Show Notes
What if the rough, scaly patch you freeze in clinic today is just the visible part of widespread sun damage? Treating only what you can see may mean missing the bigger risk. We explore how recognising and treating the entire sun-damaged area reducing progression to squamous cell carcinoma and improve long-term outcomes. I’m joined by dermatologist and Mohs surgeon Dr Chin-Yun Lin, who shares practical, primary care–focused guidance on choosing and using field therapies for actinic keratoses. Using the case of Simon, a 55-year-old builder with significant sun exposure and multiple lesions on his face and hands, we discuss: What “field treatment” really means in everyday general practice When to move beyond spot cryotherapy and treat the whole area of sun damage How to choose between topical 5-fluorouracil, imiquimod, and photodynamic therapy Preparing patients for treatment reactions and improving adherence When to refer and when you can confidently manage in primary care
This episode is full of practical tips to help you manage sun-damaged skin more effectively and reduce your patients’ long-term skin cancer risk. Practical clinical pearls : Patient Education is Key: Reinforce sun protection, ongoing self-examination, and adherence.Explain that AKs are precancerous, not benign warts—early treatment reduces risk of SCC. Preparation of the Skin Improves Efficacy: Gentle debridement, keratolytic creams (urea or salicylic acid), or low-potency retinoids before topical therapy can enhance penetration and response. Field Treatment is Often Preferable for Multiple Lesions: When you see multiple AKs or “field cancerization,” topical therapies (like 5-fluorouracil, imiquimod, or diclofenac) can treat visible and subclinical lesions simultaneously.Pick therapy based on patient tolerance, adherence, and skin location. Treatment Selection Depends on Lesion and Patient Factors:5-FU: aggressive but effective, may cause intense inflammation—good for thicker or widespread AKs. Imiquimod: immune-stimulating, good for thinner AKs or for patients who prefer intermittent dosing. Photodynamic therapy (PDT): alternative if topical therapy fails or not tolerated. Monitor for Flare or Incomplete Response: Mild irritation is expected, but severe inflammation, erosion, or ulceration may require pausing treatment. Non-responding lesions should be reevaluated for biopsy, as persistent AK may hide squamous cell carcinoma (SCC). Refer to a dermatologist: if the diagnosis is unclear, or if the lesion requires expert excision or specialized management.
Resources: https://www.rnzcgp.org.nz/events/ongoing-events/gp-dermatology-course/ https://dermnetnz.org/topics/actinic-keratosis https://dermnetnz.org/cme/lesions/topical-treatment-of-photodamage https://dermnetnz.org/topics/5-fluorouracil-cream https://dermnetnz.org/topics/imiquimod Guest bio: Dr Chin-Yun Lin is a Dermatologist and accredited Mohs micrographic surgeon. His specialty interests include the treatment of skin cancer, melanoma, dermatitis, psoriasis, acne, pigmentary disorders, and cosmetic dermatology. After graduating as Dux of Macleans College in Auckland, he went on to complete his undergraduate medical degree with first-class honours at the University of New South Wales in Australia. He undertook Dermatology advanced training at tertiary teaching hospitals in Auckland, Hamilton, and Christchurch. Further Dermatology training and a Mohs surgical fellowship were undertaken at St Vincent's Hospital and the Skin Hospital in Sydney. He is also a Fellow of the American College of Mohs surgery. Dr Lin has won various Dermatology awards such as the Trans-Tasman Scholarship for best registrar presentation at the New Zealand Dermatological Society Annual Conference, and the best poster presentation at the Australasian College of Dermatologists Annual Scientific Meeting. Dr Lin also takes interest in clinical teaching and research. He is a registered education provider for the RNZCGP. He has published
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People living with mental illness or substance use challenges experience significant inequities in physical health outcomes, with physical illness often diagnosed later or overlooked altogether. Diagnostic overshadowing where symptoms are attributed to an existing mental health, substance use, disability or a chronic health condition rather than investigated fully remains a major issue in healthcare. In Aotearoa New Zealand, this inequity is even more pronounced for Māori, where the impacts of stigma, racism, mistrust, and fragmented care intersect. In this episode, we explore why this happens, how it affects patients, and what clinicians can do differently. Practical clinical pearls: Individually: build a habit of asking “What else could this be?”. Make it a habit to perform a focused physical examination and consider basic investigations even when symptoms seem to fit with the known psychiatric diagnosis. This simple cognitive forcing strategy can interrupt premature closure and implicit bias. System‑level: implement integrated care models where physical and mental healthcare are delivered together with shared records and coordinated plans. Integrated care models have been shown to improve physical health outcomes for people with serious mental illness, reduce fragmentation, and ensure that physical symptoms receive appropriate attention regardless of psychiatric comorbidity For Māori, this means developing and funding culturally safe, Māori‑led services that integrate physical and mental healthcare, address the social determinants of health, and build trust through culturally aligned care delivery. This requires genuine partnership with Māori communities, addressing institutional racism, and ensuring adequate resourcing for Māori health services. Resources: Buhay C. Overlooked. The Horizon. Published September 16, 2025. Accessed May 18, 2026. Lazris A, Roth A. Diagnostic overshadowing: when cognitive biases can harm patients. American Family Physician. 2023;108(3):292-294. Iezzoni LI. Dangers of diagnostic overshadowing. New England Journal of Medicine. 2019;380(22):2092-2093. doi:10.1056/NEJMp1903078. Shefer G, Henderson C, Howard LM, Murray J, Thornicroft G. Diagnostic overshadowing and other challenges involved in the diagnostic process of patients with mental illness who present in emergency departments with physical symptoms: a qualitative study. PLoS ONE. 2014;9(11):e111682. doi:10.1371/journal.pone.0111682. Additional References: Hallyburton A, Allison-Jones L. Mental health bias in physical care: An integrative review of the literature. Journal of Psychiatric and Mental Health Nursing. 2023. Tosh G, Clifton AV, Xia J, White MM. Physical Health Care Monitoring for People With Serious Mental Illness. The Cochrane Database of Systematic Reviews. 2014. Hall WJ, Chapman MV, Lee KM, et al. Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes: A Systematic Review. American Journal of Public Health. 2015. Maina IW, Belton TD, Ginzberg S, Singh A, Johnson TJ. A Decade of Studying Implicit Racial/Ethnic Bias in Healthcare Providers Using the Implicit Association Test. Social Science & Medicine. 2018. Friedemann Smith C, Lunn H, Wong G, Nicholson BD. Optimising GPs' Communication of Advice to Facilitate Patients' Self-Care and Prompt Follow-Up When the Diagnosis Is Uncertain: A Realist Review of 'Safety-Netting' in Primary Care. BMJ Quality & Safety. 2022. Goetz CJ, Mushquash CJ, Maranzan KA. An Integrative Review of Barriers and Facilitators Associated With Mental Health Help Seeking Among Indigenous Populations. Psychiatric Services. 2023. Russell J, Boswell L, Ip A, et al. How Is Diagnostic Uncertainty Communicated and Managed in Real World Primary Care Settings?. BMC Primary Care. 2024. About Dr Cheryl Buhay: Cheryl is an adult psychiatrist with Takanga A Fohe Pacific Mental Health and Addictions Service within Health New Zealand Te Whatu Ora Waitematā. Prior to this she w
Kindness at work is not the same as being nice. In this special one-year anniversary episode of The Specialist GP, we welcome back the podcast’s very first guest, Dr Nicki Macklin, to explore kindness in healthcare, leadership and the supervisor–supervisee relationship. We explore what kindness really looks like when we are busy, under pressure and responsible for supporting other people’s learning and development. We discuss the difference between kindness and niceness, why trust needs to come before difficult conversations, and how we can use coaching, feedback and early intervention to support people while maintaining standards. We also challenge the idea that kindness is simply an individual quality, and consider how we can build kindness into the way our workplaces and organisations are designed. A practical conversation about supervision, leadership, feedback and creating workplaces where people can learn, speak up and do their best work. Practical clinical pearls. First, kindness is not the same as niceness. Sometimes the kindest thing we can do is have the difficult conversation, set a boundary or give honest feedback. Second, kindness is something we build into our systems. Protected supervision time, clear expectations and regular check-ins create the structure for people to do well. Third, trust is built before it is needed. The small, everyday interactions are what make difficult conversations safer when they eventually need to happen. Fourth, silence is not neutral. Avoiding a difficult conversation may feel easier in the moment, but it can leave people anxious, prevent learning and allow problems to continue. Fifth, different situations need different conversations. Coaching, feedback and intervention are not the same thing, and knowing which one is needed is an important part of good supervision. Sixth, directness can be kinder than vague reassurance. Be specific about what happened, the impact it had and what needs to happen next. Lastly, Good supervision is a shared system responsibility. Power matters in supervision. The person with less power should not be expected to carry the burden of fixing a poor supervisory relationship. Supervisors and organisations have a responsibility to create safe, supportive and accountable supervision. If the relationship is not working, seek support outside the immediate supervisory relationship. A professional mentor, another supervisor or a trusted peer can help you work out what is happening, consider your options and decide how best to move forward. Resources: · Macklin N, Lee TH, Edmondson AC. Why kindness isn’t a nice to have. Harvard Business Review. 2025 Jul 29. · Macklin N, Rapana N, Wilkinson-Meyers L, Dowell A. He Aroha Whakatō, He Aroha Puta Mai. Embedding kindness in organisational practice: lessons from a kaupapa Māori primary care team. Kōtuitui. 2026;21(3). doi:10.1002/kot2.70056. · Macklin N, Wilkinson-Meyers L, Dowell A. Defining kindness in healthcare: perspectives from international experts. SSM Health Syst. 2026;7:100270. doi:10.1016/j.ssmhs.2026.100270. · Goode S, Hodge G, Cross D. A guide in undertaking core clinical supervision: supervisors’ experiences in implementing core clinical supervision in general practice. Practice Nursing. 2025;36(1):19-25. doi:10.12968/pnur.2025.36.1.19. · Ingham G, Johnson C. GP supervisors in Australia: a cornerstone in need of repair. Med J Aust. 2022;216(4):178-181. doi:10.5694/mja2.51411. · Wearne S, Dornan T, Teunissen PW, Skinner T. General practitioners as supervisors in postgraduate clinical education: an integrative review. Med Educ. 2012;46(12):1161-1173. doi:10.1111/j.1365-2923.2012.04348.x. · O’Sullivan B, Hickson H, Kippen R, Wallace G. Exploring attributes of high-quality clinical supervision in general practice through interviews with peer-recognised GP supervisors. BMC Med Educ. 2021;21:441. doi:10.1186/s12909-021-02882-7. · ten Cate O. Entrustability of professional activities and competency-based training.
In one of my most challenging conversations of the year, Dr Diana Kopua asks us to slow down and look differently at ADHD. Equity CME poinst can be claimed. We meet Wiremu, a 22-year-old Māori man who comes to primary care with his auntie after his boss suggests he might have ADHD. He is struggling to stay focused at work and complete his apprenticeship theory, and it would be easy to move quickly towards a diagnosis. But Diana challenges us to pause. What happens when we start with the relationship rather than the diagnosis? What does context really mean when we are assessing ADHD? And what might we miss if we focus on symptoms without understanding whakapapa, whānau, culture, identity and the lived experience of the person sitting in front of us? This is not a conversation about finding a different checklist for diagnosing ADHD. It is a conversation about questioning whether the way we currently approach assessment is always serving our patients well. Diana shares how Māori models of health, including Mahi a Atua and Mauri, can change the way we think about distress and wellbeing. We talk about the role of whānau, culturally safe assessment, diagnostic labels and the uncomfortable possibility that our own clinical practice can sometimes contribute to inequity. We also ask a difficult question: when is an ADHD diagnosis actually helpful, and when might we be too quick to assume that a diagnostic label is the answer? There are no easy answers here. Instead, Diana asks us to be curious, to sit with some discomfort and to think more deeply about what we are doing, why we are doing it, and who our approach is working for. For GPs and other primary care clinicians, this episode offers practical ways to rethink ADHD consultations, while challenging us to look honestly at the assumptions we bring into the room. Sometimes better care starts with being willing to stop, listen and see the patient differently. Practical clinical pearls: Start with the relationship, not the diagnosis. Name the purpose of the consultation, establish what matters to the patient, and check how they want to approach the conversation. Bring whānau into the conversation early. Where appropriate, invite whānau participation from the beginning rather than treating it as an add-on to the consultation. Use a culturally appropriate framework. Frameworks such as Mauri can help explore wellbeing and the wider context of the patient’s experience alongside diagnostic assessment. Ask what the diagnosis will change. Before pursuing a diagnostic label, ask how it will benefit this patient, at this time. Consider whether the focus should be on potential, strengths and support as well as symptoms. Check how the consultation felt to the patient. Before finishing, ask whether they felt respected, heard and understood. Be willing to sit with discomfort, reflect on how your own practice may contribute to inequity, and stay curious about where you can do better. Feeling out of your depth? Upskill- see resources below. Resources: Te Kurahuna – Mahi a Atua – Official website for Mahi a Atua, including information about the approach, training, publications, and resources. Kopua, D., & Skirrow, P. (2023). Racism, Mātauranga Māori and ADHD: An Interview With Dr Diana Kopua. Journal of the New Zealand College of Clinical Psychologists, 33(1), 72–78. https://doi.org/10.5281/zenodo.8187808 (Mahi a Atua) Kopua, D. M., Kopua, M. A., & Bracken, P. J. (2020). Mahi a Atua: A Māori approach to mental health. Transcultural Psychiatry, 57(2), 375–383. https://doi.org/10.1177/1363461519851606 (Sage Journals) Te Kurahuna Publications & Resources – Collection of Dr Diana Kopua's publications, reports, and additional resources on Mahi a Atua, Indigenous mental health, racism, and systems transformation. About Dr Diana Kopua: (Ngāti Porou) is a consultant psychiatrist, co-founder of Te Kurahuna, and the developer of Mahi a Atua, an Indigenous approach to mental health grounded in Māori pūrākau, whak
Varicose veins are common presentation in primary care, but knowing who to reassure, who to investigate and who to refer isn't always straightforward. Today we are doing something different- we are going work through five real-world quick-fire cases to highlight practical assessment and management of VV’s. I am joined by Dr Sam Dunn. Practical clinical pearls: 1. Pregnancy- Treat the symptoms, not the veins. Compression, movement, avoiding prolonged standing and leg elevation are usually all that’s needed. Reassess 3–6 months postpartum. 2. Examine varicose veins standing up. They can disappear when the patient lies down. Look for oedema, pigmentation, eczema, lipodermatosclerosis and ulcers—and check the pulses before compression. 3. Compression isn’t automatically benign. Check arterial circulation first. If pulses are reduced or arterial disease is possible, assess further before prescribing higher-grade compression. 4. Know who needs referral. Symptoms, oedema, skin changes, ulcers, thrombophlebitis or bleeding mean this is more than a cosmetic problem and warrants referral. 5. A bleeding varicose vein is an emergency waiting to happen. Lie down, elevate the leg and apply firm pressure. If it doesn’t stop—or starts again—seek urgent medical care. Even when it stops, arrange urgent referral. Bio: Dr Sam Dunn. Sam is Medical Director at Palm Clinic and an experienced cosmetic medicine and vein physician. After beginning his career in emergency medicine, Sam has spent almost two decades practising phlebology and cosmetic medicine. He holds Diplomas in Procedural Phlebology, Skin Cancer Medicine and Community Emergency Medicine, and is a Fellow of the New Zealand Society of Cosmetic Medicine. Resources: https://www.palmclinic.co.nz/vein-care/what-to-expect https://www.anzsvs.org.au/patient-information/varicose-veins/ https://medlineplus.gov/varicoseveins.html Listen here: https://podcasts.apple.com/nz/podcast/varicose-veins-w-dr-sam-dunn/id1845748299?i=1000786889860 https://open.spotify.com/episode/4gP40UOpbqu4p48SmCD4rm?si=721f49e4bd68454c
Frailty is a common but often under-recognised clinical syndrome that has significant implications for health outcomes in older adults. In this episode, we explore how frailty develops, who is most at risk, and why early identification matters. We discuss practical approaches to assessment in primary care, the consequences of frailty, and evidence-based strategies to help patients maintain function, independence, and quality of life with specific discussions around Te Ao Māori perspective. Practical clinical pearls: Watch for the frailty pattern: unintentional weight loss, reduced activity, fatigue, slowed gait, and falls. Use the corridor as part of the consult: gait speed, chair rise, grip strength, and how they move tell you a lot. Ask family/whānau for collateral history, because gradual decline is often noticed there first. Think multifactorially: frailty is linked to sarcopenia, multimorbidity, polypharmacy, social isolation, nutrition, and environmental barriers. Prioritize resistance training and adequate protein intake; those are among the most effective preventive strategies. Review medications carefully, especially sedatives, anticholinergics, and overly tight diabetes or blood pressure treatment. Use frailty to change decision-making: shift from disease-only management to goals-of-care and whole-person planning. Keep care strengths-based and culturally grounded, especially for Māori patients: focus on what matters, what supports them, and what gives them mana. Don’t wait until someone is clearly frail; midlife is the right time to start prevention. Frailty is not just a label — it’s a signal to act.