Bridging the gap: GPs, patients, and mental health in perimenopause

Today, we’re speaking to Dr Jo Burgin, a GP and a researcher based at the University of Bristol.Title of paper: Mental health consultations during the perimenopausal age range – Are GPs and patients on the same page?: A qualitative studyAvailable at: https://doi.org/10.3399/BJGP.2025.0069Mood changes are a recognised symptom of perimenopause, for which Hormone Replacement Therapy is considered a first line treatment. Recent studies have found mental health symptoms are overlooked in menopause care, which is mostly delivered in primary care. This study identifies some key barriers to identifying perimenopause in women presenting with mental health symptoms and suggests important changes clinicians could make to their consultations to address this.

In this episode, we speak to Dr Diarmuid Quinlan, a GP and MD candidate based at the Department of General Practice at University College Cork.Title of paper: Competencies and clinical guidelines for managing acne with isotretinoin in general practice: a scoping reviewAvailable at: https://doi.org/10.3399/BJGP.2025.0135There is evidence of inequitable access to the most effective treatment for severe acne, isotretinoin. This scoping review identified the clinical competencies to safely manage acne using isotretinoin. No global consensus exists among clinical practice guidelines (CGPs) on whether GPs are appropriate prescribers of isotretinoin. Appropriately resourced and CPG-guided patient access to isotretinoin in primary care may promote safe, timely, and equitable acne management for patients and improve antimicrobial stewardship.Transcript:This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.Speaker A00:00:01.440 - 00:01:07.850Hello and welcome to BJGP Interviews. My name is Nada Khan and I'm one of the associate editors of the bjgp. And welcome to our autumn edition of the BJGP podcast.We're kicking off with a new set of interviews for the next few months. So thanks again for joining us.Today we're speaking to Dr. Dermod Quinlan, who is a practicing GP in Cork and is also an MD candidate at University College Cork in Ireland.We're here today to discuss his paper, recently published in the BJGP titled Competency and Clinical Guidelines for Managing Acne with Isotretinoin in General Practice. A Scoping Review. So thanks very much, Dermid, for joining me here today to talk about this paper.But yeah, I guess I just wanted to start by saying that this is a really interesting paper and I think it covers a very common condition that we see in general practice and covers treatment, which can be quite difficult as well for acne.But I wonder if you could just start by telling us a little bit about why you wanted to do this research and just a bit about the treatment of it and why you focused down on this topic, really.Speaker B00:01:09.610 - 00:02:59.510So lovely to meet you, Nada. I'm first and foremost a GP and I see patients three days a week, 20 hours a week.And I did a diploma in dermatology over a decade ago and I still do some online tutoring. So I have a long standing interest in dermatology and have an extended role in dermatology.I work in an urban practice with lots of young teenagers and young people in it.Acne is a common chronic disorder and I would see a lot of young people with acne of all grades of severity, mild, moderate and severe, and very severe. And as a clinician, very clearly recognize that behind acne is a patient very commonly suffering profound distress.And we know that the morbidity associated with acne and particularly severe acne, is very extensive.There's the emotional morbidity, there's psychological morbidity, it impacts people's employment opportunities, their education achievements, and then more widely, because treating acne is resource intensive, it has an impact on the healthcare workforce. And then there are concerns about the very prolonged use of antibiotics in acne, raising real antimicrobial stewardship concerns.So I have an interest in this. And then we decided that we would do research into it because we don't know the clinical competencies for safe use of isotretinoin.So I was particularly interested in severe acne and the management of severe acne, and also it didn't clearly...

Today, we’re speaking to Professor Helen Atherton. Helen is Professor of Primary Care Research based at the University of Southampton.Title of paper: What do patients want from access to UK general practice?Available at: https://doi.org/10.3399/BJGP.2024.0582Widely accepted as perpetuated by the media is that patients are unhappy with access to general practice and desire faster access to a general practitioner. This review sought to summarise the research evidence about reported patient wants from access to general practice. Patients wanted to easily make an appointment in a timely fashion, to have a positive relationship with the practice, to see a specific clinician and choose consultation modality according to individual circumstance. Communication and being kept informed about access throughout the process of making and having an appointment, was something patients wanted, and this could be addressed by general practice.Transcript This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.Speaker A00:00:00.480 - 00:01:00.150Hello and welcome to BJGP Interviews. I'm Nada Khan and I'm one of the Associate Editors of the bjgp. Thanks for listening to this podcast today.In today's episode, we're speaking to Professor Helen Atherton.Helen is professor of Primary Care Research based at the University of Southampton, and we've only just speaking to her recently on this podcast about the increasing digitalization of general practice. This time we're speaking to her about her recent paper here in the BJDP titled what Do Patients Want from Access to UK General Practice?So, hi, Helen.It's really nice to speak again about this area of research and I guess I just wanted to start by saying that access is such a loaded word and really, when it comes to general practice, it's part of a fairly negative media campaign against general practice. But it seems that this negative narrative just keeps getting pushed, despite lots of attempts to fix it.So I just wonder if you could reflect on that.Speaker B00:01:00.470 - 00:01:51.950Yeah, absolutely. So that the negative media coverage was one of the reasons that I wanted to do this review.So this review was a bit of a labour of love because I had a feeling from the work that I was doing on digital access and other research that actually the reality was probably quite different, what we were seeing in the headlines and having looked into it, although there's lots of research out there on patient experience and satisfaction, we have a national survey that looks at that. There wasn't anything about what patients actually want. And so that kind of.I thought, actually, wouldn't it be really interesting to find out from the evidence what they actually want and see if it does fit with the narrative we see in the papers and on social media. So, yes. So completely agree. And that was kind of where the idea came from, really.Speaker A00:01:52.420 - 00:02:08.180Yeah.And I just want to unpick what you really mean by access in this paper, because I think for some people it means, you know, just getting an appointment to see their GP within a day, but it can mean lots of different things to other people. So what did you conceptualize that as?Speaker B00:02:08.740 - 00:02:49.840Well, it was difficult.And you're right, there are lots of different definitions of access, and particularly in the research context, for us, we were...

Today, we’re speaking to Dr Sara Noden, a GP with an extended role in ADHD, and Dr Nishi Yarger, Consultant Psychiatrist in adult ADHD services.Title of paper: A guide for primary care clinicians managing ADHD medication side effectsAvailable at: https://doi.org/10.3399/bjgp25X742653TranscriptThis transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.Speaker A00:00:00.320 - 00:00:55.720Hello and welcome to BJGP Interviews. I'm Nada Khan and I'm one of the associate editors at the bjgp. Thanks for listening to this podcast today. In today's episode, we're speaking to Dr.Sara Noden, a GP with an extended role in ADHD, and Dr. Nishi Yarger, consultant psychiatrist in Adult ADHD Services.We're talking about the recent Clinical Practice article here in the BJGP titled A Guide for Primary Care Clinicians Managing ADHD Medication Side Effects. So, thanks. It's great to meet you both Sara and Nishi.This is a really topical area to highlight in the journal, and not least because it seems that every week there seems to be a new article in the media about the increasing diagnosis of adhd. So it's a really topical area to look at, but I guess, Sar, I just really wanted to start with what prompted you to write this article and why now?Speaker B00:00:56.620 - 00:01:39.320Yeah, so I think coming from a GP perspective, before I specialized in adhd, I think these medications did create a bit of anxiety, especially as they're controlled drugs, their stimulants, their specialist medications, and there was a lot that I didn't know about them as I since developed a special interest and it sort of demystified some of these medications. And I just.I think we wanted to pass on to primary care clinicians some of that knowledge that we've learned, some really basic things that they can look out for that may or may not be related to medications and some common things that they can advise and to know when to escalate secondary care and how to manage these patients, essentially.Speaker A00:01:39.560 - 00:01:54.040Yeah. And Saura, I wonder if you could just tell us a bit more about your role as a GP with an extended role in adhd.So you must be very much in demand at the moment, but talk us through what led you to sort of take that role and what your typical week is like.Speaker B00:01:54.320 - 00:02:58.810Yeah, So I think my interest in ADHD stemmed during my training years and I currently am working as a salary GP, but also working at CNWL under Dr. Jaga. I'm doing diagnosis and medication titrations. And I think my interest stemmed because of how prevalent ADHD is becoming.I was seeing such an increase in patients presenting to gp, suspecting they have ADHD and requesting referral, and reading about this treatment and what we can offer, I was really taken aback by not only how ADHD can impact a patient in terms of their symptoms and concentration of focus, but also the lifelong issues that can arise sometimes with adhd, like all the Research showing that it increases rates of depression, underachievement at school, even early death and accidental injuries. So I feel it's a really important, important condition for us to be able to pick up, to be able to refer promptly and start treatment.And that's where the interest started.Speaker A00:02:59.050 - 00:03:14.570And, Nishi, from your perspective, what's it like having a GP working with your team?And from a secondary care perspective, I wonder if you...

Today, we’re speaking to Dr Cini Bhanu, GP and Academic Clinical Lecturer in the Primary Care and Population Health Department at University College London. Title of paper: Antidepressants and risk of postural hypotension: a self-controlled case series study in UK primary careAvailable at: https://doi.org/10.3399/BJGP.2024.0429Antidepressants are associated with postural hypotension (PH). This is not widely recognised in general practice, where antihypertensives are considered the worst culprits. The present study examined >21 000 older adults and found a striking increased risk of PH with use of all antidepressants (over a four- fold risk with SSRIs) in the first 28 days of initiation. TranscriptThis transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.Speaker A00:00:00.480 - 00:00:56.990Hello and welcome to BJGP Interviews. My name is Nada Khan and I'm one of the associate editors of the bjgp. Thanks for listening to this podcast today.In today's episode, we're speaking to Dr. Cini Banu, who is a GP in an academic clinical lecturer based in the Department of Primary Care and Population Health at University College London.We're here to talk about her recent paper in the BJGP titled Antidepressants and Risk of Postural Hypertension, A Self Controlled Case Series Study in UK Primary Care. So, hi Cinny, it's really nice to meet you today.I guess this is an interesting area to cover, especially as the prescribing rates for some antidepressant medications are increasing.But I don't know what your feeling is, but I'm not sure if many GPs would actually know that antidepressants are associated with poison postural hypertension. So, yeah, talk us through that.Speaker B00:00:57.310 - 00:01:18.350Yeah, so I think that's one of the reasons this study is so important.So definitely from conversations that I've had with gps that I work with and it's not commonly recognized that postural hypotension is associated with antidepressants, though it is by geriatricians, for example, where it's very.Speaker A00:01:18.350 - 00:01:41.850Well recognized and in this study used a big database to look at the risk of new postural hypertension associated with the use of antidepressants in people aged over 60.I guess there's quite a lot of in depth stuff in the methods, but I guess just for a summary for people who are interested in what you did, do you mind just sort of going over it at sort of like a high level?Speaker B00:01:41.850 - 00:02:54.200Yeah, yeah. So we looked at a big database, what we call a routine primary care database called imrd.And essentially this captures data from software that gps use like EMIS and Vision System and captures a whole load of information like problems, symptoms and prescriptions. So we went into this database and identified everyone over the age of 60 that might be eligible during our study period.And for this we looked at people that were contributing at least one full year of data between 2010 and 2018. And then within that we identified people with a first diagnosis of postural hypotension.And then again we made subgroups according to people who had this diagnosis but also had a first prescription of a new antidepressant during that time.And what we were interested in, and the methodology is called a self controlled case series, we weren't interested in who got postural Hypotension, because everyone was a case, but rather...

Today, we’re speaking to Dr Jamie Scuffell, GP and NIHR In Practice Fellow at King’s College London.Title of paper: Patterns in GP Appointment Systems: a cluster analysis of 3480 English practicesAvailable at: https://doi.org/10.3399/BJGP.2024.0556GP practices in the UK are using a wide range of different appointment systems to meet patient demand and improve access. This cluster analysis of NHS appointment data from 56 million appointments and 3480 English practices demonstrates two predominant models of primary care delivery. ‘Same day’ practices tend to fulfil appointments on the same day using GP telephone consultations. ‘Routine care’ practices tend to employ non-GP staff members offering face-to-face appointments and longer appointment wait times. ‘Same day’ care practices had younger and more urban populations. Episode transcriptThis transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.Speaker A00:00:00.640 - 00:00:54.360Hello and welcome to BJGP Interviews. I'm Nada Khan and I'm one of the Associate Editors of the bjgp. Thanks for listening to this podcast today. In today's episode, we're speaking to Dr.Jamie Scuffle, who is a GP in South London and an NIHR In Practice Fellow at King's College London. We're here to talk about a really topical issue in his new paper here in the bjgp.The paper is called Paper Patterns in GP Appointment A cluster analysis of 3,480 English practices.So, hi, Jamie, it's really great to meet you and talk about this work, I guess, really just to start, as you point out in this paper, each practice has their own systems and strategies to manage appointment booking. But how do you think that this impacts on access and patient appointment booking in each practice?Speaker B00:00:55.000 - 00:02:17.300Yeah, it's interesting because I think, as you say, appointment systems have developed even further, really, since COVID and we've ended up with this a quite interesting diverse range of implementing appointments across the country, across England at least.And I suppose the things that have changed are, you know, if you phone up a practice now, actually, you might not even phone them up, you might submit an online consult, you might be triaged, you might see not a gp, but a range of other professionals as well. And also it might not be done face to face, it might be done by telephone or online.In fact, there's a new appointment system range of things that have happened across England, and actually there's some evidence that that might relate to access in some ways. So we know lots of people who don't speak English struggle to navigate that system of getting an appointment, for example.And we also know from the qualitative evidence that there's some digital exclusion as well with appointments. So, yeah, so I think there's lots of issues with access and how that relates to appointment systems.And so far what we've done is looked at components of the appointment system and how that then affects access. But what we haven't really done much of is looking at the appointment system as a whole and how that might affect access.Speaker A00:02:18.180 - 00:02:33.200Yeah.So in this study, you wanted to look at patterns of primary care delivery in English GP practices, and you used this Appointments in General Practice data set. Can you tell us just briefly what's available in this data and what you were looking at here?Speaker B00:02:33.360 - 00:03:20.700It's a tremendous data set and I think could be very useful. So...

Today, we’re speaking to Dr Steve Bradley, GP and Senior Clinical Lecturer based within the School of Medicine and Population Health at the University of Sheffield.Title of paper: General practice chest X-ray rate is associated with earlier lung cancer diagnosis and reduced all-cause mortality: a retrospective observational studyAvailable at: https://doi.org/10.3399/BJGP.2024.0466It is known that there is wide variation in the use of chest X-ray (CXR) by general practices, but previous studies have provided conflicting evidence as to whether greater utilisation of them leads to lung cancer being diagnosed at an earlier stage and improves survival. This observational study analysed data from the English national cancer registry on CXR rates for individual general practices, along with stage and survival outcomes; it found earlier stage at diagnosis and improved survival for patients diagnosed with cancer at practices that used the test more frequently. Increasing use of CXR by GPs for symptomatic patients, particularly by focusing on practices that use the test infrequently, could improve lung cancer outcomes.TranscriptThis transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.Speaker A00:00:00.640 - 00:01:06.820Hello and welcome to BJGP Interviews. I'm Nada Khan and I'm one of the Associate Editors at the Journal. Thanks for taking the time today to listen to this podcast.In today's episode, we're talking to Dr. Steve Bradley. Steve is a GP and senior clinical Lecturer based within the School of Medicine and Population Health at the University of Sheffield.Early diagnosis of cancer has been an area of research that is Steve's real strength. And we're here to discuss his recent paper here in the BJJP titled General Practice.Chest X Ray Rate is Associated with Earlier Lung Cancer Diagnosis and Reduced All Cause Mortality A Retrospective Observational Study. Hi, Steve, Great to speak again and to talk through this paper.I suppose I want to start by saying that, yes, we know that earlier diagnosis of cancer is a good thing because it can lead to earlier stages of diagnosis and treatment. And you start the paper with a short discussion about screening for lung cancer.But talk us through why this, this alone won't solve delays in lung cancer diagnosis and what else we need to be doing.Speaker B00:01:07.540 - 00:02:14.620So, yeah, this context is really important because screening is a hugely important development and the UK has led in many ways on lung cancer screening using low dose ct. And this, we hope is going to be very, very beneficial for patients.But it would be a mistake to think that this is going to solve the problem of lung cancer. And there's a few reasons for that.One is that only about half of people who get lung cancer would have been eligible for screening because screening concentrates on the highest risk population. And also we know that only about half of people who are invited for screening actually choose to participate in screening.So the upshot for general practice really is that most patients are still going to be coming through by symptoms and in the same way.So screening is good news in terms of lung cancer detection, but we still need to do as well as we can in terms of picking these patients up through symptomatic pathways. And actually, this is something we touched on in an editorial for BJGP about a year or 18 months ago, I think.Speaker A00:02:15.020 -...

Today, we’re speaking to Professor Martijn Schut, Professor of Translational AI in Laboratory Medicine and Professor Henk CPM van Weert, GP and Emeritus Professor of General Practice, both based at Amsterdam University Medical Center.Title of paper: Artificial intelligence for early detection of lung cancer in GPs’ clinical notes: a retrospective observational cohort studyAvailable at: https://doi.org/10.3399/BJGP.2023.0489In most cancers, the prognosis depends substantially on the stage at the start of therapy. Therefore, many methods have been developed to enhance earlier diagnosis, for example, logistic regression models, biomarkers, and electronic-nose technology (exhaled volatile organic compounds). However, as most patients are referred by their GP, who keeps life-long histories of enlisted patients, general practice files might contain hidden information that could be used for earlier case finding. An algorithm was developed to identify patients with lung cancer 4 months earlier, just by analysing their files. Contrary to other methods, all medical information available in general practice was used.TranscriptThis transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.Speaker A00:00:01.600 - 00:00:55.370Hello and welcome to BJGP Interviews. I'm Nada Khan and I'm one of the associate editors of the journal. Thanks for taking the time today to listen to this podcast.Today we're speaking to Professor Martin Schutt, who is a professor in translational AI and Laboratory medicine, and Professor Hank Vanwort, GP and Emeritus professor in General Practice, who are both based at Amsterdam University Medical Center. We're here to discuss their paper, which is titled Artificial Intelligence for Early Detection of lung cancer in GP's clinical notes.So, yeah, it's great to see you both here today. And Martin, I'll come to you first.I suppose we know that it's important to try and diagnose cancer early, but could you talk us through what's the potential for artificial intelligence here in terms of identifying cancer earlier based on patient records?Speaker B00:00:55.810 - 00:01:52.220Yeah, that's a very interesting question because the potential kind of like goes hand in hand with the huge amount of interest in AI. And I think there are great opportunities. There are also great challenges.But talking about the opportunities, especially in the context of the article that we wrote, is on the data side. So on the data side, the digitalization of electronic health records gives great opportunities.A lot more is digitalized, and that means that we also, in our case, have access to free text, and that we, with the advent of the large language models, with also new developments in AI, we also have better ways of making use of those data. So those two combined creates a really interesting formula for big opportunities for AI in the general practice and healthcare in general.Speaker A00:01:52.300 - 00:02:05.960And you mentioned access to free text records. So what GPs are typing into the record records?But before we get into the study, can you just briefly describe what is natural language processing and how that can be used in free text records?Speaker B00:02:06.760 - 00:03:10.100So we know that a lot of clinical risk scores, they work with features of patients, so their age and their gender or sex. And. But of course, a lot of information is also written up in unstructured way. And in our case that is...

Today, we’re speaking to Dr Afrodita Marcu, a Research Fellow in Cancer Care at the University of Surrey.Title of paper: Symptom appraisal and help- seeking before a cancer diagnosis during pregnancy: a qualitative studyAvailable at: https://doi.org/10.3399/BJGP.2024.0208There is a gap in current understanding about the experiences of women diagnosed with cancer during or around pregnancy including how they appraise and seek help for cancer-related symptoms. This qualitative study found that women and healthcare professionals often interpreted symptoms through the lens of pregnancy, particularly when symptoms were vague. Health professionals need to ensure full assessment of symptoms, timely referral, and effective safety-netting for these women.TranscriptThis transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.Speaker A00:00:01.040 - 00:01:04.650Hello and welcome to BJJP Interviews. I'm Nada Khan and I'm one of the associate editors of the bjgp. Thanks for listening to this podcast today. In today's episode, we're speaking to Dr.Aphrodite Marcoux, a research fellow in Cancer care at the University of Surrey.We're here to talk about a paper she's recently published here in the bjgp, which is titled Symptom Appraisal and Help Seeking Before a Cancer Diagnosis during Pregnancy, A Qualitative Study. So it's really lovely to meet you, Aphrodita, to talk about your research.And I think this is a really important area and I wanted to get your thoughts on just why this area is so important to research.But I think that most people will probably appreciate that during pregnancy, women's bodies are going through lots of changes, so it can sometimes be difficult to know what's normal and what's not. But talk us through why you wanted to do this study.What are the challenges faced by patients and by doctors around cancer diagnosis in women who are pregnant?Speaker B00:01:05.050 - 00:02:32.190It's an important area to research because the symptoms of pregnancy, the bodily changes that naturally occur during pregnancy, can mask the symptoms of cancer, both for the women experiencing them, but also for the healthcare professionals with whom they come into contact and with whom they share the symptoms.So it's an important area to research from that point of view in terms of understanding the potential causes for delay in receiving a cancer diagnosis.And one of the areas which we discovered was less researched was early diagnosis or timeliness of diagnosis of cancer diagnosis in the context of pregnancy.So we conducted this research because there was a lack of research, especially in the uk, on women's pathway or other pathways to a cancer diagnosis and pregnancy.And we wanted to get a more detailed understanding knowledge of how women make sense of their symptoms during pregnancy, how they seek help and why to whom they present, midwife, gp, other healthcare professionals and how they receive a diagnosis. What is the pathway to a cancer diagnosis and pregnancy?We wanted to get more clarity about that, more detail, and we were also interested to find out whether delays characterize this pathway to a cancer diagnosis in pregnancy, be they patient related delays or healthcare system related delays.Speaker A00:02:32.830 - 00:02:44.750And I guess you've touched on this. So does do we know if there are delays in cancer diagnosis amongst women who are pregnant?So do they tend to have a...

Today, we’re speaking to Dr Stephen Gibbons, Consultant Clinical Biochemist at Leeds Teaching Hospitals NHS Trust, and Dr Clare Spencer, GP Partner and Menopause Specialist at the Meanwood Group Practice in Leeds.Title of paper: Optimising testosterone therapy in patients with hypoactive sexual desire disorderAvailable at: https://doi.org/10.3399/bjgp25X741321TranscriptThis transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.Speaker A00:00:00.400 - 00:01:08.824Hello and welcome to BJJP interviews and welcome to our new season of the podcast. Hope you all had a great break over Easter and thanks again for listening to this podcast today.My name is Nada Khan and I'm one of the associate editors of the BJTP. In today's episode, we're speaking to Dr. Stephen Gibbons, consultant clinical biochemist at Leeds Teaching Hospital NHS Trust, and Dr.Claire Spencer, a GP partner and menopause specialist at the Meanwood Group Practice in Leeds. We're here to talk about the recent clinical practice paper published here in the bjgp.The paper is titled Optimizing Testosterone Therapy in Patients with Hypoactive Sexual Desire Disorder. So thanks, Stephen and Claire, for joining me here today.It's great to talk to you about this paper, especially because it's in an area of a lot of interest to patients and clinicians in general practice wondering what to do about testosterone prescribing.I guess I wanted to kick things off, Stephen, really, by asking, what made you start investigating testosterone replacement in patients with hypoactive sexual desire disorder?Speaker B00:01:08.952 - 00:03:09.662So it was actually a conversation with a colleague at work over coffee and she mentioned to me that she'd noted quite a lot of high testosterone in females of a particular age and she was asking why that might be. So I explained it's probably because of TRT in this condition called hsdd, but that was kind of quite anecdotal at that point.So we thought we'd do a clinical audit. So myself and two colleagues, Kia and eloise, we audited 100 patients from Leeds.So we looked at a sample of 100 patients on TRT for HSDD and we audited them against the British Menopause Society guidance, which state that you should do a pre testosterone measurement and then you should check at at six to eight weeks, I believe. And what we found is that actually there was quite poor compliance with the BMS guidance. And at this point we felt a little bit out of our depth.But we thought, well, this is quite alarming. Probably the most alarming thing was the number of patients with a really high testosterone that weren't adequately followed up.So we thought, right, let's bring some clinical experts in at this point. So that's when we got in touch with Dr. Spencer and Dr. Jasim and Dr. Wal Ford, who's also on the paper.She's a consultant endocrinologist at Leeds, and we kind of had a look at the data and we all agreed that, you know, there were significant findings. And the question was why?Because there are quite comprehensive guidance out there from the bms, but I think we all felt that potentially they lacked some of the finer detail. Potentially in some areas they were a little vague. So that's when we came up with these additional recommendations.And they're certainly not supposed to replace the BMS guidance, but it's a supplementary kind of recommendations to support the BMS guidance. So that's where we started, really.Speaker...