Medical Forum – July 2021 – Public Edition

Keeping men’s health on track

Men’s Health | Prostate cancer treatments, sleep apnoea, metabolic syndrome

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July 2021 www.mforum.com.au

Dr Chris Merry Cardiothoracic surgeon, WA

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Cathy O’Leary | Editor

The power of speaking up

A Perth cardiothoracic surgeon recently took a swipe at a prominent cosmetics retailer on social media over a planned ‘wellness’ event.

Her target was international A-lister Gwyneth Paltrow who, in case you missed it, promotes vaginal steaming (don’t ask) and says sunscreen only needs to be dotted on facial “high points” like the nose.

But what does beauty care have to do with heart health?

But is the reluctant male patient a cliché?

Aren’t men pretty forthcoming these days without needing prompting by their better half?

A fair bit, according to Dr Nikki Stamp, who took on the company because she was sick of people being exposed to harmful pseudoscientific nonsense – she says it’s bad for their health.

This month, we talk to activist doctors who also feel a responsibility to speak up, particularly when the stakes are high.

And behind every good man is a good woman, so they say. Perhaps that’s why some middle-aged men sitting in their GP waiting room are only there at the behest (read: nagging) of a significant female in their life.

But is the reluctant male patient a cliché? Aren’t men pretty forthcoming these days without needing prompting by their better half?

Well, as Dr Karl Gruber explains in his report, across almost every health score, men still fare a lot worse than women.

The stats for mental health problems and suicide alone paint a disturbing picture. Something is seriously amiss, with a generation of men floundering to make sense of their world.

Our health system needs to make it easier for them to stay well.

And that’s why our men’s health edition never loses relevance.

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MEDICAL FORUM | MEN 'S HEALTH

JULY 2021 | 1

CONTENTS | JULY 2021 – MEN'S HEALTH

Inside this issue 10

20 12

16

FEATURES

NEWS & VIEWS

LIFESTYLE

10 Q&A: Julian Pace,

1

60 Wine Review:

founder of Happiness Co.

12 The planet needs healing hands

16 Are men missing the boat to good health?

20 Close-up: Albany GP

4 6 8 24

Dr Darcy Smith

Editorial: The power of speaking up – Cathy O’Leary

In the news

62 The amazing life of honey

Henschke Wines – Dr Craig Drummond

In brief Letters to the editor Kicking goals for healthier hearts

27 AHPRA notifications 39 HBF opens dental clinics 41 COVID impacts on health education

43 A different gender gap – Dr Joe Kosterich

Wine Review See page 60 for Dr Craig Drummond’s extensive review of distinguished Henschke red wines. Meanwhile, Dr Lachlan Milne is enjoying the wine dozen supplied by Aphelion Wines in the McLaren Vale.

CONNECT WITH US /medicalforumwa

/MedicalForum_

2 | JULY 2021

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info@mforum.com.au

MEDICAL FORUM | MEN 'S HEALTH

CONTENTS

PUBLISHERS

Clinicals

Karen Walsh – Director Chris Walsh – Director chris@mforum.com.au

ADVERTISING Advertising Manager Andrew Bowyer 0403 282 510 andrew@mforum.com.au

EDITORIAL TEAM

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Radiation therapy in prostate cancer Dr Serena Sia

Biopsy diagnosis of bladder cancer Dr Cliff Woods

Five myths still perpetuated about varicose veins Dr Luke Matar

Lipoedema: common condition, common misconceptions Dr Adrian Brooks

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48

51

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Treatment options for localised prostate cancer Dr Tom Shannon

Management of Metabolic Syndrome Dr Julie Manasseh

Restoring quality of life after prostate cancer treatment Dr David Sofield

Primary hyperparathyroidism A/Prof Ming Khoon Yew

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Doctors maintaining good mental health Dr Andrew Jackson

Oral appliances in obstructive sleep apnoea Dr Amanda Phoon Nguyen

Prostate cancer rehabilitation and management Dr Jo Milios

Tackling unconscious bias in clinical medicine Dr Ramya Raman

Editor Cathy O'Leary 0430 322 066 editor@mforum.com.au Journalist Dr Karl Gruber (PhD) 08 9203 5222 journalist@mforum.com.au Production Editor Ms Jan Hallam 08 9203 5222 jan@mforum.com.au 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 Ryan Minchin ryan@mforum.com.au

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Suite 3/8 Howlett Street, North Perth WA 6006 Phone: 08 9203 5222 Fax: 08 6154 6488 Email: info@mforum.com.au www.mforum.com.au

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Living lighter for health and budget Melissa Ledger

Sharing and caring at med school Dr Chris Skinner

Men weighed down by body shaming Rachel Seeley

Validating men’s fear Dr Simon Yam

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JULY 2021 | 3

IN THE NEWS

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Million-dollar questions Can you mend a broken heart? Will wearing hearing aids prevent dementia? What’s the best way to treat diabetes? How can you help someone who is hospitalised after illicit drug use? Is it true we really are what we eat?

RPH Research Foundation’s new Career Advancement Fellowships program is providing more than $1 million in funding to help six of WA’s brightest researchers discover the answers to these important health questions. RPH Research Foundation’s Board Chair Professor Lyn Beazley said the Career Advancement Fellowships were created to nurture talented early to mid-career researchers. The foundation was inundated with applications for the first funding round.

Among the winners was Dr Catherine Bondonno, from Edith Cowan University’s Institute for Nutrition Research, who has helped to prove clinically that eating an apple a day can keep the doctor away by improving your heart health and reducing your risk of heart disease. And WA’s Pink Lady and Bravo varieties offer some of the biggest heart health bangs for your bite.

Another tick for kids’ hospice WA’s landmark children's hospice is another step closer to providing holistic and compassionate care to children living with a life-limiting condition. The State Government is investing an additional $3.2 million for project planning and design to finalise the detail of the project. The Child and Adolescent Health Service has entered into a partnership with the Perth Children's Hospital Foundation to build the hospice, which will cost an estimated $25m, with the foundation so far securing $5m from other sources.

The hospice will have seven beds and three family accommodation suites for families to stay onsite, which will be particularly important for regional families. The hospice will provide outreach support and bereavement care to children and families across WA. It is expected to be complete in late 2023 and open in 2024.

in people working with engineered stone. Dust disease experts at PRC have trialled the new and more detailed CT scan with improved imaging and reduced radiation dose. Silicosis, once common but now almost non-existent in mining workers, has re-emerged as a major risk for industries working with engineered stone.

Money up for grabs WA’s peak diabetes research funding group is urging the State’s medical researchers to apply for grants for 2022 projects. Diabetes Research WA is putting forward two $60,000 research grants to help keep WA researchers in the lab looking for breakthrough discoveries.

The winners of the grants will be announced around World Diabetes Day, held on November 14 each year.

Grant application information can be found at www.diabetesresearchwa. com.au, with submissions closing on July 30.

New silica testing WA recently became the first state to mandate more advanced CT scans, replacing less effective chest x-rays for workers in an update to legislation last amended 25 years ago. Now Perth Radiological Clinic is using a new way to perform CT scans to diagnose potentially lethal silicosis 4 | JULY 2021

Loo help The only Continence Nurse Specialist Course in Australia is underway at Hollywood Private Hospital, coordinated by a 79-yearold nurse with 60 years’ nursing experience. The unique course

provides 14 nurses from WA and interstate with theory and clinical placement to help people living with incontinence. Training and Development Manager Anne Green said the course had been running for 30 years, with graduates providing an important service to clients of all ages with care and compassion.

“We are the only remaining provider of such a course in Australia,” Mrs Green said. “Without this contribution there would be a devastating gap for people who live with incontinence, or struggle without knowing what options are available.”

The course is run by Continence Nurse Specialist Lesley Pitman, 79.

“Incontinence affects all different types of people, from small children to the elderly,” she said. “Many people end up in nursing homes because they are incontinent.”

Winners are grinners The South Metropolitan Health Service has recognised exceptional clinical and patient-centred care at its recent 2021 Excellence Awards attended by more than 200 staff, guests and sponsors.

The winners included: Excellence in

continued on Page 6

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Radiation therapy in prostate cancer – techniques and ‘spacers’ By age 85, one in six men will have developed prostate cancer.

Techniques in radiation therapy have significantly advanced in recent years and, ideally as part of a multidisciplinary decision, provide a treatment option in a variety of settings: Adjuvant radiation therapy (ART) is given following radical prostatectomy to patients with high risk features such as positive surgical margins, seminal vesicle invasion, extraprostatic extension and higher Gleason scores. A 2019 Finnish trial concluded that adjuvant radiotherapy following radical prostatectomy is generally well-tolerated and prolongs biochemical recurrencefree survival compared with radical prostatectomy alone in patients with positive margins or extracapsular extension.

Salvage radiation therapy (SRT) is the administration of RT in a patient with PSA recurrence (detectable PSA level ≥ 0.2 ng/mL with a second confirmatory level ≥ 0.2 ng/mL) after surgery but no evidence of metastatic disease. A predictive model in a large patient cohort showed that progressionfree survival is best when SRT is administered at the earliest sign of recurrence (PSA <0.50 ng/mL).

Stereotactic body radiation therapy (SBRT) is an extremely precise and advanced radiation technique that can be used to treat both primary tumours or metastatic disease, particularly in the lung, bone, or liver. This technique, now available in Perth, delivers high doses of radiation to the cancer in an ablative fashion over typically one to five treatments. In addition to SBRT being non-invasive, time efficient and cost-effective, there is a strong radiobiological rationale to support its use. Results from the available data indicate low rates of late adverse effects and excellent biochemical relapse-free survival outcomes. It is expected that the use of SBRT in prostate cancer will increase.

Reducing treatment side effects with spacers: While the delivery of radiation therapy now has submillimetre accuracy, radiation oncologists are highly conscious of the need to avoid radiation exposure to healthy organs. In prostate cancer, the primary ‘organ at risk’ is the rectum. The seminal vesicles are also an area of concern.

Radiation exposure to these organs can now be mitigated with the use of ‘prostate spacers’ which are inserted between the rectum and the prostate to create a stable

Dr Serena Sia MBBS FRANZCR

Radiation oncologist with GenesisCare

space. Insertion takes places under general anaesthesia, typically at the same time as the placement of fiducial markers used to ensure reproducible and accurate patient positioning.

First-generation prostate spacers use fast-polymerising polyethylene glycol which can harden in the syringe or needle if injected too slowly. While still very effective, the final shape and symmetry may be less predictable. A secondgeneration spacer, Barrigel®, uses non-animal stabilised hyaluronic acid – the same product used as a cosmetic dermal filler. The nonpolymerising attribute provides the clinician with time to optimally sculpt the spacer to the patient’s anatomy. The product is also easily viewed on trans-rectal ultrasound due to its highly hypoechoic characteristics.

Urologists working in the field of prostate cancer are experienced in the placement of these relatively new spacing products which are helping radiation oncologists to reduce radiation exposure to otherwise healthy organs.

Dr Sia is a radiation oncologist with GenesisCare.

– References are available upon request.

Our centres Bunbury • Hollywood • Fiona Stanley Hospital Joondalup • Mandurah • Wembley Tel: 1300 977 062 | connection@genesiscare.com www.genesiscare.com MEDICAL FORUM | MEN 'S HEALTH

JULY 2021 | 5

Clinical Associate Professor Sanjay Jeganathan will serve as president of the Royal Australian and New Zealand College of Radiologists for two years from next January. He works at Perth Radiological Clinic and is a consultant radiologist at Fiona Stanley Hospital and BreastScreen WA.

Plastic surgeon Dr Mark DuncanSmith has taken over from Dr Andrew Miller as president of the Australian Medical Association (WA).

The Lions Eye Institute has appointed Dr Glen Power as its new CEO.

HBF has acquired 100% of Credit Union Australia Health Ltd, owner of private health insurance CUA Health.

St John of God Murdoch Hospital has appointed consultant geriatrician Dr Andrew Wesseldine as its new Director of Medical Services.

IN THE NEWS

continued from Page 4 Clinical Care – the Comprehensive oral care project, Fiona Stanley Fremantle Hospitals Group (FSFHG); Excellence in Improving the Patient Experience – My Choice fixed menu and allergy mapping project, FSFHG; Excellence in Developing and Engaging Staff/Team – Annual IMPROVE Conference, FSFHG; Excellence in Strengthening Partnerships – Aged Care Transition and Liaison Nurse, Rockingham Peel Group; Excellence in Innovation – Frailty Assessment Unit, FSFHG; Researcher of the Year – Professor Bu Yeap, Consultant Endocrinologist, FSFHG.

It was first envisaged after Professor Sue Fletcher, PYC Therapeutic chief scientific officer, had a discussion with renowned ophthalmologist Dr Fred Chen, (Lions Eye Institute and The University of Western Australia), who was growing frustrated watching his clients suffering this condition, which is the leading cause of childhood blindness, slowly having their eyesight taken from them.

“The fact that all the key moments of the development of this treatment have been in Perth is truly remarkable,” Professor Fletcher said. “The proof-ofconcept work was undertaken at Murdoch University, in collaboration with Dr Chen and his team at the Lions Eye Institute.

Tackling blindness Western Australia is on the cusp of developing a world-first treatment for thousands of sufferers of a form of retinitis pigmentosa, which could see patients’ slow transition into blindness stopped in its tracks. The treatment, which was conceived, researched, developed and will hopefully be trialled in WA, is targeted at retinitis pigmentosa 11 – a degenerative condition that causes a gradual deterioration of vision until a person is completely blind.

Dig Deep WA Indian Doctors Foundation which does the charity work has launched a fundraising initiative to do ground work in Kolkata, India, in one of the COVID-19 epicentres.

It is concentrating on raising public health awareness to help create some resilience in the population.

To help go to www. indiandoctorswa.org.au/cini2021

Professor Peter Leedman and his team at Perkins Institute and UWA have been awarded $450,000 to find new ways to treat liver cancer, one of 12 projects funded

by Cancer Council NSW to find more targeted cancer treatments.

Perth-based Chronic Care Australia, co-founded by exercise physiologist Katie Stewart, was recognised at the Value Based Health Care Awards in Amsterdam, Netherlands, taking out the Primary Care Award for its integrated Exercise as Medicine treatment plan.

Over the rainbow Staff at North Metropolitan Health Service were encouraged to wear rainbow colours on May 17 to celebrate International Day Against Homophobia, Biphobia, Interphobia and Transphobia. The day was a celebration of sexuality, gender and diversity that aimed to raise awareness for the work still needed to combat discrimination towards LGBTQIA+ people around the world.

The NMHS said it was important that all people, no matter their sexual orientation, gender identity, or intersex variations, had access to safe health services and work in an inclusive workplace.

6 | JULY 2021

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IN BRIEF

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Biopsy diagnosis of bladder cancer in managing frequently occult urological malignancy Urological malignancies have a high incidence among newly diagnosed cancers annually in Australia with prostate (55.9/100,000), kidney (14.4/100,000) and bladder (9.3/100,000) featuring high on the list. The focus on prostate cancer results in bladder cancer often being overlooked as significant contributor to the urological-based disease mortality and morbidity.

Bladder cancer is 3-4 times as common in males as in females and median age at diagnosis is 65-70 years. The excess of bladder cancer in men is not fully explained by any differences in known risk factors such as smoking and occupational exposure. Mortality is also different between the sexes with between 2-10 deaths/100,000 males a year and 0.54 deaths/100,000 females a year.

Symptoms and signs of bladder cancer may be subtle or synonymous with presentations in other bladder diseases. Clinical symptoms include painless haematuria, urgency, nocturia and dysuria. On occasions, a delay in diagnosis may occur after an initial treatment for presumed urinary tract infection. Severity of symptoms and signs in bladder cancer is usually related to tumour size and stage both being greater at late presentation.

Radiological modalities in diagnosis of early urothelial carcinoma are usually non-contributory and cystoscopy, bimanual examination and biopsy/ transurethral resection are the optimum techniques for diagnosis and staging of urinary bladder cancer.

Urine cytology also plays a role as positive cytology often indicates the presence of a urothelial tumour somewhere in the urinary tract.

Bladder sampling results in the second most common pathological specimen (secondary to prostate) submitted to uropathologists. Urothelial carcinoma accounts for between 80% and 90% of bladder cancer and non-invasive tumours constitute most of bladder neoplasms at initial diagnosis.

These are separated into two distinct categories – flat and papillary which may be seen separately or in combination. Reporting of bladder cancer is based on histological examination with specific criteria applied to determine tumour grade and stage.

Urothelial carcinoma in situ (CIS) Flat urothelial lesions contain cytologically malignant cells, are devoid of papillary structures and are reported as urothelial carcinoma in situ (CIS). The pure form of (CIS) accounts for 1-3% of all urothelial neoplasms but is commonly seen in conjunction with high grade papillary urothelial carcinoma and associated with 4565% of invasive tumours.

Involvement of the bladder surface is usually multifocal and sometimes diffuse.

Disease can extend to involve the distal ureters and the prostatic urethra.

Non-invasive papillary urothelial carcinoma Assessment of papillary carcinoma is based on epithelial architecture and cytological morphology of individual cells serving as a prognostic indicator for recurrence and progression in non-invasive tumours. Low-risk lesions include urothelial papilloma and papillary urothelial neoplasms of low malignant potential which have essentially normal urothelium and mild architectural distortion.

Risk of progression then increases subsequently from low-grade urothelial carcinoma to high grade urothelial carcinoma with high-grade disease stratifying management and therapeutic decisions. Multifocal tumours in the bladder or involving other regions of the urothelial tract (ureters and urethra) also represent increased risk factors for recurrence and progression.

Dr Cliff Woods Specialist Urological Pathologist

About the Author Dr Cliff Woods is a specialist urological pathologist with over ten years’ experience in the field, providing a pathology service to the majority of practising urologists in Western Australia.

the basement membrane of the urothelium), this becomes the most seminal prognostic factor, designated as the T stage on pathology reports.

Tumours invasive into lamina propria (T1) have better survival than tumours invading into the muscularis propria/ detrusor muscle (T2) with poor survival outcomes for tumours with extravesical extension or invasion into pelvic structures (T3 and T4).

On pathological assessment of trans-urethral biopsy specimens, it is possible to determine the presence of T1 and T2 disease (dependant on detrusor muscle presence in the specimen), giving the treating clinical team valuable information regarding the subsequent treatment pathway. Assessment of T3 and T4 status is usually only determined on examination of definitive resection (cystectomy) specimens.

Bladder cancer is a recurrent and often progressive malignancy and although we must maintain focus on the more commonly occurring urological cancers, recognition of the role bladder cancer plays in men’s health should enable early referral, detection and pathological diagnosis, giving clinicians the best opportunity to manage this recalcitrant disease.

Invasive Urothelial Carcinoma Once determined that the urothelial carcinoma is invasive (extends beyond

Main Laboratory: 310 Selby St North, Osborne Park General Enquires: 9371 4200 Patient Results: 9371 4340 For our extensive network of Collection Centres, as well as other clinical information please visit our website at

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There’s no easy fix Dear Editor,

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LETTERS TO THE EDITOR

Father Jose, left, CEO Ben Edwards and Professor Piers Yates with the donated artwork.

As a former Head of Public Health, I have some sympathy for Health Minister Cook in his handling of the current health crisis. Many of the circumstances are historical and well beyond his control.

The first is the Federal Government's unsustainable scheme for a big Australia and GST growth by immigration of over 300,000 per year. Every new immigrant needs housing, health, roads and infrastructure; a cost that is passed to the states.

The mental health crisis can’t be solved just by money. What is desperately needed is a properly trained medical, clinical psychological and nursing workforce. After years of lobbying, I started in 1995, we will finally graduate our first new doctors from Curtin this year. It will take another five years to get our first qualified psychiatrist, that is if any choose psychiatry which is one of the lowest paid specialties.

Why choose mental health when surgical specialists take over $1 millon a year from the health system and no wonder when our Federal Government has raised the cost of university to $100,000 degrees.

The hospital system is the squeaking wheel and demands resources yet value for dollar is in preventive health.

Poverty is the biggest cause of mental health where children living in poverty are 30% more likely to have mental health problems. Then add the physical and mental health problems of those in housing stress.

Those who can afford private care are well off but why do we give billions of dollars to the private health industry and not to properly resource Medicare?

People are bypassing GPs with out-of-pocket expenses of $70 per consultation to go to public hospital EDs. State governments have their own structural problems. If WA charged the same royalties as Queensland over the last 10 years WA would have an extra $47 billion to spend on mental health, hospitals and public housing as well as offering scholarships to young West Australians who don’t have rich parents to study healthrelated degrees. Like the start I got 8 | JULY 2021

Art for art’s sake What do you do with leftover metal from orthopaedic surgery? Turn it into art, according to the Head of Orthopaedics at St John of God Murdoch. Professor Piers Yates has created and donated a sculptural piece to Murdoch – a crucifix made from metal tools, implants and equipment used in surgery. He creates many of these sculptures, but this one was especially created for Murdoch.

when I graduated in 1973 after free university due to a Commonwealth scholarship.

Dr Colin Hughes Former head Public Health East Metro Perth and former chair Royal Australian College of GPs WA.

Accumulation of neglect Dear Editor, Re: ‘Fear, resilience and our mental health’, Medical Forum, June 2021, p 43.

Yes, it may well be that we are less ‘resilient’ than previous generations.

Unfortunately, the concept of resilience is too wishy-washy.

Current generations probably do have it ‘easier’ in some regards than previous generations. I believe it is important to figure out the potential causes for this and not ignore the actual underlying issue.

One can drown in a bath and in an ocean.

I propose that one cause may be that previous generations failed to explicitly teach us what they were doing to cope. Our grandparents learnt to survive and swim in their oceans of trauma and omitted to recognise what they were actually doing to cope and thrive. So, they never actually taught us the skills they were using.

like ‘resilience’ was radically accepting their situations and responding effectively to them – i.e. doing exactly what was needed.

However, they often pushed away emotions because they were busy rebuilding.

Pushing away (and pathologising) emotions as the only strategy used for regulation of emotions doesn’t work – they eventually catch up with us. I believe that current generations are paying the price because they lack the requisite acceptance, distress tolerance and emotion regulation strategies.

We have all these new-fangled treatments being explored for when the problems get entrenched. And yet we are still not focusing on universal teaching of a broad range of psychological fitness and mental health maintenance skills in schools.

This needs to be a compulsory subject that is given the appropriate weight amidst the academic curriculum.

Reminding our children that they have it ‘easier’ than previous generations invalidates the fact that they are drowning in a bathtub.

Teaching a rich repertoire of skills and helping our young people change in ways that help them get out of their place of drowning is what’s needed.

Dr Pauline Cole Marian Centre

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FIVE MYTHS DOCTORS STILL TELL PATIENTS ABOUT VARICOSE VEINS There are five common myths patients tell us they have been told by other doctors. Ultrasound has totally reshaped our understating of venous disease and more effective and less invasive treatment methods first introduced in 1999 continue to evolve.

We recommend reading the below guide to become familiar with how these new understandings have made advice that may have been given last century no longer accurate.

1. “Varicose veins are just a cosmetic problem.”

by DR LUKE MATAR Dr Matar is a dual-qualified Radiologist and Phlebologist. His personal and family history with varicose veins fuels his ongoing passion for offering the most effective varicose vein treatments available.

As medical director of The Vein Clinic in Perth he has pioneered several innovations in vein treatment and offers a highly tailored and targeted approach to treating venous insufficiency, the cause of varicose veins and a frequent cause of restless legs.

Unfortunately, many patients report that this myth has been conveyed to them by their doctor! Whilst many patients are bothered by cosmetic appearance, a good number suffer from significant symptoms of ache, pain, discomfort after exercise, restless legs, heavy/tired legs and, of course, embarrassment and limitation of lifestyle.

veins treated with foam anywhere from 25-85%. Success depends on proper patient selection and varies with vein size, wall thickness, sclerosant used and technique. By comparison, endovenous laser is highly reliable, with average longterm closure rates of about 95%.

When left untreated, serious consequences can occur, including leg swelling, itchy and inflamed skin (venous eczema), discoloration and thickening of the skin (pigmentation and lipodermatosclerosis), ulceration and even blood clots (superficial and deep venous thrombosis).

In many countries, stripping has been completely replaced by laser and we have never encountered a saphenous vein we cannot laser due to its size. In the majority of cases, phlebectomy can be safely and effectively performed in an ambulatory setting, avoiding unnecessary general anaesthesia and the associated patient inconvenience of hospital admissions.

Between 5% and 15% of patients with venous disease will develop ulceration and they are also at four times the risk of developing DVT compared to the general population.

Up to 40% of our patients report restless legs syndrome and this can disrupt sleep, dramatically reducing their quality of life.

2. “Foam sclerotherapy is cheaper and just as effective as laser.”

This is simply untrue. We frequently treat patients that have spent a lot of time and money having inappropriate and unsuccessful foam sclerotherapy for veins that should have been treated with laser and phlebectomy.

The literature shows variable longterm closure rates for saphenous

3. “Your veins are too big for laser – you need stripping.”

4. “Wait until you’ve had all your children before getting your veins fixed.”

This outdated advice is a hangover from the pre-endovenous laser era when stripping was the only available treatment option. The ideal time to get treated is BETWEEN pregnancies.

Varicose veins often become most apparent during the last trimester and tend to get worse with each successive pregnancy. During pregnancy they swell and often cause discomfort. In addition, the risk of venous thrombosis in varicose veins is much higher at the end of pregnancy and immediately after delivery.

Treatment during pregnancy is not advised but there is definite benefit in treating abnormal veins beforehand to reduce painful complications such as clotting, inflammation, and further worsening of venous dysfunction.

5. “There is no point treating varicose veins, as they will just come back.”

In the past, even if done perfectly, stripping surgery was associated with about 50% recurrence rate at five years – hence the basis of this belief.

Foam sclerotherapy has also been overpromoted as a ‘one-stop shop’ for varicose veins and is associated with poor outcomes and recurrences in many cases, again adding fuel to this opinion.

The latest endovenous laser methods we employ have almost 100% initial closure rates and rates of up to 99% at five years. There is really no comparison between modern treatment by a skilled phlebologist and old-fashioned surgical stripping.

With modern methods utilising best practice techniques, including endovenous laser, phlebectomy and foam sclerotherapy, the chances of recurrence can be greatly reduced to the baseline risk of progression of around 3% per year.

Regular surveillance and ‘touch-up’ treatment will usually prevent major recurrences.

Perth's Only Dedicated Varicose Vein Clinic 6/28, Subiaco Square Road Subiaco WA 6008 (08) 9200 3450 | veinclinicperth.com.au

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JULY 2021 | 9

Q&A with...

Julian Pace, CEO and founder Happiness Co The tragic death of his father prompted Julian Pace to set up a social movement to improve how men deal with depression and take control of their mental health.

One of the bravest things a man can do is open up about how he feels.

MF: What is your personal experience with mental health?

JP: At 21 years of age, I went through the hardest and darkest time in my life. My father took his life and, as a result, my life came crashing down. I quickly spiralled into a dark place and adopted toxic behaviours as a distraction from my pain. After going through this period filled with guilt and shame for some time, I decided to take action and find a way to take control of my life.

Since that day, I have made it my mission to not only find my own purpose and happiness but to help other people find theirs as well. I founded my social enterprise Happiness Co, which also has a movement called the ManEnough Movement that focuses on improving the way men view happiness and vulnerability.

MF: Why do you think men struggle with their mental health?

JP: In Australia, about seven men die by suicide each day. Three times as many men as women took their lives in 2019 alone, according to Beyond Blue. These staggering statistics reflect the increasing number of men experiencing depression and who sometimes take their lives as a result.

I believe that one of the main reasons men specifically struggle with their mental health is because of the belief that asking for help or admitting to struggling is a sign of weakness. There is also a lot of pressure on men to be seen as tough, which still carries the stigma of being emotionally tough, despite the pressures this adds to men not feeling comfortable expressing how they feel.

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Q&A

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Q&A MF: How do you think men usually deal with mental health struggles?

JP: Avoidance and distraction are the most common ways men deal with plummeting mental health. I see this time after time and have personally experienced it myself.

When I lost my dad, everything happened so rapidly. I knew then that this was not something I could have prepared for. All I wanted was for the pain to go away and I had no tangible way to come out on the other end. I was stuck in the pain, too busy suffering to spend time making my life better. When the pain overwhelmed me, I believed that I was lost in a very dark cave, when in fact, I was in a tunnel – and I ultimately found my way out.

MF: How did you deal with your pain and turn it into your purpose?

JP: When I decided to take action, I was very much focused on building strategies and coping mechanisms.

I knew that I needed to focus on and envisage what I wanted in my life and the people I wanted to have around me. I then decided to make choices.

One of the big parts of this was forgiving myself and forgiving my father, as I had a lot of shame and guilt surrounding his death for a long time. I think this is a big thing for a lot of men because they often hold onto things when there is really so much power in letting go to make space for change. They so often define themselves by their mistakes rather than the person they are.

MF: How does Happiness Co help?

JP: I founded Happiness Co in 2017 as a social enterprise with the goal to impact 10 million lives in 10 years by providing tools and strategies to find and sustain happiness.

Our ManEnough Movement gives men the skills and tools to support them through life’s challenges. The work we do focuses on what kind of person they would like to be, and we then help them make decisions towards becoming that person.

Men have an incredible ability to be brave. We know this from what we see in sports, careers, achievements and many other skills.

Our aim is to show men that being open about how they feel is one of the hardest things a man can

do, and hence one of the bravest things.

MF: What advice would you give to a man who is struggling with his mental health?

JP: Something really important I would like to leave with anyone struggling is that depression is not always a bad thing when dealt with appropriately. Although it can be crippling and it is very real, it is an opportunity to learn and grow and become a stronger person.

My best advice would be to seek support and help when you recognise you are struggling because once you know this, you can gain the right support to take action and control over your life.

At Happiness Co, we offer a range of tailored programs for individuals and groups, which work in the pre-emptive mental health space in order to provide strategies and tools for getting through struggles to find happiness and purpose.

ED: For more information email wecare@happinessco.org or visit www.happinessco.org or for crisis support call Lifeline on 13 11 14.

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JULY 2021 | 11

The planet needs healing hands More doctors are actively campaigning about the biggest health threat of our time – and no, it’s not coronavirus. Cathy O’Leary explains.

12 | JULY 2021

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FEATURE

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FEATURE Activism is hardly a new phenomenon among the medical profession, with doctors known for their willingness to stand up on issues ranging from unsafe working conditions to climate change and social justice.

But their stance has taken on a more pressing edge in the past year, as global events have put in sharper focus concerns about the health of the planet and its inhabitants.

While COVID-19 hit the world like a thunderbolt and continues to ricochet around the globe, many scientists argue it was an “expected surprise”. The growing threat from zoonotic diseases had long been predicted, and genetic analysis strongly suggests the novel coronavirus originated in animals, probably bats.

Alongside the medical scientists are ecologists who argue that the pandemic points to a much bigger timebomb – climate change – that cannot be remedied by a vaccine.

We were warned In a report released last year, the United Nation’s Environment Programme warned that the science was clear that if communities kept exploiting wildlife and destroying ecosystems, they could expect to see a steady stream of diseases jumping from animals to humans.

“We were warned that the current pandemic was not a matter of if but when,” it said. “And it is a human failing that we predict, but we do not prepare.”

“I am angry and anguished about the lack of action on climate change, and the denigration of science and the evidence behind it by politicians and some aspects of the media,” she wrote.

Her concerns are shared by other WA doctors including Dr George Crisp who said scientists had been warning about increasing risks from zoonotic diseases for decades and the naysayers had said they were wrong.

“But they didn’t get it wrong and we did get a zoonotic disease, and we’re likely to get more,” he said. “That should be part of the messaging for planet change, that there are going to be a lot of expected surprises and we could see massive crop failures and people around the world starving en masse.”

Dr Crisp said some industries were trying to use the pandemic as a springboard to promote fossil fuels by arguing we need it as part of the economic recovery.

“But that’s one of the worst possible things we could do,” he said. “Unfortunately, it’s resulted in a unification of the major parties which is very disappointing, especially as I think the economics of the gas-fired recovery is almost totally false, and gas is only going to get more expensive.

“It also shows that despite their rhetoric, they don’t really ‘get it’ when they are actually looking to develop new fossil fuel industries.”

Collectively, doctors and health groups have been lobbying for change with proposals such as an 80% emissions reduction from healthcare by 2030 and net-zero by 2040; 100% renewable energy for WA by 2030; and no new fossil fuel developments.

But fears have been heightened by the proposed Scarborough gas export development in northern WA, which the Conservation Council of WA and the Australia Institute claim could generate more carbon emissions than Queensland’s Adani coal mine.

Dr Richard Yin, national secretary of Doctors for the Environment Australia, said that at a national level, climate action had gone nowhere, with both major parties failing to commit.

“At a state level, we have a climate policy but at the same time you’re looking at the approval

continued on Page 14

Kate Jones, an ecological modeller at University College London who has researched the links between loss of biodiversity and disease outbreaks, echoed those sentiments in Nature magazine last August.

“We’ve been warning about this for decades,” she wrote. “Nobody paid any attention.”

In a recent compilation of life stories, Women of a Certain Rage, Perth’s most respected child health expert Professor Fiona Stanley lamented the lack of traction in Australia.

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Dr George Crisp and his surgery vegetable patch

JULY 2021 | 13

FEATURE

The planet needs healing hands continued from Page 13 of the Scarborough project, and the emissions from that are just ginormous,” he said.

“So, we’re hearing a certain rhetoric but at the same time we’re not seeing anything commensurate with the actions required.”

Dr Yin said Australia had traditionally been dependent on fossil fuels in terms of the economy but that did not stop it from moving forward.

Close to tipping points “We’re coming very close to tipping points where if we don’t take action, and have steep declines in the next 10 years, it’s going to be too late and it’s not looking very pretty for our kids,” he said.

“Just look at the impacts of our bushfires and droughts, and we’re going to have more of that. There are significant mental health impacts too that will persist for a long time, and the social costs are going to be at least as much as the tangible costs from bushfires.”

Climate change advocates have been encouraged by a recent Australian Federal Court judgment following a class action case on behalf of Australian children against Environment Minister Sussan Ley, which sought to prevent her from approving the Whitehaven coal mine extension project in NSW. While the court dismissed the application to stop the minister from approving the extension, it found the minister owed a duty of care to Australia’s young people not to cause them physical harm in the form of personal injury from climate change.

Dr Yin said the ruling put governments on notice that duty of care will now become a legal issue, and there will also be corporate risk issues that will be subject to the same ruling to consider climate change risks.

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Doctors speaking up He said doctors needed to challenge the status quo because they had a moral responsibility to be health advocates.

“A few weeks ago, doctors and nurses held a public rally outside the Perth Children’s Hospital, and a few decades ago doctors even went on strike, and we’ve also had doctors on the front steps of Parliament for the sake of refugee children,” he said.

“We really need to lift our level of advocacy to meet the threat this is posing. And if governments don’t act, there needs to be some sort of response from us which is appropriate.”

Dr Yin said that doctors every day made risk assessments and noticed symptoms that signalled that the person in front of them was going to be really unwell and immediate action was needed.

“And all the data in front of us

about this patient, which is the planet, is very clear that it’s not particularly well and we really need to be acting,” he said.

“In parts of western Sydney, there are temperatures exceeding 50˚C and people have to understand there are consequences when average temperatures are exceeded by several degrees. We don’t know whether it will even be possible to live in the north of our state.

“Climate change isn’t going to be a little inconvenience.”

Dr Emma-Leigh Synnott, WA chair of DEA, said doctors needed to be stronger advocates.

“The position of medical doctor comes with a lot of privileges, but it

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“We just need to acknowledge the issue and address it. We did that for COVID, even though it had an economic consequence.

FEATURE

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Dr Kushwin Rajamani and Leif Cocks working for the Orangutan Project

also comes with a responsibility to act with integrity and honesty to do what we can in and around justice issues, and climate action is a justice issue,” she said.

“We’ve had to face COVID and, depending on how you look at it, there is the question of whether it’s associated with the encroachment of human activity. But one thing it has definitely spoken to is the way the community trusts the medical voice, and that voice keeps people safe.”

Dr Crisp said most Australians wanted climate action, but it was often framed as an environmental issue.

“It’s actually a health issue, and it’s a security threat and an economic threat, and that’s why doctors have a very important role.”

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Saving trees Some activist doctors are going the extra mile, like Perth cardiologist Dr Kushwin Rajamani who is personally funding attempts to prevent deforestation in Sumatra.

He has pledged to match any donations, up to $500,000, to the Orangutan Project founded by Leif Cocks, which is seeking to lease 100,000ha of Aceh’s ancient Leuser ecosystem, the last place where critically endangered orangutans, elephants, rhinos and tigers coexist in the wild.

“Doctors are generally more financially privileged and can spend on these critical issues and become role models for the community.

“I’m from Sri Lanka and my background is by no means affluent. My father can only read numbers and my mother only went to primary school, so I grew up watching the struggles of my parents.

“But thankfully I had the opportunities to progress and be successful, so I’m paying it back.”

ED: For more details of the Orangutan Project – and have any donation matched – go to www.orangutan.org.au/aceh

“It comes down to values and purpose and for me, as a father of young children, the role of citizens as guardians of the planet and future generations, rather than a parasitic relationship where it’s just ‘take, take’ by individuals and vested interests,” he said.

JULY 2021 | 15

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FEATURE

Are men missing the boat to good health?

While treatments, screening and lifestyle advice are available, not enough men are listening and their health is paying the price, Dr Karl Gruber (PhD) explains.

Every year, thousands of Australian men are diagnosed with a wide range of health problems, from poor mental health to chronic and infectious conditions.

They seem disproportionately affected compared to women, and even COVID-19 seems to affect them more severely.

Are men to blame, or is our current health system leaving them behind?

Australia has some of the world’s best evidence-based guidelines for healthy living. They recommend eating five to six servings of vegetables with few or no sugary products. Exercise 45 minutes most days of the week and you will likely keep the doctor away. We also have cancer screenings every two years for various cancers in high-risk groups.

On deaf ears However, not all Australians follow this health advice, and men seem to be particularly stubborn about it.

As a result, men are facing a range of health challenges, significantly more often than women. Males are three to four times more likely to commit suicide, with 2,502 male deaths in 2019 due to suicide, compared to 816 deaths among females.

Around 643,500 men were diagnosed with heart, stroke or vascular disease during 2017-18, whereas 510,000 women were affected by these conditions in the same time period. Other chronic conditions such as diabetes or cancer also affect a larger number of men than women. In 2017-18, 179,000 women were diagnosed with cancer compared to 250,900 men. Similarly 525,200 women were diagnosed with diabetes compared to 657,300 men.

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FEATURE

While these health problems are influenced by multiple factors, lifestyle choices are likely playing an important role. For example: • More than half of all Australian men drink more alcohol and exercise less than the official recommended guidelines.

• About 97% of men do not eat the recommended servings of vegetables, and nearly half eat too much sugar.

• More than 70% are overweight or obese. Obesity is associated with many health problems such as diabetes, some cancers, osteoarthritis, mental health and all-cause mortality.

On top of these lifestyle and health problems, men don’t seem to follow advice to keep themselves healthy.

For example, more than 60% of men choose not to participate in a free national bowel screening program that can potentially detect their cancer at an early and treatable stage. They are MEDICAL FORUM | MEN 'S HEALTH

also commonly affected by other cancers such as prostate or blood cancers.

An infection conundrum A recent meta-analysis of 92 studies involving more than three million patients concluded that both men and women were just as likely to become infected by COVID-19.

However, men are nearly three times more likely to be admitted to intensive care than women.

This finding is not odd. Previous research has shown that, compared to women, men seem to be more susceptible to bacterial, viral, fungal and parasitic infections. The factors behind these differences between the sexes are complex and multiple, likely involving differences in immune function as well as differences in lifestyle factors or genetics.

“Sex differences in both the innate and adaptive immune system have been previously reported and may

account for the female advantage in COVID-19,” the authors wrote in their study report. “Within the adaptive immune system, females have higher numbers of CD4+ T cells, more robust CD8+ T cell cytotoxic activity, and increased B-cell production of immunoglobulin compared to males.”

Women have also been found to produce more antibodies and have more severe side effects in response to the influenza vaccine (TIV)100 as well as to other pathogen vaccines.

“These findings imply that females have an increased capacity to mount humoral immune responses compared to males, and together with the data from this metaanalysis, may have important implications for the development of vaccination strategies for COVID-19.” continued on Page 18

JULY 2021 | 17

Are men missing the boat to good health? continued from Page 17 Beyond infections, Australian men are also facing sexual health issues.

When men experience erectile disfunction (ED), most think it is just a sign of the times, something that comes with old age, and they avoid going to a doctor to discuss their issues.

“Men suffering from sexual health issues (i.e. erectile dysfunction) do not necessarily see their GP about it – either they are too embarrassed or feel it’s an age thing and accept it,” Perth urologist Dr Jeff Thavaseelan told Medical Forum.

ED can be a warning sign of more serious health problems brewing.

“Sexual health is usually the first indicator of other health issues such as cardiac disease, diabetes, mental health, stress etc. In addition, it might uncover issues such as hypogonadism, which increases obviously with age but can cause many other adverse effects such as depression,” Dr Thavaseelan said.

Normal erectile function requires normal vascular, nerve and organ function.

“The vessels going to the penis can be affected by atherosclerosis just like vessels serving the heart.

For the heart we may not notice the change till one suffers angina or a heart attack. The vessels to the penis can be affected similarly but the clinical presentation is impotence,” he said.

So, it is important that any GPs treating impotence ensure that their patients do not suffer from any other CVD risk factor.

“Men may not want to do anything about the sexual side of things but a GP’s holistic approach in assessing the causes can unveil other issues related to their general health,” he added.

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Beyond infections and sex, another major problem men are facing is cancer, with more than half of all new cancers (79,421 cases) being diagnosed in males during 2020.

Bowel problems The incidence of bowel cancer, which includes colon and rectal cancer, has increased by up to 9% in people under the age of 50 since the 1990s. With the goal of curbing these figures, the Australian National Bowel Cancer Screening Program (NBCSP) was established in 2006, free to all Australians, aged 50-74 years.

The NBCSP program aims to reduce the morbidity and mortality from bowel cancer in this age group, which is the most prone to develop this cancer. The program analyses samples with an immunochemical faecal occult blood test, which is estimated to able to detect up to 85% of all bowel cancers, and men need to do this test every two years to ensure

the cancer, if it ever develops, is caught early.

Yet, more than 2.5 million men opted not to undertake the test during 2017-2018, according to the most recent report from the Australian Institute of Health and Welfare. This large figure likely contributed to the more than 8,000 new cases of bowel cancer diagnosed every year among Australian men and the more than 2,800 deaths associated with this condition each year.

Another important cancer affecting men involves the prostate.

Unfair costs for men Prostate cancer is the most common cancer diagnosed in Australia, with about 19,000 new cases every year. In fact, Australia has one of the world’s highest incidence of prostate cancer.

Part of the problem may be a lack of financial support from the government. “Prostate-specific MEDICAL FORUM | MEN 'S HEALTH

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FEATURE membrane antigen (PSMA) scans cost men $1000 but breast screens are free for women. Essential medications, continence pads and vacuum pumps are not funded by health funds,” Dr Jo Milios, men’s health physiotherapist and Adjunct Research Fellow at the University of Western Australia, told Medical Forum.

In addition, there are other issues with prostate cancer screening, particularly a lack of an official screening program such as for breast or bowel cancer.

“At the moment there is no screening program for prostate cancer but the evidence-based PSA testing consensus guidelines are very helpful here,” Perth urologist Dr Tom Shannon told Medical Forum.

Cancer Council Australia and the Royal Australian College of General Practitioners both recommend routine screening every two years, but only in men who are 50-69 years old.

If you have a family history of this disease, the screening should start earlier, at 45 or even 40 years of age. In all cases patients should be

informed of the risks and benefits of this test.

However, the population health benefits of screening for prostate cancer with the PSA test are still uncertain. According to the Cancer Council, some of the issues with the PSA test include the usually variable course of the disease, the limitations of the PSA test as a screening tool, the lack of a clear consensus on the optimal treatment of screening-detected earlystage prostate cancers, and the risk of significant adverse effects associated with treatment.

Another problem involves reluctance by men, particularly in regional areas, who fear facing their condition.

Regional men may have poorer access to medical professionals and tend to be even more ambivalent in pursing health advice than urban populations.

Dr Milios said this ambivalence was an issue in men’s health generally – a reluctance to seek preventative health measures which results them presenting at the point of critical health issues/ crisis situations.

But when it comes to testing for prostate cancer, it is important to have uniformity, Dr Shannon said.

“Although we have a high rate of PSA testing, equal to breast cancer, we do not have uniform responses to abnormal results or standards set for MRI or pathology reporting, like we have in breast cancer. It is not unusual to see men who have had two or three abnormal PSA tests before they are referred, something unthinkable with mammography and breast cancer,” he said.

Australia was in the fortunate position that it had consensus guidelines on the diagnosis and treatment of prostate cancer, which were published by the Prostate Cancer Foundation of Australia and Cancer Council Australia in 2016.

They are endorsed by the NHMRC and the RACGP. “Detection is a necessary part of the journey in cancer, but treatment does not have to be. Prostate cancer is the only cancer where observation/active surveillance of low-risk disease is widely practised,” Dr Shannon said.

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JULY 2021 | 19

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Circle of healing remains unbroken A childhood desire to help people turned Dr Darcy Smith away from a career in mining to become an advocate for regional people’s healthcare rights.

By Ara Jansen

A champion of positive mental health, supporting HIV patients and a tireless advocate for causes he believes in, Dr Darcy Smith grew up in Albany and returned with experiences that have informed his practice as a GP. Growing up in a mining family based in Albany, it was expected that Darcy would follow into the business.

Instead, his work as a St John Ambulance cadet, something he’d done since he was 11, was what really grabbed his interest.

During holidays he would sometimes ride with the local ambulance driver. With Darcy assisting, they delivered someone to the hospital who had appendicitis. It was this specific diagnostic challenge which turned on a light for the young student.

“My family were really cross that I didn’t go into mining,” he remembers. “They used to say rocks don’t talk, implying that was better.

“As there was no rural training that anyone could do as part of their course at the time, in my second term of being an intern I was sent to Kalgoorlie for four months.

That was hair-raising. There were only four GPs in town in 1975. We were expected to do an awful lot.

I used to work every second day on call for 24 hours and as it turns out, all my life I have worked or been on call for quite long hours.”

“I remember someone taking a barbiturate overdose and I intubated her overnight by myself. Not something an intern would do these days! I used to work every second day on call for 24 hours and as it turns out, all my life I have worked or been on call for quite long hours.”

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GP activism

decided not to admit any more HIV patients because the husbands of the volunteers were complaining.

Darcy preferred Kalgoorlie to the city lifestyle and made his home there for the best part of a decade.

In the 1980s, he was vocal about the relationship of the high number of paediatric asthmatic patient admissions and the relationship to late afternoon high sulphur dioxide emissions from the smelter south of the city. The smelter location was moved, for many reasons, including Darcy’s constant badgering and local asthma cases decreased.

While he’s spent most of his career as a GP, Darcy left Kalgoorlie to come to Perth for a while to take up the position of Deputy Medical Director at King Edward Memorial Hospital. At the time of moving he was delivering about 170 babies a year. Obstetrics and the intrapartum care of women has been a 40-year constant in his career.

Then a dad of four young kids, the doctor felt he wanted to bring his kids up in the country. This led him to become a country Regional Director of Health for the WA Health Department until the mid-1990s, overseeing 30 to 40 hospitals in the Great Southern from Narrogin southwards.

“In 1993, I had divorced and there was an agreement that the children would spend a week about with me. Wanting to be home with them I went back to being a GP in Albany. I ended up being on-call for every weeknight and on-call for obstetrics 24/7. I also worked every second weekend on-call at A&E. I was terribly busy!”

“I saw a need and here was a disenfranchised group of people.

While HIV patients have a similar life expectancy now (about 70 years), in the ’90s people were dying slowly and meeting miserable ends and with a life expectancy of about 40. Plus, people thought of it as a gay disease rather than a sexual disease.

“I think it’s wonderful to have seen a change, not only in people’s perceptions and acceptance but in doctors’ attitudes too.”

Darcy competing in a triathalon

bundle the kids in the car and drive 20km.”

While times have changed, Darcy saw that HIV patients weren’t being treated as well as other patients. Some of those late-night trips would include doing things like helping someone get out of a bath because they weren’t strong enough to do it for themselves.

“There was a lot of prejudice at the time and in rural Australia there was a lack of understanding of how you got HIV and a general fear. At one place, which I had asked to take an HIV patient, they had used 50 aprons in the first night. They

Throughout his career, Darcy has been active in promoting positive mental health in general practice. He’s worked on the National Working Party into Mental Health Prevention, Promotion and Early Intervention and chaired the national GP Mental Health Standards Collaboration. He strongly feels GPs must be integral to patient mental health care.

“If we can prevent mental health issues and diagnose them early, individuals and the community will be better off. The mental health issue is getting bigger and I think that the focus of programs needs to be constantly reviewed.

continued on Page 23

Picture: Chantel Concei

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A life-long triathlete and crosscountry runner, it was clocking up the miles in his sneakers that Darcy says kept him balanced. He instilled a passion for running in his children, whom he says all still run.

In 1995 he opened his own practice and initially was a solo GP and cared for HIV patients when, at that time, many health professionals hesitated to. There were often daily home visits, some in the middle of the night, and back then, unlike today, some sad outcomes.

No to discrimination “When I first opened as a GP in Albany, for whatever reason, the needs of HIV patients were not being met. Sometimes I would get called out in the middle of the night and occasionally I would have to MEDICAL FORUM | MEN 'S HEALTH

Darcy with his daughter Katherin, at her graduation from the University of Melbourne

JULY 2021 | 21

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22 | JULY 2021

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Circle of healing remains unbroken continued from Page 21

Darcy and Paul

GPs and mental health “When a 14-year-old girl comes to the ED having self-harmed, she needs help and specialised help. Groups like headspace (the National Youth Mental Health Foundation) are doing a lot of good work around Australia.

Having a phoneline which offers help is powerful, but not as powerful as personal contact for some people, particularly young people.”

Sexually abused as a child by a teacher, Darcy’s abuser was jailed two years ago at the age of 84.

Darcy used therapy to help heal the wounds of his past and keenly understands the power of keeping your mental health in check, which is one of the reasons he keeps physically active.

“I think I do attract some patients who are coming to terms with past sexual abuse. I’m thinking of one man who was 64 and had never told anyone of his sexual abuse – and he told me. His mental outlook improved after counselling. I can relate to that. I’d like to think all doctors should be getting training in mental health to offer their patients help with all mental health issues, including sexual abuse.”

Darcy was a long-time mentor for John Flynn Placement Program students, the only national rural placement program connecting medical students, doctors and communities across the country. It was unfortunately defunded in the 2021 Federal Budget.

A keen teacher, Darcy encourages teaching in rural locations because he feels this offers the greatest chance of students returning to regional Australia to live and work for longer than just a placement. He says students’ questions and challenges encourage his own learning.

Darcy was honoured earlier this year at the WA Rural Health Awards for his 40 years of service. At the ceremony he was described as an advocate for patients whose greatest joy is “developing a therapeutic relationship with patients and building on that relationship for the benefit of the patient”.

MEDICAL FORUM | MEN 'S HEALTH

is angry, they need to know how to handle that. To have good interpersonal skills is to also know oneself better.”

Knowing patients He told the attendees he strongly felt community members needed a designated GP who knew the patient history well and knew the patient’s hopes and aspirations.

“A GP should be friendly and warm,” he says. “I’d like to see more interpersonal skills taught in secondary schools. If someone

He says a key factor to being a doctor, especially in the country is to have the support, patience and understanding of a partner – in his case Paul – especially when he’s rushing off in the middle of a meal or the middle of the night to deliver a baby.

Darcy works three days a week at The Surgery and two days in A&E at Albany Health Campus.

He considers Albany the best place in the world to live, where he and Paul keep active by walking their dog, gardening and growing veggies.

JULY 2021 | 23

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FEATURE

Kicking goals for healthier heart Football is being used to lure men into a healthier lifestyle, as Dr Karl Gruber (PhD) explains.

24 | JULY 2021

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FEATURE The Aussie-FIT program is a first for WA, a program that offers an evidence-based and personalised approach to fitness enlisting a football focus to improve the health of men with cardiovascular disease.

Cardiovascular disease (CVD) is the number one cause of death and morbidity in Australia and globally.

It is estimated that nearly 18 million people die from CVD each year. In Australia, more than 640,000 men suffered from some form of CVD during 2018 and nearly 18,000 died from their condition.

CVD and obesity CVD is a complex disease that affects the heart and blood vessels, and can manifest in the form of several diseases, including coronary heart disease, stroke, heart failure, cerebrovascular disease, peripheral arterial disease, rheumatic heart disease, congenital heart disease, deep vein thrombosis and pulmonary embolism.

Among these, the most common types of CVD are coronary heart disease, stroke and heart failure, which are strongly influenced by lifestyle.

The most common cause behind these heart problems is the blockage of blood vessels due to the accumulation of fatty deposits.

This blockage results in a reduced supply of oxygen to the heart and the brain, which can lead to serious health problems such as stroke or heart attacks.

The risk developing these fatty deposits is substantially higher in people who are overweight and obese, who usually follow an unhealthy diet and engage in limited physical activity. In addition, obesity can worsen several other risk factors associated with coronary heart disease, such as high blood pressure, dyslipidaemia, blood glucose levels, systemic inflammation, and can lead to increased prevalence of metabolic syndrome and Type 2 diabetes.

Australia is overweight In Australia, about 67% of all Australians over the age of 18 are overweight or obese. This figure translates to more than 12.5 million adults currently living with an unhealthy weight that can increase their risk of heart disease and other conditions.

A major factor driving this epidemic of unhealthy weight is our lack of MEDICAL FORUM | MEN 'S HEALTH

physical activity. More than 55% of all adults in Australia do not meet the official physical activity guidelines, which recommend either 2.5 to 5 hours of moderate intensity physical activity or 1.25 to 2.5 hours of vigorous intensity physical activity on most days of the week.

For most men, it is clear that following these guidelines is a daunting task, with current statistics showing that more than 80% of men between 18-64 years of age do not meet Australia’s physical activity guidelines.

But for one Perth researcher, a way around this problem is to attract men with something they like – football.

The Aussie-Fit Project Led by Associate Professor Eleanor Quested, from Curtin University, the Aussie Fans in Training (Aussie-Fit, http://www.aussiefit.org/) project is an innovative health program that seeks to empower men who are overweight or obese. The program is delivered in a professional sport setting and is specifically tailored for men and for the needs of each participant.

“It uses men’s passion for sport as an effective ‘hook’ to engage men in healthy behaviour changes such as being more active and improving diet,” she told Medical Forum.

Aussie-Fit is a free 12-week program of 90-minute weekly sessions, run by trained coaches, where men learn to change their lifestyle, improve their levels of physical activity and their diet. The program is based on the highly successful Football Fans in Training (FFIT) program, from Scotland and is the first of its kind in WA. “The program consists of workshops on healthy eating and building physical activity and healthy eating habits, and will offer a range of exercises, ball skills and circuit training. We do before and after assessments of health indicators including weight, diet, physical activity levels, wellbeing,” A/Prof Quested said.

The idea of using a football-inspired setting is based on scientific research showing that health interventions are more effective when designed to appeal to men’s interests. “Sport spectating and passion for a favourite team is common among men and the idea of a football focused weight

management program is likely to be appealing for many men,” she added.

Participants who follow this program should see significant improvements to their health such as reducing their body weight to a healthier level and reducing their risk of heart disease and other conditions. Improvements in mental health are also commonly reported.

“Changes to lifestyle behaviours such as physical activity and healthy eating are the cornerstones to reducing obesity, managing a range of medical conditions and improving life expectancy and quality,” she said.

“As well as the health benefits identified above, men get the opportunity to meet like-minded guys in their area, a behind the scenes experience at their local club, a free Fitbit (used to self-monitor activity during the program) and a club T-shirt, to promote a sense of a ‘team identity’ among the men.”

Into the regions Previously, 130 men enrolled in the first deliveries of the Aussie-Fit program, which were delivered with the West Coast Eagles and Fremantle Dockers AFL clubs. The program has now expanded, thanks to funding from the Department of Health.

“We are recruiting men to take part in Aussie-FIT in regional locations such as Northam, Albany and Bunbury. We also have funding from the Heart Foundation to recruit men with cardiovascular disease to take part in a feasibility study of AussieFIT with this population,” A/Prof Quested said.

“This exciting new program is run at South Fremantle Football Club and Swan Districts Football Club and will tell us more about the potential for this type of intervention to benefit people with clinical conditions.”

The plan is to expand this program to other sports beyond football and to offer a suite of sport-inspired health programs that can benefit other groups, not just men.

“This might include programs for families and programs delivered in other sport contexts. I am also keen to explore the potential of the program to benefit men with other medical conditions,” she said.

JULY 2021 | 25

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How AHPRA will navigate PCH claims There has been significant finger-pointing in the fallout from the death of seven-year-old Aishwarya Aswath at Perth Children’s Hospital, in April, after delays in her emergency department treatment.

Three WA doctors – including PCH’s chief executive and the directorgeneral of WA Health – are among those who have been referred to the Australian Health Practitioner Regulatory Agency, while the child’s parents have reported the whole hospital to the agency.

Medical Forum asks AHPRA who can be referred, and what happens?

MF: Who can refer a health practitioner to AHPRA for investigation?

AHPRA: Anyone with a concern about the health, performance or conduct of a registered health practitioner can notify us of their concerns.

Registered health practitioners, employers and education providers have a mandatory obligation to notify us in certain circumstances if they are concerned about the health, performance or conduct of a registered health practitioner or student. Often practitioners and the organisations who employ them will make changes because of a notification, which we assess. If the changes made are satisfactory to protect future patients, we can report back to the notifier about how their concern contributed to the safety of future patients.

MF: Can an entire health organisation (i.e. a hospital) be referred – does AHPRA accept such a notification – and does it have ability to investigate an entity as opposed to individual registered practitioners?

AHPRA: No. We are a regulator of individual registered health practitioners not health services.

This is set out in the legislation that governs us – the Health Practitioner Regulation National Law, as in force in each state and territory. Where a notification does not initially appear to identify individual practitioners, we MEDICAL FORUM | MEN 'S HEALTH

will support notifiers to describe their concerns and identify the best way to address those.

MF: Can AHPRA refuse to accept a referral/notification if it fails to meet its reporting criteria, and would it advise the complainant?

AHPRA: Yes and yes. We can only act within our legislative framework.

While it is quite rare, if we are unable to accept a notification, we will let the notifier know why. We have a section on our website to help people who may have a complaint or concern to determine if we are the right organisation to help.

MF: What powers does AHPRA have to compel people to give evidence/ witnesses?

AHPRA: The agency does have the power to compel any person or entity to provide relevant information. The powers are set out in Schedule 5 of the National Law. The compulsion powers we have are only triggered if a committee of the national board tells us to investigate a practitioner.

MF: What avenues does AHPRA have in terms of sanctions if a notification/complaint about a health practitioner is upheld?

AHPRA: The possible outcomes following an investigation are available on the website. (ED: They range from no further action through to a caution, reprimand or cancellation of registration.)

MF: Does AHPRA release findings publicly/name the practitioner if sanctions are imposed? What happens in the event of it finding a health practitioner has no case to answer?

AHPRA: All registered practitioners are listed on the public register of practitioners. It is the most up to date source of information about a practitioner’s registration status and is updated daily. The register tells members of the public if a practitioner’s registration is current and whether the practitioner has any limitations imposed. Investigations are private.

The National Law that governs us has strict confidentiality restrictions which mean that we can’t disclose if we’ve received a notification or if an investigation is underway. This is to protect the integrity of the process, ensure procedural fairness and to protect the privacy of all parties involved.

If an investigation results in a decision of ‘no further action’ we will contact the parties involved and explain the board’s reasoning but legislation prohibits the outcome and reasons being made public. If an investigation results in regulatory action, such as a condition on practice, this will be listed on the public register of practitioners.

There are some exceptions about publication, especially if the condition is imposed because of a practitioner’s health.

Practitioners who have been found to be in breach of their board’s code of conduct, or who have engaged in practices that are a serious departure from accepted standards, may be referred to their state /territory tribunal. Outcomes of tribunal decisions are generally published and a link to the published decision is included in the entry on the public register for the relevant practitioner.

JULY 2021 | 27

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Living lighter for health and budget Cancer Council WA’s Melissa Ledger argues that when it comes to controlling obesity, an ounce of prevention is worth a pound of cure.

Spending on health in WA has more than doubled in the past 10 years and if nothing is done, is projected to account for 38% of the state budget in 15 years’ time.

The Sustainable Health Review brought into sharp focus the potential of public health to turn around the current trajectory in healthcare spend. Its number one recommendation was to increase investment in public health prevention strategies to at least 5% of total health expenditure.

WA is the only Australian state, and one of the first places in the world, to design and implement a dedicated and ongoing obesity prevention campaign. The WA LiveLighter mass media campaign uses TV, radio, cinema, social media and out-ofhome advertising to encourage West Australians to eat well, move more and avoid excess weight gain. The campaign is delivered by Cancer

Council WA and has been funded by the WA Department of Health for the past nine years.

The WA Government has just announced that it will provide $16 million to Cancer Council WA to continue the LiveLighter campaign over the next five years.

A rigorous economic evaluation recently conducted by Deakin University has demonstrated the substantial health improvements and healthcare cost savings that the LiveLighter campaign is able to deliver.

The study found that for each year that the campaign runs, about 204 health-adjusted life years and $3.2 million in healthcare costs are saved over the lifetime of the target group (WA population aged 25-49 years).

This is substantially more than the $2.46 million to air the campaign each year.

This research puts a dollar value on the impacts of “an ounce of prevention” and shows the potential for public health mass media campaigns aimed at improving dietary behaviours to have a real difference on the health of our WA population.

We know that public education campaigns can’t do all the heavy lifting and they need to be part of a broader strategy that engages environmental and policy levers for improving population health.

Policy-based approaches such as regulating junk food marketing, pricing healthy food so that it is accessible to everyone and ensuring cities are walkable are vital for achieving long-term health gains.

It’s these structural and policy changes that create an environment that support people to be healthy without the burden of decision making. It’s environmental and

Sharing and caring at med school Dr Chris Skinner mounts a case for universities to dare to be different when it comes to their medical curricula.

Since its inception in 2005, the medical school at the University of Notre Dame in Fremantle has emphasised the holistic development of its medical students. Credit for this focus can be attributed to early school pioneers such as the school’s first dean, the late Professor Adrian Bower, and Professors Jenny McConnell and Mark McKenna.

Adrian Bower once wrote in the MJA suggesting that a unique characteristic of the course was a weekly clinical debriefing (CD) 30 | JULY 2021

tutorial, facilitated by a clinician, where students reflected not only on clinical content but on the doctorpatient relationship and importantly the experience on themselves.

The aim of CD was to develop the medical student and put flesh on the ‘reflective practitioner’ and critically to inculcate a culture of doctors caring and valuing their own health – quite a transformational dream which itself has become prophetic.

Roll on 15 years and this unique CD characteristic of the medical school remains and, in fact, has

grown in content, style and delivery, which is no mean feat given the ever-changing health context and educational tertiary culture.

Let us put this CD focus into a wider educational medical school context.

Clinical debriefing is a central part of the Personal and Professional Development Domain (PPD), a domain that covers wellness, ethics and law, reflective practice, professional identity, leadership and management, and the patientdoctor relationship.

Traditional medical educational MEDICAL FORUM | MEN 'S HEALTH

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GUEST COLUMNS

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GUEST COLUMNS legislative changes that make health as equally accessible for the poor as for the rich.

teenagers’ junk food eating behaviours and overall kilojoule intake.

These changes are made at a government level, yet public health education campaigns play a vital role in affecting our community’s and decision makers’ perceptions of these policy initiatives. In 2020, most West Australians were in favour of the government taking actions to support healthy lifestyles, such as:

The ultra-processed food industries spend big bucks to run their campaigns, upwards of $30 million a year in WA alone, and this investment wouldn’t be made if advertising didn’t work. While it’s a bit of a David vs Goliath battle, LiveLighter tries to level the playing field by exposing the junk food industry’s marketing tactics and encouraging people to eat for health – and the Deakin report shows that despite our Goliath opponent, we are making a difference.

• Restrictions on junk food sponsorship and advertising at children's sporting events (85%) • Restricting the sale and promotion of sugary drinks and junk food at venues where children play sport (76%) • A health levy on soft drinks to reduce the cost of healthy foods (92%) • Restricting junk food promotions and advertisements on public transport and at bus stops (75%) An equitable system doesn’t rely on individuals making changes in the face of well-planned, strategic, industry barriers that are unevenly distributed across the population.

Junk food advertising has become the wallpaper of our lives; not just TV and billboards, but streaming services and social media, and all

curricula have often previously only spoken in hushed tones in such areas, if at all. Valuing openness, facilitated discussion and being prepared to explore individual, group/team, and organisational experiences are central.

Through small-group facilitation and mentoring, CD medical tutors are on their toes to address personal, clinical and educational aspects. The importance of what has become known as open space, where students can share and communicate openly, has become central to the evolving CD process.

For instance, a recent ‘oranges and lemon’ segment has caught on whereby students share one positive (orange) and one not so positive (lemon) as part their 90-minute CD sessions. Of course, it does depend on your positive associations (or not) towards such fruit.

Confidentiality, educational flexibility incorporating balancing structure and process is vital for the success MEDICAL FORUM | MEN 'S HEALTH

over our screens when we browse the web for work or play.

Recent research has shown that over three-quarters of the food advertisements that high school students see on their commute to school are for unhealthy foods and drinks. Furthermore, in areas of socio-economic disadvantage, the ads seen on the school commute are far more likely to be for junk food compared to those living in more advantaged areas.

Continued exposure to unhealthy food advertising influences

of CD. While the experiential aspects of emotional intelligence, mindfulness and personal case discussion are strongly valued, other more traditional cognitive elements are not forgotten.

Assessment based on reflective learning, law and ethics vignettes/ seminars and in class assessment exercises are part of the PPD curriculum. Increasingly students learn critical facilitation skills in helping steer and lead with their CD medical tutors.

So what are some of challenges in daring to be different? Acceptance of the importance of the humanities and the integration of new ways of delivering medical education beyond cognitive academic knowledge stand out.

Integration into a busy clinical medical program is not easy, and humanistic PPD topics can be easily marginalised or shelved. To its credit, the medical school at Notre Dame has been willing to support key

The dearth of campaigns targeting obesity in Australia and internationally means there are few lessons to draw on or existing campaign materials to borrow.

Thanks to WA Department of Health support, LiveLighter is able to pave the way for future campaigns in other jurisdictions that aim to address overweight and obesity, halt the unsustainable rise in healthcare spending, and ultimately to support the population to live happier and healthier lives.

ED: Melissa Ledger is the Cancer Council WA’s director of cancer prevention and research.

initiatives and allow the initial vision of the school to be sustained and advanced.

And what of the next 15 years with ever-expanding clinical knowledge and increasing economic and educational managerialism?

Understanding and developing the whole student, including both academic and human experience, needs to be fully valued and resourced. Medical educators need to be trained and affirmed in these essential skill sets. Research and evaluation must be increased to validate new learning experiences for future medical graduates.

Failure to continually value such activities will relegate medical education and future medical doctors to technical but limited real healers.

ED: Dr Chris Skinner is an Associate Professor at Notre Dame Medical School, Fremantle

JULY 2021 | 31

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To submit cases to the NMSCAS for advice or management, visit genesiscare.com/au/refer-a-patient then click on Refer to the WA non-melanoma skin cancer advisory service to download the forms. Case information must be received no later than 1 week prior to the scheduled meeting.

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Men weighed down by body shaming Rachel Seeley shares consumer insights into body image and stigma, and how it can prevent men from seeking help for weight control.

Health Consumers’ Council is working with the WA Department of Health and the WA Primary Health Alliance on implementing the WA Healthy Weight Action Plan 2019-2024.

A key consideration of the Action Plan is moving towards a framework of collective responsibility to address overweight and obesity, by recognising other contributing factors such as the social determinants of health and the obesogenic environment. With this shift in focus, we can also begin to move away from harmful stigma and weight bias.

While body image issues are often thought of as mostly affecting women, this is far from true.

According to Butterfly Foundation, the national charity for all Australians impacted by eating disorders and body image issues, evidence suggests eating disorders in people identifying as male are increasing.

WA organisation MAN UP aims to redefine the phrase ‘Man Up’ and turn it into a reminder that it is OK to be vulnerable, encouraging conversation, support, and accountability around mental health and other issues faced by young men. One of these concerns is body image. Co-founder Gareth Shanthikumar says “men, just like everyone else, experience challenges when it comes to their weight” although these may manifest in different ways.

According to the Western Australian Men's Health and Wellbeing Policy, more than 77% of WA males are overweight. However, Mr Shanthikumar says there is still a large disconnect between how men are portrayed in media and the lived experience of many men, creating unrealistic expectations around appearances.

“As men, we’ve been conditioned to believe that to be a real man, we have to look a certain way, leaving us to feel worthless when we don’t.”

MEDICAL FORUM | MEN 'S HEALTH

‘incompatibility of existing services for men’. The findings suggested “the gender imbalance and attitudes towards existing weight loss services deterred men from engaging with or continuously attending sessions. This imbalance resulted in feelings of self-consciousness, shame and a perceived stigma for men using weight loss services.

These experiences highlighted the importance of providing services which align with men’s preferences to promote engagement.”

Mr Shanthikumar believed this was an issue affecting many men, although to different degrees, “leading to body dysmorphia and unhealthy eating habits” in some.

“It’s true that men may not express these concerns so publicly, but these are thoughts that have crossed our minds at some point. Placing any sort of self-validation on our physical image can be dangerous and must be spoken about more often.

Our survey asked if weight had ever been brought up at a routine appointment and one male respondent said, “It's always felt like, ‘You could be healthier if it wasn't for your weight.’ It feels demeaning and disrespectful, especially when [I’m there for] something like a cold or an injury unrelated to my weight.”

When we asked what a health professional could do, or should avoid doing, when talking about weight, the survey responses spoke to the need to avoid generalisations, stereotypes and blame.

“A man is not someone sculpted into a Greek god, but rather someone who is confident in their body, and continuously working towards being the healthiest version of themselves.”

“Please don’t assume we are stupid or lazy or unwilling to try. We do as we are told by professionals and continue to get sicker. It’s not our fault especially if we are given outof-date advice.”

In our recent Weighing in on Weight Talk survey, we asked about experiences talking to health professionals about weight and heard from male participants about the impact of stigma in seeking support.

The men who participated in the survey echoed the responses we’ve heard from all demographics during our work on this project: consider the needs of the individual and provide resources and support for their specific circumstances.

“The framing always feels like I'm to blame for my weight, regardless of how I've spent most of my life trying to lose it, so I've actively been discouraged to seek out any help,” said one participant.

“Have a conversation with the patient about their weight and health issues and work with them, not just immediately go to ‘you need to eat right and exercise more’,” said one participant. Others suggested, “Use empathy. Listen to the person” and “try and find solutions that work for the individual.”

“[I’m] embarrassed to raise the issue as it raises prospects of being stigmatised,” said another.

A 2020 UK study exploring why men are less likely to engage with weight loss services than women identified one common theme of

ED: Rachel Seeley is part of the Healthy Weight Action Plan project team at Health Consumers’ Council.

JULY 2021 | 33

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Validating men’s fear Dr Simon Yam (PhD) shares lessons learnt from helping the mental health of men with diverse identities and backgrounds.

In the past 18 years of my professional life working with men, one thing that has consistently prevented them from accessing help is their inherent belief of what ‘being a man’ or ‘masculinity’ means.

driven approach – like the process of fixing a car. There are no endless chats based on intangible concepts.

It must be easy, clear and resultsfocused.

However, when I advise some of them to access help from their GP for a Mental Health Treatment Plan, there is often a level of unwillingness due to their fear of being seen as weak. An Asian client expressed that it would bring a level of shame to his family if they ever found out he was seeing a psychologist. In this instance, the mental trauma of ‘coming out’ as an Asian man with mental illness exacerbated the triggers that were already present.

This is a deeply embedded construct that stems from various facets of human life – gender definitions, social and cultural expectations, religious doctrines, peer influence and pressures.

As such, men are known to have greater vulnerability to various health disorders across their lifespan. They are more likely to experience serious health problems and have higher rates of substance misuse, suicide and mental health problems. Male suicide in Australia has reached tragically high levels, accounting for seven in nine suicides every day, and men are more likely to engage in risk-taking behaviour.

I have worked with men who struggle with sexual and gender identities, who misuse alcohol and drugs, and who do not have the tools to address issues with their sexual health, mental health and suicidal ideation. Men in general are conditioned by societal expectation of hegemonic masculinity, and fears being judged or ridiculed for being weak if they access help or support services.

During my years of providing peer outreach, sexual health, drug awareness education and mental health support to men who identify as gay, bisexual, or just ‘a straight fella who has sex with other men’, I have realised that social, cultural, economic or religious self-identities can affect the willingness of men to seek support services, including diagnosis and treatment for medical conditions.

When it comes to a targeted cohort such as gay men, setting up gayfriendly sexual health clinics is a good step forward, as the peer-based setting allows for a common ground for these men to identify within a non-judgmental space, and to take MEDICAL FORUM | MEN 'S HEALTH

It is essential that health service providers are continually upskilled in three areas: understanding the barriers to men seeking help; making services more malefriendly; and recognising the layers of complexity when it comes to identities for men. a step closer to understanding the importance of addressing their personal sexual health.

However, as we move along the sexual identity continuum, bisexual men, straight-identifying men who have sex with men, and straight men find it more challenging to access services.

This is not about whether the services are available. This is about fear and disclosure for these men – fear of being ‘outed’, being judged, and being positively diagnosed of a disease. In fact, these aspects of fear stems from the overall fear of vulnerability which may compromise, threaten and devalue their perceived masculinity.

This fear is consistent across my work with men in the mental health space. I have experienced the levels of resistance from my clients to seek professional help.

What works within a life coaching setting is the informality, the peerconnection between the client and the professional, and the process-

Understanding the resistance that usually accompany male patients’ visits to the GP is a first step in applying motivational interviewing to get a deeper level of information.

Refrain from asking ‘why’ questions, as this often makes them feel judged, and obliged to justify their actions.

For example, when a guy finds the courage to see his GP regarding his depressive state, the better option is to ask, “How are you feeling lately? When did you realise you had these feelings? What have you tried to do to address this issue?” This is a more positive approach than “Why are you feeling depressed? Why do you let these things affect you?” Questions like these will shut the male patient down and he will most probably never return.

Be patient with your patient. Listen to what they have to say with a non-judgmental mindset. Empathy continued on Page 37

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Validating men’s fear continued from Page 35 plays an important part in building rapport and trust. Validate their existence as a human being, first and foremost, because mental health does not discriminate. It is vital to help the patient understand having a mental health trauma does not compromise their masculine identity.

Providing referrals or developing a Mental Health Treatment Plan is a good way forward, especially when it is framed within the intent of helping him address the issue.

Men usually want to ‘get on with it’ once the issue is confronted, so even though it is not a quick fix, providing a clear and objective line of action often helps adherence to the treatment plan.

GPs can also engage in marketing campaigns or outreach targeted at men, highlighting some of the more serious medical conditions that can affect men, such as prostate cancer,

depression and suicidal ideation.

And consider changing how the GP clinic offers help to men, rather than expect men to change their help-seeking behaviour.

Ensure that the clinic has promotional materials that addresses men’s health issues and thought-triggers for male patients in the waiting room, such as “Do you know you can access 20 private and confidential subsidised mental health treatment sessions per year if you have a Medicare card?”, or “Australia loses seven men to suicide every day. You are not alone mate. Talk to your GP if you are struggling mentally.”

GPs can also promote their services through outreach targeted at men in barber shops, golf courses, gyms, construction sites, sporting clubs, men’s social groups (i.e. men’s sheds) and other locations where men tend to congregate.

I run the SafeBROSpace program at barber shops, imparting knowledge

and tools with barbers to conduct mental health brief interventions with male clients, and to provide referrals to health service providers, crisis care or personal development services.

One golden principle when we undertake with men and their health is to continually affirm men’s positive strengths and allow emerging masculine virtues to thrive.

Concurrently, we need a sustainable, integrated, and clear blueprint approach to supporting men across the public, health professionals, researchers, community groups, academics and policy makers if we are to ensure every man and boy in Australia is supported to live a long, fulfilling and healthy life.

ED: Dr Simon Yam was formerly the CEO of Men’s Health and Wellbeing WA. He is a life coach for men, founder of BROS GLOBAL and an accredited mental health first aid instructor.

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RACGP and ACRRM CPD Activity

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GP BREAST DISEASE EDUCATION FORUM Saturday 2nd October 2021, 9:00am to 3:30pm Pan Pacific Perth Please note that the forum is held in a completely separate area to quarantining guests and strict hygiene protocols are in place at the venue.

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• Breast Cancer contemporary management • Benign breast problems including dense breasts, implants, fibroadenoma and more

• Survivorship issues including menopausal symptoms, diet and exercise, fertility and bone health • Panel discussion: questions and cases for discussion can be submitted upon registration

Free all-day event for registered attendees.

Lunch, morning/afternoon tea included

To register visit https://www.trybooking.com/BPWQB To submit a case for panel discussion: info@bcrc-wa.com.au The Breast Cancer Research Centre-WA (BCRC-WA) is a Western Australian clinical research, treatment and support centre for women and men with breast cancer.

38 | JULY 2021

More information on BCRC-WA is available on our website www.bcrc-wa.com.au, phone 08 6500 5501 or email info@bcrc-wa.com.au

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GUEST COLUMN

The smile widens at HBF Dr Daniel Heredia, HBF Executive General Manager Health, argues new branded dental clinics still offer people choice.

As HBF transitions from being a passive payer to an active participant in health services, such as dental, it raises some questions for HBF members and healthcare practitioners.

Why dental?

HBF’s overarching goal is to keep downward pressure on premium increases and one way to do this is to reduce our reliance on health insurance revenue alone and diversify, which includes growing outside of WA and expanding into health services that will provide value for members.

Unlike most of the other large health funds, HBF is not for profit and members’ interests (not shareholders) are at the heart of our decisions. When we considered our diversification options, we began with the question, ‘what would our members value?’

Dental is by far our most claimed non-hospital service line, so it was an obvious place to start. We then set out to redesign the dental experience for our members, giving them everything on their wish list – high quality no- or known-gap treatment, delivered in modern, clean centres which are conveniently located and offer family friendly extended opening hours (i.e. seven days a week and Thursday evenings).

Dentistry standards We also considered, ‘how will we attract the best dental practitioners?’ We recognise that as a health insurer our expertise is not in running dental centres, so we partnered with the experienced Pacific Smiles Group (PSG) which has a proven track record of running more than 100 practices on the east coast. Our partnership with PSG gives HBF dentists access to a continual stream of education, training and upskilling opportunities.

Our business model is designed to allow ‘dentists to be dentists’, freeing them of the administrative MEDICAL FORUM | MEN 'S HEALTH

burdens that come with running a dental centre. Our dentists can focus on providing the best clinical care, knowing they have the full support of HBF Dental in areas such as HR, marketing, finance, taxation and law.

We also fully support flexible working arrangements. Our sevenday trading with extended hours provides opportunity for both part- and full-time dentists, and we are equally comfortable for our dentists to also work at other dental practices.

Will this lead to managed care?

Our dentists have full clinical autonomy. We are focused on providing the very best patient care, so in our centres the ‘dentist’s call’ is the only call regarding treatment.

Who can go to HBF Dental?

Our dental centres are available to anyone, not just HBF members, and our members will always have choice of where they go for dental care.

Our plan is to open 15 HBF dental centres in metropolitan and regional WA in the next three years. We will never have enough practices to service our whole membership (around 900,000 members in WA), so we will continue to encourage our members to visit a dentist that is part of the HBF Member Plus provider network – be that one of our centres, another dental chain or an independent practice.

Which centres are in the pipeline?

We opened our first HBF Dental at Lakeside Joondalup shopping centre in February and our second at the Galleria shopping centre in Morley in April. Plans are underway for centres to open in Mandurah, Karrinyup and Cannington later this year.

We intend to continue to open practices in major shopping centres in response to our members’ desire for ease of access. Lakeside Joondalup had 300 online bookings at the time of opening, and 500 within our first two weeks.

Will HBF move into other health services?

Yes, dental is the first, but we are looking at moving into other areas of health that will add value for our members and help positively impact their overall health.

When I think back to my medical training, I recall only one lecture on oral health. How times have changed. Nowadays, we are abundantly aware of the impact oral health has on general health.

Through HBF’s relationship with PSG, we have a wealth of educational material that we intend to share with our members to highlight this important health message. It is an exciting time at HBF, and we look forward to being an active contributor to the WA healthcare system.

JULY 2021 | 39

Need an Opinion?

Ask an expert!

Expert imaging plays an integral part in the multi-disciplinary management of prostate cancer.

Leaders in Medical Imaging Booragoon • Midland Nedlands, Hollywood Consulting Centre Joondalup, Shenton House • Nollamara Murdoch • Subiaco

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GUEST COLUMN

COVID lessons for health education The pandemic has led to nimble innovation in the health education sector that will stand the test of time, writes Professor Sandra Carr.

The arrival of COVID-19 led to a swift response from in-person to remote learning and online assessment so that students could continue with their studies in some form.

working hard and creatively to teach to the same standards, so were patient and collaborative and took responsibility for being selfdirected, adult learners.

Many educators in the health professions are talking about how the pandemic has progressed education to a place we have been trying to reach for some time. A place with more blended learning, that in many instances are studentcentred, authentic and encouraging collaborative learning.

This was most challenging around the learning activities students engage in to prepare for clinical placements, actually engaging in clinical placements or developing the personal and professional attributes of the health care professional.

Educators quickly recognised the need to create online learning environments that promoted problem solving (clinical reasoning) and replicated small group discussions to support professional values formation and to maintain student engagement.

The initial response of students and their teachers was one of anxiety and fear. Deterioration in mental wellbeing since the onset of COVID-19 was initially reported by many students and was one of the main concerns for teachers.

Some student evaluations reported the main negative impacts as effects on social connectedness, success in their studies and stress levels. Concerns related to uncertainty about returning to normal and graduation have also been expressed. We aimed to minimise the period of disruption and reassure and support students through regular and transparent communication to ensure their academic goals were achieved where able.

skills such as respiratory system examinations, worked with other students through online platforms and recorded their performance to send to others for peer review and feedback, thereby enhancing their own learning.

When engaging in evaluation around the impact of COVID, most students surveyed returned high scores on scales measuring socialecological resilience illustrating their adaptive response to adversity, practical adjustment and more stable emotional responding.

Initially students could not attend clinical placements, which for some has meant a delay in the achievement of skills through workplace experience but this has now been rectified with clinical placement providers generally responding to accommodate additional or extraordinary placements for final year students.

Once reassured, many students demonstrated their capacity to adapt, changing rapidly their approach to learning to achieve and problem-solve and this extended to international offshore students.

Of course, for some, the anxiety was more overwhelming, but they were supported with frequent and consistent communication and identification of avenues of support along with adjustments to assessments and permission to take leave of absences when required.

Many looked for creative ways to respond and made the best of what they had available during lockdown periods. For example, they engaged family members to practise history taking and clinical examination

It is worth reflecting on the approaches that worked during this time. Communication and flexibility on the part of educators and students were key. Students recognised that teachers were

MEDICAL FORUM | MEN 'S HEALTH

For some schools the use of online simulation with virtual and augmented reality or gamification has progressed more quickly and there has been a shift with the use of telehealth not only for delivery of health care but also for education.

However, there are things to be cautious about.

As we move more deliberately from on-campus to remote learning, issues related to access and equity are raised. Universities have also needed to explore cybersecurity to ensure continuity of teaching and learning. What methods work best in a remote environment will differ by discipline and the technology available, but more support for teachers in the use of technology and how to share best practice is required.

My experience suggests that, even with its challenges, it was a success. Despite restrictions and compromise the students reported beneficial aspects to working online and demonstrated a sense of camaraderie and professionalism while developing digital learning skills that are proving essential for learners and applicable for health professionals in the 21st century.

ED: Professor Carr is head of the Division of Health Professions Education at UWA.

JULY 2021 | 41

Prostate

Kidney

Bladder

Andrology

Incontinence

Robotics

Female Urology

Stones

Fertility

Multidisciplinary

4TH ANNUAL

GP UROLOGY MASTERCLASS

Topics Discussed Women’s Health | Men’s Health Urological Cancer | PSA and Mesh Update Venue Perth Convention Centre Presenters Included Guest Speakers Patient Advocates Dr Ahmed Kazmi

Perth Urology welcomed over 200 delegates to their fourth annual Masterclass at the Perth Convention Centre in June. The event was warmly received by those who attended, and GPs were eligible to register for RACGP accredited activity clinical audit.

Gold sponsors for 2021 are our two main hospital partners Ramsay Health Care and St John of God Health Care.

We further acknowledge the very strong support of our Silver and Bronze sponsors.

GOLD SPONSORS

SILVER SPONSORS

BRONZE SPONSORS

Working together to provide comprehensive urological care

www.perthurologyclinic.com.au 42 | JULY 2021

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OPINION BACK TO CONTENTS

Dr Joe Kosterich | Clinical Editor

A different gender gap One gender gap gets very little attention.

That is the gap in health outcomes where males have a lower life expectancy, higher rates of heart disease, type 2 diabetes, stroke and a host of other medical problems. The rate of male suicide is around three times that of females.

As doctors we spend our time helping others with their health and we are not always that great at looking after our own. I would urge you all to read the article on doctors’ mental health. More importantly, make sure you are looking after your own health and maybe consider checking in on colleagues with a simple – how are you doing or are you OK?

There are many reasons for this – some are modifiable and others not so much. What is notable is the lack of interest in the subject by those who are usually outraged by any discrepancy between different groups in society.

The ‘long tail’ of COVID-19 restrictions may see the suicide rate and discrepancy between the sexes rise further. There have been predictions (which hopefully are wrong) of a 50% increase in suicide over the next five years. Disproportionately it is males who have been affected by restrictions as they are more likely to do work which cannot be done from home (e.g. drive a truck or lay bricks) and are more likely to own a small business.

Females are more likely to work in the government sector or in roles which can be done from home (e.g. teaching, administration, law).

Now before you all scream, I am simply highlighting the reality of the situation and not seeking to point the finger at anyone or anything. If we don’t acknowledge that there is a problem, we will never be able to fix or even improve it.

This month we have clinical articles which examines different aspect of prostate cancer including preparation and also rehabilitation. Sleep apnoea and obesity affects both sexes but are more prevalent in males. Conversely, we look at lipoedema which affects almost exclusively females. For something completely different, unconscious bias is considered.

As doctors we spend our time helping others with their health and we are not always that great at looking after our own. I would urge you all to read the article on doctors’ mental health. More importantly, make sure you are looking after your own health and maybe consider checking in on colleagues with a simple – how are you doing or are you OK? The changing narrative around the origins of COVID-19 reminds us that genuine science is never settled. By its nature scientific inquiry starts with the premise that what we currently hold to be true is not and it must be either verified or discarded. As Tommy Lee Jones asks Will Smith in the original Men in Black – “What will you know tomorrow?”

MEDICAL FORUM | MEN 'S HEALTH

JULY 2021 | 43

Lipoedema – a common condition with common misconceptions

By Dr Adrian Brooks, Plastic Surgeon, Belmont Lipoedema was first described in 1940, yet very little is understood about the disorder affecting about one in 10 women. It’s known as ‘adiposis dolorosa’ or painful fat.

Patients will often describe themselves as being wholly disproportionate between top and bottom halves. Little is known of the cause and few doctors and therapists are able to diagnose and differentiate from lymphoedema and these patients are frequently misdiagnosed as obese. In fact, it was a patient who explained the disease to me several years ago.

The disease almost exclusively affects women who are left to run the gauntlet of health professionals, being judged as overweight, sedentary or simply from families with ‘big legs’. With progression, these women are ‘fat shamed’ and suffer significant psychological distress, sometimes developing secondary eating disorders.

In lipoedema, the fat cell hypertrophy is resistant to calorie restriction, bariatric surgery, or exercise. It is a disease of the peripheries and diabetes rarely occurs in these women. Typically, it affects the legs with about 30% also involving the arms, always with sparing of the hands and feet often with a cuff at the ankle or wrist. It ought to be and is easily distinguished from lymphoedema, although both can occur together (see Table 1).

The medial thigh following extensive water-assisted liposuction and skin only excision showing the preserved fibrous network containing lymphatics and superficial venous network.

Key messages

Lipoedema is an often unrecognised progressive condition

Women are mainly affected Better awareness will lead to better patient outcomes.

and the skin feels cold. In addition, there is no response to diet, exercise, or elevation, and it is worsened by orthostasis after exercise when hot.

Diagnostic criteria

There are five types (describing distribution) and three stages (describing skin appearance and fat consistency). Type one involves pelvis, buttocks and hips, type two buttocks to knees with medial knee fat pads, type three extends to the ankles, type four involves the arms and type five is isolated to the lower leg.

It is bilateral and symmetrical (feet spared), there is pain with pressure, but no pitting oedema, easy bruising,

In stage one there is uneven skin surface with small pearls under the skin, stage two has large growths of

Table 1

Lipoedema

Lymphoedema

Sex

Female

Both

Distribution

Bilateral extremity

Uni or bilateral

Oedema

Non-pitting, not altered by elevation

Pitting, improved by elevation

Turgor

Soft

Firm

Pain

Tender to touch

Non-tender

Infection

Rare

Common

44 | JULY 2021

nodular fat and stage three is lipolymphoedema.

The pathophysiology has swelling initially due to fat hypertrophy and hyperplasia and increased interstitial tissue fluid. Early on, the lymphatic system functions well but with progression increased fat volume and pressure can overwhelm the lymphatics and lipo-lymphoedema results. Finally, the subdermal capillary network appears to become fragile and easy bruising results.

Management Lipoedema is a progressive condition which cannot be cured. Treatment (multimodal and multi-disciplinary) is aimed at supporting lymphatic flow. Involvement of a lipoedema therapist is essential, employing manual lymphatic drainage (MLD), compression garments and sequential pneumatic compression devices (LymphaPress).

Evidence for dietary change helping this condition is lacking but the majority of patients follow a keto diet and exercise regularly to help prevent generalised obesity, which is a common problem as patients can become depressed or disheartened by a lack of understanding and empathy in the general medical community.

Surgical management is reserved for selected cases and requires the patients to be optimised first using continued on Page 45

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CLINICAL UPDATE

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Treatment options for localised prostate cancer

By Dr Tom Shannon, Urologist, Hollywood After a diagnosis of prostate cancer, many men will turn to their GP for advice on treatment choice. Below is a step-by-step guide to help you achieve the best outcomes for them by asking four questions.

4+3 = 7

Q1 What is the grade and stage of the cancer?

Patients should have a copy of their pathology report to answer this question.

Grade is how aggressive the cancer is. This will tell you how fast it will grow and risk of spread. The Gleason grade is still used, but ISUP scores are becoming more common as they are easier to understand and correlate better to risk.

Stage is how advanced the cancer is and is a function of time. T2 cancers are assumed confined and T3 extend beyond the prostate. To determine nodal and bony stage needs further scans, however, recent advances may still permit cure in more advanced disease.

Q2 Does the cancer really need treatment?

Prostate cancer is the only cancer where active surveillance is commonly practised and this can be a good option for some men. The ProTect study followed

Gleason Grade / 10

ISUP / 5

Risk

6

1

Low

3+4 = 7

2

Low Moderate

3

High Moderate

8

4

High

9 -10

5

Very High

men with largely low risk cancers (ISUP 1 and some ISUP 2) for 10 years. Equal survival was seen with treatment or observation, although more bony metastases developed in the untreated group. Older men with medical problems and lowrisk disease probably don’t need treatment.

Q3 If we treat, is a cure needed or is control enough?

Cure is desirable when there are more than 10 years life expectancy or with more aggressive disease that is more likely to escape. Cure reduces the need for ADT (chemical castration) and chemotherapy, improving QoL over time.

Surgery – cure is achieved if all the cancer cells are removed, proven by clear margins and an undetectable PSA. Stage, not grade, determines resectability. With accurate MRI staging and robotic keyhole surgery, more cancers are curable.

DXT / ADT – together they achieve control through testosterone suppression and dose dependent radiation induced oxidative tissue necrosis. Devascularisation effects reduce the risk of recurrence and although cancer cells are often still present, durable remissions are expected. Advances in radiation technology can increase dose to target and reduce the dose to other organs. (Image guided IMRT / Cyberknife) Seed brachytherapy has control rates equal to surgery but is only suitable for low to moderate risk disease.

Surgery vs radiotherapy If a patient is seeking cure, then surgery is best. They must understand they will have a period of incontinence that is likely to settle with time. Surgery continued on Page 47

Lipoedema – a common condition with common misconceptions continued from Page 44 the above therapies. Removing the painful lipoedema fat using the gentlest form of liposuction and employing lymphatic sparring techniques involves water-assisted liposuction. Removing this diseased fatty tissue has been shown to reduce pain and slow disease progression.

A downside is extensive skin laxity and so I routinely perform skin tightening but only after extensive MEDICAL FORUM | MEN 'S HEALTH

liposuction. No fat is resected, thus preserving the subcutaneous fibrous network containing the lymphatics.

The biggest problems facing these women is lack of awareness in the medical community. Many join online groups led by established lipoedema sufferers, diagnosing, and educating themselves. Early diagnosis helps slow disease progression and can prevent the debilitating later stages when pain and fatty deposits limit movement.

Currently Medicare does not recognise lipoedema as a medical

condition. Limited knowledge has seen these women often travel overseas for treatment available in Perth. Hopefully with raised awareness Medicare will recognise treatment for this chronically progressive, painful, psychologically damaging condition to become cheaper and more readily available for these women.

Author competing interests – The author is the only WA provider performing bilateral whole-limb, water-assisted liposuction and skin excision combined.

JULY 2021 | 45

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Treatment options for localised prostate cancer continued from Page 45 can help incontinence. They will have impotence that requires rehabilitation and may not recover if their cancer is locally advanced. Cure requires no further treatment and men live with normal testosterone levels. Cure is not always achieved, and adjuvant DXT/ ADT may be needed. Success is surgeon dependent.

If control is all that is needed or patients wish to avoid incontinence or anaesthetic risks, DXT / ADT should be seriously considered. The ideal patient will have moderate risk disease and be older. Low risk disease can be watched.

Overweight patients with significant co-morbidities are more likely to be sent for DXT / ADT to avoid an anaesthetic, but in our experience significant weight loss will correct most of these factors to allow surgery and improve QoL and morbidity long term.

For moderate to high-risk disease there is consistent data showing improved cancer specific and all-cause mortality with surgery over radiotherapy. The average life expectancy of a 65-year-old man is 20 years. About 75% of WA cancers are ISUP2 or more making surgery the treatment of choice for many.

QoL is improved by avoiding ADT or chemotherapy, but initial side effects may be worse.

bleeding, second cancers, urethral strictures and erectile dysfunction.

Radiation damage cannot be reversed. Local failure is more common in high-risk disease and can lead to ureteric obstruction and renal failure. Additional local treatment is usually not possible. Isolated metastases after local control can be treated, as in surgery.

ADT is routinely used for 6-24 months with DXT. Side effects include loss of muscle, central obesity, osteoporosis, tiredness, depression, altered sleep, increased rates of dementia, CV disease, metabolic syndrome and sexual dysfunction. Non cancer death rates are higher if ADT is used.

Testosterone cannot be restored after radiotherapy, as dormant cancer is still present.

If cure is the goal, yes. If control is the goal, treatment may be delayed in most cases, especially in older men to avoid ADT.

Radiotherapy side effects include tiredness, radiation cystitis, proctitis (rare with rectal spacing), LUTS,

Q4 Do we have to treat now?

Although a prostate cancer management is highly specialised, the best decisions will come from a team approach. Your understanding of the patient and their goals and life expectancy is a valuable addition to the decision tree. Cure vs control gives us a helpful base from which to make treatment decisions.

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P 08 9327 1100 | mounthospital.com.au |

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JULY 2021 | 47

By Dr Julie Manasseh, GP & Obesity specialist, Mt Hawthorn Middle-aged men over 45 will commonly be diagnosed as being overweight/obese, mildly hypertensive and having high cholesterol and/or triglycerides and impaired fasting glucose on blood tests. The doctor would then prescribe an antihypertensive medication and a statin and advise the patient that he needs to lose weight.

Managing metabolic syndrome by medical weight loss is an alternative option to commencing medication immediately on diagnosis.

The increasing prevalence of obesity has resulted in increasing prevalence of metabolic syndrome (MetS) affecting up to 25% of the world’s population and one in three people over 25 years in Australia.

MetS is a cluster of cardiovascular risk factors comprising central abdominal obesity, insulin resistance and dyslipidaemia associated with a proinflammatory and prothrombotic state. The clinical significance of MetS is that individuals with it are up to three times more likely to develop cardiovascular disease and up to five times more likely to develop Type 2 diabetes, than individuals without it MetS is infrequently diagnosed in Australian general practice, possibly due to the fact that waist circumference is infrequently recorded (under 1 in 5 patients).

Key messages

Metabolic syndrome is common but under-recognised

Take a detailed weight history Medical weight loss is effective management.

Abdominal obesity is more highly correlated with metabolic risk factors than elevated BMI. Therefore, measurement of waist circumference (WC) is important to identify abdominal obesity which is above 102cm (men) and above 88cm (women) (see Table 1).

progression to Type 2 diabetes and reduce obesity-related comorbidities. In more practical terms, weight loss may obviate the need for prescription of antihypertensive and statin medications.

The ideal management of MetS is weight loss and lifestyle interventions to reduce central obesity. The goal is to achieve a 5-10% or greater reduction in weight over 6-12 months. This can significantly reduce the severity of hypertension or dyslipidaemia, reduce cardiovascular risk and

I find patients are often well motivated to commit to losing weight once they have been diagnosed with MetS, particularly when they realise that if they lose weight, they may not have to take antihypertensive or statin medication.

48 | JULY 2021

Management approach

It is important to take a comprehensive weight history including factors which have led to weight gain (unhealthy eating habits, stress/comfort eating) and previous weight loss attempts.

Mental health problems such as depression and anxiety, sleep problems and stress management need to be addressed as these are major contributing factors to weight gain. There is a high incidence of obesity in patients with mental health problems.

Review of the patient’s current medications is important to identify those that lead to weight gain. Common culprits in the antidepressant category are mirtazapine and sertraline, and antipsychotic medications such as olanzapine, clozapine, and quetiapine. Weight-neutral alternatives include escitalopram, desvenlafaxine and other SSRI/ SNRI antidepressants and atypical MEDICAL FORUM | MEN 'S HEALTH

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Management of Metabolic Syndrome

Table 1: ATP III Clinical Criteria for the Metabolic Syndrome

Topiramate and semaglutide are used off label. Combinations of medications (e.g., phentermine/ topiramate.) can also be used.

Risk Factor Defining Level Abdominal obesity (waist circumference)

HDL cholesterol

Men

Men

>102 cm

<1 mmol/L

Women

>88 cm

Women

<1.3 mmol/L

Triglycerides

>1.7 mmol/L

BP

>130/85 mm Hg

Fasting glucose

>6.1 mmol/L

antipsychotics (e.g., aripiprazole, lurasidone).

It is also important to address sleep problems and stress management, given that stress or comfort eating is a major source of weight gain for some patients.

Appetite suppressant medications can be considered to assist with weight loss. The choice of medication should be individualised to the patient.

Weight loss medications Phentermine is an adrenergic agonist which has side effects include insomnia, palpitations, and irritability. It is best avoided in those with anxiety and insomnia.

Bupropion/Naltrexone is a dopamine/noradrenaline reuptake inhibitor and an opioid receptor antagonist. It is a good choice for patients who are stress/ comfort eaters and who drink a lot of alcohol, and who have some anxiety/depression as it reduces food and alcohol cravings, and bupropion is also an atypical antidepressant.

Liraglutide is a glucagon-like peptide receptor (GLP-1) agonist acting centrally to reduce appetite and increase satiety. Side effects include nausea, diarrhoea, constipation, and abdominal discomfort. It is a good choice for those who have a large appetite.

Counselling about diet, exercise and behaviour change is critical.

The aim is to reduce kilojoules by approximately 2100 a day whilst maintaining daily protein intake of approximately 1g/kg body weight, to reduce the risk of loss of muscle mass.

A very low carbohydrate diet (VLCD) using meal replacement shakes can be used for 12 weeks for rapid initial weight loss.

In summary, medical weight loss intervention resulting in loss of 5-10% or more of the patient’s initial weight has been shown to be effective in regressing hypertension, dyslipidaemia and insulin resistance associated with metabolic syndrome.

Author competing interests- nil

Covid Alert: Do not postpone or delay screening mammograms

BreastScreen WA does not recommend that women delay or reschedule their breast cancer screening mammogram appointments.

There is no evidence that the COVID-19 disease or COVID-19 vaccination has any adverse effect on the breast tissue. Some recently published medical studies have reported a small incidence of mild lymph gland swelling in the axilla on the side of the inoculation for up to 6 weeks after the vaccination.

BreastScreen WA is asking your patient questions about the date, arm and brand of COVID-19 inoculation, so the consultant radiologist has this information when they interpret your patient’s mammogram images. If you have any queries about this matter, please contact BreastScreen WA’s Liaison GP at eric.khong@health.wa.gov.au

Women may book online www.breastscreen.health.wa.gov.au or phone 13 20 50 Medical Forum_Covid vaccine and screening don't delay 2021.indd 1

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Restoring quality of life after prostate cancer treatment

By Dr David Sofield, Urologist, Palmyra One in seven Australian men will be diagnosed with prostate cancer in their lifetime. Early diagnosis is associated with prolonged survival – with treatment 95% will live at least five years, and in younger men 30 years or more.

Curative treatment with surgery (radical prostatectomy (RP) and radiotherapy (RT)) is effective, but side effects are common and with major impact on quality of life.

Urinary incontinence (UI) occurs in 5-40%, and Erectile Dysfunction (ED) in up to 80%. Fortunately, very effective treatments are available for UI and ED postprostate cancer treatment. Neither needs to be accepted as inevitable consequences of cancer treatment and quality of life can be restored very effectively in most cases.

Access to such treatments is unfortunately hindered by a lack of awareness amongst patients and their GPs.

Erectile dysfunction (ED) ED is a common consequence of RP and RT for prostate cancer.

This is commonly pre-existing, with 50% at age 50 having some ED, increasing 10% per decade.

Post-surgery most will have severe ED, which may improve over 12-36 months.

In recent years understanding of the anatomy of the erectile (cavernous) nerves has improved alongside the advent of roboticassisted surgery which enables improved visualisation and

Key messages

UI and ED are common following prostate cancer treatment and significantly impact quality of life.

These issues need not be accepted and can be managed effectively in specialised centres.

Awareness of treatment options is lacking and is key to men accessing care. dissection of the neurovascular bundles. Erectile nerve sparing correlates with recovery but is not always possible with locally advanced or high-grade cancers.

ED management can be nonsurgical. This includes penile rehabilitation, early post-op use of PDE5 inhibitors, vacuum device and intracavernosal injections to maintain penile tissue health whilst awaiting nerve function recovery.

Surgical management with a penile prosthesis is highly effective where non-surgical means are ineffective or unsatisfactory.

Prostheses may be inflatable (very effective, high patient and partner satisfaction), or malleable (simpler but also less effective).

Complications may include parts failure, infection and erosion.

Urinary Incontinence Any amount of uncontrolled urinary leakage is significant and can have a major impact on quality of life.

Radical prostatectomy results

in stress incontinence-urinary leakage which occurs in response to stress on the bladder (e.g., lifting, coughing, laughing etc). This is due to weakness of the voluntary External Urinary Sphincter (EUS), which resides at the apex of the prostate, due to direct injury and denervation, particularly in cases of locally advanced cancer where wide resection is necessary.

Radiotherapy can also result in UI but typically this is due to contraction of the bladder with loss of storage capacity in addition to EUS injury and typically develops over a period of years post treatment and can be very challenging to manage.

Assessment involves history, 24hour pad weights to accurately gauge loss and urodynamic testing. Non-surgical options for incontinence include pads, penile clamps and physiotherapy (pelvic floor muscle strengthening).

Ideally patients will see a physio with expertise in male pelvic floor function preoperatively as well as postoperatively. Most men will recover continence within three months.

Surgery is indicated where physiotherapy fails to correct incontinence within six months of prostatectomy. Options include a urethral sling and artificial urinary sphincter. The sub-urethral sling is effective for mild SUI (three pads or under 300ml loss per 24 hours) with 90% of well-selected patients regaining full continence. The sling is a simple, passive device requiring no patient input to operate and results are very durable.

An artificial urinary sphincter, which is patient operated, is highly effective in severe incontinence.

The complication rate (parts failure, infection, erosion) is higher than with a sling. This device is life-changing for men with severe incontinence and has a very high long-term durability.

Author competing interests – nil

Images courtesy of Boston Scientific

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JULY 2021 | 51

Primary hyperparathyroidism

By A/Prof Ming Khoon Yew, Endocrine Surgeon, Subiaco In general practice, primary hyperparathyroidism may occur as commonly as one in 2000 patients. This disorder is characterised by an elevated serum calcium, an elevated or inappropriately normal serum PTH, and frequently low serum phosphate due to renal phosphate wasting.

The signs and symptoms of primary hyperparathyroidism are classically summarised by "stones, bones, abdominal groans, thrones and psychiatric overtones”. These manifestations reflect end organ damage as illustrated in Table 1. In today’s practice, most patients are asymptomatic, and are identified on routine biochemistry, or during investigation for secondary causes of osteoporosis. Many patients may have subtle symptoms of fatigue and weakness that resolve after parathyroidectomy.

The key to patient management is having a clear and unequivocal biochemical diagnosis. Should there be any doubt with regards to the biochemistry, then performing a fasting metabolic bone study (a consolidated serum and urine assay) is usually diagnostic.

In 85% of patients with primary hyperparathyroidism, the cause is a single parathyroid adenoma.

The remaining 15% of patients have multiglandular disease.

Surgical removal of the offending parathyroid gland (or glands) is generally curative. The reason parathyroidectomy is only curative in over 98% patients with one procedure, is due to the occasional ectopic parathyroid adenoma which can be challenging to find.

Parathyroidectomy is indicated for all symptomatic patients, should be considered for most asymptomatic patients, and is more cost-effective than observation or pharmacologic therapy.

Symptomatic patients are expected to derive clear benefits from curative parathyroidectomy, and patients considered to be

52 | JULY 2021

Massive retrosternal parathyroid adenoma Table 1: Manifestations of Primary Hyperparathyroidism Stones

Renal calculi; nephrocalcinosis; diabetes insipidus; renal failure

Bones

Osteoporosis; Fractures; Osteitis Fibrosa Cystica

Abdominal Groans

Indigestion; Peptic Ulcer; Pancreatitis

Thrones

Constipation and polyuria

Psychiatric overtones

Lethargy; fatigue; depression; memory loss; psychosis; ataxia; delirium

asymptomatic frequently report improvement in quality-of-life indexes. Long-term hypercalcemia should be avoided because of potential end organ damage.

Surgeons who regularly perform parathyroidectomy should have a complication rate of under 1%.

However, the most important imaging modality prior to surgery would likely be neck ultrasound.

The key role of preoperative neck ultrasound is to exclude, or evaluate, any underlying incidental thyroid lesions prior to neck surgery.

Imaging and localisation

One of the guiding principles in thyroid and parathyroid surgery is to try to perform any surgery only once. The reason is that re-operative neck surgery does carry a higher risk of morbidity.

Therefore, it would be prudent to be aware of any incidental thyroid

The key indication for surgery is a concrete diagnosis and patient fitness for surgery. Many imaging modalities are available to assist with surgical planning and to provide the patient with differing surgical options.

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rate for cure and very low potential for morbidity. Prospectively collected audit results of our local West Australian tertiary hospital endocrine surgeons demonstrates complication rates of under 1%.

Intrathyroid parathyroid adenoma

Key messages

Unequivocal biochemical diagnosis is key

Primary hyperparathyroidism is curative in the majority of suitable surgical candidates

Evaluation and management by an experienced parathyroid surgeon is critical.

lesions so that if thyroidectomy is indicated, this is also performed at the same procedure. Additionally, ultrasound performs moderately well in identifying parathyroid adenomas.

Parathyroid localisation studies attempt to identify the diseased parathyroid gland/glands.

For confirmation of cure, serum calcium and parathyroid hormone assays should be performed six and 12 months after surgery. The key indicator for cure is maintenance of eucalcaemia. Serum Parathyroid hormone levels can sometimes be elevated in the presence of eucalcaemia. This phenomenon may occur in about 20% of patients.

This likely relates to a degree of vitamin D or calcium deficiency.

Parathyroid adenoma

Commonly available localisation studies include 4D CT / parathyroid CT scan; and sestamibi scan.

Unfortunately, none of these scans are perfect. They are operator dependent, roughly 30% of scans are not able to localise, and even when successful localisation occurs, false positives do occur in roughly 10% of patients.

However, a positive localisation study does allow the patient to have a more focused, minimally invasive operation, which is reflected in either a smaller neck incision or a scarless transoral endoscopic approach.

Vitamin D and calcium supplementation may be useful and annual repeat serum calcium and parathyroid assays would be worthwhile if abnormalities persist.

A subgroup of these patients may develop multiglandular parathyroid disease on long-term follow up, which may necessitate subsequent careful evaluation, and possible further intervention.

– References available on request Author competing interests – nil

Postoperative care Parathyroidectomy in the hands of an experienced parathyroid surgeon has a very high success

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Perth’s Prostate Cancer and BPH Centre Diagnosis – MRI and Transperineal Biopsy Counselling and Advice – Prostate Cancer Specialist Nurses (free service) Prehabilitation – Risk Assessment, Nutrition, Weight Loss, Exercise Expert Treatment – over 2000 cases experience / World Class results Rehabilitation – On site Continence Physiotherapist and Sexual Health Research – Exercise Medicine. Nutrition, Surgery and Radiotherapy Advocacy – Local Board Member PCFA LUTS Clinic – Open Access / Shared Care

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Phone: 9389 7696 Fax: 9386 1799

www.theprostateclinic.com.au 54 | JULY 2021

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How doctors can maintain good mental health

By Dr Andrew Jackson, Psychiatrist, Hollywood A targeted approach to improving our wellbeing and a thoughtful approach to managing the demands upon us can turn our work from a source of stress to a source of further wellbeing. Mental health statistics for Australian doctors are sobering with high rates of psychological distress, as well as depressive and anxiety disorders.

Work stress is often cited as a contributory factor and yet our unique work as doctors has the potential to contribute enormously to our mental wellbeing.

So, what’s going wrong and how can we change our experience of work from stressful to wonderful?

Stress is experienced when we perceive that the demands on us exceed our capacity to withstand them. We can therefore reduce our

Key messages

Doctors experience high rates of psychological distress

The PERMA+ acronym outlines components for mental health

Doctors can turn their work into a source of wellbeing.

experience of stress by increasing our resilience and/or reducing the demands upon us. We increase our resilience by improving our wellbeing.

Fortunately, we don’t need to speculate on how to improve our wellbeing. Decades of research has identified the key components that contribute to wellbeing and they are succinctly summarised by Seligman and his PERMA+ acronym.

Hypersomnolence An interactive virtual clinical masterclass on central disorders of hypersomnolence For physicians, psychologists, psychiatrists, neurologists, advanced trainees and general practitioners

Saturday 31 July 7.30am-1.30pm AWST

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Positive emotion Engagement – in activities that promote ‘flow’ and the ability to be present in the moment Relationships Meaning, purpose, a sense of being part of something bigger than ourselves Achievements - working towards goals as much as achieving them + exercise, nutrition, sleep and optimism.

By enacting on this evidence base outside of our work, we can build resilience. Furthermore, being a doctor provides incredible opportunities to find PERMA+ within our work itself. At work we can achieve flow to build relationships,

continued on Page 56

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JULY 2021 | 55

Oral appliances in adult obstructive sleep apnoea

By Dr Amanda Phoon Nguyen, Oral Medicine Specialist, Perth Obstructive sleep apnoea (OSA) and resultant sleep fragmentation and oxygen desaturation have been associated with daytime sleepiness, cognitive impairment, Type 2 diabetes, cardiovascular disease, stroke, increased risk of motor vehicle accidents and can have significant effects on quality of life. It can affect 4% to 9% of the middle-aged population (up to 34% of men in some studies) and is two to three times more common in older individuals than those under 64 years.

Sufferers require an effective and long-term treatment. The gold standard is to pneumatically splint the upper airway during sleep using continuous positive airway pressure (CPAP). Whilst highly efficacious in preventing upper airway collapse, providing a successful outcome in over 95% of users, as many as 50%

Key messages

A mandibular advancement device may be used to treat OSA

When oral appliance therapy is prescribed by a sleep physician, a qualified dentist should construct a custom, titratable appliance

Periodic review is important to monitor for side effects. of patients cannot tolerate CPAP treatment.

Many look to alternative treatment options such as a mandibular advancement device (MAD) of which there are numerous types.

Generally MAD aims to create a widening of the upper airway configuration by posturing the mandible forward. This action changes the dimensions of the

upper airway, including the hypopharynx, the oropharynx, and the nasopharynx. Imaging studies have shown the upper airway space expands, most notably in the lateral dimension of the velopharyngeal region.

MADs is hypothesised to increase muscular tonus by increasing passive muscle tension in the pharyngeal wall, thereby reducing soft tissue vibration and the turbulent airflow.

The clinical practice guideline of the American Academy of Sleep Medicine (AASM) and American Academy of Dental Sleep Medicine (AADSM) recommends that adult patients without OSA requesting treatment of primary snoring be prescribed oral appliances, rather than no therapy. For adults with OSA, both oral appliances and CPAP can significantly reduce

How doctors can maintain good mental health continued from Page 55 to find meaning and to work towards achieving goals.

The notion of deliberately reducing the demands upon us may seem quaint and impossible to many doctors at first glance. However, I would argue that not only is it possible, but it is also actually our responsibility as doctors to regulate the demands upon us. Optimal patient care requires us to be mentally healthy ourselves.

Beyond altruism, there are many forces driving us to work longer and faster. It is up to us to understand these and to regulate them – not just for our sake, but for the sake of our patients. Let’s examine a few of these.

1) Health system pressures A system that is perpetually under resourced will always ask more of its doctors. It is up to us to understand 56 | JULY 2021

this and to accept the limits of our individual capacity to meet these apparently endless needs. By acknowledging our limits within a large, complex system, we are more able to enjoy our work within it.

2) Cultural, parental and family pressures These (often unconscious and unspoken) influences are powerful forces that relate to the attainment of status and prestige. They have influenced us all since childhood and may have played a role in us selecting a career in medicine in the first place. By consciously examining the role these influences may have played, we are empowered to choose our own path.

A ‘people pleaser’ will often find it difficult to say no to patient requests and referrals. This personality trait, so common in doctors, can be an important contributor to burnout when not carefully managed.

3) Financial pressures (large debt, expensive lifestyle) Financial incentives relate to status and security. By asking ourselves “how much income and wealth do I really need”, we can find the balance that enables our work to contribute to our wellbeing, not reduce it.

Research into the association between income, wealth and wellbeing is inconclusive, with many studies failing to find a correlation, let alone causation.

By carefully reflecting on how these invisible forces impact us as individuals, we can be better placed to manage the demands upon us.

Actively managing our workload, and improving our resilience via the PERMA + approach, our unique work can be a source of wellbeing, not stress.

Author competing interests – nil

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CLINICAL UPDATE chronically impaired nasal ventilation or frequent travellers (preferring the convenience of a MAD). Consultation with the patient’s sleep physician is appropriate.

Different types of Mandibular advancement devices and a George Gauge device (F) used to measure the range of mandibular protrusion

the apnoea-hypopnea index/ respiratory disturbance index/ respiratory event index (AHI/ RDI/REI) across all levels of OSA severity in adult patients.

CPAP remains first line therapy for the treatment of adult patients with severe OSA. However, it is recommended that those intolerants of CPAP therapy or preferring alternate therapy be provided with an oral appliance, rather than no treatment.

MAD use may be more acceptable than CPAP for patients with

When oral appliance therapy is prescribed by a sleep physician, a qualified dentist who has further training in the area should construct a custom, titratable appliance over a non-custom oral device. Periodic review by the qualified dentist is important for dental related-side effects, including bite (occlusal) changes.

Potential side effects of a MAD include excessive salivation, dry mouth and pain or discomfort in the supporting teeth, oral mucosa, masticatory muscle and temporomandibular joint disorders (TMJD). They have been reported as temporary side effects during short and medium periods of oral appliance use. Mostly these side effects are transient and often treatable.

Long-term side effects include occlusal changes, most often without the presence of pain. In a few patients, persistent TMJD may result

in discontinuation of MAD therapy.

Other considerations before providing a MAD include the need to exclude active periodontal and dental disease, the amount of mandibular protrusion achievable by the patient, presence of mandibular teeth, dental wear, dentures or mouth breathing, patient preference, and potential for future combination therapy.

Broadly, the most common MAD devices may be classified as unconnected, those with front connectors, those with side connectors (Image D), tongue retaining devices and other. Nylon 3D printed MADs (Image E) are increasingly being used with good effect and are felt to be more comfortable that traditional acrylic devices (Image B, C). Bruxers may benefit from a MDSA device (front connector, Image A) which allows for side-to-side movements of the mandible often seen in bruxism. Edentulous patients may be suitable for a tongue retaining device.

Author competing interests – nil

Claremont Pain Clinic

Providing a Comprehensive Service for Chronic Pain Patients Dr David Holthouse Neurosurgeon/Pain Specialist FRACS FRACGP FPMFANZCA

Dr David Holthouse has a neurosurgical background and is a qualified GP. His major focus is procedural pain management.

He also has a keen interest in neurostimulation. David is part of the Workspine group and has a keen interest in workers compensation cases.

Dr Pat Coleman Anaesthetist/Pain Specialist FANZCA FPMFANZCA FRACGP DRCOG

Dr Pat Coleman is an anaesthetist as well as qualified GP, who has a FPMANZCA and is experienced in pain interventions such as spinal injections, rhizotomies and stimulators. He is also able to see cases with pain issues such as CRPS and post-surgical pain in any region of the body or other pain states.

Dr David Hamilton Pain Specialist/Anaesthetist BSc (Hons) MBChB MRCS FANZCA FFPMANZCA

Dr David Hamilton works as a Specialist Pain Medicine Physician at the Claremont Pain Clinic and a Specialist Anaesthetist at SJOG Midland. As a previous surgeon who has also completed the Fellowship in interventional pain procedures at SCGH, he is able to to incorporate all pain procedures, including neuromodulation, in to his holistic multidisciplinary approach to patient care.

About Claremont Pain Clinic • On-site clinical educator and a registered nurse experienced in pain • Focus on neurostimulation as a potential treatment and a comprehensive education program for stimulator candidates to attend • An affiliation with Pain Options – Specialist Physiotherapy • On-site pain/spinal physiotherapist who assists in the rehabilitation of pain patients and workers compensation patients • Close working relationship with a number of other spinal surgeons who are sub-specialists in fusion surgery and often assist in the workup and selection of patients for this surgery • Work closely with a clinical psychologist and psychiatrists with experience in pain management and pain conditions • We do not see patients with active MVIT claims, public liability cases or non-insured patients • We are unable to cater for drug addicted patients who should be referred to a public pain clinic

Workers Compensation • Workers compensation cases can be referred directly and will be dealt with quickly • Workers compensation consult and procedure slots set aside for cases to be seen urgently

Claremont Pain Clinic Phone: 9385 1323 Fax: 9463 6333 Email: reception@claremontpainclinic.com.au Address: 12/237 Stirling Highway, Claremont WA 6010 PO Box (please send all mail here): PO Box 563, Claremont WA 6910

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JULY 2021 | 57

A toolbox for prostate cancer rehabilitation and management

By Dr Jo Milios (PhD), Physiotherapist, West Leederville Erectile dysfunction and urinary and faecal incontinence are not topics normally discussed by men. However, it is important to know that the most common cancer experienced by men is prostate cancer and more than 1.2 million cases a year are diagnosed worldwide annually.

Rehabilitation is readily available to lessen these quality of life burdens but the what, where and how are the concerns for most men suddenly thrust into the world of cancer. A toolbox of skills should be mandatory for surviving well beyond treatment and, fortunately, good progress is being made.

Treatment for prostate cancer, if detected early, often results in a normal lifespan for most men diagnosed, but many side effects can be ongoing. Historically, however, men have been reluctant to seek testing which traditionally involved a digital rectal exam and confusing messages from GPs, as recommendations for PSA testing have long been controversial.

Conversation around the topic has also been relatively taboo, with most men reluctant to open up to their peers about problems in the bedroom or their private parts.

However, a new era is evolving in men’s health. With technology improving drastically over the past 15 years – including ultra-sensitive blood tests, multiparametric MRI scans, transperineal targeted biopsies (vs rectal approaches) robotic surgeries and sophisticated Cyberknife (surgical radiation) options – the opportunity to receive less invasive assessment and treatment has never been better.

This, coupled with improvements in drug therapy, exercise prescription and a better understanding of the psychological impacts of prostate cancer, means men should expect and receive better preparation, treatment and rehabilitation programs.

Rehabilitation should start with prehabilitation at the point of 58 | JULY 2021

Key messages

Urinary incontinence and erectile dysfunction after treatment for prostate cancer can be reduced

Rehabilitation starts at time of diagnosis

Exercise, both general and pelvic floor, is a key component. diagnosis. This can include improving fitness, weight loss and male pelvic floor exercises, particularly between biopsy and treatment. As most treatments – radical prostatectomy surgery or radiation therapy – will typically result in urinary incontinence and erectile dysfunction, learning how to perform contractions of the urinary sphincter and sexual muscles within the pelvic floor is imperative to minimising long-term leakage and impotency.

For patients receiving radiotherapy bowel issues are also commonplace but tend to occur after treatment has finished, which often comes as a surprise. Radiation may cause rectal bleeding, faecal incontinence and bowel leakage with flatulence.

These side effects can be despairing for men, who may feel they have ‘beaten’ the cancer only to find one to three years later, issues they never expected impact their every day.

Pelvic floor exercises also greatly assist in the rehabilitation of bowel incontinence, with contraction of the rectal sphincter the focus of treatment.

But there are gaps in knowledge.

Fortunately, research in prostate cancer has been prolific in the past decade with a strong focus on improving quality of life outcomes. A recent RCT in WA showed that 74% of men performing six sets of PFM exercises a day in standing were fully continent (i.e., no pads or urine leakage) within 12 weeks of surgery if they completed a five-week ‘prehabilitation’ program before surgery. Of the 100 men in the study, one in six were never incontinent

and had much faster recovery times with erectile function and return to sexual activity within three months of treatment.

With less incontinence, a faster return of sexual desire and confidence led to quicker commencement of penile rehabilitation strategies. This aspect of rehabilitation includes the use of medications, vacuum compression pumps and penile injections to improve blood flow and penis length which, if left untreated can lead to fibrosis and scar tissue development.

A little-known fact is that 16% of men following surgery and 12% following radiation will experience a penile deformity known as Peyronie’s disease. Penile pain, curvature and plaque formation tend to occur due to damage of erectile nerves that surround the prostate and, over many months, reduced blood flow results in tissue change. Early intervention can minimise this.

‘Exercise is medicine’ is the new mantra in cancer care and programs such as PROST! Exercise 4 Prostate Cancer.inc are providing professional, evidence-based programs in the community for men with prostate cancer.

Research shows 150 minutes per week of low intensity exercise such as walking and three hours of more vigorous exercise per week such as gym sessions that include cardio and resistance work can do much to enhance survivorship in cancer patients.

By exercising in peer support groups, the mood, muscle and mateship of men improves, ultimately reducing distress. For those in need, psychological support is available, but men’s health specialists are rare. Meanwhile, online resources, support groups and podcasts are helping to fill the rehabilitation toolbox.

Author competing interests- nil

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Recognising and tackling unconscious bias in clinical medicine

By Dr Ramya Raman GP, educator WAGPET & University of Notre Dame Unconscious cognitive processes influence, shape and alter human behaviour, beliefs and attitudes.

With no conscientious thinking, we archive and recover information to decipher and decode contexts, people and their behaviours.

Preconceived notions influence our judgments resulting in bias.

The term ‘bias’ refers to both tacit stereotypes and prejudices that mostly arise from the subconscious mind.

Unconscious bias in medical practitioners occurs in two key areas – clinical reasoning leading towards diagnosis and perceptions of patients. Notably the second, patient perception, influences subsequent interactions between medical practitioners and patients, and ensuing clinical decisions. How does bias work and where does it come from?

Two kinds of decision-making processes generally prevail that remain integrated in our teaching and practice of clinical reasoning.

Type 1 processes are fast driven by intuition, utilising less cognitive skills. These are the mental shortcuts or heuristics, which allow fast decision making. Type 2 processes involve decision making based on slower analytical methods that are consciously derived.

Many clinical decisions made using Type 1 processes lead themselves to errors. Despite the pitfalls of Type 1 processes, such pattern recognition and automatic decision making seem to be favoured as vitally necessary for human function.

Much research in human decision making strongly suggests that our intuitive biases are formed early in life, reinforced by social interactions, and influenced by our learning experiences.

Unconscious bias plays when a health-care professional intuitively decides and categorises a patient as a member of a group and applies stereotypical label, either positive or negative, to that individual.

Often, these are more likely to be MEDICAL FORUM | MEN 'S HEALTH

Key messages

Unconscious cognitive processes influence, shape and alter human behaviour, beliefs and attitudes

Unconscious beliefs about the patient play a pivotal role in interpersonal behaviour in a clinical context, interpretation of information, and ensuing decision making

Developing self-awareness of unconscious bias provides opportunities to evaluate the clinical interaction objectively, rendering better patient outcomes. activated when cognitive skills are challenged, by limitations on time and resources, compounded by physical and emotional stress.

Unconscious biases of concern are even more blatant in vulnerable groups. For example, minority ethnic groups, new immigrants, women, the elderly, children, individuals from lower socioeconomic sectors of the society, and those with low health literacy, mentally ill and sexual minorities.

Recent systematic reviews indicate implicit biases among clinicians and nurses are highly similar to the general population.

Conscious and unconscious beliefs about the patient play a pivotal role in interpersonal behavioural actions in a clinical context, interpretation of information, and the ensuing decision making. When unrecognised, the unconscious bias can lead to health management disparities.

How can we minimise unconscious bias while teaching clinical medicine?

Developing self-awareness of the unconscious bias and its control provides opportunities to evaluate the clinical interaction based on paying attention to our thought processes, responding to subtle cues, and knowing how they may influence our decisions.

Two key techniques First is relating to patients as individuals and not stereotypes.

Cultural training emphasises knowledge acquisition about common cultural groups (e.g., understanding care for patients of Aboriginal or Torres Strait Islander {ATSI} descent). This can promote reliance on stereotypes rather than individual information.

The teaching focus should be interacting with each patient as an individual with a set of social and cultural uniqueness and context.

For example, ATSI patients may not be comfortable having eye contact with the clinician during consultation, which may lead to lack of trust between the patient and the clinician. It would be more useful to learn to skilfully recognise this with the patient and build a cord of trust in a cross-cultural context.

Second is reflective practice.

Perspective-taking exercises (real or simulated) involving looking through the eyes of the patient, to consider how they may have perceived and interpreted the clinical interaction. Other reflective practices that have gained traction include imaginary exercises that counter common stereotypes and questions challenging assumptions during history taking.

Once a stereotype is activated, human nature focuses on confirming evidence (confirmatory bias) actively seeking and interpreting information that confirms the stereotype.

Understanding unconscious bias can help identify our judgments and this is likely to help deliver better patient outcomes.

– References available on request Author competing interests – nil

JULY 2021 | 59

Generations of Henschke dedication This iconic Australian producer in the Eden Valley of South Australia has over 150 years of family winemaking experience – and it shows.

It was in 2015 that I had a most amazing experience joining a Masters of Wine tour of southeast Australia – 20 produces in just nine days across three states – exhausting but exciting.

The greatest tasting we had was at Henschke in the Eden Valley of South Australia. So, when asked to review some of their wines for this article I was clearly very excited.

Henschke is widely regarded as the best medium-sized red wine producer in Australia and producing the greatest single vineyard wine in Australia – the Henschke Hill of Grace Eden Valley Shiraz.

So why the excitement?

By Craig Drummond – Master of Wine

For a number of reasons: their history for starters. One of Australia’s great wine dynasties began in 1842 with the arrival of Johann Henschke at Keyneton in the Eden Valley, a small Silesian (Lutheran) community. The first vines were planted in 1868.

Stephen (winemaker) and wife Prue (viticulturist) are the fifth generation.

They are the most charming and welcoming couple imaginable and now the family tradition is set with the sixth generation being groomed to keep alive the family tradition with Johann, Justine and Andreas all involved in the family business.

Then there are the vineyards. The ‘jewel in the crown’ is the estate vineyard at Keyneton in the Eden Valley – the ‘Hill of Grace’ – so named for the nearby Lutheran church of Gnadenberg, which translates as ‘Hill’ and ‘Grace’.

The vines are about 180 years old and the source of the greatest Henschke wines.

Added to this are other vineyards totaling 109ha across the Barossa Valley, Eden Valley and the Adelaide Hills. The major varieties are Shiraz, Cabernet Sauvignon and Riesling, but backed up by a number of other varieties.

Many of these vineyards are blessed with ageing vines, in particular, wonderful old Grenache vines.

And never underestimate the power of dedication – especially Stephen Henschke’s obsession with natural winemaking and Prue’s with organic and biodynamic viticulture.

A key to their success was their

60 | JULY 2021

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WINE REVIEW studies in Geysenheim, Germany, in the 1970s on isolation techniques, which involve isolating the best vines in the plot based on colour and healthy appearance.

The result has seen them produce some of Australia’s greatest wines.

Four red wines were tasted.

Collectively, and for the sake of avoiding repetition in my tasting notes, all four wines showed a common theme. Fruit flavours and characters abounded, reflecting vine maturity,

low yields, careful viticulture based on organic and biodynamic principles, and natural winemaking practices.

All wines show depth, ripeness, concentration and harmony. Add to this the adept use of oak. The oak is used as a vehicle as opposed to a style. It binds the wines, without being overt. Seasoned oak predominates, with only a small proportion of new oak, and generally in larger formats than the commonly used barrique.

The wines Henschke 2019 Henry’s Seven Barossa (rrp $37) Varietal makeup: Shiraz 74%, Grenache 16%, Mataro 8% and Viognier 2%, from Barossa and Eden Valleys Shiraz is fermented with the Viognier, the latter white grape gives the Shiraz an aromatic lift and more vibrant colour. Grenache and Mataro are fermented separately. Named in honour of Henry Evans who planted the first vineyard of seven acres (3ha) at Keyneton, Eden Valley in 1853.

Attractive ruby colour, the nose shows lifted aromatics, the Shiraz shines through with spicy blackberry, cedar and peppery notes. Palate shows spicy, juicy fruit with blackberry, white pepper and sage. Fine tannins and firm acid backbone give structural definition.

A great wine for current consumption, but with the power, concentration and structure to go another decade.

Henschke 2018 Johann’s Garden Barossa Valley (rrp $60) Varietal makeup: Grenache 77%, Mataro 19%, Shiraz 4% Johann is a common first name of the German Silesian pioneers of the Barossa, this wine being a tribute to them. This wine says ‘Grenache’ to me. Barossa has probably the oldest Grenache vines on the planet. Their low yielding, dry-grown fruit results in powerfully flavoured wines, and this is a great example of Barossa Grenache with its ethereal perfumed aromas of candy and roses, and its sweet-fruited flavours of bramble, redcurrant and red cherry. The addition of Mataro and Shiraz gives added structure and brings it all together. Great length and lingering sweet fruit finish.

This is my wine of the tasting for current drinking. Enjoyable now, but it has a long future.

Henschke 2016 Keyneton Euphonium Barossa (rrp $62) Varietal makeup: Shiraz 57%, Cabernet Sauvignon 30%, Merlot 7%, Cabernet Franc 6%.

Fruit from Eden and Barossa, the Shiraz vines being up to 50 years old.

A clever wine which marries the black fruits and spice of Aussie Shiraz with the cassis, herbs and mint of the Bordeaux varieties. Combines power with elegance. This is a 20-year wine.

Shows lifted vibrant aromas of dark plum, spices and cassis, leading on to a delicious palate of blackcurrant, black olive, mulberry and coffee grounds. Nicely integrated with intensity, balance and length. Enjoyable now, although cellaring will reward.

Henschke 2016 The Wheelwright Vineyard Eden Valley (rrp $130) This wine is a recent addition to the extensive Henschke range. It is a 100% single vineyard Shiraz from vines planted in 1968 on the Eden Valley estate vineyard. A beautiful high-quality Shiraz. I see it as a ‘sleeping giant’ as the fruit still needs to mellow and soften a bit more.

A couple of years in the cellar may be very rewarding. However, don’t let me put you off – it is a very exciting wine now.

Displays deep black/purple colour. Aromas of dark spices, sweet earth and roasted coffee bean. The flavours are rich, ripe and powerful, with blackberry, dark plum, bramble and nuances of dark chocolate. Grape tannins are ripe. Finishes complete/long with sweet fruit and clean acid. A wine of precision and personality.

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JULY 2021 | 61

The amazing life of honey Apiarist Rupert Phillips has dedicated his life to bees. Decades on he’s still fascinated by them and very much in love.

By Ara Jansen

From childhood curiosity to a passion and then a career and a business, bees have always kept Swan Valley apiarist Rupert Phillips under their buzzing spell.

Since becoming fascinated as a boy by a beehive and then spurred on to learn about beekeeping, Rupert hasn’t lost one drop of enthusiasm for it.

“It’s something I enjoy very much,” says Rupert. “I still have the same excitement looking after the bees.”

But as he goes on to explain, being a beekeeper is not simply looking after bees in a hive. It’s learning about the bush, its trees and flowers, the flowering cycles and climate changes. It’s about looking for patterns and signs which might allow improvements in where the hives are placed and how bees are bred. Rupert is even working on a mechanical invention to help move hives around more easily.

Born in Kenya, Rupert moved to South Africa as a child. An interest in a beehive on the family farm led his father to introduce him to an old beekeeper named Vernon, who taught Rupert everything he knew and the young devotee got his first hive.

After moving to Australia in 1982, Rupert pursued beekeeping, buying an apiary from a two-generation 62 | JULY 2021

beekeeper. In 2005, Rupert and his wife Kim (the company’s other managing director) moved to the Swan Valley to realise a lifetime dream of sharing all they knew and loved about bees and honey. In 2010 The House of Honey, a honey shop and café, opened.

Sharing the buzz “It’s intensely satisfying to share the knowledge of everything we’ve learnt with other people. I love being able to inspire people by talking about honey, bees and all sorts of related things. One of the great things about running a shop is that you can raise awareness of what these useful little creatures are capable of.

“I love that there’s room for improvement. You can never assume you know everything, especially when you think you have it sussed. You can decide something but with bees, nature always determines what happens.”

Honey and just about everything else that comes from a hive has a use – some cosmetic, some medicinal and some just plain tasty.

Among other uses, beeswax is used for cosmetics and candles, polishes and waxes while honey has anti-inflammatory and antibacterial properties, making it useful for colds, as a disinfectant and on burns to promote healing.

MEDICAL FORUM | MEN 'S HEALTH

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LIFESTYLE

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LIFESTYLE People often arrive at The House of Honey expecting the place to be swarming with bees, and while there are bees on the property, most of the hives are usually somewhere near Cervantes in the winter and move south for the summer.

The hives, which are wooden boxes marked with numbers and specially colour-coded dots, are moved by truck to spots in forests where Rupert believes will be best for the bees to feed and pollinate.

These areas, like national parks, nature reserves, state forests and timber reserves, are designated and require a licence to access. An apiary site mapping system helps with choosing the best spots.

Continually fascinating to Rupert is the bigger environmental picture, for example how an explosion of avocado tree growth in the South West relies heavily on bee pollination or how there was a recent scramble in New South Wales and Victoria to move some 50,000 colonies of bees to an area growing almonds to help the season succeed.

Rupert’s bees are usually transported at night, so they wake up in the morning in a new location.

Rupert says they are often eager to explore their new surroundings well before the boxes are even unloaded from the truck. Despite these regular moves during the year, the bees seem to be quite comfortable with the new surroundings and find their way back to their queen and hive.

The zen of bees Hanging out with the bees is Rupert’s happy place. He loves to watch them come and go from the hives, observing their collective temperament, which changes depending on factors such as the impending arrival of a low-pressure system or a sunny day.

“Sitting next to a hive and watching the bees arrive with pollen on their legs is like a state of meditation, it is very calming.”

With about 60,000 bees in each hive, Rupert estimates his colonies hold about 27 million bees at the height of summer. It’s a huge payroll – and the bees get a couple of free holidays around the state each year and are supplied with some of the diverse environments in the world when it comes to wildflowers and trees to explore.

MEDICAL FORUM | MEN 'S HEALTH

Honeybees eat nectar for carbohydrates and pollen for protein. The location of their hives has a direct impact on the type of honey they produce.

A hive which spends time amongst jarrah trees, produces honey with a nutty malt flavour which is as unique as the tree it comes from and is said to have strong antimicrobial properties. Resident bees in a citrus orchard will produce honey which can smell and taste like the fruit.

“We are so blessed in WA because we have so many different trees and wildflowers, which make it favourable for keeping bees. The European honeybee is what most people have as they are the most prolific honey gatherers and are suited to our climate.”

With a profound love for the environment and a passion for finding the best spots for his hives each season, Rupert spends a lot of time driving around the state

looking at local plant life. While his accountant might not always thank him, he’d much rather be doing that than sitting in front of a computer.

“I often say to people I have seen more of WA as a beekeeper than I would have in any other job. I get to travel all the back roads and go deep into the bush to find the best feeding ground for the bees.

“It’s like being a human extension of the bees, and we have to see the possibilities for them and look three, six or 12 months down the track to what the best places might be, taking into account flowering cycles and many other different aspects.

“That’s why beekeepers are always having collisions with trees while we’re walking around, we’re too busy paying attention to them to watch where we’re going!”

JULY 2021 | 63

Margaret River Here we come!

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