The Specialist GP

What if that red, painful breast isn’t an infection — and antibiotics aren’t needed?
Mastitis is now seen as a spectrum, often inflammatory rather than infective. Treating it as routine infection risks overprescribing and missing early, effective care.
Talking to Lactation medicine physician Dr Yvonne Le Fort we unpack the case of Kim, a well 26-year-old female, three months postpartum with a tender, erythematous breast, we cover:
When mastitis is inflammatory vs infective
What early management should prioritise
When antibiotics are actually needed
Red flags and when to escalate
Practical clinical pearls:
Mastitis is a spectrum — it may be inflammatory and is not always due to infection.
Initial management of lactational mastitis- includes pain relief, reducing breast oedema, and addressing hyperlactation.
Milk culture – consider if symptoms persist despite antibiotics, or if mastitis is recurrent or prolonged.
Antibiotics – not all cases need them. Use only for systemic symptoms or if no improvement after 24–48 hours. First-line: Flucloxacillin. If penicillin allergy: Clindamycin
Breast abscess or mass – refer urgently for imaging ± surgical drainage.
Non-lactational mastitis – usually infective; requires antibiotics and close follow-up. Refer early if cancer suspected.
Inflammatory breast cancer can mimic mastitis — maintain a high index of suspicion.

Guest bio:
Dr Yvonne LeFort, a family medicine doctor trained in Canada, has practised breastfeeding medicine for over 20 years and runs a private breastfeeding clinic on Auckland’s North Shore.
She is a dual Fellow of RNZCGP and CCFP (Canada), an IBCLC, and a Fellow of the Academy of Breastfeeding Medicine (ABM). She serves on the board of the New Zealand Breastfeeding Alliance (NZBAA), supporting evidence-based breastfeeding education for all medical and health care colleagues.
Currently, she is a professional advisor to La Leche League New Zealand, a member of NZLCA, and the founder of a Breastfeeding Medicine RNZCGP Peer Review Group.
Yvonne has recently completed a Post Graduate Diploma in Digital Health from Otago University.
She has provided both formal and informal education for IBCLCs and medical colleagues, helping to upskill healthcare workers with the knowledge needed to provide best-practice care when consulting with breastfeeding dyads. She has presented nationally and internationally on a wide variety of topics.
Yvonne is the first author of the ABM’s Position Statement on Ankyloglossia and Breastfeeding Dyads (2021), a contributor to New Zealand Aotearoa National Guidance for the Assessment, Diagnosis and Surgical Treatment of Tongue-Tie in Breastfeeding Neonates, and a co-author of Complications and Misdiagnoses Associated with Infant Frenotomy: Results of a Healthcare Professional Survey (International Breastfeeding Journal, 2022), along with several other clinical protocols.
Resources:
https://www.redwhale.co.uk/content/the-mastitis-spectrum
https://www.bfmed.org/assets/ABM%20Protocol%20%2336.pdf
https://www.tewhatuora.govt.nz/for-the-health-sector/specific-life-stage-health-information/maternal-health/breastfeeding/breastfeeding-problems/mastitis-and-breast-abscesses/
https://tewhatakura.nz/guidelines

Hyperbaric oxygen therapy (HBOT) which is used across a wide range of acute and chronic conditions, but for most clinicians, it remains something of a mystery outside of diving-related emergencies.
In this episode, we explore what HBOT is, how it works, and when it’s indicated. Using a clinical case as a starting point, we discuss the approved uses, contraindications, practicalities, and emerging areas of interest — including concussion and long COVID-19 infection.
Practical clinical pearls:
HBOT has well-defined, evidence-based indications, and referrals should be made only to accredited facilities.
For decompression illness and arterial gas embolism, air or gas embolism, carbon monoxide poisoning, sudden acute hearing loss consider referring urgently for hyperbaric assessment.
Confirm the facility’s accreditation and safety protocols before referring.
Discuss suitability with a hyperbaric service early if in doubt.
Be cautious about non-accredited “wellness” HBOT clinics promoting unproven benefits. Do no harm.

Guest bio:
Simon Mitchell is an anaesthesiologist at Auckland City Hospital, a diving physician at North Shore Hospital, and Professor of Anaesthesiology at the University of Auckland.
He is widely published, with two books and over 170 scientific papers or chapters, including co-authorship of the 5th edition of Diving and Subaquatic Medicine and the Hyperbaric and Diving Medicine chapters in the last four editions of Harrison’s Principles of Internal Medicine.
Simon has twice served as Vice President of the Undersea and Hyperbaric Medicine Society (USA) and received the Behnke Award for scientific contributions to diving medicine in 2010. Since 2019, he has been Editor-in-Chief of the Diving and Hyperbaric Medicine Journal.
Outside of medicine, Simon has had a long career in sport, scientific, commercial, and military diving. He has participated in exploratory wreck and cave diving expeditions worldwide and in 2002 performed what was then the deepest dive to a shipwreck. In 2023, he was part of the Wet Mules expedition to the Pearse Resurgence in New Zealand, where a 230 m hydrogen dive was conducted — the first of its kind in over 30 years. He is a Fellow of the Explorers’ Club of New York and was named Rolex Diver of the Year in 2015.
Resources:
·Undersea and Hyperbaric Medical Society. HBO Indications [Internet]. Available from: https://www.uhms.org/resources/featured-resources/hbo-indications.html
·National Center for Biotechnology Information (NCBI). Hyperbaric Oxygen Therapy: Patient Selection [Internet]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499820/
·UpToDate. Hyperbaric Oxygen Therapy [Internet]. Available from: https://www.uptodate.com/contents/hyperbaric-oxygen-therapy#H19
·U.S. Food and Drug Administration (FDA). Hyperbaric Oxygen Therapy: Get the Facts [Internet]. Available from: https://www.fda.gov/consumers/consumer-updates/hyperbaric-oxygen-therapy-get-facts
·National Center for Biotechnology Information (NCBI). Hyperbaric Medicine Overview for Wound Healing [Internet]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459172/
·Mitchell SJ. Decompression illness: a comprehensive overview. Diving Hyperb Med. 2024 Mar 31;54(1 Suppl):1–53. doi: 10.28920/dhm54.1.suppl.1-53. PMID: 38537300; PMCID: PMC11168797.
Please see local healthpathway for regional advice.
Email me:
[email protected]
Listen here:
Apple : https://podcasts.apple.com/us/podcast/the-specialist-gp/id1845748299
Spotify: https://open.spotify.com/episode/33slefeXuzUH3coNCiWQ49?si=oRH4uIa4QnuxMfkIJ7sybg

What if the rough, scaly patch you freeze in clinic today is just the visible part of widespread sun damage? Treating only what you can see may mean missing the bigger risk.
We explore how recognising and treating the entire sun-damaged area reducing progression to squamous cell carcinoma and improve long-term outcomes.
I’m joined by dermatologist and Mohs surgeon Dr Chin-Yun Lin, who shares practical, primary care–focused guidance on choosing and using field therapies for actinic keratoses.
Using the case of Simon, a 55-year-old builder with significant sun exposure and multiple lesions on his face and hands, we discuss:
What “field treatment” really means in everyday general practice
When to move beyond spot cryotherapy and treat the whole area of sun damage
How to choose between topical 5-fluorouracil, imiquimod, and photodynamic therapy
Preparing patients for treatment reactions and improving adherence
When to refer and when you can confidently manage in primary care

This episode is full of practical tips to help you manage sun-damaged skin more effectively and reduce your patients’ long-term skin cancer risk.
Practical clinical pearls :
Patient Education is Key: Reinforce sun protection, ongoing self-examination, and adherence.Explain that AKs are precancerous, not benign warts—early treatment reduces risk of SCC.
Preparation of the Skin Improves Efficacy: Gentle debridement, keratolytic creams (urea or salicylic acid), or low-potency retinoids before topical therapy can enhance penetration and response.
Field Treatment is Often Preferable for Multiple Lesions: When you see multiple AKs or “field cancerization,” topical therapies (like 5-fluorouracil, imiquimod, or diclofenac) can treat visible and subclinical lesions simultaneously.Pick therapy based on patient tolerance, adherence, and skin location.
Treatment Selection Depends on Lesion and Patient Factors:5-FU: aggressive but effective, may cause intense inflammation—good for thicker or widespread AKs. Imiquimod: immune-stimulating, good for thinner AKs or for patients who prefer intermittent dosing. Photodynamic therapy (PDT): alternative if topical therapy fails or not tolerated.
Monitor for Flare or Incomplete Response: Mild irritation is expected, but severe inflammation, erosion, or ulceration may require pausing treatment. Non-responding lesions should be reevaluated for biopsy, as persistent AK may hide squamous cell carcinoma (SCC).
Refer to a dermatologist: if the diagnosis is unclear, or if the lesion requires expert excision or specialized management.

Resources:
https://www.rnzcgp.org.nz/events/ongoing-events/gp-dermatology-course/
https://dermnetnz.org/topics/actinic-keratosis
https://dermnetnz.org/cme/lesions/topical-treatment-of-photodamage
https://dermnetnz.org/topics/5-fluorouracil-cream
https://dermnetnz.org/topics/imiquimod
Guest bio:
Dr Chin-Yun Lin is a Dermatologist and accredited Mohs micrographic surgeon. His specialty interests include the treatment of skin cancer, melanoma, dermatitis, psoriasis, acne, pigmentary disorders, and cosmetic dermatology.
After graduating as Dux of Macleans College in Auckland, he went on to complete his undergraduate medical degree with first-class honours at the University of New South Wales in Australia.
He undertook Dermatology advanced training at tertiary teaching hospitals in Auckland, Hamilton, and Christchurch. Further Dermatology training and a Mohs surgical fellowship were undertaken at St Vincent's Hospital and the Skin Hospital in Sydney. He is also a Fellow of the American College of Mohs surgery.
Dr Lin has won various Dermatology awards such as the Trans-Tasman Scholarship for best registrar presentation at the New Zealand Dermatological Society Annual Conference, and the best poster presentation at the Australasian College of Dermatologists Annual Scientific Meeting.
Dr Lin also takes interest in clinical teaching and research. He is a registered education provider for the RNZCGP. He has published several papers in peer-reviewed journals, and presented at international conferences such as the World Congress of Dermoscopy. He has written a practical course for GP’s on dermatology- link in resources.
Dr Lin has also served on the reviewers’ panel for the Australasian Journal of Dermatology.
Email me:
[email protected]
Listen here:
Apple : https://podcasts.apple.com/nz/podcast/field-treatments-in-sun-damaged-skin-w-dr-chin-yun-lin/id1845748299?i=1000755425551
Spotify: https://open.spotify.com/episode/3CPztsA04YtvzodwM7s2AI?si=c3ed7ee2635f4f83

Do we really hear our patients? Or just listen long enough to respond? In today’s fast-paced clinics, true listening is often the first casualty. Yet it’s far more than courtesy: it’s a clinical tool that builds trust, uncovers what matters most, improves outcomes, and even protects clinicians from burnout.
I talk with Maureen Bisognano, President Emerita at the Institute for Healthcare Improvement and global leader in healthcare quality. We explore how curiosity and “proximate listening” can transform patient care, what telehealth teaches us about paying attention, and leadership strategies to create a culture that truly listens.
We also share Bill’s story- a 90-year-old patient whose case shows how listening can be the difference between misdiagnosis and the right care.
Listening isn’t optional—it’s essential.
Practical clinical pearls:
Start with “what matters.” Asking “What would make a good day for you?” or “What’s most important for you today?” often reveals the patient’s real priorities and builds trust quickly.
Use open-ended questions wisely. Replace “Do you have any questions?” with “What questions or concerns do you have?” it affirms curiosity and doesn’t add much time.
Sit when you can. Even a moment sitting down makes patients feel heard and cared for, and increases satisfaction.
Let design help you. Face the patient while typing, use an AI scribe, reduce noise or distractions where possible, small environmental shifts signal attention.
Empower through listening. Ask colleagues “What do you think?” or “If you were in my chair, what would you change?” to invite practical solutions and strengthen teamwork.
Foster resilience by sharing stories. Creating moments to eat together, debrief, or reflect with peers reduces burnout and builds a culture of support.

Guest bio:
Maureen Bisognano, President Emerita and Senior Fellow, Institute for Healthcare Improvement (IHI), previously served as IHI’s President and CEO for five years, after serving as Executive Vice President and COO for 15 years. She is a prominent authority on improving health care systems, whose expertise has been recognized by her elected membership to the National Academy of Medicine (IOM), among other distinctions. Ms. Bisognano advises health care leaders around the world, is a frequent speaker at major health care conferences on quality improvement and is a tireless advocate for change. She is an Instructor at the Harvard School of Public Health. She chaired the Advisory Board of the Well Being Trust, co-chairs the Massachusetts Coalition for Serious Illness Care with Dr. Atul Gawande, and serves on the boards of the Commonwealth Fund, Indiana University Health and Nursing Now. Prior to joining IHI, she served as CEO of the Massachusetts Respiratory Hospital and Senior Vice President of The Juran Institute.
Resources:
Berry LL, Bisognano M, Twum-Danso NAY, Awdish RLA. The Value — and the Values — of Listening. Mayo Clin Proc. 2025;100(9):1482-1486. doi:10.1016/j.mayocp.2025.06.002
Abrahams R, Groysberg B. How to Become a Better Listener. Harv Bus Rev. 2021 Dec 21. Available from: https://hbr.org/2021/12/how-to-become-a-better-listener
Email me:
[email protected]
Listen here:
Apple : https://podcasts.apple.com/us/podcast/the-specialist-gp/id1845748299
Spotify: https://open.spotify.com/episode/33slefeXuzUH3coNCiWQ49?si=oRH4uIa4QnuxMfkIJ7sybg

How comfortable are you managing Mary? She’s 45, fit, still having regular periods, but struggling with poor sleep, anxiety and irritability. Is this stress or the start of perimenopause?
Dr Louise Kuegler talks with reproductive endocrinologist Dr Megan Ogilvie about the early, often missed phase of the menopausal transition. Long before cycles become irregular, fluctuating hormones can drive mood change, worsening PMS and PMDD, migraines, joint pain and sleep disturbance, leaving many women feeling unlike themselves.
We explore why perimenopause is a time of heightened mood vulnerability, who is most at risk, and how to recognise symptoms that do not fit the classic teaching.
The discussion moves into practical, primary care management, including when to consider SSRIs, the combined oral contraceptive pill, menopausal hormone therapy, or cycle suppression, and how to navigate the growing interest in natural therapies safely and realistically.
A clinically grounded, myth busting conversation designed to help you spot perimenopause earlier and treat with confidence.
Practical clinical pearls:
Early symptoms: Mood changes may precede menstrual changes; affect ~25% of women. Symptoms can mimic cardiology or rheumatology presentations.
Alternative preparations: Have a limited role; use with caution and be aware of potential interactions.
Combined oral contraceptive pill: Can provide both symptom control and contraception.
Menopause Hormone Treatment: Use initially as a cyclical trial, then consider moving to continuous therapy after 6–12 months. Annual review once stabilised. Always consider ongoing contraception needs. Investigate abnormal PV bleeding.
Consider newer agents and cycle suppression for PMS/PMDD: Seek specialist input if needed.
Guest bio:
Dr MEGAN OGILVIE Business Director at ERH Associates Subspeciality expertise in menopause, PCOS, athlete hormone health. PMS/PMDD, VSCs and gender-affirming medicine. Megan completed her endocrinology training in Auckland and then undertook a fellowship in London at St Bartholomew's and University College of London Hospitals. Since returning to New Zealand, Megan has worked in both general and reproductive endocrinology at Fertility Associates and at Auckland District Health Board, and now at ERH Associates. Megan has particular reproductive endocrine interests in menopause, polycystic ovarian syndrome, gender-affirming care, as well as athlete hormone health and energy deficiency. Megan was a founding member of WHISPA (a medical advisory board to High Performance Sport New Zealand, now disestablished) and has run training workshops for High Performance Sport NZ in the area of female athlete hormone health. Megan is the New Zealand representative on the board of the Australasian menopause society.
Resources:
https://www.menopause.org.au/images/stories/education/docs/AMS_Diagnosing_Menopause_Symptom_Score.pdf
https://www.menopause.org.au/hp/information-sheets/perimenopause
Magraith K, Stuckey B, Baber R. Perimenopausal Hormone Therapy Assessment and Prescribing. Medicine Today. 2022 August (23):61-67
Maki PM, Kornstein SG, Joffe H, Bromberger JT, Freeman EW, Athappilly G, Bobo WV, Rubin LH, Koleva HK, Cohen LS, Soares CN. Guidelines for the Evaluation and Treatment of Perimenopausal Depression: Summary and Recommendations. J Womens Health (Larchmt). 2019 Feb;28(2):117-134.
Faculty or Sexual and Reproductive Healthcare. FSRH Guideline for women aged over 40 years. Contraception for Women aged over 40 years. FSRH Clinical Effectiveness Unit; 2017(Amended 2025. (To download: https://www.fsrh.org/standards-and-guidance/documents/fsrh-guidance-contraception-for-women-aged-over-40-years-2017/)
Email me:
[email protected]
Listen Here:
Apple: https://podcasts.apple.com/nz/podcast/the-specialist-gp/id1845748299
Spotify: https://open.spotify.com/show/3485r5V7iF251QH9dpnC1i?si=356c46bdbbf44219