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Category: Continuing Education

  • PBSGL, peer support and resilience.

    Looking Back: Evaluating PBSGL in Salisbury Plain (2017)

    As we timetable the 100th meeting of the Salisbury Plain PBSGL group, it feels timely to revisit my first formal evaluation of the group, undertaken in 2017. At that point, PBSGL was already well established locally, but there had been little structured examination of its educational or pastoral impact within a mixed Defence primary care setting.

    In 2017, I undertook a small service evaluation to explore the perceived educational effects of participation in PBSGL. For those unfamiliar with the model, PBSGL is a structured, peer-led educational approach grounded in problem-based learning, with an emphasis on facilitated discussion and reflection (see NHS Scotland PBSGL and PBSGL England). The evaluation used qualitative thematic analysis of free-text questionnaire responses from group members.

    While educational benefit was expected and widely reported, what emerged most strongly was the role of PBSGL in peer support and professional resilience. The dominant thematic nodes identified were: morale, negative feelings, pastoral role, positive role models, seeking advice, sharing best practice, and social network. Notably, the evaluation had not been explicitly designed to explore wellbeing, yet support and morale appeared repeatedly and unprompted.

    The Salisbury Plain group was, and remains, unusual in its composition. Alongside established GPs and GP Trainers, it included GP Specialty Trainees (GPSTs) and General Duties Medical Officers (GDMOs). GDMOs are typically early-career doctors working across a broad portfolio of military and clinical roles, spending a significant proportion of their time in primary care under supervision while preparing for postgraduate examinations.

    This mixed professional demographic shaped the learning environment in important ways. Doctors intending careers in hospital specialties brought different approaches to risk, uncertainty and decision-making, informed by their anticipated professional trajectories. Exposure to the uncertainty inherent in general practice, and to peer discussion within PBSGL, appeared to enrich discussion and challenge assumptions across the group.

    Participants consistently described PBSGL as offering more than conventional CPD. Several comments explicitly framed the group as a source of pastoral support:

    “It goes beyond the purely medical and offers a degree of pastoral care – knowing that others also have the same challenges and difficulties.” (GP)

    “It’s a brilliant idea and not only improves clinical knowledge and changes practice, it also brings doctors together and improves morale.” (GP Trainer)

    Senior members highlighted the value of a wider peer reference group beyond the immediate practice:

    “The key improvement is the wider group within which to gauge opinion.” (GP Trainer)

    Junior members were unanimous in their positive views on peer support and shared learning:

    “A mixed experience group allows for the fusion of youthful exam-based knowledge with matured clinical acumen.” (GDMO)

    “Hearing different opinions on the same topic has been useful—previously I might have asked one person and taken that as gospel.” (GPST)

    These findings aligned closely with existing literature on problem-based and practice-based small group learning, which emphasises cooperative learning, constructive cognitive conflict and peer support as central mechanisms for learning and professional development¹. Similar benefits have been demonstrated in PBSGL groups involving GP trainees² and established GPs³.

    In retrospect, the relationship between peer support and resilience is particularly noteworthy. Evidence suggests that peer support within small group learning environments can help build resilience among physicians⁴. Given increasing workload, workforce shortages and system pressures in primary care, resilience is recognised as both necessary and multifactorial⁵⁻⁶. Although resilience was not measured explicitly in the 2017 evaluation, it likely contributed to the positive responses observed.

    Looking back, one of the key insights from this early evaluation was that PBSGL functioned as more than an educational intervention. Alongside its established role in knowledge exchange and practice change, it provided a structured, legitimised space for shared uncertainty, mutual support and professional affirmation—particularly valuable for GPSTs and GDMOs, for whom formal support structures were less well developed at the time.

    As the group approaches its 100th meeting, this early evaluation feels less like a snapshot and more like a foundation. Many of the pressures described in 2017 have intensified rather than diminished. That PBSGL continues to be valued for its supportive function may be as important now as its educational impact—and perhaps inseparable from it.

    References
    1. Onyon C. Problem-based learning: a review of the educational and psychological theory. Clin Teach. 2012;9(1):22–26.
    2. Rial J, Scallan S. Practice-based small group learning (PBSGL) for CPD: a pilot with general practice trainees to support the transition to independent practice. Educ Prim Care. 2013;24(3):173–177.
    3. Bruce S, Conaglen H, Conaglen J. Burnout in physicians: a case for peer-support. Intern Med J. 2005;35(5):272–278.
    4. Jensen PM, Trollope-Kumar K, Waters H, et al. Building physician resilience. Can Fam Physician. 2008;54(5):722–729.
    5. Matheson C, Robertson HD, Elliott AM, et al. Resilience of primary healthcare professionals working in challenging environments: a focus group study. Br J Gen Pract. 2016;66(648):e507–e515.
    6. Robertson HD, Elliott AM, Burton C, et al. Resilience of primary healthcare professionals: a systematic review. Br J Gen Pract. 2016;66(647):e423–e433.

  • Making Sense of Progestogens in HRT: What I Learned When I Went Back to the Evidence

    One of the areas I have found most challenging in menopause care is choosing the right progestogen. Not because options are lacking — but because there are several, each with subtly different properties, and the differences are often poorly explained in everyday practice.

    I realised I was not as clear as I wanted to be on how the commonly used progestogens really differ from one another. So I went back to the evidence. This post is a summary of what I found when I looked more closely at three widely used options in hormone replacement therapy (HRT): micronised progesterone (often prescribed as Utrogestan although other versions are available), dydrogesterone, and drospirenone.

    Why the Progestogen Matters

    In women with a uterus, progestogens are essential in HRT to protect the endometrium from unopposed oestrogen stimulation. But endometrial protection is only part of the story.

    Different progestogens have different effects on:

    – mood and sleep

    – bleeding patterns

    – metabolism and fluid balance

    – breast tissue

    – cardiovascular and thrombotic risk

    Understanding these differences matters — particularly in the perimenopause, where women may be more sensitive to hormonal effects and more likely to stop treatment if side effects are problematic.

    Micronised Progesterone: Closest to Physiology

    Micronised progesterone is chemically identical to endogenous progesterone. The “micronised” part simply refers to the mechanical process used to improve absorption by reducing the particle size.

    What stands out when reviewing the literature is its receptor selectivity. Micronised progesterone acts primarily at progesterone receptors, with minimal off-target effects. This likely explains its relatively favourable profile in relation to mood, lipids and cardiovascular risk.

    Orally, it undergoes significant first-pass metabolism, which reduces bioavailability but also produces metabolites such as allopregnanolone. Clinically, this often translates into a sedative effect, which some women find helpful for sleep — particularly when taken at night — while others find it limiting.

    When used in evidence-based doses, micronised progesterone provides reliable endometrial protection, although bleeding patterns can be variable and sometimes require adjustment.

    Dydrogesterone: Targeted and Well Tolerated

    Dydrogesterone is a synthetic progestogen, but one with a structure that closely resembles natural progesterone. It has high oral bioavailability and strong receptor selectivity, meaning effective endometrial protection can be achieved at relatively low doses.

    One of the consistent findings across studies is its predictable bleeding profile when used sequentially. Withdrawal bleeds tend to be more regular, with fewer episodes of unscheduled bleeding compared to some other synthetic progestogens.

    Importantly, dydrogesterone appears metabolically neutral. It is non-androgenic, does not adversely affect lipid or glucose metabolism, and is generally well tolerated in terms of mood and breast tenderness. Although often used off-label for HRT in the UK, its safety and efficacy data are reassuring.

    Drospirenone: Different by Design

    Drospirenone is structurally quite different from the other two. It is derived from spironolactone and has anti-mineralocorticoid and anti-androgenic properties.

    This gives it a distinct clinical niche. Its ability to counteract sodium and water retention can be particularly helpful for women troubled by bloating, fluid retention or raised blood pressure. Some women also benefit from its anti-androgenic effects on acne or hirsutism.

    Drospirenone has demonstrated effective endometrial protection in fixed-dose HRT preparations and is also licensed as a progestogen-only contraceptive (for example, the 4 mg 24/4 regimen). This makes it a useful option in the perimenopause, where contraception may still be required.

    However, long-term breast safety data are more limited, and caution is advised in women at risk of hyperkalaemia, particularly those taking other potassium-sparing medications.

    Breast and Cardiovascular Safety: What the Evidence Suggests

    Breast cancer risk remains one of the most common concerns around HRT. Observational data — particularly from large cohort studies — suggest that micronised progesterone and dydrogesterone are associated with a lower breast cancer risk compared with some older synthetic progestogens.

    These data are not from randomised trials and must be interpreted cautiously, but they are broadly reassuring. Thrombotic risk appears to be driven far more by the route of oestrogen administration than by progestogen choice, with transdermal oestrogen consistently favoured.

    Evidence around drospirenone and thrombotic risk in HRT is still evolving, but current data do not suggest a clear excess risk.

    Practicalities Matter Too

    Beyond pharmacology, practical considerations influence real-world prescribing. Cost, licensing, availability, and flexibility of dosing all matter — as does the woman’s own experience of side effects.

    It is also important to remember that oral progestogens are not the only option. The levonorgestrel-releasing intrauterine system provides highly effective endometrial protection with minimal systemic exposure and remains an excellent choice for many women, particularly those who want long-acting contraception alongside HRT.

    What This Changed for Me

    Looking back at the evidence helped me move away from thinking about progestogens as interchangeable. They are not. Each has strengths, limitations and a particular place in practice.

    For women with higher concern about breast or cardiovascular risk, micronised progesterone or dydrogesterone are often preferable. For those struggling with fluid retention, acne, or needing contraception, drospirenone may offer advantages. And for many, the “best” choice is the one that balances evidence with lived experience.

    Shared decision-making, grounded in up-to-date evidence and individual priorities, is key.

    Further Reading

    British Menopause Society. Progestogens and Endometrial Protection: Tools for Clinicians

    NICE Guideline NG23: Menopause: diagnosis and management

    Stevenson JC et al. Progestogens in menopausal hormone therapy. Drugs in Context

    Mueck AO et al. Dydrogesterone in HRT. Maturitas

    Palacios S et al. Drospirenone in hormone therapy. Maturitas

  • Supporting Women Before, During and After Pregnancy: Helpful Resources for Professionals and Families

    I’ve updated some of the perinatal resources I’ve been collecting to include the following (look under the ‘resources’ tab in the menu). The aim is to have these in one location for sharing to patients or to healthcare professional colleagues for onward dissemination. I hope all the links work but please let me know if there are any issues.

    Preconception and Early Support

    Preconception Care Partnership Toolkit A comprehensive toolkit designed to help healthcare professionals support individuals and couples in optimising health before pregnancy.

    Make Birth Better – Free Resources Resources for improving experiences of pregnancy and birth, with a strong focus on psychological wellbeing.

    Postnatal Care and Guidance

    NHS England – GP 6–8 Week Maternal Postnatal Consultation: What Good Looks Like National guidance for clinicians on delivering meaningful and effective maternal postnatal checks.

    Mending Milk – Perinatal Booklet A downloadable leaflet with clear, accessible information on perinatal wellbeing and mental health. Hearts & Minds – Perinatal Mental Health Support Map An interactive map of perinatal mental health services across the UK, helping families and professionals connect with local support.

    Physical Activity in Pregnancy and Postpartum

    Active Pregnancy Foundation – Professionals’ Hub Evidence-based advice and guidance for healthcare professionals supporting physical activity during pregnancy and after birth.

    This Mum Moves A fantastic initiative with resources and campaigns to promote safe and supportive activity for mums at all stages.

    Moving Medicine – Patient Resources Practical infographics, activity diaries, and patient-facing resources to support conversations around physical activity.

    Moving Medicine – Postnatal Return to Exercise Timeline A helpful timeline outlining safe return to physical activity in the postpartum period.

    Active Together A local partnership supporting active pregnancy and postpartum initiatives. Many areas can provide flyers, posters, or signposting to local activity groups (e.g. Active Mums clubs).

    Active Partnerships A nationwide network of regional organisations that connect communities with physical activity opportunities—including postnatal support.

    Peer Support and Community Networks

    Breastfeeding Together An example of a third sector organisation providing peer support on wards and after discharge. Local equivalents may exist in your area, or there may be opportunities to help establish one. Some regions have excellent peer support teams for new parents, often linked to maternity services or third sector organisations. It’s worth checking what’s available in your area.

  • Smartphone and Social Media use for CPD in Wessex

    I have finally written up a brief survey I did last year looking at how a selected group of Wessex GPs were using the Internet, Web 2.0 tools and smartphones for their CPD. The link to the document is here.

    I had the privilege of presenting a poster of the key findings at the Wessex Educational Fellows 2017 conference. I also learnt a number of things. Firstly, printing on linen is far easier than heavy duty paper. Secondly there’s a fair amount we can share educationally between primary and secondary care. Lastly, there are some very bright & dedicated educationalists around in medicine. The two Keynote speeches were very powerful.

    Anyway, back to the paper. You can read it in all its glory but I just wanted to comment on what I feel are a couple of important points.

    The population surveyed was only small but I suspect can be generalised to the wider GP population. As GPs, we have a suspicion of Social Media for education. It is not without its flaws but I fear we are missing out on the benefits. In order to increase the uptake, there needs to be training for GPs in how to actually use Social Media, Blogs and Podcasts. Once GPs are using it, we need to grow a Professional Network so we can share best practice, ideas, guidelines etc. For this to happen, GPs need to be convinced of the reliability & educational rigour of the material being disseminated as well as be confident in the security of any on-line discussions.

    I would like to extend my huge thanks to those who partook in the survey. I hope to do some further work in the future to explore some of the issues, day job permitting…

  • Mobile Learning and Smartphone use amongst Wessex GPs

    I have finally got around to disseminating a questionnaire to the good GPs and GPSTs of Wessex to assess the use of smartphones and their use for M-learning and CPD.  More to come but I have drafted an abstract of my findings below.

    Background and Aims

    There is an increasing use of smart phones for both under and postgraduate medical education. Despite this, uptake amongst general practitioners is poor. This survey examined the current use of smartphones for medical education amongst a cohort of Wessex GPs and GPSTs. Also explored was the use of social media for medical education.

    Method

    An online questionnaire invite was sent out via email. The questions included closed demographic questions and open free text responses. The survey population was composed of GPSTs and GPs on the Wessex PBSGL database. Responses were analysed using a grounded theory approach to identify themes.

    Results

    There were 61 respondents from 253 invitees. 98% had smartphones, 77% used smartphones for medical apps, 65% used smartphones for medical education, 69% used smartphones for social media and 20% used social media for medical education.  Thematic analysis of free text responses identified 58 nodes which were grouped into 21 minor themes in 8 categories.  These were: Accessing learning; Educational impact of online and m-learning; Educational networking; Learning involves social interaction with peers and mentor; Physical constraints of mobile devices; Signposting to guidelines and learning via the Internet; Technical challenges of online and m-learning; Work life balance

    Conclusions

    This is a snapshot of a small population but does raise some important key messages.  There is a training requirement for GPs in how to use social media for education.  GPs valued the networking between colleagues at courses and conferences.  However, most respondents recognised the future benefits of mobile learning platforms and wanted to engage more.

  • A Meta-Analysis of Continuing Medical Education Effectiveness (Mansouri and Lockyer 2007)

    Free text from here.

    In trying to justify why I think PBSGL is a good way of learning, I have done a lot of literature searching and reading about how different CME interventions can change what we do as physicians. The more recent research on PBSGL has demonstrated that Small Group Learning (SGL) is associated with several positive outcomes. For example, implementing guidelines into practice, an activity that is often associated with many difficulties (Macvicar, Cunningham et al. 2006). If only patients would do what they’re told, it would be so much easier! Clearly primary care is not about the sapiental ‘all knowing’ doctor. It is about empowering patients to make decisions. This generates uncertainties. Sharing these uncertainties in a SGL group with a trained facilitator frees up the physician to say what they think with reduced fear. I have often wanted to ask questions in a GP update lecture but am embarrassed to ask simple things about chronic disease management, something we are not always good at working for the MOD with a young population.

    I have also found lectures a mixed bag of usefulness. I write furiously in my learning journal, coming up with all sorts of ideas for audits and interventions only to reflect on them (usually just prior to my appraisal) wondering where has all that enthusiasm gone? This is why I have been such an advocate of SGL and what it can do to enhance our learning and improve patient care. Hence my review of this article for both my professional project and for general interest.

    This meta-analysis is not a new article but is a solid piece of work where the authors undertakes a literature review of CME interventions and looks at outcomes. The main type of interventions examined are active (workshops & individual training), passive (conferences and lectures) and mixed (SGL and post-course feedback). Three types of outcomes are looked at: physician knowledge, physician performance and patient outcome. There were 31 studies which actually generated 61 interventions (as some studies had multiple outcomes). The interventions were entered separately into the meta-analysis. All outcomes had positive & significant effect although the size was generally small. The data was also grouped and analysed for various types of CME. No surprises for guessing the results (summarised in table 3). Interactive SGL, case discussions, multi-faceted programmes and longitudinal workshops all had the largest effect.

    What was interesting was the small number of studies looking at patient outcomes. I decided to look in detail at one of these. Gask et al used role playing actors with videotaped consultations to look at consultation behaviour pre- and post educational intervention (Gask, Usherwood et al. 1998). The subject was depression. In what seems to be a nicely constructed but probably expensive study, ratings of the consultations with the role players were carried out in the context of assessment and management of depression. The intervention involved small group work in five 2 hour sessions. It included intensive training, review of videoed consults, role playing etc. In other words, a very intensive package and probably impractical for a busy GP nowadays.

    It would be a fair conclusion to draw that the least effective methods of delivering education (e.g lectures) are probably the most popular as they are cheaper to provide. More intensive training eg with SGL is associated with better outcomes, but with increased number of hours of intervention so the cost of delivery is probably more. I would argue that case based training can be cost effective and in the one relevant study included in this meta-analysis, physician knowledge improved considerably (Doucet, Purdy et al. 1998).

    Two other findings piqued my interest. The first was that when the assessment was done was important.  This is not surprising. If the assessment is performed 52 weeks later, the impact is likely to be less. The other finding was that mixed disciplines fared less well than single group disciplines. Details were patchy but it is something to consider if planning some interdisciplinary education. It may be that with increased specialisation and training of practice nurses, plus delegation of management to them by GPs, this effect will be less in 2016 than it was in 2007. An adjunct to this was that increased participants had a negative correlation although it is not clear if this this was related. One would expect increased numbers at passive interventions so it may be a secondary effect.

    Doucet, M., et al. (1998). “Comparison of problem-based learning and lecture format in continuing medical education on headache diagnosis and management.” MEDICAL EDUCATION-OXFORD- 32: 590-596.

    Gask, L., et al. (1998). “Evaluation of a training package in the assessment and management of depression in primary care.” Medical Education 32(2): 190-198.

    Macvicar, R., et al. (2006). “Applying evidence in practice through small group learning: a Scottish pilot of a Canadian programme.” Education for Primary Care 17(5): 465-472.

    Mansouri, M. and J. Lockyer (2007). “A meta‐analysis of continuing medical education effectiveness.” Journal of continuing education in the health professions 27(1): 6-15.

  • Hall, Pippa, and Lynda Weaver. “Interdisciplinary education and teamwork: a long and winding road.” Medical education 35.9 (2001): 867-875

    This article looks at education in an interdiscplinary team.  Most people have heard of a multi-disciplinary team where a team of specialists (in their own right) discuss cases.  Think of the MDT approach to hospital based disciplines and particualr complex cancer care.  At the other end of the spectrum is transdisciplinary where there is role blurring within the team members.  This is increasingly the case in primary care with practice nurses taking on more chronic disease management and the use of physician assistants.  Interdisciplinary is probably a more traditional primary care model however where there are distinct roles yet the team works together with a common focus being the patient.  That is not to say this isn’t the case with a MDT but there is more role blurring with interdiscliplinary teams as well as some professional overlap.  It’s what often happens when we discuss patients in primary care as a team looking at all outcomes for a patient.  These could be physical, social or psychological.  The question this article attempts to answer is how do we address the educational needs of that team?

    My professional project is a service evaluation of PBSGL.  This method of CME has been evluated before with generally favourable findings.  My ‘unique selling point’ so to speak is how having a mixed skillset group can enable peer support.  For example, having GPSTs, First5 GPs as well as more experienced GPs.  Whilst this doesn’t fit in with the definitons above, there are some transferable findings.  The article talks about System Issues and Content Issues.  Both are relevant.  Three areas discussed I think are important.

    1. Non-traditional teaching methods such as Problem Based Learning helps focus the team on ‘idea dominance’. This puts teamwork at the fore, with the patient as the focus. This is an important aspect of PBSGL.
    2. Faculty development – who does the education within the team & how do they as educators develop? This role is extremely important in the early days of initiating a programme and it would be easy to become disillusioned if there is apathy towards interdisciplinary education.
    3. Leadership skills – a hugely important yet often overlooked. We probably are demonstrating good leadership in primary care already but may be need to qualify it to allow development. This article pre-dates it but the NHS Academy Medical Leadership Competency Framework is a good start with a self assessment toolkit for those responsible for faculty development and who are facilitators.

    Whilst an older article, it does raise important aspects of how we assure and develop education within the Primary Care Team.  This is perhaps more of an imperative due to the changing roles of the different Primary Care Team members since the article was written and further ‘role blurring’.

  • Hall, Pippa, and Lynda Weaver. “Interdisciplinary education and teamwork: a long and winding road.” Medical education 35.9 (2001): 867-875.

    This article looks at education in an interdiscplinary team.  Most people have heard of a multi-disciplinary team where a team of specialists (in their own right) discuss cases.  Think of the MDT approach to hospital based disciplines and particualr complex cancer care.  At the other end of the spectrum is transdisciplinary where there is role blurring within the team members.  This is increasingly the case in primary care with practice nurses taking on more chronic disease management and the use of physician assistants.  Interdisciplinary is probably a more traditional primary care model however where there are distinct roles yet the team works together with a common focus being the patient.  That is not to say this isn’t the case with a MDT but there is more role blurring with interdiscliplinary teams as well as some professional overlap.  It’s what often happens when we discuss patients in primary care as a team looking at all outcomes for a patient.  These could be physical, social or psychological.  The question this article attempts to answer is how do we address the educational needs of that team?

    My professional project is a service evaluation of PBSGL.  This method of CME has been evluated before with generally favourable findings.  My ‘unique selling point’ so to speak is how having a mixed skillset group can enable peer support.  For example, having GPSTs, First5 GPs as well as more experienced GPs.  Whilst this doesn’t fit in with the definitons above, there are some transferable findings.  The article talks about System Issues and Content Issues.  Both are relevant.  Three areas discussed I think are important.

    1. Non-traditional teaching methods such as Problem Based Learning helps focus the team on ‘idea dominance’. This puts teamwork at the fore, with the patient as the focus. This is an important aspect of PBSGL.
    2. Faculty development – who does the education within the team & how do they as educators develop? This role is extremely important in the early days of initiating a programme and it would be easy to become disillusioned if there is apathy towards interdisciplinary education.
    3. Leadership skills – a hugely important yet often overlooked. We probably are demonstrating good leadership in primary care already but may be need to qualify it to allow development. This article pre-dates it but the NHS Academy Medical Leadership Competency Framework is a good start with a self assessment toolkit for those responsible for faculty development and who are facilitators.

    Whilst an older article, it does raise important aspects of how we assure and develop education within the Primary Care Team.  This is perhaps more of an imperative due to the changing roles of the different Primary Care Team members since the article was written and further ‘role blurring’.

  • Chronic Pain

    After our 2 sessions on chronic pain, we have performed a couple of audits at Bulford.  My own is here: 20150121-Opiate audit . Tony (D) has also done one.

    I found both sessions incredibly useful.  I am finding I am being more pragmatic with patients and being realistic with outcomes.  I think the main learning points for me have been

    a. what is feeding the chronic pain cycle?  Catastrophising I think is an excellent term.

    b. recording follow up thoroughly in follow up using the 6A’s.  In particular affect, adverse effects and analgesic effect.

    I think there is probably some more work to do on the occupational aspects of strong analgesia.

  • PBSGL Oct 14 – Post Menopausal Symptoms

    An excellent discussion. Lots of areas where there was learning and confirmation of practice. There was also discussion about our role as patient advocate in 2 of the cases. Should we stop the HRT in the 74 yr old lady suddenly? What about if it was contra-indicated. Also the role of alternative medicine – if we advise it as an option & the patient is harmed, where do we stand?

    Unaswered questions were:

    1. Circulate a Menopause Rating Scale (ASW to do)
    2. Should we ask opportunistcally about peri-menopausal symptoms?
    3. When using topical E3 gel as a systemic therapy (as opposed to vaginal gel), what are the options for providing progesterone? The IUS was discussed as an excellent option but what about if it was contra-indicated or if the patient declined? Are progesterones actually required if use of E3 gel is intermittent and on a PRN basis? (JCS to find out).
    4. Which is the best primary care tool for memory/dementia screening (TW to find out).
    5. What are the absolute contra-indications for HRT and smoking? (ASW will investigate).

    Two new members (both young males) expressed concern about the limitations of their knowledge in this area. Whilst we all expressed this (we do not have many patients with peri-menopausal symptoms), it is something that needs to be raised on the PQO/PGMO course. The curriculum should cover common urogenital problems in middle aged women at least so GDMOs are confident in raising the subject. Women are known not to volunteer conditions such as loss of libido and stress incontinence.

    Areas of learning we discussed:

    1. The use of a topical E3 gel as a systemic therapy.
    2. Use of self help web sites – Amarant Menopause Trust.
    3. One of the scenarios involved a concern about dementia. We moved on to scoring systems in primary care – 6 question CIT, MMS.
    4. We all agreed the time constraints in a single consultation would rule out a comprehensive history, examination and investigation. Another option was to spread over 2-3 consults with the patient doing some research in the interim.

    There shouldn’t be too many barriers to change. ASW will raise the issue of the curriculum change with the GP Dean next week on the Tri-Service Trainers Course.

    Most of what we discussed had mutual agreement. Some guidelines were discussed and we agreed that a single sheet of pros/cons of the long term risks & benefits might be a useful tool in the surgery.