Home

Bluesky · LinkedIn

Category: Medical Education

  • Does Gender Integration Reduce Military Effectiveness?

    Greenberg K, Wasserman M, Weber EA. The Effects of Gender Integration on Men: Evidence from the U.S. Military. Quarterly Journal of Economics. 2026.

    The integration of women into frontline military roles has long been accompanied by concerns that combat effectiveness, cohesion and operational performance might suffer. These arguments have influenced military policy around the world for decades, despite relatively little high-quality evidence to support them. This study examined a large natural experiments in workplace gender integration: the opening of all previously male-only combat roles in the U.S. military to women from 2016 onwards. Using the staggered introduction of women into infantry and armour companies, the authors employed a robust difference-in-differences design to assess whether the arrival of female colleagues affected the performance, behaviour and attitudes of male soldiers. Administrative records covering promotions, retention, disciplinary actions, fitness, medical profiles and criminal investigations were combined with annual Defence Organisational Climate Survey responses, providing both objective and subjective measures of workplace impact. The findings offer some strong evidence that integrating women into combat roles does not reduce operational effectiveness, while highlighting the more subtle ways organisational culture and perceptions evolve during periods of change.

    Objective performance remained unchanged

    Perhaps the most striking finding was that the arrival of women had virtually no adverse effect on measurable performance. Across a wide range of outcomes—including retention, promotions, demotions, misconduct, criminal investigations and medical downgrading—men performed just as well after integration as they had before. In fact, several outcomes showed modest improvements. Rates of separation for misconduct fell following integration, suggesting that the presence of women may have had a small positive influence on behaviour. The only statistically significant deterioration was a very small reduction in physical fitness scores, although this did not affect pass rates, operational deployability or career progression. Overall, the study found no evidence that integrating women reduced combat readiness or organisational effectiveness. 

    Perceptions and reality diverged

    Although objective performance remained stable, men’s perceptions of their workplace became less positive after integration. Survey responses demonstrated small but consistent reductions in ratings of organisational effectiveness, unit cohesion, leadership, inclusivity and confidence in how harassment and discrimination were managed. This disconnect between attitudes and actual performance is one of the study’s most important findings. It demonstrates that changes in organisational culture may initially be perceived negatively, even when measurable performance remains unaffected.

    Female leadership appeared to drive much of the change

    The reduction in workplace perceptions was not seen uniformly across all units. Instead, it was concentrated in companies where a female officer joined the unit during integration. Interestingly, units that integrated only female junior enlisted soldiers often showed neutral or even improved attitudes among men. Crucially, there was no evidence that female officers were less capable than their male counterparts. They had similar qualifications, education and experience, while the units they commanded performed at least as well—and sometimes slightly better—than comparable units led exclusively by men. This makes it unlikely that the observed change in attitudes reflected differences in leadership quality.

    Why did perceptions worsen?

    The authors propose two main hypotheses. The first is that female leaders increased awareness of workplace problems that had previously gone unnoticed or unreported. After female officers joined units, male soldiers reported observing more bullying, hazing and inappropriate workplace behaviour. Rather than indicating that these behaviours had become more common, the authors suggest that women in leadership positions may have encouraged greater openness and discussion about issues that had previously been normalised or overlooked. Supporting this explanation, female soldiers themselves often reported fewer workplace problems when a female officer was present, suggesting that leadership may actually have improved the working environment despite increased reporting.

    The second hypothesis is based on social identity and leadership research. A substantial body of literature suggests that some men respond negatively to women occupying positions of authority, particularly in traditionally male professions. Such reactions may reflect unconscious bias, perceived threats to established group identity, or challenges to long-standing cultural norms. The findings are consistent with this explanation, as the decline in attitudes was greatest when women entered leadership roles rather than junior positions. Importantly, however, these negative perceptions did not translate into poorer discipline, reduced performance or retaliatory behaviour.

    Implications beyond the military

    Although conducted in the U.S. Army, the findings have much wider relevance. Similar concerns are frequently raised whenever women enter historically male occupations such as policing, firefighting, engineering or emergency services. This study provides robust evidence that fears of reduced productivity or organisational effectiveness are largely unsupported. Instead, the challenges associated with integration appear to relate primarily to organisational culture and perception rather than capability or performance.

    For leaders managing workplace change, the findings are particularly instructive. Objective outcomes and employee perceptions may evolve differently during periods of organisational transition. Monitoring performance data alongside staff attitudes may therefore provide a more balanced understanding of how integration is progressing. Where negative perceptions emerge, these may reflect changes in awareness, cultural adaptation or attitudes towards leadership rather than genuine declines in organisational effectiveness.

    The evidence from this natural experiment is clear. Introducing women into previously all-male combat units did not reduce men’s performance, increase misconduct or compromise operational readiness. Instead, the principal impact was on perceptions of workplace quality, particularly when women assumed leadership roles. These findings challenge long-standing assumptions about gender integration and suggest that resistance to organisational change may be driven more by culture and perception than by any measurable effect on performance. For military organisations and other traditionally male professions alike, the study provides some compelling evidence that inclusion and operational effectiveness are not mutually exclusive—in fact, they can coexist without compromising organisational performance. Finally, it will be interesting to see if these findings are replicated in the UK Armed Forces which has allowed women to serve in all roles since 2018. I suspect it will although the numbers are a lot smaller given the relative sizes of the US and UK Armed Forces.

    This is a LLM summary created from my dictated notes made while reading the above article.

  • Movement Through the Perimenopause: Why How We Exercise Matters

    A common areas of discussion when talking to women about the perimenopause is what sort of exercise should I be doing now?

    It is an important subject. The perimenopause is a time of significant hormonal, physical and psychological change, yet advice about physical activity is often vague or overly simplified. The evidence suggests something more nuanced: different types of exercise appear to support different aspects of perimenopausal health.

    I must admit to not knowing much about this area so, as one of my topic investigations for my Menopause Professional Certifcate, I looked at the evidence and did a ‘mini’ literature review. This post aims to distil what I found about how a range of physical activities can help manage perimenopause symptoms — not in an optimisation-driven way, but in a way that works with a changing physiology rather than against it. This blog is an AI assisted summary of my topic investigation.

    A Brief Physiological Context

    The perimenopause is characterised by fluctuating and eventually declining ovarian hormone production, particularly oestradiol and progesterone. These hormones influence far more than the menstrual cycle. Oestrogen receptors are found throughout the body — including bone, muscle, brain, cardiovascular tissue and connective tissue — which helps explain why symptoms can be so varied.

    Common experiences include fatigue, low mood, anxiety, sleep disturbance, joint pain, changes in body composition, and reduced exercise tolerance. For many women, there is also a sense that what used to work no longer does. Understanding how different forms of exercise interact with these physiological changes can be empowering.

    Strength Training: Supporting Muscle, Bone and Confidence

    If I had to choose one form of exercise with the strongest evidence base for perimenopausal health, it would be resistance training.

    As oestrogen levels fluctuate and decline, women experience accelerated loss of muscle mass and bone density. Strength training directly counters both. It improves muscle protein synthesis, helps preserve lean mass, and provides the mechanical loading needed to maintain bone strength.

    Beyond the physical effects, strength training has been shown to improve insulin sensitivity, reduce central fat accumulation, and support functional capacity. Clinically, many women describe feeling stronger, more stable, and more confident in their bodies — outcomes that are often underestimated but deeply important.

    Crucially, strength training does not need to be extreme. Two to three sessions per week, focused on progressive but manageable loading, appears sufficient for meaningful benefit.

    Cardiovascular Exercise: Heart, Brain and Metabolic Health

    Cardiovascular risk increases across the menopause transition, partly due to the loss of oestrogen’s protective effects on vascular function and lipid metabolism. Regular aerobic exercise remains a key protective strategy.

    Moderate-intensity activities such as brisk walking, cycling or swimming improve cardiorespiratory fitness, blood pressure and metabolic health. There is also consistent evidence for improvements in mood, anxiety and cognitive function, likely mediated through neurochemical pathways including endorphins and brain-derived neurotrophic factor (BDNF).

    However, the dose matters. High volumes of prolonged, high-intensity endurance exercise can exacerbate fatigue, sleep disturbance and stress responses in some perimenopausal women. Shorter bouts, interval-based approaches, or lower-impact steady activity are often better tolerated and more sustainable.

    Mind–Body Exercise: Regulating Stress and Sleep

    Yoga, Pilates, tai chi and similar mind–body practices are sometimes viewed as secondary to “proper” exercise, but the evidence suggests they play an important role during the perimenopause.

    Hormonal fluctuations can increase sensitivity of the stress response system, making anxiety, poor sleep and emotional lability more common. Mind–body exercise appears to support autonomic regulation, reducing sympathetic overactivity and enhancing parasympathetic tone.

    Studies suggest benefits for sleep quality, perceived stress, anxiety and depressive symptoms. Many women also report that these practices help them reconnect with their bodies at a time when bodily signals may feel unfamiliar or unreliable.

    A Blended Approach Works Best

    Rather than asking “Which type of exercise is best?”, a more helpful question may be:

    “What combination of movement supports my body and brain right now?”

    The evidence supports a blended approach — incorporating strength training, cardiovascular activity and mind–body exercise — tailored to the individual and adaptable over time. Needs and capacity may change from month to month, and flexibility is not a failure but a feature of effective self-care in this phase of life.

    Exercise during the perimenopause is not about chasing previous performance or forcing compliance with rigid routines. It is about maintaining function, protecting long-term health, and supporting psychological wellbeing.

    Final Thoughts

    One of the most striking features of the perimenopause is how often women blame themselves for changes that are entirely physiological. Physical activity can be a powerful tool — but only when it is framed as support rather than correction.

    When movement is aligned with evidence, context and lived experience, it becomes not just a health intervention, but a way of rebuilding trust in a changing body. And that matters just as much as any measurable outcome.

    Further Reading

    British Menopause Society. Tools for Clinicians: Lifestyle and the Menopause

    NICE Guideline NG23: Menopause: diagnosis and management

    Daly RM et al. Resistance training and musculoskeletal health in menopausal women. Journal of Bone and Mineral Research

    Elavsky S. Physical activity and mental health during the menopause transition. Menopause

    McNeil J et al. Exercise, stress regulation and sleep in midlife women. Sports Medicine

  • 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

  • Prostate Screening – an update

    Roobol MJ, de Vos II, Månsson M, Godtman RA, Talala KM, den Hond E, et al. European Study of Prostate Cancer Screening – 23-Year Follow-up. N Engl J Med. 2025 Oct 30;393(17):1669–80.

    Long-Term Outcomes of PSA Screening
    This paper caught my eye while reading a summary in one of the broadsheets. Also, being a man of a certain age, it has a more personal relevance. It was the reporting of the final 23-year results of the European Randomized Study of Screening for Prostate Cancer (ERSPC), providing a comprehensive assessment to date of PSA-based screening. After more than two decades of follow-up, prostate-cancer-specific mortality was 13 % lower in men invited for screening compared with controls.


    This represented an absolute risk reduction (ARR) of 0.22 %, meaning one prostate cancer death was prevented for every 456 men invited or every 12 men diagnosed. Although the absolute benefit remains small, it has strengthened over time — from an ARR of 0.14 % at 16 years to 0.22 % at 23 years — indicating a gradually improving mortality benefit with extended follow-up. Screening continued to increase prostate cancer incidence by around 30 %, largely through the detection of low-risk tumours unlikely to cause symptoms or death. Only one in four positive biopsies confirmed malignancy, highlighting the burden of unnecessary investigations and potential over-treatment. The data reinforced the enduring challenge of balancing early detection with the harms of over-diagnosis.


    A Changing Clinical Context
    The landscape of prostate cancer diagnosis and management has evolved substantially since the ERSPC began in 1993. Multi-parametric MRI, targeted biopsy techniques, and risk-stratified screening algorithms have reshaped practice, allowing clinicians to focus investigation on those most likely to benefit. Meanwhile, active surveillance (I have a handful of patients undergoing this) and nerve-sparing surgery have reduced the long-term morbidity once associated with over-treatment. Collectively, these innovations have improved the harm–benefit profile of PSA-based screening.


    Towards Risk-Based Screening
    I get asked by a lot of men about prostate screening and if they can add a PSA to a well man profile. Admittedly these are men in their mid 40s to early 50s (the ERSPC inclusion age was 55-69). My interpretation is the ERSPC is a valuable contribution to quantifying the trade-off between benefit and harm over time. The evidence supports a move away from population-wide screening towards individualised, risk-based assessment, taking into account age, comorbidity, life expectancy, and patient preference. As diagnostic precision improves, the rationale for targeted screening—rather than universal testing—becomes more relevant. The long-term data remind us that progress in screening is incremental: the aim is not simply to detect more cancers, but to detect the right cancers, in the right patients, at the right time.

  • Putting up with the Perimenopause

    Peters et al., 2025 – “Just Put Up With It: Women’s Experiences of Perimenopause and Menopause” (J Adv Nurs)

    Back in 2021, myself and my brilliant colleague, Kate King, undertook some research looking at the experiences of servicewomen who were suffering from symptoms of the perimenopause. Although this was a cross-sectional survey, with all its limitations, what really hit home were some of the challenging experiences our servicewomen were having, from the Chain of Command and Healthcare Professionals, as well as in their working environment.

    With my educator hat on, I then looked at how confident our GPs were in offering advice in the perimenopause. While most were up to date with their knowledge and familiarity with guidance, the lack of regular experiential practice and limited patient contact meant that confidence in applying guidelines was a real issue. In other words, knowledge wasn’t the barrier — experience was.

    Fast-forward to this year, and a paper by Peters and colleagues in the Journal of Advanced Nursing has captured, through a mixed-methods approach, what many of us already recognise in our clinics and conversations: that women are still being told, in one form or another, to “just put up with it.” Their study of over 400 women in Australia uncovered three familiar themes — the unexpected sequelae on daily life, stigma and shame, and feeling dismissed and devalued.

    The accounts are powerful. Women spoke about the intensity of symptoms — heavy bleeding, insomnia, brain fog, hot flushes so severe they avoided social events. They described the shame of not talking about menopause, even with friends or family, and the frustration of health-care encounters where symptoms were minimised or met with antidepressants. The words “shouting into the void” stand out.

    What strikes me most is how transferable these experiences are to our own setting in Defence Primary Care. We know that stigma, silence, and gendered assumptions still shape the care women receive. The same structural issues — limited appointment time, inconsistent access to specialist advice, and discomfort in talking about reproductive health — all play their part.

    Peters et al. end with a clear call to action: better education for all clinicians, nurse-led multidisciplinary care, and workplace policies that recognise the real impact menopause can have on performance and wellbeing. For me, that aligns perfectly with where we need to go in Defence — normalising the conversation, building confidence among clinicians, and creating an environment where women feel supported rather than sidelined.

    Menopause shouldn’t be something our patients have to endure. It’s a phase of life that deserves understanding, compassion, and competence — and that starts with us being willing to talk, listen, and learn.

  • Making Sense of the PCA Model: Turning Problem Cases into Learning Opportunities

    Clinical learning rarely follows a neat script. More often it emerges from the difficult cases – the ones that unsettle us, challenge our assumptions, and force us to rethink how we practise. Years ago, we developed a Problem Case Analysis (PCA) model during a GP Trainers ‘retreat’ in Germany. It provided a structured approach to making sense of these experiences. It works by using the case itself as the “curriculum,” guiding the learner through a reflective cycle that fosters deeper understanding and future growth.

    The model is built around five domains, each tapping into key principles of adult learning theory:

    1. Define Needs/Wants: Clarify

    Key questions: “Why is this a problem for you?” “What about this bothers you?”

    This domain gets to the heart of the learner’s agenda. In adult learning, relevance is king – adults are motivated to learn when they can see immediate value (Knowles, 1980). By identifying why the case matters to the learner, the educator ensures the encounter feels personal and worthwhile. Sometimes the need is technical (e.g. uncertainty about investigations), sometimes emotional (e.g. frustration with a demanding patient), and sometimes relational (e.g. difficulty negotiating with colleagues). Surfacing these concerns clarifies where the learner’s energy lies.

    2. Explore Understanding

    Key questions: “What do you think is going on?” “Have you seen something like this before?”

    Here, the learner’s existing knowledge structures come into play. From an adult learning perspective, this step draws on:

    Constructivism: adults build new knowledge upon prior experience. Cognitive load theory: if a case is rare but important (a “high-affinity, low-occurrence” scenario, like recognising temporal arteritis or meningitis), learners may struggle because their schemas are underdeveloped. By revisiting similar past encounters, they reduce intrinsic load and strengthen memory traces. Kolb’s experiential cycle: reflection on prior experience (“Have you met this before?”) feeds directly into abstract conceptualisation and future action.

    In practice, this step often reveals biases (“I always worry about missing cancer”) or blind spots, which become fertile ground for learning.

    3. Define Options: Challenge to Look at New Dimensions

    Key questions: “What other ways are there of dealing with this problem?” “This is what I think… how would you feel about using this?”

    This is where the educator encourages cognitive flexibility. The learner may be anchored in one way of managing the case, but by introducing alternatives – diagnostic, therapeutic, or communicative – we widen their repertoire.

    Here, transformative learning theory is relevant: disorienting dilemmas (such as a case that “doesn’t fit”) can trigger perspective shifts when the learner is guided to explore new frames of reference (Mezirow, 1991). Encouraging multiple options fosters resilience in the face of complexity, and mitigates the “tunnel vision” that can occur under stress or cognitive overload.

    4. Summarise & Confirm Understanding

    Key questions: “What will you do now?” “How will you handle this type of problem next time?”

    This step consolidates learning. The act of summarising is more than repetition – it represents schema reorganisation, where the learner integrates new perspectives into their existing mental models.

    Feedback here is vital. Adults value feedback that is specific, respectful, and actionable. Drawing on Vygotsky’s “zone of proximal development,” the educator scaffolds the learner’s performance just enough to push them beyond their current level without overwhelming them. This also reduces extraneous cognitive load, as the learner leaves with a clarified plan and less mental clutter.

    5. Future Learning

    Key questions: “What have you learnt from this?” “What else do you need to know?” “How will you handle this in future when I’m not here?”

    This final domain turns the case into a springboard for lifelong learning. It encourages:

    Self-direction: adults prefer autonomy in setting their learning goals (Knowles). Metacognition: thinking about how they learn, not just what they’ve learnt. Forward transfer: preparing to apply insights in new, unpredictable contexts.

    A Clinical Example

    Take a GP trainee wrestling with a patient who repeatedly attends with vague chest pain.

    Define Needs/Wants: The trainee admits they are worried about “missing a heart attack” but also feels the patient is becoming dependent.

    Explore Understanding: They recall a previous case of ACS but admit they struggle to balance reassurance with risk.

    Define Options: Together, you explore structured risk assessment tools, shared decision-making, and safety-netting approaches.

    Summarise & Confirm: The trainee outlines a plan to use the QRISK tool, document carefully, and agree a follow-up strategy.

    Future Learning: They commit to reading about “frequent attender” management and plan to discuss psychosocial factors in their next tutorial.

    Through the PCA lens, the case is transformed from an anxiety-provoking encounter into a structured learning opportunity, reducing cognitive load and increasing confidence for future practice.

    In summary: The PCA model works because it respects the principles of adult learning – relevance, experience, self-direction, and reflection – while providing a clear framework to process difficult cases. It helps learners move from discomfort (“Why does this unsettle me?”) to capability (“How will I manage this better next time?”).

    Adult Learning Theories in Action:

    • Knowles’ Andragogy (1980):
      Adults learn best when the material is relevant, problem-centred, and connected to their own goals. The PCA model starts with the learner’s agenda, ensuring alignment with this principle.
    • Kolb’s Experiential Learning Cycle (1984):
      Learning arises from cycling through concrete experience → reflective observation → abstract conceptualisation → active experimentation. PCA mirrors this cycle by encouraging learners to reflect on past cases, integrate new ideas, and plan for next time.
    • Cognitive Load Theory (Sweller, 1988):
      Working memory is limited; learners struggle with high intrinsic load (rare, complex cases) and unnecessary extraneous load (poor explanations, irrelevant detail). PCA reduces this by structuring reflection, linking to prior knowledge, and clarifying next steps.
    • Transformative Learning (Mezirow, 1991):
      Disorienting dilemmas – like challenging cases – can trigger a shift in perspective. By exploring alternative options, PCA helps learners reframe their thinking and grow professionally.
    • Desirable Difficulties (Bjork & Bjork, 2011):
      Effortful, challenging learning (e.g. grappling with difficult cases) enhances long-term retention and adaptability. PCA encourages learners to lean into discomfort and use it productively.

  • Decoding Depression: How Hormones Shape Mental Health Through Menopause

    Chirinos DA, Yin Z, Schreiner PJ, Appiah D, Wellons MF, Lewis CE, et al. Trajectories of depressive symptoms in a population-based cohort of Black and White women from late reproductive age through the menopause transition: a 30-year analysis. Menopause. 2024;31(12).

    https://journals.lww.com/menopausejournal/abstract/2024/12000/trajectories_of_depressive_symptoms_in_a.3.aspx?context=latestarticles

    The menopause transition, or perimenopause (PMP) is often framed as an important period for women’s mental health, with fluctuating hormones blamed for mood swings and depressive symptoms. A recent study published in Menopause: The Journal of The Menopause Society tried to shed more light on this, by examining the long-term trajectories of depressive symptoms across a 30-year period in women. The findings offered some further insights into the role of oestrogen and hormonal contraception in shaping mental health outcomes during midlife.

    The study used data from the Coronary Artery Risk Development in Young Adults (CARDIA) project, a large population-based cohort that tracked 2,160 women aged 23–60. The researchers assessed depressive symptoms every five years using the Center for Epidemiologic Studies Depression Scale (CES-D), a validated tool for measuring depressive symptoms. The participants were classified into three distinct trajectories:

    1. Minimal Symptoms (61%): Most women showed consistently low levels of depressive symptoms.

    2. Intermediate Symptoms (31%): This group experienced moderate depressive symptoms over time.

    3.Persistent Symptoms (7%): A small but significant proportion faced ongoing, high levels of depressive symptoms.

    By identifying these patterns, the study demonstrated that depressive symptoms are not random but follow stable trajectories influenced by sociodemographic, behavioural, and hormonal factors.

    The Role of Hormones: Oestrogen and Contraception

    Hormonal changes during menopause are often implicated in mood disturbances, but the findings challenge the oversimplified view of hormones as mere culprits of midlife depression. Women who used oestrogen therapy to manage vasomotor symptoms (VMS) like hot flushes were more likely to experience persistent depressive symptoms. The odds ratio (OR) of 1.71 indicates a higher likelihood of depressive symptoms among oestrogen users compared to non-users. While this might suggest a negative impact of oestrogen, the researchers proposed a different explanation that women with severe VMS—often treated with oestrogen—may have been more prone to depressive symptoms in the first place. Conversely, hormonal contraceptive use was linked to a protective effect, with lower odds (OR 0.69) of persistent depressive symptoms. This finding is similar to previous research showing that hormonal contraception can stabilise mood by maintaining consistent hormone levels. These results reiterate the complexity of hormone therapy, suggesting that its effects on mental health may depend on individual circumstances, including the presence of VMS and pre-existing mood disorders.

    Sociodemographic and Behavioural Factors

    Beyond hormones, the study highlights the influence of sociodemographic and lifestyle factors on mental health. Women in the persistent depressive symptoms group were more likely to be black, have lower income and education levels, and engage in unhealthy behaviours, like smoking and excessive alcohol consumption. Body mass index (BMI) also emerged as a significant predictor, with higher BMI associated with persistent depressive symptoms. This reinforces the interconnectedness of physical and mental health, suggesting that obesity and depression are linked, possibly through shared biological pathways. This is probably somewhat generalisable to the UK population although the number of black women was proportionally much higher in this cohort. There is also no mention of other ethnic groups which again limits how the results might apply to a UK population.

    Menopause: A Myth-Busting Moment

    One of the study’s most intriguing findings is that the menopause transition itself did not appear to exacerbate depressive symptoms. Depressive trajectories remained stable before, during, and after menopause, suggesting that midlife mental health is shaped by other factors, such as early-life influences, than by the hormonal fluctuations of menopause. This challenges the narrative that menopause is inherently a time of heightened vulnerability to mood disorders. Instead, the study calls for a broader view of women’s mental health, one that considers lifelong influences rather than focusing solely on menopause. I would argue this may represent a limitation of the study. While the 30 year timeframe is a good period for a longitudinal study, it is observational and relied on self-reporting measures every 5 years (with a 71% response rate). I had not come across the CES-D before. It seems to be a reliable tool, but the 20 items are depression related, with no questions about anxiety. These 2 areas, self-reporting and not asking about anxiety, would suggest the study may have under reported some of the cognitive issues women I see with perimenopausal symptoms really struggle with, but may not volunteer freely. Additionally, the use of the CES-D at five-year intervals may have missed shorter-term fluctuations in depressive symptoms, particularly around menopause.

    Implications for Practice

    This had some interesting findings, but for me, the take home is (once again) having a holistic approach to women presenting with cognitive symptoms during the PMP. Lower socioeconomic status or higher deprivation are perhaps beyond the scope of primary care, but addressing lifestyle factors (high BMI, lifestyle, strength training versus extreme cardiovascular exercise) can help alongside any pharmacological intervention. Enquiring about previous mental health presentations is also important. Is this the first time or is this an exacerbation of an underlying common mental health disorder? I have also had a few women questioning undiagnosed neurodiversity which has been made worse by the PMP. I think offering a pragmatic approach to medication can be helpful. Hormone Replacement Therapy is recommended as first line treatment for VMS of the PMP but crippling anxiety can be helped by anti-depressant medication, especially when there are few other symptoms. And while this study is interesting, it won’t really change my practice in this area. One area that I might raise in a consultation is the effect of combined contraception on mood. This does provide some evidence of a positive impact, and could be discussed where a woman has a concern about this effect.

     

  • Understanding the Link Between Obesity and Respiratory Infections

    Maccioni L, Weber S, Elgizouli M, Stoehlker AS, Geist I, Peter HH, et al. Obesity and risk of respiratory tract infections: results of an infection-diary based cohort study. BMC Public Health. 2018 Feb 20;18(1):271.

    Another PUN/DEN for me as I knew there was a link, but couldn’t cite any particular evidence. I knew about various triggers and reasons why it might make a difference, but it was good to look it up. I used a new AI tool I have been trialling called Consensus. Really easy to use and a good free plan. Anyway, this is a brief critique of one of the papers I found.

    Recent research has highlighted the connection between obesity and respiratory tract infections (RTIs), revealing how excess body weight may contribute to a higher risk of these infections. RTIs can significantly affect quality of life, lead to high healthcare costs, and result in missed work. Given the rising global obesity rates, understanding how obesity influences RTIs is increasingly important.

    The study found that obese individuals were more likely to suffer from a variety of RTIs, including influenza-like illnesses, bronchitis, pneumonia, sinusitis, and rhinitis. The risk was even higher for long-lasting or frequent infections. This suggests that obesity may weaken the body’s immune defenses, making it harder to fight off respiratory pathogens.

    Interestingly, the link between obesity and RTIs was stronger in women than in men. Previous studies support this gender difference, indicating that obesity may affect the immune system differently in women, possibly due to variations in immune cells that are more affected by obesity in women than in men.

    The study also explored how lifestyle factors like physical activity and diet might influence the obesity-RTI connection. Surprisingly, obese individuals who were more physically active or reported healthier diets had a higher risk of RTIs. This could be due to increased oxidative stress from intense exercise, which may impair immune response, or it might suggest that those who try to lead a healthier lifestyle are more aware of their symptoms. Alternatively, there could be a genetic factor linking obesity and a higher susceptibility to infections.

    Despite these findings, the study had some limitations. It relied on self-reported data, which can be inaccurate, and had a disproportionate number of female participants, which might affect how broadly the results apply.

    In conclusion, the study supports the idea that obesity increases the risk of frequent and prolonged RTIs, particularly in women. However, the unexpected findings regarding physical activity and diet suggest that more research is needed to fully understand these interactions and how they influence the risk of infection. Future studies should aim to better measure physical activity and dietary habits to clarify these relationships.

  • Ugly black skin lesion causes alarm

    I have been trying to explain to bemused friends and acquaintances why, at my own expense (*), I recently travelled to Argentina and back to be at a …

    Ugly black skin lesion causes alarm