The Dr Louise Newson Podcast - 132 - The benefits and pitfalls of evidence based medicine with Jonathan Underhill

Episode Date: December 28, 2021

Pharmacist, Jonathan Underhill is a consultant clinical advisor for the Medicines Optimisations team at the National Institute for Health and Care Excellence (NICE). His work is focussed on evidence-based medicine but, as he explains, this is more than simply telling people what to do. One of the particular focuses of Jonathan’s work is the process known as ‘shared decision making’ between the clinician and the patient and he’s interested in how you involve a person in choices and decisions about their own healthcare. Jonathan outlines some of the reasons NICE was originally set up – to reduce uncertainty and variation in prescribing – and with Louise, he evaluates whether this has been the outcome 6 years down the line, after the release of the NICE guidelines on menopause diagnosis and management. Jonathan’s tips for shared decision making as a patient: It’s OK to ask questions. If you need it, take someone with you that you trust who can listen and advocate for you And for healthcare professionals: David Haslam’s (former Chair of NICE) consultation skills advice for doctors were basically ‘shut up and listen, show empathy, and know something’. If you can do these 4 things well it will make a big difference Practice your conversation skills as a clinician. You can learn to communicate better with your patients. The NICE guidelines on menopause can be read in full here and more about shared decision making can be found here. If you are a healthcare professional, the following link offers 4 hours of free online learning in shared decision making from NICE and Keele University: https://www.nice.org.uk/guidance/ng197/resources/shared-decision-making-learning-package-9142488109

Hello, I'm Dr Louise Newsome and welcome to my podcast. I'm a GP and menopause specialist and I run the Newsome Health Menopause and well-being centre here in Stratford-Bron-Avon. I'm also the founder of the Menopause charity and the Menopause support app called Balance. On the podcast, I will be joined each week by an exciting guest to help provide evidence-based information and advice about both the perimenopause and the menopause. So today in the podcast I have with me, Jonathan Underhill, who was very kindly introduced to me recently, and he's a pharmacist, but he's also a consultant clinical advisor for the

Medicines Optimisation Team at Nice, which is the National Institute of Health and Care Excellence. And it's a real honour, actually, to talk to you because I got in touch with you about some guidelines, which we'll talk about. But before we talk about those, Donnie, Jonathan, I'd just like to say, welcome to the podcast. Hello, Louise. And just, that's a bit of a mouthful. So, medicine's optimisation team, you actually said MOT, which for most people, it's about their car, is it really? Just explain, if you don't mind, like what your role is with this and how you got into that, if that's okay.

Sure, yes. So it's obviously nice, as you say, as the National Institute for Health and Care Excellence. We are the organisation funded by the Department of Health, who we aim to reduce uncertainty and try and reduce variation in care. So we produce clinical guidelines where we look at the evidence that's out there for particular how you treat, diagnose, manage different conditions, and create recommendations that are aimed to help clinicians to make better decisions for the patients under their care. And we also will do health technology assessments. If a new medicine comes to market, then what we will do is we look at the evidence for that technology

do a cost-effectiveness analysis of it and say whether it's likely to be a cost-effective option for the NHS to use. So within NICE, NICE is a big organisation now, 500-odd people working there. The medicines team is around it. It's quite a small team. We've got about 20, 25 people. We work in the Centre for Guidelines at NICE. We are largely pharmacists, like myself. we have some, a couple of doctors as well and sort of operation staff. And our role really is to look at those clinical guidelines where there is a, what we call a large medicines component to it. Because most nice guidance does contain something about medicines, but some of them don't.

So we concentrate on those ones where we can add value to the process really and look at it from a medicine's perspective. I came into the organisation from another organisation called the National Prescribing Centre. The MPC, yeah. The MPC, yeah. So we were a Department of Health Organization who were primarily, R.M was to support prescribing and, again, medicine's usage. We produce prescribing bulletins.

We do educational events and produce educational resources to try and, again, support the sort of medicine's optimization out in the NHS. So as a pharmacist, that was quite useful for me. It's an interesting journey for me as well, because I spent a lot of time doing sort of educational events for prescribers, for GPs, for nurses and pharmacies. And if you like, being a proponent of evidence-based medicine, thinking that if I just told people the evidence or taught them the evidence, that that would miraculously change their practice. It doesn't.

And of course, it's much more complex than that. And that took me down with colleagues into a sort of interest in how humans make decisions. and how people learn and how we influence other people. And latterly, in the last few years, I've become really, really interested in shared decision-making and how you involve patients and people in the decisions about the choices they make around their own healthcare. It's really interesting, and I've talked about this before in the podcast,

actually, so when I qualified in the early 90s, it was very old-fashioned paternalistic medicine. We'd give them the green piece that pay for all in hospital. It was just, this is you, that you go on a ward round, you'd prescribe drugs wouldn't even tell them what they were actually. And you do their TTOs, their takeaway drugs, and, you know, a nurse might go through with it, them, or sometimes a pharmacist,

but people generally wouldn't know what they were taking, but they would probably take them, or maybe they'd end up in their cupboard in their bathroom. I've got no idea, but you think you were doing a good job as a doctor because that's how you were taught. And obviously things have really changed, but it's really hard to keep up to date as well, isn't it? Especially as a GP, because you've got so much going on,

And I've always been really key with evidence-based medicine. But I've had the luxury, though, Jonathan, of working part-time. So I've done a lot of medical writing and a lot of education in my last sort of 25 years, I suppose. And so it's given me time to reflect and sit and look at the original papers, not just the abstracts. And for my own opinion, based on evidence, but for many people who work full-time at the front, you know, clinical practice, it's too difficult. you're too tired in the evening. So nice is brilliant when they've reduced the guideline. You know that it's there and it's good

and it reduces that need, doesn't it, to go back and look at the originals? Absolutely. I mean, I've been very lucky to do some work with some people in America, Dave Slosson, Alan Shawnessy, who talk about the need for you as a clinician to have trusted sources of evidence

rather than going away and doing a medline search for yourself. Because first of all, how do you know you've got the right papers there. And then if you come to read and critically appraised the papers, if you're a clinician, you're doing other things. So you'll go on a critical appraisal course maybe, and then a few months later when you try and critically appraise a paper, you can't do it because you've forgotten how to do it. So very much as those trusted sources, and I think nice is a trusted source. We have people who use job it is to do critical appraisal 24-7.

Which is so important. I mean, I did an extra degree. I did a pathology and immunology degree in 1992. In those days, when you wanted a reference, you'd go to the library. Yes. And you'd have to search for it, and they'd all be bound. And the one paper you really wanted had been sent off to be bound, so you couldn't get it. So then you think, oh, I'll go to the second one. So you'd probably missed, like, the most important reference.

But you'd, you know, you didn't want to go back to the library because you want to go out with your friends later on. And I'm sure you've been there as well. So now it's a lot easier with PubMed. But actually, it isn't, it isn't, because there's so many that you can just, with a little search, anyone can access them. But you don't know the source, you don't know the authors, you don't know the context sometimes. Exactly. You can only get the abstract. You can't read it all.

And taking things from base value is really dangerous, actually, isn't it? And this happens in all sorts of aspects of medicine, not just in menopause. And then the problem is, I've seen a lot of articles that have a press release associated with them. And then the press get hold of it. And then that's it. It's a car crash, isn't it, for sometimes? Yeah, so, I mean, it's not as much of a problem as it was, as you. you say historically, but the problems now are different because there is massive information overload

in the advent of the internet and almost the democratisation of evidence has brought its own problems because then as you say, if someone gets hold of a press release, often that gets in the media before people like us have had time to critically appraise it in an objective way as possible, an unbiased way as possible. Everyone's biased because we're human beings, but... Yeah. And certainly the GPI had lots of people that would come to me on a Friday or whenever the health section of the mail would come out and they'd say, oh, can I have this drug for my Parkinson's disease?

Quite. And then I look at, even in the mail, it's saying a study of nine people or something, and I'm going, oh, I'm really sorry. You know, and it's expectations these poor people. But it is interesting. So we'll talk about a couple of the guidelines, if we may. Firstly, I think we need to talk about nice menopause guidance, because actually it came out November 2015.

It's been a while ago, wasn't it? 21, yeah. And up until this time, I've been prescribing HRT based on my knowledge of the evidence. And I've worked with partners who refuse to prescribe it. So as quickly as I'd put people on HRT, they would take them off. And they were saying, well, that's just your word against mine. I'm really sorry, Louise, I don't agree. You shouldn't be doing this. This is dangerous medicine. And I said, well, the evidence is. So when the November came around and the nice guidance came out, it's the happiest time I've ever been to see a nice guy. which was a little bit conservative, but actually it was really good, really powerful just to say, for the majority of women, the benefits that way the risks. And they did a really good section on POIs, the premature ovarian insufficiency, women under the age of 40. Because I was taught at medical school, if a young woman hasn't had their periods, just make sure she's not pregnant and don't worry about it. So I feel awful that was what I was taught, but that's all I knew. And there's quite a lot about vaginal dryness on there too. So I was thinking, this is absolutely fantastic.

Around that time, there were probably about 8 or 9% of women then taking HRT. So six years later, do you know what the percentage of women taking HRT is? It's probably higher than that, but not as high as it should be, or that you might think it is. Is that fair? Yeah, it's about 12%. In some areas, it's about 2%. And women from low socioeconomic classes, it's about 29% less.

See, Louise, that's the thing that really, and I said right at the start, one of the reasons nice came about into being was to reduce unwarranted variation. And what you've just described to me is, I can see no good reason why in some areas prescribing of HRT is as low as 2%. And in other areas, it must be as high as 25, 30%. So can someone explain that to me why that is?

And especially, as you see, if it's associated with inequalities, a deprivation as well. That's something that knows I really keen on. And it certainly is, I was talking to someone who's a doctor in Morecam actually, and she said, how and her partner, they're both doctors in Morecam.

slightly different areas and the HRT prescribing really varies. But it's uniformly low and actually since I left my GP practice, every single patient's been taken off HRT. So it'll be zero where I was. You know, and I think even if you don't believe the evidence, you don't want to believe it, if nice are saying it. But then it's also about dissemination of guidance, isn't it? And I think this whole thing also about confirmation bias that's still very much there. I was listening to Tim Minchin. I went to his live, one of his live gigs recently. I loved him. He's so brilliant.

He's so good. In fact, I went twice because I took my daughter and then I went with some friends. So I had a pleasure of him twice. But he talks about confirmation by it. So if you're driving along and a white van cuts you up, that's it. All white van drivers are awful. And so now we've got this with HRT and breast cancer. If a woman gets, if she's on HRT and gets breast cancer, of course it's the HRT that's caused it.

And how do you know that? Does she clean her teeth every morning? Does she brush her hair every morning? Well, maybe it's that. So maybe it's because she wears blue pajamas tonight. An association is not a cause, but we've got this massive. And then we've got to try and change and unpick the evidence. And how do we do that?

And I'm sort of quite surprised that even Nice can't do it with the menopause. And it's quite shocking because most women who we see and speak to have been given antidepressants first line, end off. And often they've been given three or four and just said, this is all you can have because HRT is too dangerous. So it's a problem, isn't it, trying to get guidance out? What you've just described there is the benefits and the pitfalls of evidence-based medicine, actually, because the benefits are it reduces things like confirmation bias or recall bias

or availability bias where you see things with your own eyes and you therefore associate that, you ascribe that to be something that's a cause and effect. And of course, the only way that you can be sure of doing that is by doing that, a randomised control trial, where you have two groups of people separated by a random process and you give half of them the intervention and half of them the comparator. You follow them up for a period of time and you see what happens to them. Fantastic. Science at its best.

That's how you determine if there's a true difference or not. The problem with that is, of course, that clinical trials are very, very expensive to run. They tend to be run by or funded by pharmaceutical industry, especially with their own medicines, because they're expensive, so there is the need for return and investment. And I think in particular with the menopause guidance and the menopause evidence, some of it is based on studies that were done 10, 20 years ago, where the HRT that was used then is very different to the HRT use now.

But the problem with that, Louise, is that that's the evidence that we have. have. So one of the models that we use to describe what we do at Nice is we call it the RN-L-I model. So it's not the lifeboat people. R stands for research. So we translate the research into national recommendations. That's the N. And then you have the next step, which is you take national recommendations and create local care pathways, which is what your local teams do in localities. and then the third translation is from that local care pathway into the individual person. So our job at Nice, as I say, is to take the research, the best available evidence, and create recommendations for the population that we can do.

So if the best evidence is this stuff from 10, 20 years ago, and there isn't the same evidence for the new so-called modern HRT, it's really difficult for us to make strong recommendations about where that should be used. And that's where I think some of the variation comes in because in the other two translations you create choice if you like this is what you would do locally and then individually that's where you get real variation potentially

because it all depends on how it's been explained to the person and indeed what that person values to them and thinks important to them. It's absolutely right and I think lots of the work that I do obviously we prescribe transdermin and eustodermin because it's not quite a clock risk or whatever. But actually a lot of times, especially when I'm educating healthcare professionals, say, look, even if everyone just went to the nice guidance, which I said are a bit conservative, but that's fine, they're still very clear about what's safe and what's good and what risks are they. And even if you look at those risks that are in all their tables that are quite hard to understand, actually, it's actually the risk is still really low.

And it's looking at benefits as well. And I think this is where nice were very good because they do talk about osteoporosis. They're not looking at other health benefits, but it's still, it's fine. But I think the other thing then is looking at the individuals, and this is where the other guidance, the shared decision-making guidance, I think it came out, when did it come out in June this year, wasn't it? Yeah, it came out in June this year, yes. Yeah, and I think this is where it comes down to individuals, isn't it?

So do you mind just describing what that means? No, I don't mind at all. It would be my absolute pleasure. I thought you were going to say, no, I'm not going to do that. No, I mean, I don't mind. It's an interesting one, because I've talked about evidence-based medicine before. So evidence-based medicine was something that came about in, 1995. It was David Sackett and some comedies who got together and said, we need to do something

about this kind of people just basing their practice on what they've always done or what they see with their own eyes. So evidence based medicine has got three components to it. And I'm sorry if I think I'm going on a bit, but there's a reason why I'm... No, it's really important. I think it's great. There's a reason why I'm kind of explaining this. So evidence space medicine is the best available evidence. So the science that I've just explained before, you know, the randomized control trial evidence or the best that we have, the clinicians' expertise and experience and the person's values and preferences. So back in 1995, evidence-based medicine was always supposed to be about best available evidence, clinicians' experience and the individual's values and preferences. And along

the way, what we've done is we've concentrated on generating as much evidence as we can, And we've forgotten, I think, a little bit about the most impulsive bit. How do you put the person at the centre of this and that we're doing the right thing for them? So shared decision making, there's a whole sort of movement that came out of that. And was nice, I'm happy to say, and proud to say we're at the kind of the centre of that in many ways. But there's been lots of other people around the world who have led the way around shared decision making. And so as part of this international collaborative, one of the things that we were asked to do was to produce a guideline on shared decision making. So we could look at the evidence and say,

right, how do you do this? What is shared decision making? How do you do it? Can you make some recommendations for commissioners and organisations, make some recommendations for individuals as to what they can do to make share decision making part of their everyday practice? And it's probably worthwhile just focusing on what shared decision making is. And as I said, we came up with a definition of it. And there's quite a few important points to it. So it's a process, first of all, where the patient and the clinician work together and have a conversation in partnership with each other and they identify the best course of action at that point in time

for that individual. So it's about sharing what matters to them, it's about finding out what matters to them, and then it's about explaining the different interventions that are available to them and the different risks and benefits of those different interventions so that they can make a decision as to what's most important. under them. So it's interesting before. I'm just going to pick you up with something you said

before Louise, because you said, and we all do it. You said the risks and benefits of HRT, the risks are quite low for HRT. So what you've done there is you've put your own value on that low. And I think most people would agree with you, but we should avoid using terms like low and high because what's low to one person might not be low to another. And I think risk is a really difficult thing. So if someone says to me, Louise, you've got a three in a thousand chance of dying by crossing the road. That means nothing to me. Am I going to be those three? Am I going to be one of the nine? I don't care about all the other people. I just want to know about me. And then the whole relative risk, absolute risk, is a minefield. It's a minefield. It's quite soon after the

menopause guidance came out, I realized that I was peri menopause on myself. Because my brain had gone and my joints and muscles were stiff and I was a moody, miserable thing. And so I started taking HRT and I thought, wow, this is amazing, my brain's coming back, very exciting. And then the British Journal of Cancer brought out a paper on the 23rd of August.

And I remember it because it was my daughter's birthday and I was taking her to a drama group and I opened the headlines at 6 in the morning when I got up. And it was like, oh my goodness, breast cancer three times risk with HRT users. Classic. And I was like, oh my God, I'm going to take my patch off.

Just as I'm feeling better. And my poor daughter was so annoyed because I ended up being on a news and all sorts of media stuff. But I still wasn't sure what does this risk mean? What is three times? And you're absolutely right. So if my only concern in life was about breast cancer, if that's every day I was worried about it, then a very small risk is a massive risk. Exactly.

It's all I would worry about. So if you as my physician or pharmacist would say to me, the risk is really low. But that's going to ruin my life worrying. And if I get breast cancer, I'm going to blame myself for taking the HRT. Well, don't ever take, because we can never prove anything. Quite. Whereas if my fear, actually, my personal fear is osteoporosis and dementia, actually.

But that's an individual. And I think what's very interesting, actually, is when I started my clinic, I started my clinic, actually, I just wanted to do one day a week to help some of my friends get off antidepressants, who weren't my patients. And I felt sorry for them being on antidepressants. and I couldn't get a job as you know in the NHS so my mentor said

just to set up a private clinic which is still really great to men I hate doing private medicine so I thought I'd do one day where it helps for my friends and then lots of other women decided to come and see me and they'd say do you know what

I just don't want HRT just tell me what I can do so I started printing off booklets so I could give them information and I'd go through everything and I'd say well just have a read and I wasn't doing the podcast and I obviously didn't have the app

or as many resources so I said it's absolutely your decision, but why don't you have a read and come back and we'll talk about it again. So then one by one they'd come out and say, do you know what, I really want HRT. And I've also, I spend time saying everything's reversible. So what you decide today is not necessarily what you're going to decide tomorrow or in three months time. And you are in control of this medicine so you can stop it at any time because I think that's really important, isn't it, for people to know. Absolutely. But now people come to the clinic and they say,

I've downloaded balance app, I've listened to your podcasts, I've read this information, and a lot of them have read nice guidance. They know it better than I do now. And they say, I really want HRT actually. And I've been refused it because for no reason, but I want it and I'm prepared to take any risk. And then we see a lot of women who've had breast cancer and this is a very specialist area,

but they say, I've made the decision based on how I feel and the information I've read. And again, we spent a lot of time. But I think this individualisation of care, not just in menopause, but anything we do, it's really important, but also the reversibility as well. And I think that's what comes out in the shared decision-making guidance, isn't it? Nothing set in concrete.

Well, no, as I said before, it's about what's best for you at this moment and time, and you are allowed to change your mind. Yeah. So within the guideline, we talk about the importance of it. The benefits of shared decision-making, people think that, if I involve people in decision-making, then that will increase my consultation time. Then that's not true. It doesn't seem to be the true from the evidence.

And you said before, things are getting better from that. sort of the paternalistic approach to medicine, but they're still not anywhere near as good as they should be, I don't think. The CQC every year do a primary care survey and an inpatient survey and ask lots of questions of people about the standard of care. One of the questions they ask is, did the doctor have a conversation about you as if you were not there? So talk to the team around you but didn't actually address you. How many people out of 100 do you think says that that happens often. It should be zero. I'd love to say less than 10, but I'm sure it's more than 50. It's about 9% of people who say that happens. And that should be a never event, as far as I'm

concerned. And it goes back to, I mean, some of the other stuff, the other basic kindness and empathy that needs to come out of this. Kate Granger is a great example of, she was a doctor herself and was diagnosed with cancer and talked about her experience of having the diagnosis has broken to her and it was apporned. So then she said that the Hello My Name Is campaign. Yes, I know. Which is phenomenal. It is phenomenal. But you think

we need a campaign so that people can be basically nice to each other and kind. Do you know what, Jonathan, a few years ago, I had pancreatitis. I was really pulling in hospital and I really missed my children actually and I had been in hospital about five days and the nurse came to see my blood pressure

and my daughter just sent me a little video of her playing the trombone. And I burst into tears just because I really missed her and the nurse came up to me And she said, you're right. I said, I won't really missing my daughter. Oh, I'll come back and do your blood pressure later, she said. She didn't say, oh, you're getting so much better.

You'll be home soon. Or didn't say, oh, that's sad. You know, and I, it's really stuck with me. And I know she's busy, and I know she wanted to do her around. And I always think, yeah, and I've always tried to really listen and just, you know, because I think everyone's got stories and everyone's got something else. But it's difficult. Well, they have, indeed.

And I don't know a healthcare clinician here. who wakes up in the morning and says, well, I'm going to do a really bad job today. Absolutely. But people, as you say, get busy and you forget. And I think the problem is also when I try and talk about, come on, let's improve menopause care in the NHS. Everyone just goes, oh, we've got too much to do.

And menopause are women, and I can say it because I was one, a very demanding actually. And they're very anxious, and they ruminate a lot. And they talk a lot. And, you know, I was refused HRT from my GP. So I had to go to one of my mentors at, actually. And when I phoned his clinic, they didn't have an appointment for six months. And I was so rude on the phone to the receptionist. And it was just awful looking back. But, and so you can

see, you can see how you're perceived. It's like, oh, this crazy men are pools of women, which of course I was. But actually, you know, we know that we did a survey of women that come to the clinic, 17% have seen at least six GPs in the year before they come. And that goes down to less than 2% in the year after. Because they're not going back, because they feel better, They're not going back with their joint pains and their headaches and their palpitations and their urinary symptoms and everything else. They're also not going out with their craziness. You know, come on, give me a diagnosis.

I'm not got fibal manager. I haven't got chronic fatigue. I haven't got non-COVID. Help me. And so these women, you know, I had women the other day. She said, I've been back to my doctor every week for the last year. And they're just sick of me. I know they are, but I know something's not right.

So actually, it's a real investment. And we worked out, actually, I did a survey of 5,000 women. and we found that 7% took at least 10 GP a consultation just to get diagnosis of the menopause, which of course they can do themselves if they've got the right tools. If that gets reduced to two, we worked out with some modelling

that it would save 750,000 GP appointments a year. Yeah. So it's worth it really. It is. And again, one of my great passions is the communication skills and consultation skills and how you have meaningful conversations with people in an efficient yet effective way.

Conversations can solve, complex problems but just doing more data doesn't solve complex problems. It's the conversations that are important. No, you're absolutely right. And when I start in general practice, my trainer said you're going to be an awful cheap pre-laws because you've come from the hospital medicine and you won't be listening to the patients at all. And so I made a big effort to really listen. And also play with the consultations a bit because you can really change them depending on what the patients want and their expectations. And actually my husband's a surgeon and we were talking about consultations the other day and he said his most rewarding consultations

was actually when he refuses to operate on people. Yes. And that sounds really weird, doesn't it? But he's very special. Lots of people come to him for they think he's going to cure them and do this. And he does a lot of amazing surgery. He does a lot of reconstructed surgery. But sometimes, actually, these people don't want to be fobbed off by another operation.

They want someone to listen to them and know that their story is real. Quite. And it's not all going to be corrected by something or a treatment or a surgery or whatever. And that's so important, isn't it? I mean, one of the things we talk about in the shared decision-making guideline is the concept of the three-talk model. I don't know if you've heard of that. Where you have your choice talk, your option talk and your decision talk. And part of it is introducing that you have a choice here.

And also finding out what the person's agenda is. It's estimated that only about 20% of consultations results in full disclosure of the person's agenda. So in other words, what's important to them, what good looks like would look like to them next week, next month, next year. And then the option taught where you sort of, that's when you can potentially introduce the different options that are available. So for a menopause it would be, right, here are your options here. One of them being do nothing, of course, not do nothing as such, but you're not necessarily an intervention. Introducing the different options and then actually allowing people to go away and have a think about it, giving them some literature, perhaps, as you described,

where you talk about the benefits and risks of taking HRT, the different types of HRT that are available. And then maybe rearranging for another appointment to say, right, okay, go away, have a thing about it, chat to your nearest and dearest and people you trust. And then come back and we'll make a decision together on this. And if you do that, you know, that doesn't sound terribly onerous, but when you're in the busy maze of general practice and you've got a massive queue outside the door.

I can see how people just firefight and perhaps don't take the time that potentially, if they did, then it would actually make their lives a bit easier because people would be, as you say, would be less likely to come back in the future. Yeah, and it's quite scary. My trainer John Sanders years ago said to me,

sometimes when you're having a difficult consultation, don't know where it's going, just say to the patient, what were you expecting to happen today? Exactly. And I've never asked that before. In an asthma clinic, you wouldn't ask that. And he said, no, try it.

And it's like, oh, why have you come today? What is it about today that's important to you? And sometimes they're like, well, I didn't get an appointment on another day. But it's often that's the most revealing and you realize what they're coming for and what they're concerned. So, yeah. The other rabbit hole that I've become very interested in is conversational analysis and linguistics, the use of language and how important it is. I mean, what you've just said there is asking open questions, which is really important, rather than asking closed questions where you just get a yes or no answer. But even saying something at the end of the conversation,

and this is about revealing people's agendas, if you say to someone, is there anything else I can help you with? Or if you say, is there something else I can help you with? There's about 60% more disclosure if you say, is there something else compared to is there anything else? Isn't that fascinating? Just that one word,

believe that just one part of a word can make such a difference. It's incredible. It's, you know, and I've always said it's such a privilege. Being a medical person, being a doctor listening, and it's all about words, I think it's so important. So I'm really, really grateful for your time to say, Jonathan, and their shared decision making guidelines are available for anyone on the nice website or put a link in the notes, because I really feel everyone should look at them for any area of medicine.

But just before we finish, Jonathan, can you just give me three tips for people who maybe feel they're not being listened to in a consultation? How can they use this shared decision making for their advantage? So maybe two tips for patients and one tip for a healthcare person. provider if that's possible. Yeah, okay. So I think the first tip for a patient would be it's okay to ask. So ask questions. And if you're not confident about asking questions, actually take somebody else along into the consultation with you and advocate. Somebody, again, you trust, who can listen for you and remind you of the things that you'd discussed beforehand that are

important to you. In terms of for clinicians, I was really impressed. The previous chair of nice was a guy called David Haslam, who was a GP, and he was just great. And he talked about consultation skills for doctors. And he said, there's all these different ways that you can teach consultation skills, but there's only four things you need to have good conversations. Shut up, listen, because if you don't shut up, you can't listen. Show some empathy and know something. Not everything, but know something. If you do those four things in every consultation, then you do really well. People tend to interrupt people when they're having conversations rather than letting people talk. So shutting up and listening is really, really important. And I think the other thing

that I would say would be practice your conversation skills. It's not something that we get taught enough of as human beings, whether it's a doctor, whether it's a pharmacist. You know, an undergraduate curriculum tends to be about knowledge and learning facts, not learning how to communicate. And you can do it and you can get better at it. One of the things we did with the shared decision-making guideline was produce the need learning resource. And one of the things that we have in that are computer-based patients where you can practice your consultation skills in a safe environment.

So the problem about practicing conversation skills with a real person is that you can upset that person and you can destroy your relationship. The good thing about a computer is they don't have feelings. So if you say something wrong to the computer, it doesn't matter. it doesn't matter you just start again. So there would be my three things, I think. Great advice. Really, really great. And very empowering and uplifting.

So thank you ever so much for your time, guys, and I really appreciate it. Thank you, Louise. For more information about the perimenopause and menopause, please visit my website, balance, hyphen, menopause.com, or you can download the free balance app, which is available to download from the app store or from Google Play.