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April 9, 2019

 

A conversation with Dr Jenny King, Former Chair UGSA – March 2019

 

Georgia Main:               Well, Dr. Jenny King, you are the Chair at UroGynaecological Society of Australasia. You’re the outgoing chair, end of your two-year term. How would you describe the last couple of years?

Dr Jenny King:               Look, this has been a difficult time for urogynaecology. Most people will be aware of the concerns over vaginal misuse and the complications suffered by some patients and the changes in practice that have led from that. We’ve been having to deal with all of that, and a lot of theory negative publicity that we were not prepared for you. I think we’ve made mistakes in medicine many times over the years in terms of new devices, and how quickly we introduce them, and how well we researched them. But equally, a lot of those have turned out to be very good devices. We don’t want to have a climate in medicine, where people don’t innovate, where we don’t develop new products, where we don’t try new things. There’s some very interesting data. If you look back at when we first introduced angiography, which is where you put dye into a vein. You come up to the heart and you can look at problems people have with their heart, and were they’re going to have a heart attack.

Dr Jenny King:               Now, when that was first introduced, the complication rate was around 50%. It was sky high. Had we not persevered, we’d have had a lot more patients who just didn’t survive their cardiac issues. It does need to be done, but we have to do it carefully and safely. That’s been the dilemma we’ve had over this period. There are many things. In retrospect, we probably would have done differently or more slowly, but we’re now in a situation where we’re fearing much limited in the treatments we can offer women. Treatments we know are very reasonable and very good procedures because of that adverse publicity and because of the consequent action of legislators, who’ve been quite rightly responding to concerns of patients. Within that, we’ve gone too far the other way. We’ve lost sight of what we can offer those ladies and what would be good to do.

Dr Jenny King:               This two years has been a real balancing act. The biggest thing I feel is we’re still striving to retain good treatments, and to be able to give our patients the care that they need in the face of all that opposition.

Georgia Main:               You’ve had to work very closely with government, I would imagine. Given that, what is that work in progress? What more needs to be done?

Dr Jenny King:               Look, it’s difficult, isn’t it? We have a body, the College of Obstetricians and Gynecologists who represent us. We’re a smaller group, urogynaecology within our major injury college, but they have a lot of other things to worry about. Basically, women’s health across the board. I think they haven’t taken on the fight, in particular when it comes to your gynecology. What we need to do as an organization, as UGSA, is to be able to work more closely with governments, with our legislators. We’ve had good relationships with the various state health departments. We’ve been able to work also with the Federal Minister for Health, Mr. Hunt, who’s been very understanding of those issues. He’s in a position of trying to defend our patients, also trying to advance patient care.

Dr Jenny King:               We have had good responses in some ways. Unfortunately, I’d have to say there’s been very much a policy with some of the bureaucracy, throw out the baby with the bathwater, that there’s been so much concern. They’ve said, “Stop this practice altogether.” That’s not good for our ladies. That denies so many of our patients the best care. That’s the struggle we have ongoing with our legislators, with our health departments, with the various bureaucrats.

Georgia Main:               What is the state of play at the moment? I would imagine what members are looking to you to find out what the future does hold?

Dr Jenny King:               In practical terms, the state we have at the moment is that there are two main products involving mesh that have been used vaginally. Now one of those is for stress incontinence they called slings or types. This would be the best-researched operation, basically, in the history of mankind, certainly in the history of continence. It is a good operation. We have excellent data. That has been contaminated by some extent, because we have less good data and less good outcomes with transvaginal mesh. As a consequence of the senate inquiry, I’m feeling unhappy about this. As surgeons, as doctors, as clinicians, we don’t find it difficult to look at that data and to separate those operations. Despite all the advice that were given the senate inquiry, which had no other medical people involved, it was all politicians, did have trouble distinguishing between slings and vaginal mesh for prolapse.

Dr Jenny King:               They have aid, and this is all the public hears, should be used as a last resort. Now, we haven’t had quite that attitude from the legislators otherwise. Currently, we do still have vaginal mesh slings for urinary incontinence. They are a great operation. They’re better than anything we’ve had before. I’ve been around a long time now. I can remember those previous operations. Let me tell you. They were not a piece of cake for the patients, and the outcomes were not as good. We do, fortunately, still have those. What we have is a lot more. Look, sometimes very good restrictions on their use in terms of how do we make sure they used for exactly the right patients, and used by the world-trained, best-trained surgeons. That’s the regulations we have at the moment. I think all of that is good. Unfortunately, it has generated a lot of fear in the community. What we’re seeing is that women are just not coming for treatment for their stress incontinence. They are basically so frightened of what might happen.

Dr Jenny King:               The very biased information they’ve been hearing that they are sitting at home, stay and wait because I think that is the only safe option. Now I find it incredibly distressing. There are great treatments out there. Not everyone needs an operation. By all means, conservative management works for lots and lots of our ladies. If it doesn’t, I don’t want you not to come because you’re frightened. Fine, if you say to me, “I don’t want surgery.” Not a problem at all, because it is about what you need and what’s important for you as a patient. But don’t not come because you’re frightened, and you’ve been scared by things I know are not true. I would like the opportunity to be able to reach to those people and say, “We have lots of options in treatment. Let’s work out together what’s right for you.”

Georgia Main:               That’s the challenge, I guess, isn’t it for your group in the future?

Dr Jenny King:               To get that word out there so people know that they have a choice. They can talk to us about it, but they’re running scared.

Georgia Main:               I’d imagine that there’s a lot of, by the time women come to see you, I think there was some. Instead of 70%, or something of those issues could have been managed previously, if people who hadn’t waited so long. Is that right?

Dr Jenny King:               It’s true. Certainly, you can resolve a lot of problems with continence with all the sensible things. The losing weight, the doing your pelvic floor exercises will make a big difference. That’s all a lot of people need. What we’ve got to remember is our older women, once you pass menopause, you really do need vaginal estrogens as well to try and keep your pelvic floor nice and strong because we get you’re on genital aging just as we get aging anywhere else. There are those measures that a lot of people wouldn’t need to come see me at all. Look, nobody ever died of stress incontinence. We’re not saying it’s crucial you have an operation, but at least look at the options, look at the treatment and decide, in your situation, how troublesome is it? How much does it get you down? If it’s stopping you doing things and enjoying activities with your family, then that’s not on. We should look at that. We can do something about that.

Georgia Main:               Do you think that working relationship with the government in getting that voice out there will be the next challenge?

Dr Jenny King:               Yes, I do. I would very much like to extend the relationship we’ve had with government to keep back that relationship stronger so that they see. Here is a group, this is their passion. This is the only thing I care about pelvic floor medicine. I want to help those ladies come to us, work with us. We will work in any way with government, with consumer groups, with health departments in getting across the information that is needed. We’re very keen to be much more involved in that. That’s where I’d like to see UGSA extend its role.

Georgia Main:               That data I guess is coming to the fore now. Is that right? There’s been a long time coming, I guess. We’re looking at just that last couple of years. But now, there’s some long-term data that’ll be crucial to see where we go next.

Dr Jenny King:               I’d have to say, I couldn’t imagine how much more data you need on the slings for incontinence. We have operating. We use follow up. We’ve had nearly 100 really high-standard, randomized control trials, as well as lots of other trials. The data is there on midurethral slings. What we don’t have yet is the data on vaginal mesh for prolapse. That’s a bigger area and a more complex area. But as you say, the data is coming. What I would hope is that when that long-term data is available from international studies, that the legislators, that governments will look at it and not just run scared, which is what’s been happening at the moment.

Dr Jenny King:               I understand that the data from the state’s long-term, three-year, follow up for these patients, which is very important will be here in a couple of years. Please, can we look at that? No, we are not suggesting everyone needs a mesh for goodness’ sake. But if you do, it really can make such a difference to your life. Let’s not deny those were that option. Let’s just make sure we look at the data. We assess all of them individually. We have really well-trained surgeons. We look at our work. We analyze their data so we can provide what they need. That isn’t happening at the moment. Australia isn’t quite as bad as some other countries, but it’s a lot worse than a lot of others as well. I hate to say our women denied that choice of treatment.

Georgia Main:               You said before to that the urogynaecologist in Australia, they feel a bit uncertain at the moment because they don’t know where things are going to go in terms of government and those sort of things. What do you say to them?

Dr Jenny King:               Look, we have always, we’ve been taught day one, as a medical student, collect your data. Monitor your patients. Use that data to determine your practice. Please, look at that data. You know it’s good data. Continue to practice in the right way. There are other operations we can go to for people who can’t have mesh procedures, but they’re not the best operations. We do have something else to offer, ladies. I think be true to your training. Don’t be frightened of that data. It is there. Now, the other side of that is, as individual surgeons, make sure you’re as well-trained as you can be. Don’t take on things you don’t know. Don’t be reluctant to refer people.

Dr Jenny King:               Part of the problem we have in Australia is because of the tyranny of distance and size, we don’t have enough urogynaecologist throughout the country. I can understand someone in the country doesn’t want to travel 300 kilometers to get their dodgy bladder sorted out. They would like to be done close to home. Now, that may not always be practical. There are a lot of areas of medicine we do not have the expertise in every country town in every rural area. As a surgeon, you have to say, “Is this my expertise? Do I feel I do enough of these? Do I feel I’ve been adequately trained? Can I properly assess this lady?” If I am not the best person for her, I need to explain, “Darling, you are better to travel to get to someone who can really deal with your problems better than I can.”

Dr Jenny King:               That’s hard because of the lady doesn’t want you to say that to her either but that’s where the honesty comes in. I’m arguing that we be honest about the data we have. We know these are good operations. Also, be honest as an individual surgeon about what you can best do for that lady.

Georgia Main:               What do you think of some of these recommendations that have come in? I’m thinking of the pelvic pain. Clinics that are set up in Queensland at the moment, that perhaps might be more widespread. What do you think about those?

Dr Jenny King:               All major cities have clinics where we can see women who’ve had complications from their mesh surgery or scared they may have had complications from that. They are available in centers in every capital city where there are urogynaecologists. Now again, it’s not perfect. People from country areas have to travel, but those centers are available. I’m worried that we’re somehow not getting that information out there that there are people who think they still have to go to America. That’s the biggest con of all time. American surgeons have no more expertise than Australian surgeons. If you need that mesh removed, we can do it here. But unfortunately, that information doesn’t seem to be getting out there. If you live in Tasmania, you do have to come to Melbourne. If you live in the ACT, you come to Sydney. They’re not everywhere. There aren’t enough of them, but those major centers that exist, do have the expertise unquestionably.