The Dr Louise Newson Podcast - 060 - Menopause Education & Fourteen Fish - Dr Mark Coombe & Dr Louise Newson

Episode Date: August 11, 2020

Dr Mark Coombe is the educational director of Fourteen Fish, a UK based company specialising in medical appraisals. They provide education for over 40,000 GPs and healthcare professionals in the UK. In this podcast, Mark and Dr Newson talk about a new menopause education programme they are developing together which has just been launched and is available for healthcare professionals. Dr Newson has created the content with three other GPs with a special interest in the menopause, Dr Rebecca Lewis, Dr Alice Duffy and Dr Sarah Ball. Frustratingly many healthcare professionals have little or no formal education in the menopause which results in women being given the wrong advice and treatment. Education for healthcare professionals needs to be done in an evidence-based and non-biased way. It is also important that healthcare professionals are monitored and assessed regularly for their education so this platform is ideal for launching the menopause education programme on.  Dr Mark Coombe's Three Take Home Tips About the Menopause Education Programme: This programme is evidence-based and current. The information is fresh and right up to date. It is online and so easily accessible. You can pick it up and put it down whenever suits you and can focus on specific modules. "We will be working towards helping you provide evidence in your appraisals so you can justify being looked upon as someone with a specialist interest in menopause and HRT." www.fourteenfish.com

Welcome to the Newsome Health Menopause podcast. I'm Dr Louise Newsome, a GP and menopause specialist, and I run the Newsome Health Menopause and Wellbeing Centre here in Stratford-upon-Avon. So today this podcast is unusual for two reasons. Firstly, I'm not in my clinic. I'm down near Sillsbury in the studios for a company called 14 Fish. And secondly, it's unusual because I have a man, not a woman with me. And I usually interview women.

I have had a few men. So today I'm really excited to have Mark Coombe, who is the educational director for 14 Fish. So thanks for agreeing to do this, Mark. It's my pleasure. So I'm here because we've had a really exciting meeting talking about a menopause education program that we're working together on, which is really going to help give healthcare professionals confidence in diagnosing and managing the menopause. So before we talk about that, Mark, can you just talk a bit of? about your background and what led you to be sitting here in the headquarters of 14 fish?

Essentially, I qualified in London at St George's, had a brief spell in the military, and then when I left, the military became a GP. But during my time as a GP, I've been a GP now for about 20 years. My main other interest is being in assessment and education, and in particular assessment of people to make sure that they're competent for doing a job. And that's at various levels in all sorts of specialities, including general practice and nursing. As part of that education and assessment, I got involved with, as Louise says, a company called 14 Fisher at the time, we're very much looking at an annual appraisal and revalidation of GPs. And it seemed obvious to me that if you were doing that, to be able to appraise every year and to be able to revalidate, you needed to do some education.

So I set up the education part of 14 fish. So appraisal, that's something that all GPs and nurses have to go through? Yes, so appraisal is an annual event in which a doctor or nurse or indeed anyone now working in primary care. So healthcare assistants, pharmacists will be expected to have a portfolio of learning, to demonstrate that they're keeping up to date and giving their patients, the best outcomes. Which is really important, isn't it? Because I know certainly my day, when I just started training and I'm sure your day as well,

we didn't have appraisals. No, not at all. We could choose really what we wanted to do. And so when appraisals came in, there was quite a lot of resistance initially and people thought it was going to create a lot of work. Yeah, definitely. But actually, I find it quite stressful having to get the work together. But actually, to have a period of time with someone else who's either a mentor or an equal,

or someone else, just to have time away from a busy job, where someone actually talks about what you've achieved, what you've done, what you've learned. And there's a lot of reflection. So it's not just saying, I've read this article, I've been on this course. It's how it's it's changed your practice. No, very much so.

And I think exactly, as you said, I'd have to admit that before appraisal was around, we certainly used to do a lot of education, doing things that we enjoyed doing. So if you had to do a number of hours education, you would do it on a subject you were normally very strong on, I think the emphasis on appraisal is to identify your gaps in your knowledge. And so I think the massive improvement and what appraisal has done for a lot of primary care

clinicians and workers is that it helps you identify the areas that you're weak and the areas where a little bit of education, a little bit of study will make a big difference to your patient's outcomes. So 14 fish, why is it? It caught 14 fish. There are two stories, really. The first story is the true story, which is we wanted a name that people remembered. And if you speak to any management consultant, they'll tell you that people remember numbers

and animals. And so 14 fish was born in that way, the untrue story, which most people seem to believe and has not been told by us, is that if you get a shoal of 14 fish, if one goes the other way, then everyone will follow. So it's the philosophy that only takes one to change direction. But sadly that was made up. Yeah, but it's true, isn't it? I think certainly in general practice.

I mean, you're still a working GP, aren't you? I was a GP for many years. And it's no doubt got busier. And sometimes you're on a conveyor belt, aren't you? You're too busy to think and reflect. And this is why I think the appraisal process is good, because you do have a bit of time for a reflection. But you're so overwhelmed often, not always with clinical work,

often with non-clinical work, that you just follow the past of least resistant sometimes and you learn things that you feel that you should, but also in general practice, there are certain key areas that you have to know about, such as diabetes, blood pressure, heart disease, asthma, really important areas. And you can see where this is coming, can you, of course. So the menopause has been quite neglected. And when I first was introduced to 14 fish as a company and I thought, gosh, what you do is amazing. And if any of you listening are healthcare professionals, their website's 14fish.com, it's very easy.

It's very intuitive. It's very clean. It's very modern, isn't it? And I mean, the idea behind the education that we're doing is to give people something which is very relevant and up to date. we read a lot of the big guidance documents. You know, we have various guiding bodies like Nice and Sign, and they produce extensive and very time-consuming, if you're going to read them in detail, documents on what we should be doing in today's practice. And what we do is summarise those into a practical way

that over a short period of time, normally about a 15 to 20-minute video, then you can up-to-date, get yourself up-to-date, and confirm that the practice that you're doing at the moment with your patients is the best that we can do at this very moment. Which is really important because as a busy GP, there are so many new guidelines, aren't there, that come out, so many new papers, lots of new research. And it can be quite hard to keep up to date.

So having something where someone has done all the hard work is really good. And to be able to do it when you're at home, you can, because it's online, you can choose when you can do it. Which makes it really accessible, doesn't it? And I think that's why. we were so excited when you approached us about doing something around HRT and the menopause, because it's not just guidance that alters the way that we behave and perform as GPs, but we are put under pressure by the public and sometimes even more under pressure by the newspapers

and by press. And so there has been such a lot of negative press around HRT and so much a cultural thing that encouraged us to ignore the menopause. encourage women to just get on with it, which is completely unfair and completely unnecessary. So when you approached us, we were very, very keen to really get a proper new look at where we are today in 2020 about understanding the menopause and understanding how to go about, giving women in that episode of life a much fair ago. And so over this journey of us preparing the HRT and menopause package, I really have learned a huge amount and it's altered the way that I'm practising. And I really think that when we release it fairly shortly, that it will

alter a number of healthcare professionals approach. Which I think is really interesting because I know when we first spoke a few months ago, you've been giving women HRT for a long time. You're very pro-helping women, which is really important because we know current figures in the UK show about 12% of women who are menopausal take HRT. Some of these women choose not to take HRT or can't take it first line for various medical reasons. But actually the majority of women would benefit from HRT and the National Institute of Health and Care Excellence guidelines are very clear that for the majority of women,

the benefits of taking HRT outweigh the risks. And I think, you know, just going back to the newspapers and various other things, I'm a trainer in my practice, and so over the last 20 years, I've had a number of trainees come through. And certainly the attitude over the last few years has been of fear to prescribe HRT because of the sort of unreasonable press and uneasidence-based. And, you know, looking back on the background to some of the papers, some of the evidence that the papers were taking is completely faulty and wrong. And we've never really had a chance to properly look back again at that. It's quite amazing, isn't it? So certainly when I first graduated, we used to give HRT out all the time.

It was a bit like giving a statin. If someone's got raised cholesterol, it was given. And I think one of the facts was in the perimenopausal period, about 50% of female GPs were on HRT. So as a group, we really believed in HRT then. Yeah. And then, as some of you might know, in 2002, a big study, a big randomized control study came out called the Women's Health Initiative.

And the take-home message that went to the papers straight away when it came out was that HRT causes deaths, caused breast cancer, caused heart disease even. And it's taken a long time to try and really unpick the evidence properly. And the sad thing about this study was that it was done with good intentions. But a lot of women in this study were post-menopause. So they were, the average age was 63, 65. So a lot of them didn't have menopausal symptoms. A lot of them were overweight and had heart disease in the past. And then they were given types of HRT, which we tend not to prescribe

first line. So they were given very high doses of tablet estrogen and an old-fashioned progestogen, which we know has risks of heart disease as well. So you can't equate that to what we do now. And like you say in the perimenopause, so the time when periods start changing, when hormones levels reduce, that's the best time to really start taking HRT. And we know that if women take HRT during the perimenopause or within 10 years of their menopause, then they have a reduction risk of heart disease and also other important conditions such as diabetes, osteoporosis, even dementia, and also bowel cancer. I'm sure you know taking HRT reduces risk of bowel cancer, which a lot of people don't realise. But I think if you did a quiz in young GPs, then they

wouldn't give you those answers because they're being given misinformation. And so I'm very hopeful that to me, as I say, having been involved in education for the last 20 years, good education is absolutely key. And so I'm hoping that with what we've done together, then we'll make a real difference. Yeah. And so certainly how many GPs and healthcare professionals access 14 fish at the moment? So currently we have over 40,000 healthcare professionals. using our site for one reason or another. And so, you know, we really would hope, if we can

key into this group, we would really hope that we can make a difference. It's a huge amount, 40,000, isn't it? And it's increasing, isn't it? Increasing all the time. In fact, we've gained, you know, 10,000 in the last 12 months. So, you know, with any luck, we'll be well ahead of that by this time next year. And we've just taken on the e-portfolio for the Royal College of GPs. So we're looking after all of the trainees in UK now. And it's best to get people during their training. So this is a great group that we can now access. Which is really important, isn't it?

And I think there's, you know, there's lots of choice out there for GPs, but to have that many shows that you're doing lots of things right, which is excellent. I hope so. And also, I think, as a company, you're constantly evolving. You're listening to what people want, aren't you, which is really important. Yes, I think it's backed down to that. It's very easy to do an educational event or to do educational material like a book. And that book sits on the shelf and stays the same forever.

And so if you reference it a year after it's been written, it's probably getting out of date. I think the advantage of online education and the way that we approach it is it's a live bit of education in that we can update it all the time. And so whenever you've gone to the site, you could look back at a video that you saw last year and actually the video's already been updated. Yeah, which is brilliant.

So let's talk through about our ideas. It still hasn't been launched it, but for the Menopause Education Programme, So we've done four lectures. I've been working with three other colleagues, Rebecca Lewis, Sarah Ball and Alice Duffy, who are all GPs like me with an interest in the menopause. And so we've got these educational lectures talking about the menopause with some questions and answers because it's not enough, is it, just to listen to a lecture.

It's important to show that you have learnt from it. No, I think there's been a lot of misunderstanding. As we've just been talking, Louise, then education, and appraisal and assessment of competence has evolved hugely over the last few years. And we both used to go to courses and come away with a certificate that we would file to show somebody that we'd educated ourselves. But having a certificate really is of very little use. It shows that you were there.

What modern education needs to be about is that you do a bit of education, whether it's reading or whether it's online videos in the way that we do them. But you've got to demonstrate that you're understanding. is improved. So doing questions before the video and questions after the video to show that your understanding is improved and then going into your learning diary and reflecting on how that might improve or change or even just confirm the practice that you're doing currently. So, you know, this is the importance of good education. It's not just being there and providing a certificate. It's about demonstrating that you improve your performance. Yeah. And then the other thing

we've done, which is a bit novel, I suppose, is we've used some really great actresses and we've pretended that they're patients and we've managed to film a series of 10-minute consultations and they're different cases. So women who are very menopause. There is nothing, there is nothing better than in education putting theory into practice. So actually, the way that Louise has done this is to pick some typical type patients that come into your clinic, that certainly come into my clinic. I've seen them, you know, certainly on a weekly, but definitely on a monthly basis, coming into the clinic and looking at how to manage them, how to, the sort of questions to ask them. So the practical approach, which I

absolutely love, is looking at a real patient and how you would deal with them within clinic and how you would prescribe and manage them and how you would follow them up. So really, really useful for day-to-day practice. Which is so important because at the end of the day, we want to help doctors and clinicians who are really busy to try and make it easier for them. And then we've also got, with the consultations, there'll be questions and answers so we can assess how people are learning. And the great beauty about 14 fishes, it will record, won't it, the time that's been spent and what people have looked at as well. And unlike when you go to a lecture and miss something because you didn't quite hear it or,

you know, your phone buzzes or somebody next to you interrupts you, you know, if it doesn't make sense or you're not understanding it, you can pause the video, you can go back and have another listen, or you can look on other reference material just to make sure that you've understood what's been said correctly. Yes, which is really important. And then with these consultations and the lectures, we are going to make it very easy for healthcare professionals to pull off some fact sheets and resources for women as well. So even in the consultation, they can download them, they can print them off,

or they can just direct women to the right parts of often my website, but also other areas as well, to really empower patients because certainly consultations have changed, haven't they, since we graduated from medical school. It's more about patient choice, and the consultation should be very dynamic, shouldn't they, involving our patients? Oh, definitely.

You know, gone of the days where the doctors are sort of didactically speaking to the patients and, you know, a bit like a headmaster. it's much more involving the patient and finding out, you know, what they're worried about and what they want, what they're hoping for from the consultation. And, you know, making sure that at the end of the consultation, you're both speaking the same language. I mean, I have to say that as a working GP and not as an educationalist, having looked at the elements of this package, I'm sure that any GP or any primary care health professional, having gone through the package in detail, will feel extremely confident in the vast majority of consultations around the menopause and around prescribing

H.R.T. I really do think it's a great new addition. Yes. And what frustrates me a lot is there's certainly now a lot of women find that they can't get the right treatment. And we've done a survey of 3,000 women showing that 66% were either offered or given antidepressants first line for their symptoms. And when I've spoken to GPs about it, they said, well, HRT is dangerous. And the antidepressants will help their low mood. Yet we know from evidence it doesn't improve low mood and HRT isn't dangerous if it's the right type for the right person. But it's very easy to blame GPs, but actually it's not their fault, is it?

It can be really hard to get the right information. As I say, we've had lots of very oppressive, very factually incorrect stuff in the press. Some of our leading bodies like the MHRA have given us very strong guidance about HRT. And I really do think we need to turn the tables around and, you know, 50% of the population are women. And I really think we're neglecting them a really important phase. You know, if somebody has hypothyroidism so that their thyroid gland isn't working, you give them thyroxin, which is a replacement for their thyroid hormone. So when somebody's ovaries stop producing estrogen, then we should certainly be looking at in a number of women giving estrogen replacement,

which is what HRT is. Yes, and certainly some of the work I'm doing is to try and even stop the word menopause because it's not a very nice word. To thinking of it as a long-term female hormone deficiency because women are always going to have low hormones if their ovaries aren't working, aren't they? Yes, absolutely. So there's always health risks. And possibly symptoms. I see some women, I saw a lady a couple of weeks ago in my clinic who's 72 and she had her ovaries removed in an operation when she was 48. and every half an hour she's been having hot flushes and sweats.

And every day practically she thinks this will be the end, I won't guess. And it's a long time. And I have to say, having been in practice for 20 years, then we were taught at medical school that hot flushes and menopausal symptoms were relatively short-lived. And just like Louise has said, I've got women 20 years after the menopause who is still having horrific invasive flushes and night sweats and so on. And so certainly for those women, often, and we do give very low doses of HRT,

and it can make a difference even after having symptoms for such a long period of time. We've recently uploaded a leaflet on my website, just talking about this for women who want to start HRT when they're older and they've been longer since the menopause because there's less evidence that it's as beneficial as starting it younger, but women can still often benefit from it.

So if you are suffering, it's worth trying to seek help from a healthcare professional. The other part of the program, it's not all about HRT. So it's very important that lifestyles address, isn't it? Yes. And so I think when women go through the menopause, they have an increased risk of heart disease and osteoporosis and obesity, the metabolic changes that occur

mean that women tend to put on more weight. So some of the module is talking about how to improve lifestyle because that's so important in everything we do. And a hand in hand with active treatment is always lifestyle in a number of our long-term conditions. Although I remember going on some menopause education some years ago and the tutor was very insistent that we immediately said to anyone with menopausal symptoms for them to stop smoking,

stop drinking and take some exercise. I thought that was probably a good way to get punched in the face. But joking aside, then lifestyle is important, but just telling somebody off for something that they're doing and let's face it, you know, in times of crisis, lots of us have gone to. stopping exercise, eating badly, drinking more alcohol. And so being told off when you're using that as medication or as a crutch is not going to help.

So it's lifestyle in conjunction with the positive support and, you know, where necessary, HRT. I think it's so important. And I think also even before thinking about management of menopause, it's thinking about diagnosis. So we're talking earlier about a urine testing kit that's available in some supermarkets looking at a hormone. FSS, follicle-stimulating hormone, to diagnose the perimenopause and menopause. And we were both saying how horrendous it is because this is for £10, you can buy this testing kit,

but actually it's not reliable. No. And so FSAH in urine, I'm not even sure what that means. We sometimes do FSAH levels in blood, but it can be normal even if someone's going through the menopause. I mean, I think somebody explained to me once that it's like looking through the window for a couple of minutes, you know, during a 24.

hour period and it might well be that during that time it's raining or it's sunny, it might be that it's dark, but actually it doesn't give you a picture of the whole day. And so that's why we don't really use f-sh in urine or in blood and very much go on the symptoms. So if someone has got menopausal symptoms and there are a large number of them, you would treat the symptoms and not that very small look through the window. Yeah, and I think that's really important because there's a lot of women I see and speak to who have been misdiagnosed with having fibromy because they've got muscle pains or they've got worsening migraines and they've been sent to a migraine clinic or some women because of the brain fog and memory problems that occur, they're worried

they've got dementia. So even before thinking about treatment, if a healthcare professional said to them, look, these symptoms can all be related. I think it's related to your hormones. That can be very reassuring, can't it, for quite a few women. I mean, I think it's nice to be given a diagnosis and a treatment plan and you may not opt to go for that plan, but just knowing that it's not in your mind that there is potentially a treatment is very reassuring and very normalising. You know, when you're not feeling well, and it doesn't matter what that is, when you're not feeling well, you feel very isolated and you feel anxious about what the outcome of this is going to be and the outcome in relationship to, you know, lots of other people around you and your work and,

you know, it has so many implications. So I think having an open, mind around this sort of age, both for healthcare professionals and for patients themselves, will make it much easier to make the diagnosis and even, you know, a trial of treatment. So if you trial a treatment and it doesn't work, then you can think of something else. But if the trial of treatment does work, then fantastic. You know, we know exactly where we are. Yeah, which I think is so important for people to know that there are options there. And we know from some studies that less than a half of women actually go and see their GP

when they're experiencing menopausal symptoms. And I think sometimes this is because clearly the menopause isn't a disease. It's a natural process or women will go through if they live long enough. But actually because of the health risks associated with the menopause, it is really important that people speak to a healthcare professional. And it doesn't have to be a GP, does it? A lot of practice nurses can be a really good place to start. Our senior practice nurses, who not surprisingly to get to that sort of level,

they often prescribe and run, you know, minor illness clinics themselves are by and large around that sort of age. And so they understand the menopause better than anybody else and are hugely sympathetic. So, you know, if you wanted to speak to a senior practice nurse, then please do. And certainly the education that we're going to be doing, we're going to be very inclusive with nurses and we'd love them to come and see it and listen to it because I'm sure it would be a huge benefit. Brilliant. So thank you ever so much for your time. That's been brilliant. Before we finish, can I just ask for three take-home tips? So three sort of reasons why a healthcare professional would want to go on to the new menopause education program that we're

developing. So the first thing is that it's evidence-based and it's very current and there's been a lot of very bad information about HRT and the menopause and you're certainly not going to get that here. So the first thing would be it's fresh and new and right up to date. The second thing is it's very easily accessible. So it's online. You can pick it up and put it down when it's convenient to you. You know, we all have incredibly busy lives and things happen unexpectedly where you can't sit down for a day and just do some education.

Well, with this, you can do it as and when you've got time to do it. And you can do it if there are modules that you're finding difficult or if they're modules that you just want to refresh on, you can listen to them or watch them as many times as you like. So the second thing would be it's very. accessible and very flexible. And the third thing is we're going to be working towards helping you provide the evidence in your appraisals that you're competent to work at a decent level around the menopause and HRT and that you can justify being looked on as someone with a specialist

interest. Brilliant. Thank you so much for your time today, Mark. Really kind of you. Thank you. It's absolutely pleasure. Thanks for having me. information about the menopause, please visit our website www.menopausedoctor.com.uk