Medical Forum WA Public Edition July 2019

Surviving FIFO Men’s Health Value-Based Care Exercise, Male Infertility, Prostate & Eyes

MAJOR PARTNER

July 2019

www.mforum.com.au

More specialty expertise.

More doctors protected.

We’ve got your back.

Dr Nicole Leeks Orthopaedic Surgeon Western Australia

As a respected doctor, you stand by your reputation and our reputation is built on protecting yours. The fact is, no medical indemnity insurer has more resources or expertise to safeguard your reputation than Avant. With Avant, you’ll have the support of award winning Avant Law, Australia’s largest specialist medico-legal firm. And more doctors on staff delivers

the unique support and understanding that only a peer can provide. The depth of our experience and expertise gives us knowledge of your specialty that’s simply unmatched. We’ve got your back.

Don’t risk your reputation. Talk to us today about Professional Indemnity Insurance.

1800 128 268 avant.org.au/practitioners *

IMPORTANT: Professional indemnity insurance products are issued by Avant Insurance Limited, ABN 82 003 707 471, AFSL 238 765. The information provided here is general advice only. You should consider the appropriateness of the advice having regard to your own objectives, financial situation and needs before deciding to purchase or continuing to hold a policy with us. For full details including the terms, conditions, and exclusions that apply, please read and consider the policy wording and PDS, which is available at avant.org.au or by contacting us on 1800 128 268.

2258.6 06/19 (0811)

EDITORIAL Jan Hallam, Managing Editor

Men's Big Business The WA Health Minister Roger Cook last month launched the local Men’s Health and Wellbeing Policy to coincide with Men’s Health Week.

There is certainly some sympathy for those who throw up their hands citing a full-blown case of chronic report and policy fatigue.

As one of our correspondents in this issue said, you can have the brightest and shiniest policy but if it doesn’t reach the ground then it is a waste of money, resources and goodwill from those who participated in its creation and from those for whom it is intended.

A lot of effort goes into producing these documents but they are designed to be adopted and not simply form part of a plank of election promises to be ticked off.

Those who have met and heard the current minister speak can’t deny his commitment nor his vision for a sustainable health system, but he will be the first to say individuals need to take charge of their health by taking responsibility for their choices.

I can hear more than a few doctors saying the same thing.

But in the same breath, all those close to the ground know that it’s not that cut and dry and nor is it easy. As the report states simply, there are levels of disadvantage. Not everyone starts from the same spot socially, economically and politically.

The policy boldly explores that disadvantage and how it plays out in social and lifestyle factors such as smoking, excessive alcohol intake, and poor nutrition.

Men – and they identity the cohorts they will focus on: Aboriginal men, men living with a mental illness or disability, men living in rural and remote areas, men in low socioeconomic circumstances, those from CaLD backgrounds,

PUBLISHERS Karen Walsh - Director Chris Walsh - Director ADVERTISING Marketing Manager Felicity Lockyer (0403 282 510) mm@mforum.com.au

MEDICAL FORUM

EDITORIAL TEAM Managing Editor Ms Jan Hallam (0430 322 066) editor@mforum.com.au Advisory Medical Editor Dr Robert McEvoy (0411 380 937) mcevoy.rob@gmail.com

young men (10-24 years), older men (65 years and older), males with diverse sexualities, intersex men and men with transgender experience, men engaged in FIFO work – THESE men, are all at higher risk of poorer health outcomes.

We had the good fortune of meeting media blitzer Dr Michael Mosley last month. His crusade to eradicate Type 2 diabetes through diet is well known and widely publicised in just about every medium known to civilisation.

What was particularly interesting was his view that personal choice could only go so far in this world of corporate and political influence.

Everyone, not just men, and not just those kicking off from a negative handicap, have an uphill battle against explicit and implicit forces and need the help of policy makers.

However, if we return to our Renaissance roots as we should all do from time to time, didn’t God give us the free will to Fall?

It’s a nifty way to avoid hard political and social decisions, and isn’t particularly helpful in the fight against chronic diseases that are killing people unnecessarily and costing taxpayers the earth.

The men’s manifesto recommends building healthy public policy through legislation, fiscal measures, taxation and organisational change.

Health, income and social policies to be used to foster equity and ensure: • safer and healthier goods and services • healthier public services • cleaner more enjoyable environments.

It continues: “Policies need to identify obstacles to health and seek to remove them, making the healthier choice the easiest one.”

It urges a reorientation of health services: “A shift towards a health system which promotes health, rather than curative services is necessary to focus on the needs of the whole individual, not just their injury, illness or disease.”

Meanwhile, back in the consulting room…

Journalist James Knox (08 9203 5599) james@mforum.com.au

Supporting Clinical Editor Dr Joe Kosterich (0417 998 697) joe@mforum.com.au

Clinical Services Directory Editor Karen Walsh (0401 172 626) karen@mforum.com.au

GRAPHIC DESIGN Thinking Hats hats@thinkinghats.net.au

JULY 2019 | 1

CONTENTS JULY 2019

INSIDE 10 Spotlight Cave Diver Dr Craig Challen 14 Surviving the FIFO Life 16 Three Amigos Dr Desiree Silva, Dr Michael Mosley & Dr Clare Bailey

18 Deeper Way of Seeing Prof Bill Morgan

14

10

NEWS & VIEWS 1 Editorial: Men’s Business - Jan Hallam 4 Letters to the Editor:

16

18

8 9 20 25

More Addiction Specialists Needed - Dr Richard O’Regan VAD has Doctor Support - Doctors for Assisted Dying Choice (WA) Fair Go for Senior Doctors - Dr KC Wan Pain Tool is Valuable - Jason Burton Attack Unjustified - Dr Anh Nguyen Have You Heard?

Beneath the Drapes Seeing the Patient Differently E-Poll Male Doctors & Practice

LIFESTYLE 46 Photography: For the Birds - Dr Tony Tropiano & Georgia Steytler 48 Social Pulse: SJG Subiaco Retirements 49 Wine Review: Vasse Felix - Dr Craig Drummond 50 Theatre: Revolting Roald 51 Funny Side 52 Theatre: Bell Shakespeare 52 Wine Winner: Dr Senq Lee 53 Competitions /medicalforumwa/

/MedicalForum_

MAJOR PARTNER 2 | JULY 2019

MEDICAL FORUM

CONTENTS JULY 2019 CLINICALS

5 Syphilis – what’s old is new again Dr David New

28 Men are Made to Move Mr David Beard

33 Prescribing PrEP Dr Christine Dykstra

29 Support for Prostate Patients Ms Julie Sykes

35 Surgical Management of Erectile Dysfunction Dr Trent Barrett

30 Is Male Fertility Decreasing?

Prof Roger Hart

38

37 Urethral Stricture Dr David Sofield

Pterygia – What Action Required?

Dr Tom Cunneen

Medical Forum Changing Hands Working Together for a Smooth Transition After over 20 years of producing a quality, informative, independent and entertaining Medical Forum, it is time for Jenny Heyden and Dr Rob McEvoy to hand over the baton to new owners Chris and Karen Walsh.

31 Managing LUTS Dr Tom Shannon

41 Recommendations for MSK Pain Dr Roger Goucke

43 Testosterone for Women Dr Yin Min Hew

The editorial and clinical team of Jan Hallam and Dr Joe Kosterich remain, as only Jen and Rob are hanging up their keyboards!

Chris and Karen are successful business owners and it is ‘business as usual’ for Medical Forum readers and clients. They will ensure the quality and integrity of the magazine continues.

Everyone has been working hard to make sure a smooth transition occurs.

Left to right: Dr Rob McEvoy, Jenny Heyden, Karen Walsh and Chris Walsh

The team at Medical Forum looks forward to your ongoing support.

45 Female Androgen Excess Dr Jennifer Ng

INDEPENDENT ADVISORY PANEL for Medical Forum John Alvarez (Cardiothoracic Surgeon), Astrid Arellano (Infectious Disease Physician), Peter Bray (Vascular Surgeon), Pip Brennan (Consumer Advocate), Joe Cardaci (Nuclear & General Medicine), Fred Chen (Ophthalmologist), Chris Etherton-Beer (Geriatrician & Clinical Pharmacologist), Mark Hands (Cardiologist), Stephan Millett (Ethicist), Kenji So (Gastroenterologist), Alistair Vickery (General Practitioner: Academic), Olga Ward (General Practitioner: Procedural), Piers Yates (Orthopaedic Surgeon)

MEDICAL FORUM

JULY 2019 | 3

More addiction specialists needed Dear Editor, The WA branch of the Australasian Chapter of Addiction Medicine (AChAM WA) is supportive of the WA Government’s announcement of an additional investment of $42.5 million towards the provision of treatment in support of individuals and families affected by methamphetamine, alcohol and other drug use.

AChAM WA has been expressing its concern regarding the harms caused by methamphetamine throughout WA for some time, noting that the State has regularly recorded the highest levels of both methamphetamine and ecstasy use Australia wide.

Remote and regional WA record the highest rates of alcohol and drug use, so it is commendable that significant resources are being directed to these locations, such as the $20 million towards the North West Drug and Alcohol Support Program and the establishment of an additional 33 beds for residential rehabilitation and withdrawal services in the South West.

While the announced funding in alcohol and drug treatment was positive, we have concerns at the low numbers of addiction medicine specialists in WA. The WA government currently employs the equivalent 7.3 full-time specialists, four of whom are over age 60, with the equivalent of 1.6 registrars in training. We are at real risk of losing expertise and leadership in WA without boosting the specialist workforce.

State hospitals have expressed significant concern regarding presentations

to emergency departments by individuals suffering from the effects of methamphetamine toxicity (which includes agitation, aggression, and psychosis) and methamphetamine withdrawal (which may include mood swings, anxiety, depression, suicidal thoughts or actions).

There are no addiction medicine specialistled drug and alcohol units in any WA hospital, a feature which is common in hospitals in other states around Australia. Complex clients with severe medical and psychiatric conditions arising from amphetamine, alcohol and other drug use need a multidisciplinary team approach and addiction medicine specialists should be a part of the mix.

Dr Richard O’Regan, WA Branch Chair Australasian Chapter of Addiction Medicine ......................................................................

VAD has doctor support Dear Editor, Andrew Burrell’s article Doctors mobilise to halt euthanasia push (The Weekend Australian, June 1-2, 2019) relies heavily on quotations from a Specialists’ open letter published in The Weekend West 25 May 2019. But it fails to recognise the weaknesses in that open letter.

Glib statements such as “doctors mobilize,” and “doctors are increasingly worried” omit the word “some” as in some doctors. It suggests that all doctors are acting as one, or that there is a groundswell of doctors, or even a majority. None of this is true.

A majority of doctors support voluntary assisted dying (VAD) and do not see it as contravening medical ethics, as suggested.

If you don’t know where you’re going, any road’ll take you there.

George Harrison SYNDICATION AND REPRODUCTION Contributors should be aware the publishers assert the right to syndicate material appearing in Medical Forum on the MedicalHub.com.au website. Contributors who wish to reproduce any material as it appears in Medical Forum must contact the publishers for copyright permission.

DISCLAIMER Medical Forum is published by HealthBooks as an independent publication for health professionals in Western Australia.

4 | JULY 2019

Words such as euthanasia, suicide and kill are deliberately used to offend, to stigmatise and to generate a negative emotional response.

Current terminology is that of voluntary assisted dying (VAD). This term is used in the Victorian Act and it has been used for some time throughout the country.

Support for voluntary assisted dying, where there are appropriate safeguards, is over 80% of the population in all parts of Australia.

We see VAD as a matter of individual choice.

We see it as a way to deal with severe suffering, unresponsive to other measures.

We see it as an act of kindness towards the dying patient and loved ones.

Finally, the statement that voluntary assisted dying is not a medical treatment or a part of palliative care seems to serve little purpose.

VAD is a part of medicine if we see it as such. Its place is well established in many jurisdictions.

Dr Peter Beahan, Dr Alida Lancee, E/Prof Max Kamien, Dr Richard Lugg, Dr Roger Paterson, Dr Johan Rosman & Dr Ian Catto, Doctors for Assisted Dying Choice (WA) ......................................................................

Fair go for senior doctors Dear Editor, Re: Restoring limited practice registration category for parttime, restricted practice or retired doctors that has been recently been terminated

by AHPRA. To practise as a medical practitioner now requires full registration, full medical indemnity insurance, full 100 hours of CPD points to be achieved annually and proof of recency of practice.

This draconian policy impacts adversely not only on the doctors who wish to practise part-time but also results in the loss of medical expertise to the community as full registration is mandatory for any form of medical practice including giving unpaid opinion or advice as a volunteer or teaching.

continued on Page 6 The support of all advertisers, sponsors and contributors is welcome.

Neither the publisher nor any of its servants will have any liability for the information or advice contained in Medical Forum. The statements or opinions expressed in the magazine reflect the views of the authors.

Readers should independently verify information or advice. Publication of an advertisement or clinical column does not imply endorsement by the publisher or its contributors for the promoted product, service or treatment.

Advertisers are responsible for ensuring that

advertisements comply with Commonwealth, State and Territory laws. It is the responsibility of the advertiser to ensure that advertisements comply with the Trades Practices Act 1974 as amended.

All advertisements are accepted for publication on condition that the advertiser indemnifies the publisher and its servants against all actions, suits, claims, loss and or damages resulting from anything published on behalf of the advertiser.

EDITORIAL POLICY This publication protects and maintains its editorial independence from all sponsors or advertisers.

MEDICAL FORUM

BACK TO CONTENTS

LETTERS TO THE EDITOR

BACK TO CONTENTS

Major Partner: Clinipath Pathology

By Dr David New, Clinical Microbiologist

Syphilis – what’s old is new again Syphilis is a bacterial, sexually transmitted infection caused by the spirochete Treponema pallidum (subsp. pallidum). The causative organism was first identified in 1905 but the disease has been around for hundreds of years (congenital syphilis was depicted on a Peruvian vase from the 6th century AD).1 Research suggests syphilis evolved from yaws (Treponema pallidum subs. pertenue) some 3000 years ago, acquiring various mutations that increased its virulence over time.1

About the Author

KEY MESSAGES

David is a consultant Clinical Microbiologist and Private ID Physician at Clinipath Pathology and also works at Armadale and Royal Perth Hospitals. He has just returned to Perth after completing his training in Melbourne.

Syphilis is still common and becoming prevalent in all sections of the community.

Syphilis should be part of any routine STI screen, especially in MSM Serology is the mainstay of diagnosis

Interpretation can be confusing, so if there is any doubt, liaison with clinical microbiologist is recommended.

interpret a serology results, a history of past infection or treatment should be sought).

There are two types of syphilis serology:

In WA syphilis rates have been rising. The table below shows the steady increase in notifications since 2014. The majority of notifications are from the MSM (men who have sex with men) population.

Management Syphilis is always sensitive to penicillin, the first line of treatment.

• Treponemal-specific tests: TPPA, TP-EIA, FTA • Non-treponemal-specific tests: RPR, VDRL

The resurgence of this ancient disease has been dramatic.

• The current outbreak affects four states (WA, QLD, NT and SA) mainly Indigenous young adults in remote regions • The first case of congenital syphilis in WA since 2013 has been reported • Total notifications to the year ending 2018 was 34% higher than the previous 12 months and more than double the previous 5-year mean.

Overall numbers, however, are still small so the reasons behind these trends are still uncertain.

Diagnosis of syphilis Syphilis testing should be performed in any routine STI screen and as part of routine antenatal care. If a patient has an ulcer, take a dry swab for syphilis PCR. For best results on the former, gently scrape the lesions to obtain the serous fluid. Syphilis ulcers are generally painless - always check any site of sexual contact.

Treatment of primary syphilis is benzathine penicillin 1.8 g (=2,400,000 units) intramuscularly, as a single dose. Note that other penicillin preparations such as benzyl-penicillin are not effective. Sexual partners must be identified, tested and treated, to prevent re-infection of the patient and transmission in the community.

Secondary and tertiary syphilis require more doses of penicillin.

The treponemal-specific tests detect past or current exposure to syphilis and remain positive for life. Non-treponemal tests correlate with disease activity. Thus, they are highest in the early stages of syphilis and decline with time (faster with treatment, but declines without treatment as well).

It is possible to have late latent or tertiary syphilis with an undetectable RPR - further testing (such as a lumbar puncture) is then required to confirm disease.

Doctors who cannot access benzathine penicillin via retail pharmacies or who need assistance with contact tracing, should contact their local public health unit.

In Australia, screening is performed using treponemal-specific tests, normally via enzyme immunoassay (EIA). If detected, the test is confirmed with second different, treponemal-specific test. It takes two positive treponemal-specific tests to confirm syphilis exposure (as a single positive result may be a false positive).

Patients with confirmed penicillin allergy are more difficult to manage and specialist consultation is advised.

Further reading: The Australian Therapeutic Guidelines and the Australian STI Guidelines.

The author would like to acknowledge Dr Smathi Chong and Dr Sharon Halasz of Clinipath Pathology and the Communicable Disease Control Directorate for their contributions to this article.

Here are some common syphilis serology results:

EIA

Most cases are diagnosed with serological testing, which does not determine the clinical stage of the disease. That decision is based on history, examination and if available, and past serology results (to

RPR TPPA LIKELY SCENARIO

+

-

-

False positive EIA result, or very early syphilis

+

+

+

Active syphilis infection (rarely a serofast reaction with low RPR)

+

-

+

Late latent or tertiary syphilis OR Past treated infection

References: 1. Tampa, M et al. “Brief history of syphilis.” Journal of medicine and life vol. 7,1 (2014): 4-10.

2. https://ww2.health.wa.gov.au/ Articles/N_R/Notifiable-infectious-diseasereport?report=syphilis_(infectious) 3. Quarterly Surveillance Report: Notifiable Sexually Transmissible Infections and Blood-borne Viruses in Western Australia. Available: https://ww2.health. wa.gov.au/Articles/A_E/Epidemiology-of-STIs-andBBVs-in-Western-Australia

Infectious syphilis notifications by quarter, WA, 2014 to 31 March 2019

2014

2015

2016

2017

2018

2019

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

2

3

4

1

18

32

23

22

28

34

55

49

86

73

105

77

102

61

74

86

97

91

106

135

148

Main Laboratory: 310 Selby St North, Osborne Park General Enquires: 9371 4200

Patient Results: 9371 4340

For information on our extensive network of Collection Centres, as well as other clinical information please visit our website at

www.clinipathpathology.com.au

MEDICAL FORUM

JULY 2019 | 5

continued from Page 4 The current unreasonable requirements deter and discriminate against senior doctors who wish to work part time or volunteer or teach. Many of my colleagues have given up because of these onerous unreasonable unjustified demands

by AHPRA. Senior doctors with their wealth of experience and contribution to medicine should be encouraged to pass on their expertise as trainers and be respected rather than to be viewed as incompetent because they are old! Senior doctors have formed the Australian Senior Active Doctors Association (ASADA) but we do not have sufficient numbers to change the current AHPRA policy. About 35,000 doctors are over 55 years, and 1700 are over 75.

I am 75 years old and practise part-time as a consultant occupational physician and also as a supervisor for RACP trainees. I may also soon give up as it is not worthwhile to continue.

Dr KC Wan, specialist in occupational & environmental medicine, Adj/Prof Occ Med ECU & Curtin University ED: The author sent this letter to Dr Alison Soerensen, who is standing for WA President of the AMA, and copied it to Stephen Milgate from ASADA, Have A Go New and Medical Forum.

......................................................................

Pain tool is valuable Dear Editor, Re: Facing up to Pain (June edition), with prevalence of dementia on the rise, and now one of the leading chronic health conditions in Australia, improved clinical techniques and care practice is urgently required to respond.

Unrecognised and untreated pain in people living with more advanced dementia is a challenge that health care services are continuing to fail to meet. As a person’s verbal communication skills deteriorate, the ability to explain the level of pain and location of pain becomes increasingly difficult.

In my clinical practice time I have heard and come across many cases of people living with dementia having broken bones, dislocated joints, or chronic arthritis, tooth or other causes of pain which have not been identified by practitioners or family.

Often the person communicates this distress and discomfort through non-verbal ways. They may refuse care or support for activities of daily living, or may be constantly uncomfortable and unwilling to stay still.

This behaviour due to pain is often put down to the dementia and labelled as Behavioural

6 | JULY 2019

and Psychological Symptoms of Dementia (BPSD) when it is in fact a very normal response to being in pain.

Dementia Support Australia, the provider of the dementia behaviour management services and Severe Behaviour Response services, last year released statistics showing that up to 70% of the people whose behaviour had been referred to their service had untreated pain.

Too often we quickly ‘denormalise’ a person with dementia’s behaviour, label it and lay the cause on the dementia. The reality is the cause is often something quite different to the pathological changes in the brain and is treatable, especially if the cause is due to pain.

Painchek provides another useful technology-based tool to help recognise pain in a person living with dementia who may not be able to verbalise. Its true value will only be realised if we are vigilant in looking for pain in a person and stop labelling behaviour as BPSD, instead seeking to understand what is happening for the person and why they are in distress.

Jason Burton, Head of Dementia Practice and Innovation at Alzheimer’s WA ......................................................................

Plastic surgeon defends specialty Dear Editor, In response to the Sydney Morning Herald’s article, Instagram over ethics - egodriven plastic surgeons put on notice, this attack on plastic surgeons was unjustified, inaccurate and lacked insight as well as the bigger picture.

The Chair of ASPS Ethics Committee Dr Richard Theile has issued an excoriating rebuke of his own specialty, describing “a worrying deterioration of standards” and “erosion of trust in the community”.

I have the utmost respect for Dr Theile as a senior respected plastic surgeon. However, I find his claims are inflammatory and sensationalist and are not facts backed by evidence. I personally don’t know any of my colleagues in the plastic surgery fraternity who don’t take pride in their work and who are not committed to applying their expertise and judgement to ethically practise plastic surgery to help their patients achieve the best possible outcome.

I take exception to his assertions that I or any of my colleagues, who were all selected under the same selection criteria and all trained to the same highest standard of integrity, excellence, professionalism, and collegiality, would put profits or convenience

ahead of outcomes.

As an entrepreneur, I also take exception that there is something dirty associated with being a business person while also being a plastic surgeon. An entrepreneurial spirit for me encompasses more than a simplistic goal of profit.

It’s about growth and championing the value of plastic surgery and changing misperceptions that it is an unnecessary luxury for vanity rather than a surgical specialty rich in history and diversity that combines science and art to transform people’s lives physically, functionally and aesthetically.

In order to be able to do any of this we need to have a practice that is a viable business and not solely relying on the public health system to support us. This does not necessarily mean with the primary intent of profits above patients. I strongly believe as medical professionals first and foremost, we practice to do good and not do harm, above financial benefits.

I am sure if we were truly driven by money, any savvy financial adviser would advise alternative pathways to become wealthy rather than embarking on a 15-year or a longer journey with no guarantee of attaining the specialist recognition and no riches along the way.

I personally believe that social media provides a tool for plastic surgeons to showcase their work, share their patients’ stories and provide a platform for open honest discussion, information, and education. This is important for patients today when they are selecting who to trust.

To assume patients are swayed by advertisements and generic or stock images is an oversight of how discerning our potential patients are. They look for experience and qualifications such as a FRACS and to see if they are a member of the Australian Society of Plastic Surgeons (ASPS).

I fully support the ASPS code and the principles of ethical practice and integrity for the benefit of patients. I do not believe the problem of making false claims and degrading marketing, as claimed by Dr Theile, is by the plastic surgeons.

This space of cosmetic surgery is dominated by promotions and ads and marketing from non-plastic surgeons. The danger in restricting what plastic surgeons can say and do to champion our specialty and take the so-called moral high ground is leaving the consumer exposed to material promoted by those not necessarily trained to the highest standards in plastic and aesthetic surgery.

Dr Anh Nguyen, Specialist Plastic Surgeon, Perth ......................................................................

MEDICAL FORUM

BACK TO CONTENTS

LETTERS TO THE EDITOR

MAJOR PARTNER Australia’s Most Popular Seminars & Learning Resources for GPs

Drugs for obesity – copout or cure?

By Dr Linda Calabresi GP and Healthed Medical Editor

Pharmacotherapy for obesity has a bit of an image problem in general practice. Both doctors and patients often perceive it as a quick fix solution or a desperation measure when multiple attempts at losing weight through diet and exercise have failed.

But as Professor John Dixon, Head of Clinical Obesity Research at the Baker IDI Heart and Diabetes Institute in Melbourne, points out, the reality is that obesity is a chronic disease and is very unlikely to be fixed by diet and exercise alone. Research shows that with lifestyle changes, the majority of obese patients in primary care will only manage between 1-3% weight loss at six months to two years.

According to Professor Dixon – who will be lecturing on this topic at the upcoming Perth Women’s and Children’s Health Update seminar – an obese person needs a sustained weight loss of 5% to have a clinically meaningful effect, and this target is largely unattainable without the addition of pharmacotherapy or surgery.

In Australia, we now have a number of medications available to treat obesity. These include orlistat, phentermine, liraglutide and the newest therapeutic agent, an extendedrelease tablet that is a combination of naltrexone and bupropion (Contrave).

It’s important for GPs to be well versed on the risks and benefits of each of these agents as patients need to have realistic expectations before commencing treatment including time frames for assessing effectiveness, side effects and the need for behaviour modifications.

Three months on full dose is usually sufficient time to assess effectiveness, but, importantly, obesity medication needs to be seen as a long-term therapy as with medication for other chronic diseases.

Why this condition develops is difficult to determine, but it is a common presentation in sexology practices and is believed to affect many more women who largely suffer in silence.

Vaginismus can be primary, with the first sign of a problem being an inability to insert a tampon. Or it can be secondary, developing later in life, or it can be situational, for example, being able to insert tampons but not being able to have penetrative sex.

The diagnosis is largely made on history alone, and while examination is necessary to rule out any contributing organic

Molly's story Endometriosis is in the spotlight, targeted by the federal government as a condition worthy of greater recognition and research.

Vaginismus

It affects up to one in 10 women sometimes severely, having a major negative impact on their careers, relationships, physical health and overall life quality. But it shouldn’t.

Effective treatments are out there and help should be sought early at the various stages in a woman’s life where endometriosis is likely to impact.

Vaginismus is a misnomer, says well-known sex therapist Dr Rosie King.

In an interactive panel presentation at the Perth Women’s and Children’s Health

“There is no point stopping an effective drug if it’s well tolerated and reduces risk,” Professor Dixon says.

THE

The fact is, women with this distressing and relationship-threatening condition actually have nothing wrong with their vagina but it is being compressed by extremely tight pelvic floor muscles, making penetration by a finger, speculum or penis virtually impossible without incurring significant pain.

13th Annual

ren’s ’ & Ch i l d

WOMEN S ^HEALTH UPDATE 2O19 PERTH, SaTuRday 17 auguST 2019

PWCH19-210x30-Banner-Ad.indd 1

MEDICAL FORUM

pathology, Dr King, who will also be presenting at the Perth Women’s and Children’s Health Update seminar, warns against doing a speculum examination.

She also says care must be taken in terms of the language used by the doctor.

Comments such as ‘just have a glass of wine before sex’ or ‘use a lubricant’ can be particularly unhelpful.

Treatment usually involves education, counselling, anxiety reduction, pelvic floor muscle relaxation and retraining and time, but the good news is – treatment is usually effective.

Hear more from Professor John Dixon and Dr Rosie King on these topics at the upcoming Perth Women’s and Children’s Health Update seminar, which is being held at The Perth Convention & Exhibition Centre on August 17. See below for details.

Update seminar on August 17, Dr Terri Foran, sexual health physician, presents Molly; a young girl, still at school who seeks help for her distressing menorrhagia and dysmenorrhoea. We then follow her and her endometriosis through her early adulthood, her contraception phase, her conception phase, her older adult life, menopause and beyond.

With opinions offered by other experts such as a gynaecologist and a fertility specialist, a multidisciplinary evidencebased approach is used to assess, diagnose and treat Molly at these different stages. A real-life presentation with real world solutions.

Grab a $30 discount by using the code PERTH30 before August 2.

Register now at healthed.com.au

11/6/19 4:10 pm

JULY 2019 | 7

BACK TO CONTENTS

HAVE YOU HEARD? Med student takes on Geneva Third year Curtin medical student James Leigh attended the WHO’s World Health Assembly in Geneva as part of a Global Voices scholarship. James, 20, said he was ambitious to change people’s lives and promote a healthier society, specifically in remote indigenous communities. “I plan to work in regional communities here in Australia and internationally.” Curtin social work PhD student Rebecca Field, also won a scholarship and attended the OECD forum in Paris. Prior to departing for their conferences, both students had a three-day briefing in Canberra with 10 other students from across the country where they met Australian Government officials, senior academics and policy experts.

US Spotlight on O’Neil Subiaco addiction doctor George O’Neil is making waves in the US with his clinic and his Fresh Start program making headlines in the New York Times. Dr O’Neil uses his own devised naltrexone implant to alleviate the cravings for opioids for months at a time. The implant is just one part of the program at Fresh Start, with the clinic taking a holistic approach to treating addiction by addressing physiology, housing, relationships, education and employment of his patients. Dr O’Neil told the New York Times, “I don’t win with everybody, but I try.” https://www.nytimes.com/2019/06/06/world/ australia/opiate-opioid-treatment-naltrexone.html

Miscarriage and men A Monash University study has examined the effects of miscarriage on men and the lack of support systems in place to help them deal with their loss. The study found men reported substantial grief following their partners’ miscarriages and the heaviness of the burden trying to hide their emotions while supporting their partner.

The study also found men received little in the way of acknowledgement of their loss when compared with their female partners and recommended support programs tailored for men. https://journals.plos.org/plosone/article?id=10.1371/ journal.pone.0217395#sec001

Men and bowel screening GPs are being urged to follow-up their male patients’ participation in the National Bowel Cancer Screening Program.

Recent data from the AIHW shows that 60% of the screening kits sent out won’t be used. In the January 2016-December 2017 campaign, 4.1 million people were invited to participate yet only 1.6 million responded. In a 2018 study examining the benefits, harms and cost-effectiveness of the NBCSP’s home test kit versus other potential screening approaches found that the current bowel screening program was the most effective strategy to prevent bowel cancer and bowel cancer deaths in Australia. Two new age groups (52 and 56) have been added to the scheme which means every patient seen by a GP

8 | JULY 2019

between the ages of 50 and 74 will now receive a free home test kit in the mail.

limited to 25 and over. Cannabis like alcohol, in the US, has a minimum age of 21.

Insurer backdates claims

https://www.nytimes.com/2019/06/16/opinion/ marijuana-brain-effects.html

An Australian Securities and Investments Commission inquiry has prompted a redefining of the medical definitions of severe rheumatoid arthritis and heart attack which will impact on the claims to insurance company MLC. This is good news for patients who had previously claims rejected by the insurance company.

Slater and Gordon lawyer Sarah Snowden told SeniorAU: “Often a doctor’s definition of what you are suffering from does not match your insurance company’s definition”. The backdated claims for a heart attack go back to 10 September 2012; for severe rheumatoid arthritis the backdate is 1 January 2014.

Epigenetics and fewer sperm?

http://seniorau.com.au/8739-your-rejected-severearthritis-or-heart-attack-insurance-claim-could-bevalid

While UWA professor of reproductive medicine Roger Hart explores some of the environmental and lifestyle causes of low sperm counts on P30, a local study has found an association between in-utero exposure to stress and lower sperm count in male offspring. The researchers suggest early and late gestational exposure to stressful life events cause high cortisol levels which may impact sperm numbers and cause reduced androgen activity.

The authors say evidence from previous epidemiological studies indicate that reduced net fetal androgen actions may be associated with male infertility, poor semen quality and reduced testosterone levels in adulthood.

Medicinal cannabis and PTSD

https://academic.oup.com/humrep/advance-article/ doi/10.1093/humrep/dez070/5499161

A research project looking into the use of medicinal cannabis to treat PTSD in patients who have been resistant to other programs has been 'green lit'. Pharma company BOD Australia is looking for 300 people with PTSD to participate in the 12-month longitudinal study which aims to evaluate the effects of medicinal cannabis on patients’ emotional and cognitive symptoms. This could be a step forward for medicinal cannabis in Australia if the patient outcomes are proven to be more effective than the current psychological and pharmacological interventions.

Weed and developing brains Also on the green trail, an opinion piece by two doctors in the New York Times has addressed the potentially deleterious impact of legal cannabis usage on the cognitive development of under 25-year-olds due to their still developing prefrontal cortex.

Alongside the proliferation of legal cannabis in the US, the potency of the drug is increasing. The mean THC content of seized cannabis in the 1990s was 3.7%, while the mean THC content of the now legally dispensed drug in Colorado is 18.7%. The authors are urging authorities to increase the minimum age for cannabis sales to be

Rural moves to specialty Leaders of the Australian College of Rural and Remote Medicine (ACRRM), the Royal Australian College of General Practitioners (RACGP) and the National Rural Health Commissioner have set up a joint taskforce to oversee the formal application to have Rural Generalist Medicine recognised as a specialised field within the specialty of General Practice. The federal government has pledged $62.2 million over four years to see the process through. ACRRM’s Dr Ewan McPhee said the process involved regulatory hurdles including consultation with the Medical Board of Australia (MBA), the Australian Medical Council (AMC), the Office of Best Practice Regulation, and the Council for Australian Governments (COAG) Health Council.

WA women live longer THE AIHW annual report on the disease burden in Australia found that West Australian women, at 75.3 years, had the highest healthy life expectancy (HALE) with the NT the lowest at 68.6 years. ACT men had the highest, at 72.6 years and and the NT recorded the lowest at 66.8 years. HALE was reported to be highest in

MEDICAL FORUM

BACK TO CONTENTS

major cities and declined with increased remoteness, with people in remote areas expecting to live 5.2 years less that their city counterparts and in very remote areas 5.8 years. Overall HALE for females is 84.6 years and males 80.4 years. The study found females could expect to live 88% of their lives at full health and males 89%. https://apo.org.au/sites/default/files/resourcefiles/2019/.../apo-nid241161-1365486.pdf

Loving public hospitals More from AIHW, its hospital report is showing increased activity in public hospitals compared to private hospitals, continuing a trend since 2013-14. In actual days, the numbers are staggering with 20.3 million patient days of care provided in public hospitals and 10 million days in private facilities. In WA, there were 1.87 million patient days in the public system and 1.01 million in private. The one area where private hospitals received a larger intake was elective surgical admissions with 180,541 patients electing to go private and 77,879 taking the public option. https://www.aihw.gov.au/reports/hospitals/ admitted-patient-care-2017-18/contents/at-a-glance

Private cover decreases APRA has released its Quarterly Private Health Insurance Statistics, reporting 44.5% of the population, 11,256,108 people, has hospital cover, a drop of -0.1% from the past quarter, though it did have 14,471 new members coming on board.

Nearly 54% of the population has general coverage, steady from the last quarter, with the addition of 44,287 new members.

WA and the ACT have the highest cover of all states with 54.2%. There were 88.5% of over 30s not paying the loading penalty with 933,275 insurers subject to

1

Art from the Air Hospitals, both private and public, have long invested in the healing power of visual art.

Our hospitals’ art collections are impressive beasts and any chance to experience any part of them is to be celebrated. At St John of God Murdoch Hospital, the stunning works of aerial photographer Richard Woldendorp are taking pride of place on

MEDICAL FORUM

the loading – a decrease of 63,770 from last year. The loading seems to be a disincentive for some to maintain hospital coverage. The number of individuals who have had the loading removed was 112,928, so not everyone felt the pinch.

Consumers wising up Consumer sentiment has been drawn in, with a collaboration between Health Consumers Forum and NPS MedicineWise with materials to help consumers contribute to their own medical treatment.

NPS MedicineWise CEO Adj A/Prof Steve Morris said he was concerned that people were willingly having tests, taking medicines and undergoing surgeries without asking basic questions about the necessity, the risks or other options.

We’d be interested in hearing from readers what their perspectives are on consumer engagement.

Cyclist accidents rising The number of cyclists injured or killed is on the increase. An AIHW report said in the past 17 years 650 cyclists had died in crashes, with 90% of the fatalities occurring on the road. Men made up the vast proportion of those killed, with older men representing 50% of thosse fatalities.

Non-fatal hospitalisations made up almost 160,000 since 1999-00, with the rate of hospitalisations growing on average 1.5% a year, or 9000 admissions. Older males were more likely to be hospitalised and the severity of injuries rose with age.

2

200 metres of wall space in the hospital’s main corridor. Richard attended a preview evening along with his daughter and sonin-law, who also happens to be the pilot on his artistic missions. Murdoch CEO Ben Edwards said the exhibition acknowledged the valuable role the arts played in the healing process. “There is plentiful research demonstrating a clear link between patients’ mental state and their ability to heal,” he

Some local health professionals have been honoured in this year’s Queen’s Birthday honours. Dr Robert Larbalestier, Prof Richard Pestell and Prof David Mackey have been awarded the Officer of the Order of Australia (AO). Dr William Carrol, Prof Phillip Della, Dr Prudence Manners, Dr Lindy Roberts and Prof Dao-Yi Yu have been awarded the Member of the Order of Australia (AM). Dr Peter Faulkner has been awarded medal (OAM) in the general division.

Head of the Telethon Kids Institute Prof Jonathan Carapetis is the new President of the Association of Australian Medical Research Institutes (AAMRI).

Dr Alan Leeb, whose vaccine surveillance app actively monitors vaccine safety, is the recipient of the 2019 AMA Excellence in Healthcare Award.

UWA researcher and clinician Prof Gary Lee has been named Cancer Council WA’s 2019 Cancer Researcher of the Year.

The Health Minister Roger Cook announced that four of the inaugural Health Service Board chairpersons have been reappointed for a further three years.

At the helms are Debbie Karasinski (CAHS), Robert McDonald, (SMHS), Ian Smith (EMHS) and Prof Neale Fong, (WACHS). Jim McGinty was appointed in July last year to chair the NHMS board.

3

said. The Woldendorp exhibition will be on display until the end of July.

1 Jan Ende, Richard Woldendorp and Ben Edwards 2 Connie Petrillo, Dr David Cooke and Ian Jenkins 3 Judith Hugo and Anna Kanaris

JULY 2019 | 9

Dive picture courtesy of Leigh Bishop

BACK TO CONTENTS

CLOSE UP

The Dive of His Life Diving deep underground, into dark, mysterious waters to explore new and unseen worlds transformed cave diver Dr Craig Challen into a lifesaver.

O

n June 23, 2018, 12 boys from a local football team and their 25-year-old assistant coach entered the Tham Luang Cave in the Northern Thailand province of Chiang Rai with the idea of having a birthday party for one of the boys.

The mood rapidly swung from celebration to survival when heavy rains flooded the cave, trapping the team on a narrow rock shelf, 4km from the entrance, with limited food, dwindling oxygen and pitch darkness.

With limited options to free the boys, and further rains expected which would have completely flooded the cave, the decision was made to send in a dive team to mount a rescue.

This is how cave divers (and current Australians of the Year) WA veterinary scientist Dr Craig Challen and South Australian anaesthetist Dr Richard Harris came on the scene.

Speaking to Medical Forum, Craig said few thought the diving option could be done but there was simply no other choice.

And give it a go they did despite the zero visibility and tight spaces to traverse to reach the boys. It took six hours going against the current, and five hours on the journey back.

But how did Dr Craig Challen get involved in the rescue in the first place? A matter of 22

10 | JULY 2019

years is the short answer. That’s how long Craig has been cave diving and with such extensive experience, he was an obvious choice for the rescue call-up.

Airport dash “When it became plain that the cave diving rescue was the way it was going to happen, Richard and I got the call and had two hours’ notice to get to the airport,” he said.

“It’s not always the professionals and governments that are best skilled for these specialised types of rescues. It’s often the amateurs who are the most skilled.

Normal emergency services, police or military are not equipped to operate in this environment.”

When rescuers reached the boys, Craig said they were surprisingly calm and composed.

“They were pretty good and phlegmatic.

Kids are kids. They were lean and I am sure they had had enough of caving and would rather be somewhere else but they were unbowed and up for it,” he said. “They were smiling and happy and joking around and acting like kids.”

The miracle was that all 12 boys and their coach survived the rescue and it was down to the efforts of up to 10,000 volunteers and Thai government workers.

“The whole thing only lasted four days and we got this extraordinary outcome which nobody was expecting. No one was more surprised than me,” he said When Craig returned to Australia, it didn’t take long for him to realise that his life was not going to be the same.

“At the time we had no idea that it was such a big story. I didn’t realise the whole world

was watching on and then it just kept going like a juggernaut.”

Juggernaut might be an understatement with Craig and Richard’s 2019 Australian of the Year nominations.

“The end of January was supposed to be our major diving expedition for the year, which conflicted with the Australian of the Year awards. We tried to explain to the Australia Day Council we wouldn’t be attending because we would be diving and it did not go down very well at all.”

Hero’s welcome Showing up to the awards ceremony turned out to be a good idea as the pair took out the main gong and since then life has turned upside down.

“There are certainly a lot of speaking engagements, it’s just about a full-time job. People do really get a lot of uplift and inspiration from this story; you know it is a bloody good story,” he said. “But it doesn’t come easily when you suddenly find yourself a minor celebrity.”

Craig has leveraged his new found profile into philanthropic endeavours.

“I am doing some charity work with the Smith Family, something that is close to my heart. I’m lucky to have had opportunities because of my education, and I’d like to work to reduce others’ disadvantage.”

Even though the year has kept him out of caves, he has his eyes set on a big expedition to Canada in January, New Zealand in February and the UK in July.

“I have a whole year to catch up on,” he said.

By James Knox

MEDICAL FORUM

You’ll breathe easier with us on the team

There’s only one bank that really knows how to treat medical professionals and ensure they get the help and assistance they need.

And that’s us.

We’ve specialised in your profession since 1993. In those 25 years, we’ve learned a great deal about how you work and what you need. This experience has proved invaluable in building flexible solutions to help achieve your goals.

Call us anytime. We’re confident you’ll breathe a sigh of relief.

Visit us at boqspecialist.com.au or speak to your local finance specialist on 1300 131 141.

Car loans | Commercial property | Credit cards | Equipment finance | Fit-out finance | Foreign exchange | Home loans | Personal loans | Practice purchase | Practice set-up | Savings accounts | SMSF | Transaction accounts | Term deposits | Vehicle finance The issuer of these products and services is BOQ Specialist – a division of Bank of Queensland Limited ABN 32 009 656 740 AFSL no. 244616 (“BOQ Specialist”).

MEDICAL FORUM

JULY 2019 | 11

INCISIONS

Bikes and Cars Must Co-Exist More needs to be done to reduce cycling injuries on the roads says Hollywood Private Hospital CEO and avid cyclist Peter Mott. and I’m at my desk at Hollywood by 8.30am. It is a fantastic way to start the day.

West Australian cyclists continue to be killed or injured on the roads and doctors and other health workers across Perth hospitals are seriously concerned at the increase.

But the benefits don’t stop there.

Parking is at a premium in most hospitals in Australia so cycling offers a good alternative to driving, and it helps alleviate traffic problems more broadly.

New statistics released by the AIHW illustrate the dangers, particularly to older people. It shows that between 1999/2000 to 2015/2016 nearly 160,000 Australian cyclists were hospitalised.

Many cyclists who ride to work are motivated by environmental concerns.

However, with an average of 38 deaths a year, or 650 in total during that period, there is no doubt that it is the fatality rate that is alarming doctors and authorities.

Most of these deaths and injuries could have been prevented.

I switched from running to cycling in 2015 because of bad knees and since then I’ve been riding on average three times a week travelling a total of 140km.

During that time, I’ve witnessed a number of cycling accidents and I’ve had a couple of minor accidents myself.

of cycling paths and poor road markings, surface quality, weather, lighting and visibility, the condition of bikes/vehicles, poor safety gear, and a lack of awareness and/or education.

In WA we are fortunate to have some beautiful scenic rides, which more people are enjoying.

Most spills I’ve seen haven’t involved cars, but when they do they are usually very serious.

In the health sector, we are seeing more employees riding to work, and for doctors, cycling is becoming the new golf because it is an enjoyable and time efficient way to stay fit and network at the same time.

Cycling accidents are caused by a range of factors, including driver/cyclist error, lack

On my weekday rides I cover 35km, have a coffee with my riding group (The Frommers)

At Hollywood Private Hospital we have a strong focus on the health and wellbeing of staff and the environment. Many staff choose to participate in a 'boot camp' fitness program we offer, whilst others opt to participate in our TravelSmart program which incentivises staff to car pool, take public transport or ride to work.

The reality is that while there have been improvements to cycling safety in WA in recent years with new paths being built and old ones being revamped, in addition to the introduction of the one metre rule in 2017, we have to do more.

In the wake of this latest report, I’d like to see more bike paths being built and improvements in road planning and construction so that cars, bikes and pedestrians can more safely share our roads.

Best Practices Since 2002, WA based Medifit has helped hundreds of healthcare providers across Australia create their dream practices.

• We are Australia’s medical design and construction specialists.

• We do ground up builds, new space fitouts and refurbishments.

• We cover the entire project cycle from initial design concepts to lockup • We will deliver the practice you want, in your time frame and budget without unnecessary stress.

• We provide the highest level of service and a quality standard which is unsurpassed in healthcare design and construction.

Contact Medifit today for a no obligation consultation and benefit from our experience.

1300 728 133 www.medifit.com.au

MEDIFIT_MFWA_THIRDPAGE_Ad_Feb2018_v2.indd 1

12 | JULY 2019

10/01/2018 11:20:53 AM

MEDICAL FORUM

Page left intentionally blank to comply with Medicines Australia Code of Practice.

FEATURE BACK TO CONTENTS

Surviving This FIFO Life As research points to serious mental health issues among FIFO workers and stresses on relationships, improvements are growing on small successes.

I

f you have lived several decades in Western Australia, the state’s boom and bust cycle will be nothing new. However, what has been an economic and social game-changer is the rise of the Fly-In Fly-Out worker – recognised in every airport and mine site by the moniker FIFO and the telltale high-vis uniform.

By far the biggest boom the state, indeed the country, has seen began in 2003 when China’s demand for minerals exceeded everyone’s wildest expectations. Big money was being made in mining and downstream.

The WA boom, which withstood even the GFC of 2007, powered on a few years more. In the 2008-09 financial year, iron ore mining alone represented 47% of the state’s resources – in dollar terms, $33.56 billion with $1.7 billion flowing into government coffers form royalties.

Welcome the hospital construction boom!

While the industry burnt hot, alarm bells were beginning to sound for the physical and mental health of workers whose shifts and conditions varied enormously depending on how enlightened their employers were.

In 2015, a WA parliamentary inquiry into FIFO worker health led to a report commissioned by the WA Mental Health Commission, which delivered its findings in December last year.

One of the contributors to the inquiry and report was social worker Julie Loveny,

14 | JULY 2019

whose focus for the past seven years, along with colleague Sue Crock, has been to improve particularly the mental health and safety of WA workers through onsite and online engagement programs.

This has meant working with management and counselling workers and their families.

Tough times Having seen the industry expand and contract over the years, the pair note both disturbing and encouraging workplace trends. Still, there’s no denying that mining does have a tough work culture in tough physical conditions.

“The resource sector tends to be male dominated and bullying and harassment does exist, but I think it is a broader society issue about how we understand, interact and manage people,” Julie said.

“Thankfully we are seeing a lot more awareness but, nevertheless, the old school way of managing continues to be one of command and control and that can often look like, and be experienced, as bullying.”

“In the FIFO resource sector, where you have people not only working together 12 hours-plus but living together the rest of the time, the opportunity lends itself to bullying on a 24/7 basis.”

Once upon a time, the workforce was unionised but in the post-Accord era it seems militancy has been replaced with more of a watching brief. Julie said that while there was an impression of less union

mobilisation, they were deeply involved in the FIFO research.

“The unions were on the reference group and had a strong voice and worked alongside us, but in my time on site I haven’t felt that presence strongly. There is also a feeling that on some sites unions are not welcome,” Julie said.

“There are potentially poorer working conditions and job insecurity with some contractors. It is very much a world where if you want the work, you have to suck it up or get out. That attitude is quite disappointing because there’s no sense of responsibility to change poor work conditions.”

“There is now extensive research showing that FIFO workers do experience psychological distress and suicidal thinking at a greater rate than the general population and a benchmark group with similar characteristics.”

“We have lived through the era of the decline of the asbestos industry. When it was discovered that it caused serious health issues, we didn’t say, well you chose it, put up with it and keep working. We expect employers to mitigate risks so that it is safe for employees to go to work.”

Dealing fairly “Somehow mental health is perceived differently; that it has to do with an individual weakness, yet psycho-social risk is the same as physical risk. Workplaces have a way to go but I have seen a lot more

MEDICAL FORUM

BACK TO CONTENTS

FEATURE awareness of mental health, particularly in resource sector.”

Mine sites are complex beasts with a number of contractors maintaining their own workforces. While the big mining companies provide good facilities and reasonable rosters, some contractors offer vastly different conditions.

Julie said this recent research was showing that the big players were now wanting to ensure that their contractors are meeting certain standards on mental and physical health and safety.

“It’s encouraging to see some of these changes beginning to occur. Back in 2015 I couldn’t get a mining company to speak to me about mental health. As far as they were concerned it wasn’t an issue,” she said.

Julie has been a regular visitor to mining sites, initially has a trauma counsellor attached to the employee assistance programs.

“Getting onsite gives you deeper insight into the FIFO experience and the workers’ issues. I’m again back onsite at the moment with leadership training. It’s a different role but nevertheless, being back I’ve certainly seen a shift in awareness, particularly among the leadership groups.”

“It’s OK to have a fancy policy, but what does it actually look like on the ground?

How does your average employee experience this? If their experience is an authoritarian, bullying manager, or they are in conflict with colleagues, or they don’t have role clarity, or a monotonous job with no choice, that policy is not translating onto the ground.”

“Those frontline managers need training. Many get promoted to positions because they have been excellent technicians, not because they are good with people. What I hear consistently from these managers

MEDICAL FORUM

are the problems they have with people!

They thought they were going to be pulling trucks together, rather than pulling people together.”

So what can workers who are struggling do?

Communication vital “Most companies have employee assistance programs that offer free, confidential counselling and support from an external body for a worker and for their family,” Julie said.

“But it is also really helpful to have someone in the workplace you can trust; someone you can talk to so you are reassured you are not alone and not the only one who struggles with things.”

“Many of the site jobs are isolating, with not many chances to talk, so it’s important to be linked in with something in the camp.

Unfortunately, the most common place is the wet mess, with few other options.”

“We found any activities that encourage social connection are important, so we are seeing more social sports, quiz nights, barbecues, which encourage participation by people who may not be attracted to the wet mess.”

“While drinking is restricted onsite, research found that FIFO workers were more susceptible to single session risky drinking off-site but if the only place to socialise on camp is the wet mess, that reinforces a drinking culture.”

Mine workers were also encouraged to take care of themselves – to eat, exercise and sleep well. Research released in May from the UWA Sleep Centre indicated that this was easier said than done.

Addressing a Pilbara sleep health summit organised by RPH Research

Foundation, Prof Peter Eastwood told the gathering that 97% shift workers were unable to adjust their body clocks between day and night shifts and it was putting them at high risk of fatigue.

He said sleep disturbance was associated with many health risks and was the fourthmost common mental health problem for Australians aged 12 to 24, after depression, anxiety and drug abuse.

“When you take this into account, it becomes imperative to look at ways to improve the management of fatigue and shift work,” he said. “More research is needed into sleep health in the resource sector, considering designing shifts based on objective information and ways of monitoring sleep to support the reduction of inherent fatigue risk.”

That sense of fatigue is made worse by workers trying to fit everything into their limited downtime.

“With limited time between finishing a shift and looking after yourself, there’s also the family back home to consider. For many workers, there is only a small window of opportunity to talk to family. Often when the time is right for the worker, the partner at home is feeding and attending to children. It can give rise to tension and misunderstanding,” Julie said.

Family planning “It’s important to have a plan with your family so you can work out how and when that communication can happen so it works well for everyone.”

Returning home from a swing carries its own set of problems.

“Transition times – leaving home and coming to camp and vice versa – are tricky times. Workers are encouraged to communicate what they need first up, whether that’s sleep or chill-out time,

continued on Page 17

JULY 2019 | 15

FEATURE BACK TO CONTENTS

The Three Amigos

Doctors Clare Bailey, Michael Mosley and Desiree Silva

T

hirty-four years ago, a cohort of young doctors graduated from the Royal Free Hospital medical school in Hampstead and last month three of them found themselves sitting around a meeting table at the Telethon Kids Institute in Perth.

Paediatrician research Dr Desiree Silva invited her uni pals Dr Michael Mosley, of BBC fame and author of the Fast 800 program and his wife, GP Dr Clare Bailey, to see the new facilities housed at the Perth Children’s Hospital.

Michael had been invited to speak at Science on the Swan and also at a WA Department of Health symposium on child health.

This gathering was a chance for friends to reflect on uni days and a time when diabetes was more of a novel disease than the sadly chronic status it bears today.

Michael: “We all started medical school in 1980. I was a mature student … much older and wiser than these guys having done a politics and philosophy degree at Oxford University.”

Desiree: “I remember clearly the dean addressing us on the first day saying that four people in the room would marry each other. I looked at the person next to me and thought to myself it was hardly likely.

But it worked for you two, and two other great friends (WA doctors Tim Haggett and Clare Tait).”

16 | JULY 2019

Michael: “We got to know each other well when we put on our annual revues. I did this sort of stuff at Oxford alongside more talented people like Rowan Atkinson and Richard Curtis (of Four Weddings and a Funeral fame) who were contemporaries of mine. I recycled the material when I went to medical school.”

Desiree: “Our final year revue was the big show. I was producer and Mike was the director. One of the sketches was Doctopussy and Clare was the star – we had a female James Bond, we were ahead of our time. Who wrote that?”

Michael: “An amalgam… I blame other people.”

Clare: “Desi made it happen. She was known as Miss Fixit. I remember having balloons strapped to my chest like Kenny Everett. It was all in very bad taste.”

Michael: “It was my first big break in show business. The offers rolled in after that.”

Desiree: “They did, really.”

Michael: “Just before the finals, BBC did offer me a job but I turned it down. But I proscrastinated for weeks and bore all my friends by asking their advice. Eventually I said yes and thought I’d do it for a couple of years and then go back to medicine.

That was 34 years ago.”

With the three going off in different career trajectories, they find themselves back on the same page working towards long-term solutions to chronic disease.

Michael and Clare, through her own GP practice, are vocal advocates of diet in the management and cure of diabetes.

Clare: “Guiding patients with diabetes on the Fast 800 has been hugely rewarding for them and for me too. There are extraordinary changes people can make with diet and it frustrates me that the NHS website continues to describe diabetes as a lifelong condition and that’s just not true.

It is very demotivating.”

Michael: “There have been two great recent health revolutions, I think, which have changed our understanding, The first is Barry Marshall and Robin Warren’s work to cure peptic ulcers. It was considered a lifelong condition until Barry and Rob came along and said, ‘that’s not true’. They went on to win a Nobel Prize. It feels a similar thing now with Type 2 diabetes and that affects even more people. The science is strong now that if you lose weight and change what you eat, you can put T2DM into remission but that’s not the message most patients receive. These ideas need to be embraced and governments need to take direct responsibility for what food companies do in exactly the way they did for tobacco.

Clearly food has an incredible impact on our bodies. Just telling people to self-regulate is pointless. It doesn’t work and all we will see is catastrophic failure. So one of my missions in life is to bang on about it anyway I can. It has to be taken seriously.”

MEDICAL FORUM

BACK TO CONTENTS

FEATURE continued from Page 15

Surviving This FIFO Life which can alleviate frustrations. Equally their partner is exhausted as they have been managing the family on their own and are looking forward to having a bit of downtime as well by having their FIFO partner stepping in and taking over.”

“So working out all of those different needs and different understandings is vital but people are not always well equipped to do this and it can cause tensions in relationships. For workers, stuck in a donga at night with no one to talk to, in a macho culture you need to stack up to, you can you can see why people can struggle.”

Given that the boom-bust cycle in mining is as certain as the sun coming up each day, it was interesting to hear Julie explain that one of the first questions she asks workers is ‘why are you doing FIFO?’.

“Invariably it’s for financial reasons but the stereotype of the single cashed-up FIFO bogan is few and far between. More men and fewer women want to do it for their families, to give them more choice and opportunity. It’s invariably well motivated,” Julie said.

“I also ask them if they were to give advice to a new FIFO worker, what would they tell them. Many said to go in with a plan – a financial plan and have an exit strategy to avoid the golden handcuffs.”

“Most of these workers I spoke with didn’t have a plan and many now recognised how important it is. It’s their big piece of advice.”

Companies step up Companies are becoming more acutely aware of the importance of their workers’ families and some have family days on site, flying up partners and children to see where dad or mum works.

“A mining site really is another planet and it’s not until you actually see it can you imagine what it must be like to live and work there,” Julie said.

“The kids love it, but it’s also important for partners to see that the FIFO worker in their life isn’t actually holidaying on some resort island when they are away from home.”

In a world where job security has been turned on its head in many sectors, redundancies in mining come as no surprise, but they can still deliver a mighty personal blow.

“Folk that have been in mining a long time, are better able to recognise it and plan. Some of these old timers express concern seeing young fellas getting into big mortgages, thinking booms last forever, and when it comes crashing down, they are in trouble.”

“Without a doubt, in my role in trauma support, the most stressed people I have ever seen were those made redundant. Such a lot of identity is tied up in work and many of these guys, particularly, who saw themselves as the provider and doing well by family, experience loss of face, and challenges around how they can manage, and what’s out there for them.”

Julie said that for many families, FIFO worked well but she emphasised that those who saw it as a positive were also the most resilient.

“Couples who enter FIFO has a partnership and with aims, do well emotionally and there are a growing number of positive stories. For many it is giving their family’s future financial stability and options; many cite great camaraderie on site.”

“This kind of work style is not going to stop so we have to look at the challenges differently and keep plugging away to improve it.

More and more companies are saying, ‘we get it’, and attend to rosters and give workers more choices. It’s encouraging but there’s still a heck of a lot to do.”

By Jan Hallam

MEDICAL FORUM

JULY 2019 | 17

BACK TO CONTENTS

CLOSE UP

A Deeper Way of Seeing Helping to restore sight has been Prof Bill Morgan’s lifetime ambition that has seen him work in state-of-the-art labs and in Bali villages.

O

phthalmologist Prof Bill Morgan has one eye on improving the sight of his fellow West Australians and the other on helping train doctors in Indonesia to attend to the many thousands of people there who need sight-saving interventions.

Indonesian universities and the health care system, a bond which saw him return regularly to teach, operate and foster relationships between WA and Indonesian ophthalmologists.

Bill’s first experience of Asia came just after graduating from his medical degree when he decided to take time off to explore the diverse peoples and cultures. Along the way he also formed deep ties with

“At that time, modern cataract surgery was just coming in and it was evident what a huge difference it was making to the quality of life of patients, so I became hooked,” Bill told Medical Forum.

A fortuitous term of ophthalmology during his studies piqued his interest in the speciality.

Witnessing his grandmother lose her eye sight to glaucoma, he decided to subspecialise. After starting his PhD around 1993 and finishing his specialised training in 1994, Bill started up a private practice at the Lions Eye Institute (LEI) around 1995.

Around this time LEI boss Prof Ian Constable asked Bill to accompany him to Surabaya in Indonesia to do some teaching and demonstration surgery.

Responding to need “I immediately liked Indonesia and the people there. I met a number of ophthalmologists and you could tell they were very keen to learn and there was great need. Glaucoma is about 10 times more common in Indonesia than it is here in WA, and much more severe as well.”

So Bill’s interest in the condition, and it being so prevalent, meant Indonesia was never far from his mind.

“I came back from that trip stimulated but I had a young family, so I was quite limited in how much travel I could do and didn’t return to Indonesia for around eight years when I was asked by the Fawcett Foundation to help out.”

“There is more angle closure and open angle glaucoma in Indonesia. Broadly speaking there are two main categories of glaucoma, one where the angle is open, which is part of the eye that regulates pressure and allows the fluid to drain; and

18 | JULY 2019

MEDICAL FORUM

BACK TO CONTENTS

CLOSE UP

the other is closed angle. In that situation, the glaucoma tends to be more aggressive and nastier and that’s much more common in Indonesia for various genetic reasons.”

“That’s one of the areas of research we are focusing on at LEI. On the ground in Indonesia, the reality is that patients usually present very late in the course of the disease, often with a blind eye and relatively poor vision in the remaining eye and it’s a much more difficult situation to treat without causing problems.”

Bill went to Bali for the Fawcett Foundation first in 2002 where he worked in mobile clinics and mobile operating theatres.

“I did quite a lot of surgery, teaching and saw a lot of patients but also met a lot of people and then decided it was something that I really wanted to do consistently and I have since visited Indonesia at least once or twice a year.

Passing on knowledge On one of his trips to Bali, Bill met Dr Oktarina, a young doctor from Jakarta, who came to Perth to complete a fellowship with the LEI and Royal Perth

MEDICAL FORUM

Hospital. She was keen to work on a research project that would have significance for her country.

Bill sees the relationship between WA and Indonesian ophthalmologists as mutually beneficial.

“We talked a lot about what could make a difference,” Bill said. “The issues back then still exist – that most patients present fairly late and the standard eye drop treatment does not work very well. Many patients also need surgery but the standard trabeculectomy often fails within a few years leaving a glaucoma drainage device being the only sight-saving option.”

“Their medical skills are growing very, very quickly and we want to be a part of that and we think we will, in the future, have a lot to learn from them,” he said.

“This is a plastic device we implant in the eye. The current glaucoma drainage devices cost about $1400/$1500, which is clearly beyond the reach of the average person in Indonesia. So we decided we’d design and build our own that would fit Indonesian eyes better, be easier for surgeons to insert and cheaper to manufacture.”

“So that was the nuts and bolts of Dr Oktarina’s PhD. Now in the last 2½ years, Dr Oktarina has surgically implanted about 280 of these devices, which will be released nationally in probably July at a tenth of the standard price.”

“It will make a tremendous difference. Dr Oktarina, has already taught the technique at about eight centres across Indonesia.”

Dr Oktarina is just one of many Indonesian ophthalmologists to have come to Perth to complete fellowships with glaucoma specialists at the LEI.

Taking Bill to their hearts Through the Fawcett Foundation, Bill has formed a connection with Udayana University in Denpasar, where he has been invited to become a visiting professor of ophthalmology. The university has also signed a memorandum of understanding with the LEI. “The main aim has been to help teaching with clinics and surgeries and the result is a dramatic improvement in their clinical skills,” he said.

As the exchange program matriculates more eager young doctors and graduates industry ready specialists, the role of the Australian ophthalmologists has shifted from teachers to peers.

“This year, as the clinical skills improve, they have been seeing a large numbers of patients. Quite frankly I’ve learnt a lot myself by seeing how they work and what they are doing, so the balance is shifting.

I’m becoming deliberately redundant because these guys are now very good.”

By James Knox

“We work very much as a team here, so everyone has been helping with the teaching and showing the young doctors how the surgery works, while RPH has been great helping with the visa requirements.”

JULY 2019 | 19

Seeing the Patient Differently A whole new world opens up with the introduction of the 5G network as doctors at Curtin University discovered.

Dr Daniel Xu, Adj/Prof Joshua Dass and Dr Jill Orford

A

team of WA doctors associated with the Curtin Medical School road-tested the 5G network with a team of specialists at a Nanjing hospital to see just how good it could be in aiding diagnostic decisions from vast distances.

Paediatrician Dr Jill Orford told Medical Forum that the exercise was not only effective but exciting as well.

Jill, who engages regularly with telehealth with her rural patients here, said the quality of the images was very good and a big improvement on the current network.

The Perth-based team was Dr Daniel Xu who acted as interpreter, Jill and Adj/Prof Joshua Dass, who is head of radiation at SCGH. They were working with director of the Jiangsu Province Hospital of Traditional Chinese Medicine’s radiology department, Dr Wang Zhongqiu, Director of the Accelerated Rehabilitation Surgery Dr Jiang Zhiwei, and Director of Neurosurgery, Dr Gao Juemin.

Jill said the Perth team discussed the diagnosis and potential treatment of a 40 year-old person with a brain tumour.

One of the significant differences in treatments offered between Nanjing and Perth was the cost structure. When it was suggested by the Perth team that a fine needle aspiration before surgery would be a good idea, the Chinese team said that the cost would burdensome for the patient and their family.

The 5G technology – an advanced and secure form of video conferencing suitable for medical cases – enabled the international team to discuss the case, transmitting their responses to one another in a millisecond.

20 | JULY 2019

MEDICAL FORUM

BACK TO CONTENTS

NEWS & VIEWS

GUEST COLUMN

Cultural Competence in Health Care The road to culturally responsible care is long but Prof Sandra Thompson and Dr Rosalie Thackrah urge doctors to take important steps.

Australia has a long and sad history of mistreatment of Aboriginal and Torres Strait Islander people, hereafter respectfully referred to as Indigenous Australians. This includes past massacres, child protection policies and stolen generations, curfews and exclusion zones, poor rations, unpaid wages and stolen land, and the ongoing legacy of intergenerational trauma.

Historically many Indigenous people were not allowed to use their traditional languages, were forced into bondage, and denied access to health care and education. Even where this was available, it was so often provided in a way that was discriminatory and paternalistic.

Stories that are readily collected from older Aboriginal people go something like: "if you were, or your child was sick, we'd be told to wait on the verandah and then we might be seen at the end of the day if they had time"and "women had to give birth in the morgue because they weren't allowed into the hospital". Consider the impact of that.

The collective memory of Indigenous Australians in relation to this treatment is reflected in their poor health status; diminished trust still impacts upon their willingness to access health and education today.

So here we are in 2019 talking about ‘Reconciliation’. We need to understand that the hurt experienced by some Indigenous Australians is so deep they don't want to reconcile. And those Indigenous Australians who do want to move forward to a better relationship with non-Indigenous people rightly deserve recognition and an apology.

For healing to occur in this space, we must, individually and collectively, recognise and apologise for the wrongs of the past and for those that endure, and develop culturally respectful relationships. We must also encourage others in our work and personal lives to do the same.

What does this mean for health care providers?

In the past two decades, there has been increasing focus on the need to deliver culturally safe care (also called by various other terms). There is little point in arguing about what the best of those terms are; our energies are much better directed to what it means and how we train health care providers to deliver culturally responsible care.

MEDICAL FORUM

However, the term cultural humility captures the relevant attribute practitioners should cultivate; it is not about reaching a particular level of awareness at a point in time, but signals the requirement for an ongoing openness, receptiveness and responsiveness to the views and experiences of others of another culture.

Much has been written about the failure to provide care that is ‘culturally acceptable’ and the barriers that this creates for Indigenous people in accessing care and adhering to recommended treatments.

Indigenous people are too commonly blamed for late presentations when the failures lie with us.

So learning to deliver care in a way that is culturally appropriate is a critical skill, one now acknowledged in both undergraduate and postgraduate training.

But how to teach it, how to practice it, how to assess it and what influence does it have on health attendance and outcomes?

For example, a recently reported randomised trial intervention in general practice, which included guidance to practice staff by cultural mentors, workshops, care system redesign, and organisational partnerships to facilitate Aboriginal community engagement did not result in any improvements in the selected care outcomes.

While 'failures' raise many questions, they do not mean there is no point in making efforts to improve cultural safety in our professional practice. They instead suggest that changing practice and systems is difficult, takes time and sustained effort.

Opportunities to work alongside Indigenous Australians who are committed to partnerships and willing to impart understanding of Indigenous knowledge, culture and sensitivities is known to support change in these areas.

This is more than just ‘training’ or professional development, or having an Indigenous person tell you what to do; it is about working together with goodwill and a common vision for improving health outcomes for Indigenous patients.

It may be that learning opportunities

are easier in community health activities than in clinical work, but there are relevant examples of best practice in clinical settings.

Journal article titles "gotta be sit down and worked out together" and "at the grassroots it's about sitting down and talking" provide examples where clinical approaches are built upon trust and respectful two-way relationships.

Embedding these approaches early in practice will help and it is possible that those in established practice will have difficulty with learning, unlearning and relearning as is required to develop cultural empathy and to ensure cultural security.

However, transformative learning can occur by taking students and practitioners out of their comfort zone as a means of increasing their receptivity to understanding appropriate cultural ways of working.

There is emerging evidence of the longterm impact of this on the practice of those exposed. In turn, they can and do become agents of change.

How we measure progress is another fraught area. Similarly, we must question the priority given to randomised controlled trials as the means to produce evidence in a space so deeply dependent upon the relationships built and the trust developed.

Improvements of outcomes that reflect complex social issues require the use of multiple indicators and long-term sustained efforts. Ultimately progress will be seen by reductions in health and other inequities between Indigenous and other Australians.

In the meantime, all practitioners can work towards making themselves and their practice environment more culturally secure. This could start with improving the identification of Indigenous Australians in their clinical practice, taking time to build trust, listening attentively around patient concerns, symptoms and needs, and developing care plans that are realistic for the life circumstances of Indigenous Australians.

There is a wealth of testimony and evidence from research that describes what is needed; it is timely to remember the importance in informing and improving clinical practice.

ED: Prof Sandra Thompson is head of the WA Centre of Rural Health and Dr Rosalie Thackrah is in the School of Population and Global Health, UWA

JULY 2019 | 21

GUEST COLUMN

Volume to Value – the New Frontier The path towards value-based care is fraught but IT expert Rafic Habib is among the many who see it essential to overcome future healthcare dilemmas.

Age has been a battleground long fought in the quest to beat ageing.

The advancement of medicine, quality of life and lifestyle have created an unusual paradox between longevity and the despair of getting older.

Australia’s ageing population as it continues to grow, places demands on the demographics of an economy where the health system is stretched to cope with what getting old creates.

Michael E. Porter’s, Redefining Health Care calls it a “Zero-sum competition in health care”. His interpretation of the lack of competition in a sector such as health reduces our ability to maximise value.

Porter writes, “…value-based competition will not only lead to more patients being cared for by excellent providers, but also inspire and drive innovation in medical care”.

Simply, ageing is becoming overwhelming for Australia.

The need for an efficient healthcare system requires agile creative thinking, making valuebased care a new paradigm of engagement.

If value-based care is to produce the benefits it promises, then two important requirements are critical from an Electronic Medical Record platform – patient engagement through portals and information at the point of care for clinicians with mobility and effective good reporting.

And yet, with pressure to change from insurers and government, the emphasis of our healthcare system to enhance key outcomes, lower budgets and grow general access, we are strategically shifting away from a fee-for-service model.

Moving towards value-based care, patient outcomes, reducing hospital readmissions,

Exciting opportunity for emergency physicians 22 | JULY 2019

advanced health IT systems, improving preventative care, and a reimbursement plan, are vital cogs in a compelling argument for healthcare providers to deliver better care initiatives.

The demand from public and commercial forces to reduce costs and improve healthcare delivery is pushing people away from volume-based healthcare to value-based healthcare, aiming to adjust payment and objective measures of quality medical care.

Implementing value-based care reimburses providers, helps patients take control of their health, diminishes incidence of chronic diseases and allows people to live better lives thereby easing the national healthcare burden.

So why isn’t value-based healthcare in play?

The answer lies with the technology required to engage patients in order to measure outcomes. Patient portals and apps are required to drive feedback that will track and analyse to understand the value provided.

Expressions of interest are invited from specialist emergency medicine physicians (FACEM) to join the proposed Emergency Department at Hollywood Private Hospital.

Already the largest private hospital in Western Australia, Hollywood’s site master plan will see significant growth over the next decade.

This is an exciting opportunity to join an amazing team of talented health professionals working in a world class health precinct.

For further information please contact: Dr Daniel Heredia, Deputy CEO and Director of Medical Services Ph 9346 6249 hollywoodprivate.com.au

MEDICAL FORUM

GUEST COLUMN • Patient data provides enhanced care and management; • Value is the benchmark for private health insurers and pay is centred on quality of care; • Patient quality engagement rises in standard when the shift is away from volume to value.

Transitioning from fee-to-service to valuebased care will take time to implement, but in any paradigm shift, change always produces hurdles before there is a clear run to the straight.

Healthcare providers strive with dedication and care to help patients in all aspects of health management and recovery. Putting aside strategies to support a value-based model, conducting strong patient outreach programs are equally important.

Value-based care aims to establish practices where prevention is paramount, along with initiatives that guard an individual’s health via programs reducing the need for expensive tests and medicines.

A number of medical and healthcare providers already participate in a valuebased healthcare model. The payment process encompassing doctors, hospitals and other providers is forged on a different measurement tool which includes quality, effectiveness and cost-enhancing patient experience.

Shifting toward a value-based model is driven by market pressures to reduce costs and improve the quality of healthcare.

Government, employers, healthcare plans and consumers need to work together to deliver on value.

Value-based healthcare looks to ensure:

Offering positive experiences through the use of innovative technology will help deliver quality healthcare at a lower cost and it is critical to the viability of a successful value-based care model.

ED: Rafic Habib is The CEO and Chairman of Clinic to Cloud a cloud-based practice management software provider.

• Patients remain the focus of healthcare and are supported by a specialised care team; • Proactive care, treatment and medication is delivered;

EVERYDAY FUNCTIONALITY. THE BMW X3 sDRIVE20i.

FROM $69,900 DRIVE AWAY.

AUTO CLASSIC 48 Burswood Road, Victoria Park. Tel 9311 7533. autoclassic.com.au LMCT2271 WESTCOAST BMW 17 Luisini Road, Wangara. Tel 9303 5888. westcoastbmw.com.au LMCT2271 *Recommended Promotional Drive Away Price for a new BMW X3 sDrive20i xLine with metallic paint. Offer applies at participating BMW dealers while stocks last to vehicles ordered and delivered by 31 December 2019 and cannot be combined with any other offer. Stock may vary between BMW dealers. Excludes fleet, government and rental buyers. Terms and conditions apply. Consult your participating BMW dealer for further details. BMW Group Australia reserves the right to change or extend the offer.

MEDICAL FORUM

JULY 2019 | 23

24 | JULY 2019

MEDICAL FORUM

BACK TO CONTENTS

EPOLL

Pitfalls for Male Doctors?

Poll Profile Male

67.5%

Female

32.5%

Specialists

50%

General Practitioners

41%

Doctors in Training and Other

9%

Responses within a five-day window

Q

Can you think of an instance among your male patients where PBS changes around androgen prescribing have forced a man, against your better judgement, off HRT altogether?

2019

2016

Yes

11%

15%

No

31%

23%

Uncertain

13%

14%

Doesn't apply

45%

49%

Q

In your view, during your formative years while growing up, did you have a satisfactory male role model?

2019

2016

Yes

79%

73%

No

13%

21%

Uncertain

8%

6%

Q

Should private health insurance premiums be discounted for verifiable healthy lifestyle choices?

Yes

70%

Perhaps

14%

Undecided

16%

Q

Child abuse has been prominent in the media for some time. Has this increased the awkwardness you experience in dealing with younger children at work as a doctor?

2019

2016

Yes

18%

22%

No

72%

74%

Uncertain

10%

4%

MEDICAL FORUM

COMMENT: Do you have anything to say around child abuse and how this relates to male doctors (optional)?

“Always have another person present.”

“I am a female doctor and I have had male victims say they find it easier to see a female and talk to her, as they are still very wary of men.”

“I am keenly aware of ensuring that children/teenagers when being examined are in the constant view of their parents i.e. not having the curtains closed. In addition, in the past I felt comfortable looking after a child while the mother or father went off to produce a sample or deal with reception in the middle of a consultation. Not now.”

“Always have a parent present, explain to parent and child what you wish to do and why, and wait for consent.”

“I fail to see how this relates more to male doctors.”

place. I am reluctant to be involved for fear of accusations being made.”

“Very difficult to make decisions because of associated legal ramifications.”

“It is extremely rare for GPs to have unsupervised/parent-free access to children, so unfair accusations wouldn't appear to be a great risk for us.”

“This question relates to male doctors. You forgot this in the wording. Most doctors are women!”

“Male doctors are generally very sympathetic apart from the odd troglodyte.

However children and mothers often feel uneasy if a male doctor (same sex as most of the perpetrators) is involved.”

“Doctor gender is not a major issue.”

It’s tricky with adolescent adults.”

“Always remember a chaperone.”

“It’s much easier for female doctors.”

“You have to be very cautious, but I have confidence in my ability to treat patients in a safe and courteous way.”

I'm a female doctor and think male doctors need to have chaperones with them in today's world, sadly.”

“In general I fear being caught in a situation where a child may be lost/alone in a public

“A big problem. Needs to be discussed at its source. Parental training is in order.”

JULY 2019 | 25

26 | JULY 2019

MEDICAL FORUM

GUEST COLUMN

Technology – Coming, Ready or Not! As one generation makes way for another in its influence and decision making, technology will be the future doctor’s greatest ally, says Gihan Perera.

Four hundred years ago in China, people would pay their local doctor an ongoing fee to keep them healthy. When they became ill, the doctor was still required to treat them, but they wouldn’t be paid until the patient became well.

most efficient way to provide care. With increasingly sophisticated technology, consumers will be able to manage much of their own care from home.

Of course, I’m not suggesting we should use the pre-scientific, superstition-based approach of ancient Chinese medicine in clinical care. But leaving that aside, consider changing our system so healthcare providers are paid only when patients are healthy.

People are now expecting to be treated like customers, not patients. As with other commercial transactions, they want more choice, instant responses, apps, tech-savvy providers, digital records, connected health data, online access, better understanding of products and services, and the ability to shop around.

This is such a radical change it’s impossible to imagine in practice. But technology – through big data, artificial intelligence (AI), automation, and smart devices – could make similarly dramatic transformations to the healthcare system in the not-too-distant future.

Here are four examples of just how: • What: From Sickness to Wellness We say prevention is better than cure yet prevention is only a tiny fraction of a system that is almost exclusively focused on curing sick people

Recently, we have seen significant growth in the wellness movement, fuelled by social media, smartphone apps, and other technology.

• Who: From Patients to Consumers

What does this mean for you?

You might see our healthcare system constantly improving, but that’s only if you compare it with itself. It’s also shrinking in its role as part of a much bigger health ecosystem. From a patient’s viewpoint, their primary care provider might be their watch, a Facebook group, or an Instagram entrepreneur.

You don’t have to give up your practice and become a wellness blogger! But it’s important you can have better-informed conversations with patients. So invest in yourself, expand your mindset, and understand the bigger picture.

ED Gihan Perera is a business futurist, speaker, and author of The Future of Leadership and Disruption By Design.

Healthcare professionals are mostly missing from these platforms, which has unfortunately led to vast amounts of pseudo-science and misinformation.

• How: From Biology to Data In 2013, technology investor Vinod Khosla claimed that: “In the next 10 years, data science and software will do more for medicine than all of the biological sciences together.”

Already, personal monitoring devices such as the Apple Watch or FitBit collect vast amounts of data, which AI can then mine to monitor and analyse health indicators, and (eventually) prescribe preventative action.

• Where: From Hospital to Home Currently, patients have to travel to centralised healthcare locations – such as surgeries and hospitals – because that has been the

FOR SALE 44 Leura Street, Nedlands

Domestic violence climbs Domestic and sexual violence continues to increase according to the latest report from the AIHW. Its findings show one in six women and one in 16 men have experienced physical and/or sexual violence by a partner with one in four women and one in six men experiencing emotional abuse by a partner and one in five women and one in 20 men were sexually assaulted and/or threatened.

It reported that some of the most vulnerable women were pregnant, had disabilities or experienced financial hardship. Both women and men who experienced abuse or witnessed domestic violence as children were also identified as most at risk.

MEDICAL FORUM

POTENTIAL MEDICAL CONSULTING ROOMS New Zoning - Mixed Use Development RAC3 Check with the Nedlands City Council on the redevelopment possibilities.

457sqm next door to park with northern aspect facing the park. Quiet street, one street back from Hampden Rd. Front and rear boundary 12.19sqm North and south boundary 37.5sqm

Claire Young

0417 179 814 claire@gdre.com.au

JULY 2019 | 27

Men are made to move

By Mr David Beard, Exercise Physiologist specialising in diabetes & men’s health, Nedlands Men are physiologically designed to move. They have more muscle and less fat (when healthy) than females.

Their body adapts to demands placed on it quicker and more than a women’s.

There are positives and negatives to a man’s body being more adaptable. Given the right stimulus (lifestyle), men can improve their health and fitness more. But given the wrong lifestyle, a man’s body adapts in ways that impact both short- and long-term health.

The accumulation of body fat is a good example. Women naturally tend to store fat on the hips and thighs (below the waist) while men store it around their middle (above the waist). Fat stored around the waist and in the viscera (gut) is more metabolically active, releasing substances that negatively impact health. This puts men at greater risk of metabolic conditions such as diabetes and cardiovascular disease.

The upside of men’s physiology however is that given the right environment, (diet and sleep) and the appropriate demands (exercise and stress) a man can achieve and sustain good health into old age.

Exercise is without doubt the most significant tool a man can use to optimise his health. Used strategically it can set men up for life.

During puberty and their 20s, men should be thinking about building capacity, taking advantage of higher levels of testosterone.

This is the time to build muscle, develop neural pathways and maximise physical capacities. The effort put in during these years lays the groundwork for lifelong fitness.

By the thirties and beyond, life seems to make it harder to stay active with work and family responsibilities taking up more time. During these years, men need to be efficient with their exercise to maintain capacity they built in younger years.

There are primarily two types of exercise that men need to focus on.

Aerobic exercise In younger men the focus should be on building a solid aerobic base. They should aim to do exercises such as running, cycling, swimming and rowing for periods up to an hour at a pace they can (just) sustain for that period. They should also incorporate some higher intensity intervals to really challenge their system, so it adapts and gets fitter.

In older and busy (work and family) men, who only have time to get out for short periods or the weekends, it is important to be safe and smart when exercising. The last thing a busy and stressed man needs is an exercise routine that adds more stress. Pushing hard for long periods of

Exercise is important but age and the intensity of exercise need to be considered carefully.

time puts unnecessary stress on the heart and muscles. A safer aerobic exercise regime is to work at a comfortable pace for most of the session, with just a few higher intensity intervals during the session.

For a runner this might be pushing up hills.

A cycling group might incorporate some “sprints” into their route; ride fast for a short period but sit up, recover and wait for the group. Unfortunately, many “weekend warriors” or competitive middle-aged men falsely believe that they have to push hard the whole time. This isn’t the case and may in fact increase the risk of atrial fibrillation.

Strength training The tendency in younger men is to focus on how they look at the expense of getting stronger. Focusing on their chest and arms can lead to muscle imbalance and postural issues. It is more important to do a range of exercises that use the major muscle groups (chest, back, shoulders and legs).

Impatience and wanting quick results lead some men to use steroids to artificially stimulate growth. Steroids place an enormous stress on the body and carry significant health risks in the short term and into the future. While steroids help muscles get bigger, they don’t necessarily get stronger and the gains are lost once use is stopped. Younger men should aim to do strength training 2-3 times per week.

In older men, strength training becomes more important but so does protecting tendons and joints from injury. The same principle of focusing on major muscle groups applies, however how the exercises are done is different. Older strength trainers should do exercises slowly and controlled but still work almost to failure. They reap the same strength benefits but without the risk of injury.

The good news for men is that regardless of age their body will adapt to exercise provided they are smart and choose the right program.

ED: Men who haven’t exercised for some time or have health issues may be better off under the guidance of an Accredited Exercise Physiologist (of which there are about 400 in WA).

28 | JULY 2019

MEDICAL FORUM

BACK TO CONTENTS

CLINICAL UPDATE

BACK TO CONTENTS

CLINICAL OPINION

Providing supportive care to people affected by prostate cancer

By Ms Julie Sykes, Prostate Cancer Specialist Nurse, Joondalup Every year, about 20,000 men are diagnosed with prostate cancer (the most common cancer in Australian males), while an estimated 200,000+ Australian men are living with it. Whilst about 95% of people with prostate cancer survive for at least five years, prostate cancer is the second most common cause of cancer death in Australian meni.

and clinical care is widely recognised.

Treatment given intends to eradicate the disease or offer palliation from symptoms in the event of disease spread. Individual treatment plans are determined by a number of factors including the grade and stage of disease, age, other comorbidities and patient preference. This often involves a multi-modal approach.

The primary role for the Prostate Cancer Specialist Nurse (PCSN) is to provide care and services aimed at improving an individual’s cancer experience.

Side effects are a common feature for many who receive treatment, and they can persist for many years and require specialist advice and intervention.

The role of the Nurse Specialist The role of the nurse in specialist supportive

In response, Prostate Cancer Foundation of Australia (PCFA) introduced a Prostate Cancer Specialist Nursing program in 2012, which provides four positions in WA. As the only community-based position in the PCFA program, the GenesisCare Prostate Cancer Specialist Nurse provides an area wide service to men and their families living in the Joondalup and Wanneroo shires.

The PCSN assists men by: • Provide an ongoing point of expert contact and support • Assist men with access to hospital and community services • Provide reliable information about diagnosis and treatment • Provide information about how to deal with the effects of treatment and get further help with specific problems.

• Coordinate care • Enable men, their families or carers to access support groups • Provide education and training to other health care workers and those affected by prostate cancer Patients may present to the PCSN at any point in their cancer journey be it at diagnosis, during or after treatment. The nurse works within the multidisciplinary team and provides care and information to all patients across all treatment modalities including surgery, radiation therapy and drug therapy. Being a central point of contact for the treating team is also a vital component of the role.

The GenesisCare PCSN also delivers group education sessions for people affected by prostate cancer on continence, sexual dysfunction, diet and exercise in partnership with other local providers.

These are free for the community to attend.

More information about the Prostate Cancer Specialist Nurse service in your area can be found at: pcfa.org.au

SPECIALISTS IN PROSTATE CANCER AND BPH

WO

RL

Mr Tom Shannon FRACS

DC

LA

SS

RE

Robotic and Laparoscopic Surgeon Surgical Results

In organ confined disease 100% primary resection success (Literature averages 60-85%) In extra prostatic disease 90.1% complete rescection (Literature averages 40-65%)

Cancer Control (PSA over 0.2 after surgery)

Confined disease - 3% (One third of published average PSA failure rates) Extraprostatic disease - 16% (Half the rate of published average PSA failure rates) Source Uropath WA Radical Prostatectomy Database

MEDICAL FORUM

SU

LT S

Patient Support and multidisciplinary team

Extensive website Prostate cancer specialist nurse - education and support Sexual health nurse practitioner - rehabilitation programs Dietitian - rapid weight loss programs Exercise physiologist - weight loss programs, exercise in cancer programs

Nedlands Phone: 9389 7696 Fax: 9386 1799 drtomshannon@theprostateclinic.com.au www.theprostateclinic.com.au

JULY 2019 | 29

Is male fertility decreasing?

By Prof Roger Hart, Professor of Reproductive Medicine, UWA, fertility specialist, Claremont In about a third of instances where a couple is having difficulty conceiving, the principal cause is related to the male partner. We may be witnessing a gradual reduction in sperm counts across the Western world, although this is difficult to prove as, surprisingly, we are unclear what a ‘normal’ sperm count is.

While the reference values supplied by the WHO relate to the fifth centile for all parameters for men whose partners conceived within a year of trying, it hardly describes a normal reference range.

Studies on young men (most not actively trying for a family) in WA, showed that only 14% had satisfied all WHO parameters.

Furthermore, the sperm parameters of these men were generally worse than a sample of men undergoing IVF treatment in our unit at the same time.

We may be on the cusp of a large increase in couples seeking fertility assistance due to impairments of semen parameters.

Good evidence suggests that semen parameters are often a reflection of underlying male health. It is poor medicine to proceed directly to IVF/ICSI treatment (isolating a sperm from the semen sample and using it to inject into the egg for fertilisation) without first addressing any potential underlying cause of male infertility.

Poor health, poor sperm Poor metabolic health, smoking, being overweight, binge drinking, substance abuse, anabolic steroid use and poor diet are often reversible causes of impaired semen parameters. Men need to accept the same level of responsibility for their health as their female partners when a couple is trying to conceive.

Men are to be encouraged to attend their GP to address any concurrent medical conditions to assist conception.

Significant impairments of semen parameters can be considered testicular (impairment in spermatogenesis), obstructive (an obstruction of the sperm transit to ejaculation) or central (impediment to normal gonadotrophin stimulation).

With obstruction, there will be no sperm in the ejaculate despite a good seminal volume, (e.g. post vasectomy, or in presence or absence of the vas deferens (often in presence of being a carrier of cystic fibrosis, so screening is imperative).

30 | JULY 2019

In this instance a simple local anaesthetic needle aspiration of the testicle (TESA) should reveal an abundance of sperm to store for a future IVF/ICSI cycle.

However, the semen characteristics, when the cause of male infertility is testicular, either due to damage from mumps, chemotherapy/radiotherapy, history of undescended testis, or a significant varicocele, will often be oligospermic (impaired), and hence it is imperative to cryopreserve several ‘straws’ of sperm for future fertility.

With time, ejaculated sperm will decline.

When there is no sperm in the ejaculate, azoospermia, a micro-TESE is often required. This is a protracted, meticulous dissection of the testicles, under an operating microscope, to identify tubules which may have sperm residing in them.

Few surgeons in WA routinely perform this procedure.

Road to donor sperm If no sperm are retrieved, often despite presurgery medical treatment, the only option may be sperm donation.

When the cause of infertility is genetic (e.g. Klinefelter syndrome), often testicular exploration is unrewarding. However, if successful, pre-implantation genetic screening of the resulting embryos may be advised to prevent transmission of the genetic disorder to the next generation.

With central (hypothalamic and pituitary) causes of subfertility, an experienced endocrinology assessment is often

required by either by a trained infertility doctor, or an endocrinologist. After exclusion of significant central pathology, the fertility specialist will often start induction of spermatogenesis with injections of hCG +/- subsequent Follicle Stimulating Hormone (FSH) injections, aiming for natural conception, and freezing semen samples for possible future use.

The treatment regime can be protracted, but often rewarding for the couple. Semen parameters may improve substantially, but not sufficiently for natural conception, and IVF may still be required – albeit with much better sperm.

Other causes of male infertility include spinal injury where the ejaculation is often impaired, and the sperm are immotile, so testicular sperm aspiration and IVF/ICSI is performed. Bladder neck injury/dysfunction where retrograde ejaculation occurs is another when post ejaculatory urine is centrifuged to derive sperm suitable for IVF/ICSI. The male partner should be as healthy as possible, and take his role in the fertility treatment seriously as there is increasing data suggesting that his health at conception has potential to influence the offspring’s health.

References on request

Author competing interests: The author is Medical Director of a fertility business; he has received educational sponsorship from MSD, Merck-Serono and Ferring Pharmaceuticals.

MEDICAL FORUM

BACK TO CONTENTS

CLINICAL OPINION

BACK TO CONTENTS

CLINICAL UPDATE

Managing lower urinary tract symptoms (LUTS)

By Dr Tom Shannon, Urologist, Nedlands The majority of LUTS can be managed in general practice without urological intervention.

The aims of management are to minimise symptoms and to prevent irreversible bladder damage or renal impairment. To do this requires a structured assessment aimed at classifying the LUTS as mild, moderate or severe. With practice this can be done quickly and efficiently in a routine consult.

Many patients present with symptoms are concerned about prostate cancer. This should be regarded as a separate issue with different diagnostic steps.

I would strongly suggest using the International Prostate Symptom Score (IPSS) sheet, which is filled in by patients in the waiting room. This validated questionnaire gives an objective score from seven questions covering obstructive and irritative symptoms. This can be combined with the International Index of Erectile Function (IIEF) score sheet, which can act

Up to half of older men have bothersome voiding symptoms, making LUTS a common complaint.

BPE is usually the cause but LUTS is now favoured to remove assumptions.

KEY MESSAGES LUTS affects up to 50% of older men Accurate history is paramount Treatment depends on severity

as a vascular health screening tool, a useful motivator for lifestyle change. IPSS score results – mild up to seven, moderate 8 to 19 and severe from 20 to 35. Both score questionnaires are available online.

Voiding history is important. A sequential story can be easy to remember for patients. Capture nocturia (times), urgency, urge incontinence, hesitancy (time), intermittent flow, incomplete emptying, daytime frequency, haematuria, dysuria, previous UTI’s, constipation, and stone disease. Hesitancy time is the most reliable measure of dysfunction. Examination includes general abdominal and DRE.

Useful investigations include a urine dipstick or MSU and an Hba1c if diabetes is suspected. PSA should be discussed and used if over 50 or younger with a family history. For patients with moderate to severe symptoms flow rate and residual urine value is a better test than an ultrasound alone. It is an objective measure of real-world function that can predict pathology and guide treatment choices.

Treatment guide In mild cases, advise weight loss, correction of diabetes, salt reduction and evening fluid restriction. Medication

continued on Page 39

Home of the SKG RADIOLOGY PATIENT PORTAL Get your images and reports online www.skg.com.au

MEDICAL FORUM

JULY 2019 | 31

32 | JULY 2019

MEDICAL FORUM

BACK TO CONTENTS

CLINICAL UPDATE

PrEP – prescribing it to your patients

By Dr Christine Dykstra, Sexual Health Service, Royal Perth Hospital Before prescribing PrEP, become familiar with the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM) PrEP guidelines - a comprehensive resource designed for primary-care prescribers. A quick reference tool and online module is at www.ashm.org.au. Prescribing courses are available through the Health Department of WA. The medication is available on the PBS for those over 18 at medium to high-risk of acquiring HIV and in whom the HIV test is negative within seven days of the prescription being written.

Are you looking for at risk patients to offer them this treatment? If not, you should be. In addition to prescribing the medication, three monthly STI testing is also recommended.

How effective is PrEP? The risk of HIV acquisition is reduced by 95-98% if the medication is taken correctly. On a population level, the EPIC NSW trial has shown new infections roughly halved in GBM communities with the highest PrEP uptake since the trial began. Poor adherence causes most new HIV diagnoses in people on PrEP - there have only been a handful of true failures to date.

KEY MESSAGES PrEP usage reduces HIV incidence Offer PrEP to suitable patients Monitor closely After initial PrEP discussion, ensure they are not seroconverting or already infected with HIV and check renal function. Review threemonthly for HIV serology, renal function tests (eGFR must be >60ml/min/1.73m2 [six monthly if stable]), STI testing, and a repeat prescription.

Adherence is vital to PrEP success. Three monthly screening is critical to detecting PrEP failure early, renal function monitoring and managing other STI’s. Encourage condom use and three monthly STI screening. PrEP is very effective at reducing the risk of acquiring HIV, but provides

Recent research shows that taking Truvada (tenofovir DF 300mg/ emtricitabine 200mg) daily reduces HIV. Will this see the end of HIV? The treatment is called PrEP- Pre-Exposure Prophylaxis. no prophylaxis against other STIs, unlike condoms. While condoms are a good HIV and STI prevention strategy for those who use them consistently and effectively, experience shows this is not a realistic or preferred option for everyone. For people at significant risk of HIV, PrEP can provide an alternative HIV prevention strategy.

ED: The author acknowledges the assistance of Dr Jenny McCloskey in presenting this update.

Author competing interests: nil relevant disclosures. Questions? Contact the editor.

WA HIV notifications by exposure category - April to March 12-month periods from 2014/5 to 2018/9

To whom and how to prescribe PrEP Offer to gay and bisexual men (GBM) and trans and gender diverse people with multiple male partners and inconsistent condom use, travellers to high HIV prevalence countries who practice risky sex (i.e. unprotected sex with locals), needle sharing with someone who either has HIV or is at significant risk of having undiagnosed HIV (e.g. unknown HIV status GBM) and sexual partners of people with HIV that have not yet attained a sustained undetectable viral load or are poorly compliant with therapy.

Graph courtesy CDCD Health Department WA: it highlights a temporal association with reduced GBM HIV notifications and increasing PrEP uptake.

Rapid growth for AI and the regulators in healthcare Artificial intelligence (AI) and machine learning (ML) algorithms are growing exponentially in the software as a medical device (SaMD) industry and the regulators are struggling to keep up, especially in the US. AI/ML-based SaMD algorithms are currently being used in three distinct healthcare areas: for clinicians to have accurate image interpretation; for health systems to reduce medical errors while improving workflow; and for patients’ autonomy enabling them to process their own data.

MEDICAL FORUM

The Federal Drug Administration (FDA) is addressing the need for a robust AI/ ML based SaMD policy with a whitepaper outlining a proposed regulatory framework which it says will future-proof the agency and ensure they have a policy in place to regulate these algorithms.

Currently, the FDA is appraising algorithms as non-self-learning software, which means there is potential for the approved applications to self-learn beyond what the FDA has measured.

But for some context, the FDA has approved 23 AI algorithms for clinical use last year, compared to 2014 when only one algorithm was approved.

A regulatory framework that can appraise the ability of an AI/ML based SaMD algorithm is good for the industry too, as it ensures their efficacy and safety for use by health care professionals and consumers.

JULY 2019 | 33

Perth’s Newest Specialised Cancer & Haematology Day Clinic

Introducing Medical Oncology Services to our clinic DR WEI-SEN LAM MBBS FRACP MHA

Dr Wei-Sen Lam is a medical oncologist who treats a broad range of cancer with interests in lung cancer and melanoma.

Dr Lam graduated from University of Western Australia and completed his specialist training at Fiona Stanley and Sir Charles Gairdner Hospital.

Wei-Sen has a keen interest in research and is actively involved in clinical trials.

Dr Lam was a successful recipient of the WA Cancer and Palliative Care Network Fellowship and is a principal investigator in several lung cancer trials at Fiona Stanley Hospital. Dr Lam is actively involved in education as the co-chair for WA Clinical Oncology Group (WACOG).

He also has a Masters of Health Administration with Monash University and is currently the clinical lead for Medical Oncology and TeleOncology for WA Country Health Service. He is passionate for improving cancer services for rural and remote WA and is known for his kind and approachable manner.

Our Haematologists: Dr Maan Alwan, Prof. Ross Baker, Dr Peter Tan

Our Clinic: • Patient focused with family support & involvement • Tranquil setting • Clinical Trials • Allied Health

Western Haematology & Oncology Clinics 18 Prowse Street, West Perth WA 6005 P: 08 6146 1400 E: info@whoc.com.au 34 | JULY 2019

MEDICAL FORUM

BACK TO CONTENTS

CLINICAL UPDATE

Surgical management of erectile dysfunction

By Dr Trent Barrett, Urologist The aetiology of Erectile dysfunction (ED) is largely organic. ED is increasingly common with an ageing population with more widespread cardiovascular risk factors. As well, there has also been a cultural shift towards awareness and a willingness to address the condition. Despite this, ED remains undertreated (about 50% of affected men) and of those who seek treatment, a proportion drop out and remain unsatisfied.

Primary care The initial management of ED occurs in primary care. A history needs to focus on cardiovascular risk factors, as erectile dysfunction can herald other cardiovascular disease. Medical treatments are well established with ‘blue pills’ and other phosphodiesterase-5 inhibitors (PDE5-I) being entrenched in the public consciousness since the late 90s. They remain first line therapy with reported success ranging from 43-89%.

For those who fail medical therapy, second line therapies include either vacuum erection devices (VED) or intracavernosal injections (ICI). These therapies work well, but the long-term satisfaction rates are poor (50-64% satisfaction after two years for VED and a 40-68% drop out rate for ICI). Both of these therapies require external equipment and can interrupt the natural flow of a sexual encounter.

Surgical care

Once an organic cause is thought likely, surgical implants become the endpoint of a stepwise escalation of efforts to relieve ED.

KEY MESSAGES Patients presenting with ED need medical workup for cardiovascular risk factors Conservative stepwise therapies are offered but will not be effective/acceptable in all Discuss surgical therapies earlyillustrate a practical end point to management

Patients are kept in hospital overnight and are able to recommence intercourse at around six weeks. The ability to have a reliable and concealable internal method of achieving erections is appealing to patients, with long-term satisfaction rates around 90%.

Surgical therapy can be offered to patients who fail first- and second-line therapy or it can be discussed with motivated patients who have side effects or dissatisfaction with the non-surgical treatments. It is

important that the initial discussions include information about surgical therapy.

Patients may be poorly compliant with medical ED therapy because they perceive a barrier to escalating their treatment. There is a big jump in terms of perceived complexity and invasiveness between the first line oral (PDE5-I) and second line interventional (VED, ICI) therapies. It is understandable that they discontinue treatment, inhibited by the idea of second line therapies and are not informed about the options beyond this.

Through outlining a comprehensive, stepwise approach to the management of ED (including the endpoint of surgical management) patients can be kept engaged.

Author competing interests: No relevant disclosures.

Do you have patients with breast implants?

Patients who had surgery overseas?

Now available to you is a multidisciplinary clinic with a Specialist Plastic Surgeon Medical Director CLINICAL PROTOCOLS INCLUDE:

Third line therapy involves surgical implantation of a penile prosthetic. These are either rigid, or more commonly inflatable devices that generate erections on demand.

The three-piece inflatable device (IPP) is the gold standard. It involves implanting inflatable cylinders within the penile corpora.

These are connected internally to a fluid reservoir in the retropubic space and a pump within the scrotum that is used to activate and deactivate the device. The penis appears natural in its flaccid and erect state after the device is implanted.

MEDICAL FORUM

Education re. Breast Lymphoma and Breast Implant Illness Clinical evaluation Radiological screening

Communication with the Primary Care Specialist Psychological screening Haematology where indicated

BREAST IMPLANT CHECK | 9228 0038 369 BULWER STREET, WEST PERTH

implantcheck.com.au JULY 2019 | 35

MRI | CT | PET | Ultrasound | X-Ray | NucMed | Dental

Fully licensed MRI at Envision Envision is pleased to have the newest fully licensed MRI in WA with the state’s only rebateable Siemens Skyra 3T MRI scanner ALL Medicare rebateable MRI items are now available for GPs and Specialists We have expanded to become WA’s largest private radiology site including 2 MRIs, cardiac CT, Nuclear Medicine, PET-CT, X-ray, Ultrasound and the state’s only dedicated extremity CT machine all located conveniently at our practice in Wembley FREE on-site parking available

Envision. Much more than a picture.

178-190 Cambridge Street | Wembley | 6382 3888 | envisionmi.com.au 36 | JULY 2019

MEDICAL FORUM

BACK TO CONTENTS

CLINICAL UPDATE

Update: urethral stricture

By Dr David Sofield, Reconstructive Urological Surgeon, Palmyra Strictures of the male urethra are one of the oldest known surgical afflictions and are a major cause of morbidity and mortality throughout the world.

Untreated, strictures may lead to urinary retention, sepsis, bladder and renal failure. Today, the correct approach is to consider reconstruction at the outset. A single dilatation, particularly in the setting of urinary retention (or incipient retention) is reasonable but stricture recurrence is best referred.

Urethral strictures are caused by spongiofibrosis, that is, scarring of the spongy erectile tissue which surrounds the urethral lumen. Breach of the urethral mucosa by trauma or infection leads to extravasation of urine into the delicate spongiosum, followed by inflammation and resolution by fibrosis.

The mainstay of treatment has been dilatation, despite the fact that it is ineffective (long term success of <5%).

MEDICAL FORUM

KEY MESSAGES Urethral strictures are a major cause of morbidity Dilatation is palliation, curing <5% of strictures Urethroplasty is curative in 85% with a single procedure in expert hands

Many men follow years of painful selfdilatation which is not curative, and in fact, can continue the trauma/scaring cycle and cause any stricture to become longer and denser, making subsequent repair more difficult.

Men with urethral strictures need help, and the patient’s circumstances are best weighed up. These notes will assist doctors make decisions in each man’s best interests. urethra is divided into three parts: • Membranous (from prostate to external sphincter) • Bulbar (sphincter to penoscrotal junction) • Penile urethra

Reconstruction of the urethra is highly specialised and effective. A ‘father’ of West Australian urology, Dr Stan Wisniewski said, "Dilatation is palliation, urethroplasty is cure".

1. Membranous strictures are most commonly associated with pelvic fractures e.g. MVA. These are often managed with initial insertion of a suprapubic catheter and delayed reconstruction. Such injuries are often associated with erectile dysfunction and repair is challenging due to the very deep position of the injury within the pelvis and extensive scarring associated with bone fragments.

The likely cause and management of strictures differs by location. The male

continued on Page 38

JULY 2019 | 37

Pterygia – what action is required?

By Dr Tom Cunneen, Ophthalmologist, SCGH and Subiaco Pterygium, is common, affecting 10% of Australian adults, associated with UV light exposure. The precise pathogenesis is unknown.

Theories on cause One theory is that light passing in a lateral to medial direction is focused by the protruding cornea onto the nasal conjunctiva leading to localised, intense UV damage.

Histologically it consists of conjunctival epithelium with hypertrophied subconjunctival connective tissue.

Clinically pterygia are fleshy, vascular growths which grow onto the cornea and are more common nasally. A histologically similar lesion is the pingueculum which has a pale yellow, fatty colour and is less vascular. This doesn’t extend onto the cornea.

Symptoms Patients with pterygia often suffer irritation and chronic erythema. As the pterygium grows it distorts the cornea

KEY MESSAGES Pterygium is common and can be managed with high patient satisfaction.

OSSN is a rare but serious differential diagnosis. inducing irregular astigmatism which isn’t correctable with spectacles. When the pterygium approaches the visual axis, the vision deteriorates further because of light scatter or blockage from the pterygium itself. Rarely large pterygia can limit ocular motility and cause diplopia.

The differential diagnosis of pterygia includes pseudopterygia which are areas of conjunctival scarring on the cornea and ocular surface squamous neoplasia (OSSN). Atypical features for pterygia include a non-nasal location, rapid growth and thickening, a gelatinous or leukoplakic surface and irregular or exuberant vascularity. Anecdotally patients which OSSN tend to be more symptomatic.

Annoying pterygia sometimes require surgery. The reviewing doctor must exclude OSSN, a rare but common reason for persistent annoyance.

What can be done Non-surgical options for pterygia include regular ocular lubrication and treating other ocular irritants such as posterior blepharitis and allergic eye disease. Short courses of topical steroids such as fluorometholone (FML) are appropriate; however, they shouldn’t be used long term due to the risks of raised intraocular pressure and cataract. I image all pterygiums to provide a baseline.

Surgery involves removing the pterygium and the adjacent subconjunctival connective tissue. The cornea should be left as smooth as possible.

If the defect left by the pterygium is left bare the recurrence and complication rate is unacceptably high. The current gold standard involves harvesting a thin

continued from Page 37

Aurora 136 Riseley St, BOORAGOON

FOR LEASE / SALE 455 M² Dental / Medical Suites 8 Carbays +

For Viewing: Contact MJ on 0412 996 556 Email: mjascend@gmail.com / Skype: Mjascend

38 | JULY 2019

Update: urethral stricture 2. Bulbar urethral strictures are traumarelated, most commonly fall-astride impacts (often quite minor) and iatrogenic injuries (e.g. traumatic catheterisation or an endoscopic procedure e.g. TURP).

Repair of these strictures almost always is achieved in a single stage using either an excision and anastomosis or graft technique, utilizing free grafts of oral mucosa. Results are excellent with 85% patency at ten years, in experienced hands.

3. Penile urethral strictures are most commonly associated with Balanitis Xerotica Obliterans (BXO) and /or childhood hypospadias repair. These can be challenging strictures due to the progressive nature of BXO, multiple previous surgeries and disordered blood supply associated with hypospadias.

Repair often requires a staged approach, again using free grafts of oral mucosa.

With appropriate timing and experience, functional and cosmetic outcomes are excellent.

MEDICAL FORUM

BACK TO CONTENTS

CLINICAL UPDATE

BACK TO CONTENTS

CLINICAL UPDATE continued from Page 31

Managing lower urinary tract symptoms (LUTS) Fig 1: Pterygium

Fig 2: 6 weeks after pterygium excision and conjunctival autograft.

conjunctival graft from the superior bulbar conjunctiva and securing this into the defect – a fibrin glue secures the graft and improves postoperative comfort by avoiding ocular sutures, with recurrence rate 5%.

Regional peribulbar long acting anaesthesia provides post-operative analgesia and doesn’t disturb the operative field (GA rarely required).

If a recurrence occurs, topical steroids and intralesional 5 fluorouracil are effective if used early.

Mimicking squamous neoplasia OSSN encompasses both conjunctival intra-epithelial neoplasia (in situ disease) and invasive squamous cell carcinoma OSSN is rare but serious. Patients who are immunosuppressed, have extensive UV exposure or exposure to petroleum derivatives are at increased risk.

Fig 3: Leukoplakic lesion - biopsy demonstrated high grade dysplasia.

Fig 4: OSSN demonstrating irregular vascularity and a temporal location.

Impression cytology may have a role in differentiating benign from malignant lesions, however the false negative rate is high as only the surface cells are sampled.

If OSSN is suspected the lesion is resected with cryotherapy to the margins.

The defect can be closed directly by mobilising adjacent conjunctiva, or amniotic membrane can be grafted into the defect to provide a basement membrane for healing. If the lesion is too large to be safely resected, or there are other contraindications to surgery, then topical interferon alpha 2A can be used. This is well-tolerated and has the advantage of providing regional treatment to the entire ocular surface.

has a role in moderate symptoms. Highly selective alpha blockers (tamsulosin / silodosin) have less hypotension, but Prazosin can be useful in hypertensive patients at higher doses. Retrograde ejaculation is a common side effect.

Five alpha reductase (5AR) inhibitors - (finasteride / dutasteride) shrink the gland, but may cause sexual side effects and decrease athletic performance.

Combination alpha/5AR is the drug of choice in older men with larger glands.

Complicated or severe LUTS should have a full urological assessment which may include cystoscopy. It is likely that surgery could be used, or combination medical therapy.

References available on request.

Could you or someone you know benefit from participating in this study?

Are you a male aged 60 to 80?

Do you have memory concerns?

No significant medical or neurological conditions?

Not received testosterone therapy?

Is your testosterone possibly on the low side of normal?

The Australian Alzheimer’s Research Foundation is currently seeking participants to take part in a clinical trial investigating whether testosterone taken alone or together with fish oil has a benefit on memory tests, brain scans, and other measures of Alzheimer’s disease risk.

For more information, please contact Shane Fernandez on 6304 3966 or email s.fernandez@ecu.edu.au

MEDICAL FORUM

JULY 2019 | 39

we've got you covered Nedlands Murdoch Joondalup Mandurah Geraldton Albany

Working together to provide comprehensive urological care Dr. Jeff Thavaseelan Dr. Shane La Bianca Dr. Andrew Tan Dr. Akhlil Hamid Dr. Trenton Barrett Dr. Matt Brown

Hollywood Clinic Suite 15 / Ground, Hollywood Medical Centre 85 Monash Avenue, Nedlands WA 6009 Phone (08) 9322 2435 / Fax (08) 9322 5358

refer@perthurologyclinic.com.au 1800 4 UROLOGY (1800 487 656) Healthlink: jthavase

Wexford Clinic Suite 23 / Level 1, Wexford Medical Centre 3 Barry Marshall Parade, Murdoch WA 6015 Phone (08) 6189 2970 / Fax (08) 6225 2105

www.perthurologyclinic.com.au 40 | JULY 2019

MEDICAL FORUM

BACK TO CONTENTS

CLINICAL UPDATE

11 Recommendations for high value musculoskeletal pain care

By Dr Roger Goucke, Pain Specialist Are we managing musculoskeletal pain well in men?

We can do better, according to these authors.

CASE REPORTS: A middle-aged patient with slow onset shoulder pain was concerned about the results of a left shoulder ultrasound that showed a partial tear in the rotator cuff. Since the result they had worn a sling to protect the shoulder from â&#x20AC;&#x153;further tearingâ&#x20AC;?.

This patient had a one-year history of disabling low back pain, and depression, worse since she separated from her partner. For six months they had been prescribed repeat oxycodone and celecoxib.

There had been no engagement with allied health.

Further questions would determine whether their health care management was of high quality. Unfortunately, clinicians such as doctors, physiotherapists, chiropractors, osteopaths and others who work with patients with musculoskeletal pain, donâ&#x20AC;&#x2122;t always practice in a way consistent with research evidence. Over-use of imaging, the prescription â&#x20AC;&#x2DC;opioid epidemicâ&#x20AC;&#x2122;, increases in unproven surgeries, and a failure to provide patients with self-management advice are just some of the problems.

We need to change the way musculoskeletal pain is managed.

A recent systematic review of contemporary musculoskeletal pain clinical guidelines may help with starting this change. We were interested in whether, across musculoskeletal pain conditions, we could identify common recommendations to manage musculoskeletal pain. We thought if we could, it would provide consumers, clinicians, educators and health decision makers with a way of knowing what higher quality care of musculoskeletal pain looked like.

Unfortunately, not all musculoskeletal pain guidelines were rigorously developed or reported. However, we were able to rank 11 (out of 32) clinical practice guidelines as high quality. From these we identified 11 common recommendations for the care of musculoskeletal pain conditions.

1. Care should be patient centred; it responds to the individual context of the patient, employs effective communication and shares decision-making.

given rocker shoes or orthotics, receive disc replacement surgery, or injections into the back when there was no leg pain associated with back pain. Patients with osteoarthritis should be wary of having arthroscopic knee surgery. Many clinicians will not find these recommendations new.

To assist clinicians and patients we have developed an infographic to use as a simple communication tool (see below). Infographics in Italian, German and Portuguese have surfaced online and may be useful for patients who prefer these languages.

The authors urge readers to review these recommendations, critique them, send us some (constructive) feedback â&#x20AC;&#x201C; good or bad.

The author acknowledges help in writing this article from Dr Ivan Lin. Reference: Lin I, Wiles L, Waller R, et al. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Br J Sports Med 2019:bjsports-2018-099878.

Â&#x20AC; ­

Â?Â&#x201A;

Â&#x192; ­

2. Screen patients to identify those with a higher likelihood of serious pathology/red flag conditions.

3. Assess psychosocial factors.

Â&#x201E;

( )

 ­

/

4. Radiological imaging is discouraged unless:

i. Serious pathology is suspected.

ii. There is an unsatisfactory response to conservative care or unexplained progression of signs and symptoms.

 �

Â?

Â?

6. Evaluate patient progress, including the use of outcome measures.

9. Apply manual therapy only as an adjunct to other evidence-based treatments.

10. Unless specifically indicated (e.g. red flag condition), offer evidence-informed non-surgical care prior to surgery.

Â?

Â?

7. Provide education/information about their condition and management options.

8. Provide management addressing physical activity and/or exercise.

iii. It is likely to change management.

5. Do a physical examination, including neurological screening tests, assessment of mobility and/or muscle strength.

Â?

/ Â?

Â

/

11. Facilitate continuation or resumption of work.

We also identified treatments for certain conditions that should not be provided. For example, patients with low back pain should not be prescribed opioid-based medications or paracetamol alone,

MEDICAL FORUM

Reference: Lin I, et al. Br J Sports Med 2019;0:1â&#x20AC;&#x201C;10. doi:10.1136/bjsports-2018-099878

See http://dx.doi.org/10.1136/bjsports-2019-100821

JULY 2019 | 41

THE VEIN CLINIC CELEBRATES 5 YEARS

A dva nc e d Va r ic os e Ve in Tr eatmen ts

The Vein Clinic is thrilled to be celebrating its 5th anniversary and wishes to acknowledge all of our valued referrers.

Venous Eczema

BEFORE

Varicose Veins

AFTER

BEFORE

AFTER

Why refer to us?

Key milestones to date

We are Perth’s only dedicated Varicose Vein Clinic and as such our advanced treatments overcome many of the limitations associated with traditional sclerotherapy and surgery.

• Over 1,500 new patients consulted

We have a laser focus on excellence in the diagnosis and management of superficial venous disease.

Our results speak for themselves with a 99.5% initial closure rate being achieved with laser (EVLA) treatments on Saphenous Veins.

• Over 1,000 procedures performed • Eight new/improved vein treatments developed/introduced We have come a long way in five years and with your support will continue to grow and deliver optimum results and patient outcomes over the next five years and beyond.

Could you or someone you know benefit from our services?

What we offer patients Highly tailored multimodality treatments (ie. EVLA/Glue/Foam/Phlebectomy) Short waiting times

Clinic based diagnosis and treatment Walk-in walk-out procedures

Streamlined assessments

Central convenient location (opposite Subiaco Station)

Value and convenience

Private health insurance is not required

Advanced modern treatment options

Medicare rebates apply

Call us today on 9200 3450 or visit veinclinicperth.com.au 42 | JULY 2019

Unit 6, 28 Subiaco Square Road, Subiaco | admin@veinclinicperth.com.au

MEDICAL FORUM

BACK TO CONTENTS

CLINICAL UPDATE

Testosterone use in women

By Dr Yin Min Hew, Sexual Health Physician, Nedlands Sexual dysfunction is common in both men and women. When it comes to exploring sexual dysfunction, most clinicians can identify the manâ&#x20AC;&#x2122;s sexual dysfunction problems.

In females, this subject is not greatly understood and knowledge is lacking.

Testosterone in women is clearly beneficial in HSDD and the currently available 1% transdermal preparation is safe and easy to use. More data is needed to assess longterm side effects of testosterone in women.

Background Female sexual dysfunction includes low libido, loss of interest, painful intercourse, orgasmic disorder and lubrication problems. An estimated 40% of premenopausal females have sexual dysfunction.

Hypoactive sexual desire disorder (HSDD) is a diagnosis where a low or loss of desire is associated with personal distress. This can occur in both premenopausal and postmenopausal (prevalence 10-14%) women.

The lack of sexual satisfaction can greatly impact the general wellbeing of the woman. Most women believe an active sex life is important and this can lead to better emotional satisfaction. On the other hand, lack of sexual activity is associated with decreased quality of life, which in turn

affects their mental, physical and emotional wellbeing. Women sometimes engage in sexual activity despite having a loss of interest in sex.

Sexual function in a woman is complex and the aetiology can be multifactorial.

One factor may be a contributory is low androgen state and treating the low level deserves merit especially in the diagnosis of HSDD. Testosterone supplementation Testosterone, an essential hormone for the wellbeing of a man, is equally important for a woman. Many studies of testosterone are conducted in men and studies in women alone, or even comparing to men are lacking.

Testosterone is not only important in maintaining sexual function but it also has positive effects on cardiovascular, cognitive and musculoskeletal health. In women, most testosterone comes from the ovaries and the rest from the adrenals.

Many randomised controlled trials indicate that testosterone therapy is effective as a treatment for HSDD in postmenopausal females. There are two small studies indicating the same benefit in premenopausal females with HSDD.

When is it best to use testosterone in women? At a titrated dose - trial and see is the order of the day?

Transdermal testosterone patches and implants were popular for women but are no longer available in most countries â&#x20AC;&#x201C; instead, many physicians use compounded testosterone and off-label male testosterone prescriptions which is not ideal.

The drawback is that some compounded testosterone has not been clinically evaluated for safety and efficacy. In Australia, the only licenced testosterone formulation for women is 1% transdermal testosterone cream (Andro-Feme). Studies have shown that it is efficacious in treating HSDD and an improvement in libido and quality of life was noted. The standard dose is usually 10mg daily (applied to the lower torso or upper thigh) but this can be decreased to 5mg if needed - improvement in symptoms can take up to 3 months and side effects are minimal.

Most testosterone therapy is not licenced for use in women. Women require less testosterone compared to a man.

NEW SPECIALISTS SESSIONAL ROOMS QUEENSGATE, CANNING VALE

Do you want to expand your practice into south-east metro?

Are you tired of parking hassles for you and your patients at the big medical precincts?

New fully equipped sessional rooms are opening April/May 2019.

Plenty of free parking and very attractive rates.

CONTACT ASHLEY HICKS ON 0410 192668 FOR FURTHER DETAILS MEDICAL FORUM

JULY 2019 | 43

Page left intentionally blank to comply with Medicines Australia Code of Practice.

BACK TO CONTENTS

CLINICAL UPDATE

Investigating female androgen excess: fishing in a sea of PCOS

By Dr Jennifer Ng, Endocrinologist Nedlands Clinical features of female androgen excess include acne, hirsutism, menstrual disturbance and infertility.

Severe hyperandrogenaemia leads to virilisation, characterised by deepening of the voice, clitoromegaly and fronto-temporal balding.

Clinical details including symptom severity and rate of progression, ethnicity and family history will determine the most likely aetiology and guide investigations.

The challenge is to catch the serious yet treatable causes in the sea of functional hyperandrogenism.

PCOS accounts for the vast majority (70-80%) and is diagnosed if two of three features are present after eliminating other causes: menstrual irregularity, clinical and/or biochemical hyperandrogenism and polycystic ovaries on ultrasound.

As metabolic dysfunction is common, a cardiometabolic assessment is important once PCOS is diagnosed. Symptoms typically begin peri-pubertally and virilisation is uncommon. Most importantly, PCOS is diagnosed by exclusion.

KEY MESSAGES PCOS is a diagnosis of exclusion.

Exclude thyroid dysfunction, hyperprolactinaemia and pregnancy if menstrual disturbance is present.

Rapid symptom progression or total testosterone over 5 nmol/L raise suspicion for a virilising tumour Non-classic Congenital Adrenal Hyperplasia is clinically indistinguishable from PCOS and is present in 4.2% of hyperandrogenic women. The prevalence is higher among Ashkenazi Jewish, Mediterranean and Middle Eastern people. A high LH/FSH ratio, polycystic ovaries and insulin resistance may all be present. Therefore, routine biochemical screening with an early morning, follicular phase 17 OHP is crucial, particularly for those desiring fertility. Consider specialist referral for confirmatory testing if 17 OHP is elevated, or if normal but clinical suspicion persists due to high

Female Androgen Excess: Biochemical Investigations

Serum Total Testosterone by a reliable assay

First line for investigating symptoms of female androgen excess Ideally, a follicular phase sample in menstruating women (Day 2-5).

Cease oral contraceptive pill for 3 months prior as it suppresses androgen production

SHBG, Free Androgen index, calculated free testosterone or calculated bioavailable testosterone

These indices are recommended in addition to total testosterone for diagnosing biochemical hyperandrogenaemia in PCOS.

Reproductive hormone profile: LH, FSH, oestradiol, progesterone

Facilitates interpretation of androgens in the context of menstrual cycle phase.

Androgens rise at mid cycle and are slightly higher in the luteal compared with the follicular phase.

17 OHP

Request an 8am, follicular phase sample in women with menstrual cycles or on any day if amenorrhoeic. Consider specialist referral for confirmatory testing if basal 17 OHP is elevated or if normal, but clinical suspicion persists due to high risk ethnicity or family history. Basal 17 OHP is normal in 10% of non-classic CAH. Peak 17 OHP > 30 nmol/L by immunoassay is diagnostic following adrenal stimulation

Androstenedione

Often elevated in Non-classic CAH, may be elevated in PCOS

DHEAS

Assess if virilising tumour is suspected Significant elevation exclude adrenocortical carcinoma

TSH, prolactin, pregnancy test

Particularly if menstrual disturbance present

Screen for Cushing’s syndrome (1mg dexamethasone suppression test, late-night salivary cortisol, 24 hr urine free corticoids) or Acromegaly (IGF-1)

If suggestive clinical features are present: Cushing’s- rapid central weight gain, striae, dorso-cervical adiposity, proximal weakness Acromegaly- enlarged hands and feet, coarsened facial features, headaches, excessive sweating, thickened, oily skin, skin tags, osteoarthritis

Cardiometabolic risk assessment

If PCOS is diagnosed

Serum AMH

Often elevated in PCOS but not currently recommended for diagnosis and not Medicare rebatable

MEDICAL FORUM

Hirsutism, a common clinical problem, can undermine a women’s confidence and self-esteem.

However, its significance extends beyond cosmetic inconvenience as it may indicate the presence of an endocrine disorder. Most androgen excess is idiopathic or PCOS related. risk ethnicity or family history. Molecular diagnosis and testing of the reproductive partner will facilitate counselling regarding risk of life-threatening Classical CAH in off-spring. Glucocorticoids are effective for anovulatory infertility and may reduce miscarriage risk.

Endocrinopathies such as Cushing’s syndrome and acromegaly can masquerade as PCOS. However, specific clinical features are usually present to flag the need for screening. In women with menstrual disturbance, exclude hyperprolactinaemia, thyroid dysfunction and pregnancy.

Rapidly progressive virilising symptoms or a serum total testosterone over 5 nmol/L raise suspicion of an androgen-secreting tumour. Although rare in premenopausal women, 50% are malignant and 80% are ovarian. Transvaginal ultrasonography is the imaging test of choice, but MRI may be more sensitive. If DHEAS is markedly raised, an adrenal CT is indicated to exclude adrenocortical carcinoma.

Ovarian hyperthecosis is more common after menopause but can occur in premenopausal women. Severe insulin resistance and hyperandrogenaemia are characteristic and virilisation may occur.

The ovaries are enlarged, with a solid rather than cystic appearance.

Don’t forget to consider transfer of topical testosterone from the partner or use of anabolic steroids, testosterone or valproic acid.

Author competing interests-nil relevant disclosures. Questions? Contact the editor.

JULY 2019 | 45

The Screaming Toodyay, WA: This young Blackshouldered Kite was calling all morning from its perch on our TV antenna. Eventually I went outside with my camera and as I did so, its parent came up with lunch.

Some days you get lucky. Camera: Canon EOS-1D X; Lens: Canon EF 500mm F/4L IS USM; Shutter speed: 1/4000, F-stop 8, ISO 1250, Handheld (Georgina)

For the Birds Retired Mandurah GP Dr Tony Tropiano and award-winning nature photographer Georgina Steytler have put their lenses together for these magnificent bird images.

H

ere they have compiled some of their insights.

Tony: Most modern cameras including phones take close to perfect photos on AUTO mode in ideal conditions.

At times shutter speed can let you down with anything moving fast. The rule of thumb about keeping shutter speed at a number similar to lens focal length is barely OK on still subjects. I double for hand held. E.G. 1/400sec for 200mm lens and prefer 1/3200sec for birds or action. With bird photography, try to get as respectfully close as possible, striving for a sharp, wellexposed photo. Creativity and composition are accumulating bonuses. Photoshop can't fix a blurry photo.

Georgina: There are six steps to good bird photography.

• A Good Lens. There is no getting around the fact that the better the quality of your lens, the better chance you have of getting a sharp image, even in low light. If you are just starting out, or if it's always just going to be a hobby, then avoid a large prime lens and stick with a good zoom lens. The maximum focal length of the lens should be at least 300mm.

such as camouflage/hide/blind, long lens, teleconverters, remote triggers.

But it’s best to let the bird come to you.

• Shoot at Eye Level. If that means lying on your belly in the mud at the river's edge to get a duck at water level, then that is what you do!

• Keep the eye sharp.

• Watch the background. We are often so focused on the bird that we forget to check what is behind it. A background can make or break an image. Generally speaking, you should aim for a background clear of distracting elements. Have fun! Bird photography should be relaxing. Don't ever get so caught up in taking the perfect photo that you forget to enjoy yourself.

1

1 Brolgas I was Doctor/Photographer for a Variety Bash and spotted birds from the vehicle. 1/1600sec F10 ISO 1000 lens at 200mm. Setting was more for cars with 70-200mm lens (Tony) 2 Buller's Albatross Lord Howe Island, NSW, The boat was rocking in a large swell and it was pouring with rain. I was being sick overboard when this stunning Buller's Albatross came in close.

Sometimes a photo is worth the pain.

Camera: Canon EOS 7D Mark II; Lens: Canon EF 300mm f/4L IS USM; Shutter speed 1/3200; F-stop: 5.6; ISO: 640; Handheld (Georgina) 3 Ethereal Mandurah, A misty morning and still waters on the estuary. The Great Egret was one of the few birds looking for an early catch. Camera: Canon EOS-1D X; Lens: EF 500mm F/4L IS USM + 1.4x Canon teleconverter; Shutter speed: 1/1600, F-stop 7.1; ISO 1250; Handheld (Georgina) 4 Juvenile Australian Fairy Tern Woodman Point, WA, As I lay on the beach, these young fairy terns (Sternula nereis) became so comfortable that some landed very close to me. Camera: Canon EOS-1DX; Lens: Canon EF 500mm f/4L IS II USM + Canon EF Extender 1.4X; Shutter speed: 1/2500; F-stop: 5.6 (exposure bias of +1); ISO: 1000; Handheld (Georgina)

• Get up early (or stay late). The light just after sunrise and just before sunset is soft and golden. It can transform an ordinary bird photo into something extraordinarily beautiful. Cloudy days can be surprisingly good allowing for pleasing low contrast images.

5 Galahs and White Cockatoos are bold and silly. You don't have to wait long for something to happen. When to press shutter? I just try to "pick the moment" one shot at the time, others "rapid fire".

Setting 1/3200sec, ISO 800. F5.6 and 600mm lens. (Tony)

• Get close. Generally, the closer you get to your subject the better. There are lots of ways of getting closer to your subject,

https://www.photographyrrudrone.com and https://georginasteytler.com.au

46 | JULY 2019

MEDICAL FORUM

BACK TO CONTENTS

PHOTOGRAPHY

BACK TO CONTENTS

PHOTOGRAPHY

A Fishy Present Bremer Bay, WA, with a lot of activity on the rocks this male Crested Tern was trying to impress the females, flying around me several times with its fish, looking for a mate willing to accept his precious gift. Camera: Canon EOS-1D X; Lens: Canon EF 500mm f/4L IS II USM + Canon Extender EF 1.4X I; Shutter speed: 1/4000; F-stop: 9; ISO: 1250; Handheld (Georgina)

2

4 MEDICAL FORUM

3

5 JULY 2019 | 47

SOCIAL PULSE 1

BACK TO CONTENTS

For Distinguished Services St John of God Subiaco Hospital paid tribute at a special dinner for Prof Mark Edwards, Dr Tony Geddes, Dr Hamid Hamzah, Dr Michael Holt and C/Prof Neville Knuckey who were retiring from the SJG Subiaco Hospital family. More than 150 of the hospital’s accredited doctors and their guests, as well as the families of retiring doctors, attended the dinner at Fraser’s Kings Park.

Cardiothoracic Surgeon Prof Mark Edwards conducted the first pulmonary thromboendarterectomy in WA. He was also instrumental in starting heart transplantation in WA, as well as serving on the Council of the College of Surgeons for 10 years and Chair of the Court of Examiners and ultimately Censor-in-Chief.

Orthopaedic Surgeon Dr Tony Geddes, was educated at Melbourne University before moving to Perth in 1987. After finishing his training he spent two years overseas, at Royal Sussex, Great Ormond Street, in the UK, and Portland, Oregon. Returning in 1994 he practised paediatric orthopaedics, primary hip and knee joint replacement, foot and ankle surgery, knee and shoulder arthroscopic surgery, trauma and general orthopaedics. He was a RACS examiner from 2007 to 2015.

Anaesthetist and Pain Medicine Specialist Dr Hami Hamzah’s association with the hospital started in 1979 where he has collaborated with many surgeons in the fields of Orthopaedics, Oral Surgery and Obstetrics. He helped establish the first anaesthesia roster for

2

5

48 | JULY 2019

Obstetrics at Subiaco, when epidurals for labour first became common. He was Chairman of the Cambridge Private Hospital Medical Advisory Committee from 1983 to 1997.

Orthopaedic Surgeon Dr Michael Holt was a third of the way through his orthopaedic training when his interest in paediatric orthopaedics became evident.

He worked at the Hospital for Sick Children at Great Ormond Street, collaborating with colleague Don Johnston to introduce a new technique to fix long bone fractures, and introducing the Ilizarov technique to children in Perth.

Neurosurgeon C/Prof Neville Knuckey has worked concurrently at SJG Subiaco as well as RPH and SCGH (where was department head for 20 years and medical co-director of the neurosciences division).

3

He was awarded the Eccles's medal from the ANU for his lifelong contribution to neuroscience research, and the EF Haywood Prize at SCGH for excellence in clinical teaching. His clinical passion is developing neuroprotective agents after cerebral ischemia.

1 Dr Hamid Hamzah, Dr Tony Geddes, C/Prof Neville Knuckey, Dr Michael Holt, SJG Subiaco CEO Prof Shirley Bowen and Prof Michael Edwards.

2 Dr Michael Gannon and Dr Mariam Bahemia 3 Prof Shirley Bowen, Dr Melissa O’Neill and Dr Joo Teoh 4 Dr Eva Denholm and Dr David Knox 5 Dr Brigid Corrigan, Julia Allen and Dr Christopher Allen 6 Tracey Collopy, Jane England, Dr Corrine Jones and Dr Dermott Collopy

4

6

MEDICAL FORUM

BACK TO CONTENTS

WINE REVIEW

Pioneering Vasse Felix Shows the Way It was in 1955 that distinguished American viticulturist Prof Harold Olmo assessed the potential for wine production in Western Australia outside of the Swan Valley. He concluded that WA’s premium region would be the Great Southern district and that the Margaret River district was too wet for premium production. This latter conclusion was challenged by noted Perth agricultural scientist Dr John Gladstones, who said that if well-drained soils were chosen, then world-class wines could be produced – and how right he was.

Perth cardiologist Dr Tom Cullity planted the first vines at his Vasse Felix property in 1967, setting the scene for arguably Australia’s finest premium wine region, and now a region of world renown. Soon to follow were other iconic producers of the region: Moss Wood (1969), Cape Mentelle (1970), Cullen (1971), Sandalford (1972) and Leeuwin Estate (1974).

Vasse Felix has been blessed by a procession of fine winemakers. Cullity employed Cumbrian cheese maker and self-taught winemaker David Gregg.

I was lucky to work the 1987 vintage with David and witnessed his prowess.

He became owner and his hard work set the wine styles that have made Vasse Felix great. He sold to the Holmes a Court family in 1987 and their winemakers, Clive Otto and currently Virginia Willcock, have pursued quality to an even higher level.

By Dr Craig Drummond Master of Wine

Vasse Felix Margaret River 2018 Filius Chardonnay (RRP $28)

Vasse Felix Margaret River 2016 Filius Cabernet Sauvignon (RRP $28)

A very good MR Chardonnay. Clean, linear, pure fruit profile. Great textural mouth-feel from oak and malolactic ferment. Nose is initially restrained then opens up with nashi pear and green apple.

Flavours of white peach and citrus tones. Structurally defined with firm acidity and integral oak. Finishes fresh and clean. Can be enjoyed over the next few years.

A medium to full-bodied MR cabernet style. With three years’ ageing, the vibrant purple colour gives way to brick red. Aromas are typical MR – leafy, herbaceous, blackcurrant. Slightly austere savoury/cedar characters. Full fruit flavours of blackberry and dark plum. Fine drying tannins and balanced acid. Nice length, great finish. If this charming wine is the Filius, then I am very keen to taste the premium varietal and the Heytesbury cabernets.

Vasse Felix Margaret River 2017 Shiraz (RRP $37) An excellent Shiraz from the premium varietal range. Wow, the nose is so complex/ethereal, with interwoven fruit and oak, blackberry and allspice. Leads onto a complex palate of blackberry and redcurrant, a touch of white pepper and spice. This is a great Shiraz which will give pleasurable drinking over 10-12 years.

Vasse Felix Margaret River 2018 Sauvignon Blanc Semillon (RRP $26)

REVIEWER'S

PICK

A wonderful example of a renowned Margaret River blend. This wine is 82% Sauvignon Blanc which is reflected in its vibrant lifted aromas, bright fruit and crisp acid backbone. The nose shows fragrant tropical fruits and citrus. The palate has fruit weight but with freshness. Lemon curd and guava flavours. There’s texture and structural definition from the winemaking influences of fermentation on skins, and half of the fruit fermented and matured in oak. I love the balance of this wine. Drinks well now but has the weight to go another 3-5 years.

MEDICAL FORUM

JULY 2019 | 49

BACK TO CONTENTS

THEATRE

Revolting and Beastly!

K

ids and Roald Dahl’s books go together well, like, Revolting Rhymes and Dirty Beasts! These iconic verses and folk tales have mesmerised both young and the not-so-young for decades and now these vivid tales are coming to life, on stage, at the Heath Ledger Theatre in August.

Medical Forum spoke with Ross Balbuziente, the artistic director of the Helpmann Award-winning shake & stir theatre company about the production and what it means to him to recreate Dahl’s works.

did, if not more now.”

Ross believes Dahl’s works have an incredible allure for children.

“His lens is always through the eyes of the child, and the meanies are always the adults. He really did pave the way for pushing boundaries of young people’s fiction.”

And this is what Ross and the team at shake & stir are channelling with the theatre adaptation, along with the blessing of the Roald Dahl estate.

“I was a child of the 1980s and Roald Dahl was my childhood. I loved reading him as a kid and Revolting Rhymes specifically was the first book I was given as a child. After that, I became infatuated with the entire Roald Dahl catalogue. He has this way of speaking directly to that demographic,” he said.

“Revolting Rhymes and Dirty Beasts was the first foray into adapting Dahl for stage, in fact it’s the first stage adaptation to occur professionally in the world. And back in the day when we pitched the idea to the writer’s estate, they almost suggested it was impossible, given that they were just short poems,” he said.

“Reading Dahl, you often thought you were doing something a bit naughty and subversive but the beauty of his work is that he has the perfect balance of grit and wit which speaks perfectly to that age.

And, of course, the adult readers too. I still read his books and I still find myself chuckling and enjoying them as much as I

“But they quickly changed their tune when they discovered the treatment and the production we were gearing to create.

They have definitely given us their tick of approval and thankfully they love the work.”

50 | JULY 2019

they are bite-sized stories. We’re treating it a bit like a pop or rock ‘n roll concert for children. Every poem and every story is treated like a song in the concert and each story is given full theatrical value with lots of effects, lights, pyrotechnics, bubbles and all sorts of things kids love to experience.”

“It’s so important to get this right. For many of our audience, this is their first theatrical experience. It’s got to be good.”

By James Knox

“The beauty of Roald Dahl and especially Revolting Rhymes and Dirty Beasts is

MEDICAL FORUM

BACK TO CONTENTS

Q: Who are the coolest blokes at the hospital?

A: The ultra-sound guys!

Q: Why did the leprechaun wear two condoms?

A: To be sure, to be sure

during the night. Then he said: “But you know Doc, I'm blessed. God knows my eyesight is going, so he puts on the light when I pee, and turns it off when I'm done!”

A little later in the day, Dr Smith called George's wife and said: “Your husband's test results were fine, but he said something strange that has been bugging me. He claims that God turns the light on and off for him when uses the bathroom at night.”

Thelma exclaimed: “That old fool! He's been peeing in the refrigerator again!” *** A man suggests to his wife, “Darling, shall we try swapping positions tonight.”

At one American university, students in the psychology program were attending their first class on emotional extremes. “Just to establish some parameters,” said the professor to the student from Arkansas, “what is the opposite of joy?” “Sadness,” replied the diligent student. “And the opposite of depression?” he asked of the young woman from Oklahoma. “Elation,” she said. “And you, sir,” he said to the young man from Texas, “what about the opposite of woe?” The Texan replied, “Sir, I believe that would be 'giddy up.” *** Eighty-year-old George went for his annual check-up. He told the doctor that he felt fine, but often had to go to the bathroom

MEDICAL FORUM

“That's a great idea,” she replies. “Why don't you stand by the ironing board while I sit on the sofa and break wind.” *** A man says to his new girlfriend: “Since I first laid eyes on you, I've wanted to make love to you really badly.” “Well,” she replies, “You succeeded.” *** A man flying in a hot air balloon realises he is lost. He reduces his altitude, spots a man in a field down below and shouts, “Excuse me, can you tell me where I am?” The man replies, "Yes, you're in a hot air balloon, about 10m above this field.”

“You must be an engineer," says the balloonist. “I am. How did you know?”

says the man. “Everything you told me is technically correct, but it's of no use to anyone.”

The man below says, “You must be in management.” “I am. But how did you know?" says the balloonist. “You don't know where you are, or where you're going, but you expect me to be able to help. You're in the same position you were before we met, but now it's my fault.” *** Q: "Granddad, what's the best thing about being 104?"

A: "No peer pressure" *** It's a stockbroker's first day in prison and he meets his psychotic-looking cellmate, who tries to allay the stockbroker’s fears.

“I'm in for a white-collar crime, too," says the cellmate. “Oh, really?” says the stockbroker, sighing with relief. “Yes, I killed a vicar.”

JULY 2019 | 51

BACK TO CONTENTS

THEATRE

Revenge is Sweet

I

Zindzi Okenyo is Beatrice in the Bell Shakespeare Much Ado About Nothing, Director James Evans

t’s true that most of Shakespeare’s so-called comedies carry a nasty sting in their tails. Much Ado About Nothing carries a heftier kick than most.

A regular Renaissance tale, perhaps.

While the central characters, Beatrice and Benedick, wittily fall in love while spitting and sparring with one another, the innocent young Hero’s reputation is shredded by the vengeful, spiteful Don John with the complicity of her lily-livered, spineless fiancé Claudio.

Director James Evans told Medical Forum that Shakepeare’s depiction of the pack mentality of men in the play could have so easily been plucked up out of the now, such is its relevancy and potency.

Wine winner

The Bell Shakespeare company will be bringing its considerably talented team to Perth next month to present Much Ado for a new generation.

The feminist elements are also wonderfully fresh. While an Elizabethan audience would require the taming of the shrewish Beatrice, Shakespeare does give her some wonderfully strong lines … not the least:

Rheumatologist Dr Senq Lee was gearing up to run the HBF Run for a Reason half marathon when he came to Medical Forum to pick up his case of Houghton reds.

Senq, a great lover of red wine was understandably very pleased with a selection that included the prestigious Jack Mann.

52 | JULY 2019

“O God, that I were a man! I would eat his heart in the marketplace."

James said he is blessed with his cast and at the forefront is Zindzi Okenyo as Beatrice and Duncan Ragg as Benedick.

“We have been three days into reading and the Zindzi and Duncan are not leaving anything behind. Their passion and steeliness really light up the stage,” he said.

“This is a powerful exploration of the struggle for identity and self-knowledge in a male-dominated world. I think the audience will see a lot of their own lives and world in this play.”

James is associate director at Bell Shakespeare and says that while the founder John Bell stepped away from the day-to-day running of the company in 2015, his spirit is everywhere in everything the company does. He also materialises from time to time in an acting capacity.

“John not only built a company, he built a legacy and now everyone in the company lives those values,” he said.

MEDICAL FORUM

BACK TO CONTENTS

COMPETITIONS

Enter Medical Forum's competitions!

Simply visit www.medicalhub.com.au and click on the ‘Competitions’ link.

Movie: Once Upon a Time in Hollywood Quentin Tarantino’s Once Upon a Time... in Hollywood visits 1969 Los Angeles, where everything is changing, as TV star Rick Dalton (Leonardo DiCaprio) and his longtime stunt double Cliff Booth (Brad Pitt) make their way around an industry they hardly recognize anymore. A film with multiple storylines in a tribute to the final moments of Hollywood’s golden age.

Dance: Bangarra: 30 Years of Sixty Five Thousand

In Cinemas, August 15

The wonderful Bangarra Dance Theatre celebrates its landmark 30th anniversary season with a national tour and some exciting firsts. The threepart program combines a restaging of Frances Rings’ monumental Unaipon (Clan, 2004), Stamping Ground by acclaimed Czech choreographer Jiří Kylián, and a powerful collection of dance stories – to make fire – from the company’s archives curated

by Bangarra Artistic Director Stephen Page and Head of Design Jacob Nash.

Movie: Danger Close An Australian production that explores the savage Battle of Long Tan as seen through the eyes of Australian and New Zealand soldiers. Major Harry Smith (Travis Fimmel) and his company of 108 young soldiers fight to hold off an enemy force of 2,500 battlehardened Viet Cong and North Vietnamese soldiers.

In cinemas, August 8

These works will be performed by Aboriginal and Torres Strait Islander artists from across Australia.

Choral: Swoons

As Australia’s only major performing arts company with its origins in the land, Bangarra is inspired by 65,000 years of culture and the continual evolution of Indigenous storytelling.

Perth Symphonic Chorus will make your heart leap with its blend of Liebeslieder waltzes of Brahms, intoxicating Debussey choral songs full of love and charm, humorous miniatures by Benjamin Britten and the best of the Jazz era arranged for choir and a small band plus a new work by Perth composer Rod Christian.

Heath Ledger Theatre, July 31-August 3

Christ Church Claremont, July 28, 2.30pm

Winners from May

M E D I C A L F O R U M $ 12 . 5 0

You don’t buy a practice every week, but we do

Theatre: Much Ado About Nothing

Movies: German Film Festival – Dr Alem Bajrovic, Dr Monica Keel, Dr Kevin Yuen, Dr John Williams, Dr Bill Thong

Bell Shakespeare presents the sharpest of the Bard’s comedies. Claudio and Hero are deeply in love.

Beatrice and Benedick would rather swap sassy insults than sweet nothings. This production is a powerful exploration of the struggle for identity and self-knowledge in a male-dominated world.

It’s a big decision, Huge. For most, it’s a once in a lifetime proposition.

Into the Wild

We take this very seriously too.

So much so, that over the last 25 years we’ve developed a process for medical professionals looking to go out on their own.

But we don’t just look at you, we look at the business as a whole. We act as your partners in ensuring that it is a viable and profitable opportunity. We assess everything - location, competition, client-base and growth potential.

Then, and only then, we tailor a loan to meet your needs.

Forgive the pun, but we have a lot of practice when it comes to buying a practice.

Visit us at boqspecialist.com.au or speak to your local finance specialist on 1300 131 141.

M AY 2 0 19

Movie: 2040 – Dr Luciano Marino, Dr Joanne Keaney, Dr Jenny Elson, Dr Linda Wong, Dr Dian Harun

Car loans | Commercial property | Credit cards | Equipment finance | Fit-out finance | Foreign exchange | Home loans | Personal loans | Practice purchase | Practice set-up | Savings accounts | SMSF | Transaction accounts | Term deposits | Vehicle finance

Women’s Health Workplace Culture Pregnancy & Fertility

The issuer of these products and services is BOQ Specialist – a division of Bank of Queensland Limited ABN 32 009 656 740 AFSL no. 244616 (“BOQ Specialist”).

MAJOR PARTNER

Movie: Red Joan – Dr Michael Leung, Dr Keith Grainger, Dr Colin Lau, Dr Philippa Adams, Dr Robert Weedon Movie: Never Look Away – Dr Sarah Harris, Dr Clare Matthews, Dr Helen Mead, Dr Gavin Leong, Dr Ruby Chan Movie: Men In Black: International – Dr Belinda Lowe, Dr Moira Westmore, Dr Esther Eu, Dr Peter Baumgartner, Dr Maria O’Shea

MEDICAL FORUM

May 2019

www.mforum.com.au

Heath Ledger Theatre, August 7-10

Kids Theatre: Revolting Rhymes & Dirty Beasts Think you know the stories of The Three Little Pigs, Cinderella, Little Red Riding Hood, Snow White, Goldilocks and Jack and the Beanstalk? Think again!

Roald Dahl’s take on the classics bursts off the page in a spectacular live show. Everyone will love this show!

Heath Ledger Theatre: August 13-16

JULY 2019 | 53

Page left intentionally blank to comply with Medicines Australia Code of Practice.