient sexual
exploitation. Med J Aust 2004;181:380–83.
3. Martinez R. A model for boundary dilemmas: ethical
decision-making in the patient-professional relationship.
Ethical Human Sci Serv 2000;2(1):43–61.
4. Medical Board of Australia. Good medical practice: A
code of conduct for doctors in Australia. Available at
www.medicalboard.gov.au/Codes-Guidelines-Policies/
Code-of-conduct.aspx
Reprinted from Good Practice Issue 10, October 2015
23

NUTRITION
BMI and older people
JANE WINTER
Does the healthy
weight range apply to
older patients?
Jane Winter is an accredited practising dietitian
currently undertaking a PhD at Deakin University.
Her area of study is malnutrition in community-based
elderly people, identifying nutritional risk in the
primary care setting for this population. Jane is also
Medical Affairs Manager at Nestlé Health Science.
References
1. Morley JE. Anorexia of aging: physiologic and
pathologic. Am J Clin Nut 1997;66(4):760–73.
2. Vivanti AP, McDonald CK, Palmer MA, Sinnott M.
Malnutrition associated with increased risk of frail
mechanical falls among older people presenting to
an emergency department. Emerg Med Australas
2009;21(5):386–94.
3. Guo JJ, Yang H, Qian H, Huang L, Guo Z, Tang
T. The effects of different nutritional measurements
on delayed wound healing after hip fracture in the
elderly. J Surg Res 2010;159(1):503–08.
4. Feldblum I, German L, Bilenko N, et al. Nutritional
risk and health care use before and after an
acute hospitalization among the elderly. Nutrition
2009;25(4):415–20.
5. Payette H, Coulombe C, Boutier V, Gray-Donald
K. Nutrition risk factors for institutionalization in a
free-living functionally dependent elderly population.
J Clin Epidemiol 2000;53(6):579–87.
6. Winter JE, MacInnis RJ, Wattanapenpaiboon
N, Nowson CA. BMI and all-cause mortality in
older adults: a meta-analysis. Am J Clin Nutr
2014;99(4):875–90.
7. Coin A, Veronese N, De Rui M, et al. Nutritional
predictors of cognitive impairment severity in
demented elderly patients: the key role of BMI. J
Nutr Health Aging 2012;16(6):553–56.
8. Heber D, Ingles S, Ashley JM, Maxwell MH, Lyons
RF, Elashoff RM. Clinical detection of sarcopenic
obesity by bioelectrical impedance analysis. Am J
Clin Nutr 1996;64(3 Suppl):472S–77S.
9. Kohara K. Sarcopenic obesity in aging population:
current status and future directions for research.
Endocrine 2014;45(1):15–25.
10. Murphy RA, Patel KV, Kritchevsky SB, et al.
Weight change, body composition, and risk of
mobility disability and mortality in older adults: a
population-based cohort study. J Am Geriatr Soc
2014;62(8):1476–83.
11. Somes GW, Kritchevsky SB, Shorr RI, Pahor
M, Applegate WB. Body mass index, weight
change, and death in older adults: the systolic
hypertension in the elderly program. Am J Epidemiol
2002;156(2):132–28.
12. Flanagan D, Fisher T, Murray M, et al. Managing
undernutrition in the elderly - prevention is better
than cure. Aust Fam Physician 2012;41(9):695–99.
Most healthcare professionals are likely aware
that the World Health Organization (WHO)
defi nes the healthy weight range as a body
mass index (BMI) of 18.5–24.9 kg/m 2 , but is
this appropriate for older people?
This range was determined from studies
that primarily focused on younger people
and there has been ongoing debate about its
suitability for older people, generally considered
to be those aged older than 65.
Older people face unique nutritional issues
resulting in a greater risk of under-nutrition
rather than over-nutrition. These issues include
physiological changes associated with ageing
(the anorexia of ageing), chronic disease,
polypharmacy and psychosocial changes. 1
Under-nutrition has serious consequences,
such as increased risk of falls and fractures, 2
poor wound-healing, 3 increased risk of
hospitalisation (with greater length of stay) 4 and
entry to residential aged care. 5 However, undernutrition
often goes unrecognised and using
the healthy weight range to assess appropriate
body weight may be misleading in older people.
BMI analysis
Although healthcare professionals often use
a higher BMI range as the more appropriate
reference for older people, there has been
much debate in the area. To answer this
question, the Dietitians Association of Australia
conducted a meta-analysis of 32 studies of
community-living populations aged 65 years or
older, including nearly 200,000 individuals. 6
The results showed the lowest mortality risk
was at a BMI of 24–31 kg/m 2 (compared with
a reference BMI of 23 kg/m 2 ). A BMI of
21–22 kg/m 2 was associated with a 12%
increase in mortality risk, with the risk starting
to increase at a BMI of less than 23 kg/m 2 .
Other studies in older populations have
shown that a low BMI in older people is
associated with other poor health outcomes.
For example, a BMI of less than 25 kg/m 2
has been associated with the development of
dementia and severity of cognitive impairment
in those with dementia. 7
Using BMI as an indicator of nutritional status
in older people is further complicated by the
age-related changes in body composition. With
increasing age, muscle mass declines and the
proportion of body fat increases with a change
in fat distribution. This shift in body composition
gives rise to the problem of sarcopenic
obesity, a term used to defi ne excess body
fat in combination with reduced lean mass. 8
Sarcopenic obesity has been associated
with more signifi cant functional decline than
simple obesity. 9
Given the altered relationship between BMI
and mortality with older age, weight change
is likely to be a more relevant indicator of
nutritional risk in older people. A loss of 5%
in one year (especially if unintentional) is
considered to be signifi cant and associated with
greater disability and mortality. 10 Studies have
shown that even in the presence of low or high
BMI, weight stability is associated with reduced
mortality risk. 11
Identifying nutritional risk
Although identifying under-nutrition in older
people is not as easy as simply recording
BMI, the general practice setting is ideally
suited to the early detection of nutritional risk,
when intervention and improvement may be
more effective. A 2012 article in Australian
Family Physician (AFP) included the following
recommendations: 12
• Routinely screen for nutritional risk. A short
screening tool such as the mini nutritional
assessment short form (MNA-SF) can
easily be incorporated into the 75-and-older
health assessment.
• Monitor weight, looking for unintentional
changes in weight.
• Weight loss should only be recommended
if function is compromised due to
excess weight.
• Review dietary restrictions, such as low-fat
diets, to determine appropriateness.
• Encourage physical activity.
• Refer patients with complex needs to an
accredited practising dietitian for a full
assessment.
Monitoring older patients for signs of nutritional
decline and intervening with medical, dietary
and/or social supports can improve quality
of life and reduce the risk or impact of other
comorbidities. Interventions for this population
should not necessarily be based on the
standard healthy weight range – a more
appropriate range for older people may be a
BMI of closer to 23–30 kg/m 2 .
24 Reprinted from Good Practice Issue 10, October 2015

TRIENNIUM UPDATE
Have you completed this triennium’s
Quality Improvement (QI) requirement?
What is Quality Improvement?
Quality Improvement (QI) is the process where an opportunity
to change practices occurs as a result of learning.
Professional advice and a growing body of evidence
demonstrate quality improvement activities lead to positive
change in practices, particularly when involving a whole
practice team approach.
How to meet your QI requirement?
1. Complete a QI activity
2. Participate in a pre-approved QI activity delivered
by an Accredited Activity Provider
3. Identify a Category 1 activity you have already done,
reflect on how you applied the education to your practice
and complete a ‘Quality Improvement Reflection’ form.
130
points
2
CATEGORY 1
activities
including 1
QI activity
1
CPR
Examples of QI
Evidence Based Medicine Journal Club
Supervised Clinical Attachment (SCA)
GP Research
Clinical Audit
Plan, Do, Study, Act (PDSA)
Small Group Learning
Royal Australian College of General Practitioners

FINANCIAL PLANNING
Value
of trusts
TERRY MCMASTER
Structuring the
business as a trust can
offer a general practice
several advantages.
Helpful resources
Australian Securities and
Investments Commission – Your
business structure (http://asic.gov.
au/for-business/your-business/
your-business-structure)
Taxpayers Australia – Business
structures: choosing the right
business structure (www.taxpayer.
com.au/KnowledgeBase/10185/
Small-Business-Tax-Super/
Business_structures#Trusts)
Australian Government:
Business – Key aspects
of a trust (www.business.
gov.au/business-topics/
business-structures-and-types/
business-structures/trust/
Pages/default.aspx)
Australian Tax Office –
Assessing the risk: allocation of
profi ts within professional fi rms
(www.ato.gov.au/business/
starting-your-own-business/
in-detail/professional-fi rms/
Assessing-the-risk--allocation-ofprofi
ts-within-professional-fi rms)
Terry McMaster is the founder and principal
director of McMasters’ Accountants, Solicitors,
Financial Planners. He has worked exclusively
with medical practices for more than 20 years
and holds degrees in law and commerce from
Melbourne University.
The best tax planning is not schematic or
transaction-based. It’s easy, inexpensive and
won’t raise the eyebrows of the Australian Tax
Offi ce (ATO). We are talking about trusts.
Trusts are one of many ways in which you
can run a practice and they stack up very
well against the alternatives: companies,
individuals (sole trader) and partnerships.
Two types of trusts are particularly well
suited for use in general practice.
Personal services income trusts
Smaller practices that don’t engage other fee
earners, and which don’t have signifi cant plant
and equipment, are generally best served by
a personal services income (PSI) trust. This
type of trust doesn’t allow fl exible income
distributions and requires all medical income
to go to the GP who generated it.
The PSI trust helps shield the GP from
negligent acts or omissions by other GPs,
takes advantage of the concessional car
fringe benefi ts tax rules and facilitates the
genuine employment of related persons.
The PSI trust also gets GPs out of the
pay-as-you-go withholding tax cycle and
streamlines their accounting, since there is
no need to make sure the trust ‘breaks even’
every year in the same way a company does.
Business trusts
Business trusts offer a number of tax
advantages. Practices that engage other
fee earners, or have signifi cant plant and
equipment and meet the ATO’s defi nition of a
business, would reap the most benefi ts from
using a business trust.
A business trust is usually a garden-variety
family trust, but multiple-owner practices may
use a unit or hybrid trust. Business trusts
allow fl exible income distributions because
medical income does not have to go to the
GP who generated it.
The ATO accepts business trusts provided
the defi nition of a business is met and one of
three additional tests is satisfi ed: the fi rst test
says the business trust will be accepted if the
average rate of tax paid on medical income is
at least 30% (equal to the company tax rate),
the second test says the amount distributed
to the owner-GP must be at least equal
to the amount paid to the most highly
remunerated non-owner-GP, and the third
test says the amount distributed to the
owner GP must be at least 50% of their
patient billings.
The fact the ATO has decreed that only one
of these test needs to be met makes it easier
for doctors to comply with the rules. The
three new tests apply in the fi nancial year
ending 30 June 2016 (this tax year).
A business trust will allow doctors who were
paying average tax rates of more than 30%
to lower their average rate by distributing to
lower tax rate benefi ciaries.
Business trusts don’t just reduce tax,
however; they can make service trusts
redundant, reducing complexity, costs and
accountants’ fees. Business trusts work even
if there are no tax advantages.
How to make the change
Changing a practice from a company,
individual or partnership structure to a
trust-based setup is usually relatively simple,
but owner-GPs would be well advised to
seek some guidance before they make any
such changes (refer to breakout for more
information).
Capital gains tax has to be considered, but
this will likely not be an issue since general
practice goodwill values are low and various
tax concessions apply under the Federal
Government’s small business tax concessions
regime. The ATO’s public rulings accept
that a practice can change to a trust-based
structure without breaching the anti-taxavoidance
rules.
ATO opinion
The last few years have seen the ATO
conduct a wide-ranging review of the basis
of taxing professional practice income, which
included some medical practice audits. The
ATO subsequently released guidelines,
Assessing the risk: allocation of profi ts within
professional fi rms, in 2014.
These guidelines apply to all professionals,
not just GPs, include the three business tests
noted above and confi rm that the familiar
public rulings for doctors’ incomes still apply.
The guidelines’ most important public
ruling for GPs is ‘IT 2369’ (dated 20 June
1991). This ruling was negotiated by the
Australian Medical Association (AMA) and
sets out the ATO’s rule of thumb that a
general practice is a business if it has at least
as many non-owner material fee earners
as it has owners on an equivalent full-time
basis. ‘Fee earners’ includes practitioners
other than doctors.
PSI and business trusts continue to be
accepted by the ATO, but doctors with
business trusts must ensure they meet one
of the three tests set out above before they
lodge their 2016 tax returns.
26 Reprinted from Good Practice Issue 10, October 2015

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16
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