The Specialist GP

People living with mental illness or substance use challenges experience significant inequities in physical health outcomes, with physical illness often diagnosed later or overlooked altogether. Diagnostic overshadowing where symptoms are attributed to an existing mental health, substance use, disability or a chronic health condition rather than investigated fully remains a major issue in healthcare. In Aotearoa New Zealand, this inequity is even more pronounced for Māori, where the impacts of stigma, racism, mistrust, and fragmented care intersect. In this episode, we explore why this happens, how it affects patients, and what clinicians can do differently.
Practical clinical pearls:
Individually: build a habit of asking “What else could this be?”. Make it a habit to perform a focused physical examination and consider basic investigations even when symptoms seem to fit with the known psychiatric diagnosis. This simple cognitive forcing strategy can interrupt premature closure and implicit bias.
System‑level: implement integrated care models where physical and mental healthcare are delivered together with shared records and coordinated plans. Integrated care models have been shown to improve physical health outcomes for people with serious mental illness, reduce fragmentation, and ensure that physical symptoms receive appropriate attention regardless of psychiatric comorbidity
For Māori, this means developing and funding culturally safe, Māori‑led services that integrate physical and mental healthcare, address the social determinants of health, and build trust through culturally aligned care delivery. This requires genuine partnership with Māori communities, addressing institutional racism, and ensuring adequate resourcing for Māori health services.
Resources:
Buhay C. Overlooked. The Horizon. Published September 16, 2025. Accessed May 18, 2026.
Lazris A, Roth A. Diagnostic overshadowing: when cognitive biases can harm patients. American Family Physician. 2023;108(3):292-294.
Iezzoni LI. Dangers of diagnostic overshadowing. New England Journal of Medicine. 2019;380(22):2092-2093. doi:10.1056/NEJMp1903078.
Shefer G, Henderson C, Howard LM, Murray J, Thornicroft G. Diagnostic overshadowing and other challenges involved in the diagnostic process of patients with mental illness who present in emergency departments with physical symptoms: a qualitative study. PLoS ONE. 2014;9(11):e111682. doi:10.1371/journal.pone.0111682.
Additional References:
Hallyburton A, Allison-Jones L. Mental health bias in physical care: An integrative review of the literature. Journal of Psychiatric and Mental Health Nursing. 2023.
Tosh G, Clifton AV, Xia J, White MM. Physical Health Care Monitoring for People With Serious Mental Illness. The Cochrane Database of Systematic Reviews. 2014.
Hall WJ, Chapman MV, Lee KM, et al. Implicit Racial/­Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes: A Systematic Review. American Journal of Public Health. 2015.
Maina IW, Belton TD, Ginzberg S, Singh A, Johnson TJ. A Decade of Studying Implicit Racial/­Ethnic Bias in Healthcare Providers Using the Implicit Association Test. Social Science & Medicine. 2018.
Friedemann Smith C, Lunn H, Wong G, Nicholson BD. Optimising GPs' Communication of Advice to Facilitate Patients' Self-Care and Prompt Follow-Up When the Diagnosis Is Uncertain: A Realist Review of 'Safety-Netting' in Primary Care. BMJ Quality & Safety. 2022.
Goetz CJ, Mushquash CJ, Maranzan KA. An Integrative Review of Barriers and Facilitators Associated With Mental Health Help Seeking Among Indigenous Populations. Psychiatric Services. 2023.
Russell J, Boswell L, Ip A, et al. How Is Diagnostic Uncertainty Communicated and Managed in Real World Primary Care Settings?. BMC Primary Care. 2024.
About Dr Cheryl Buhay:
Cheryl is an adult psychiatrist with Takanga A Fohe Pacific Mental Health and Addictions Service within Health New Zealand Te Whatu Ora Waitematā. Prior to this she was a Clinical Director within the non-government organisation sector providing mental health and addiction support to communities across the country, and several years a Primary Care Liaison psychiatrist for Health New Zealand working closely with General Practitioners and their teams. She is the Chair for the NRPTP Vocational Training Committee for Psychiatry and an Honorary Senior Lecturer with the University of Auckland.
Listen here:
https://open.spotify.com/episode/0qrYj2lLuxrTEszZW3Hzro?si=f789f964a93f43fe

Kindness at work is not the same as being nice.
In this special one-year anniversary episode of The Specialist GP, we welcome back the podcast’s very first guest, Dr Nicki Macklin, to explore kindness in healthcare, leadership and the supervisor–supervisee relationship.
We explore what kindness really looks like when we are busy, under pressure and responsible for supporting other people’s learning and development.
We discuss the difference between kindness and niceness, why trust needs to come before difficult conversations, and how we can use coaching, feedback and early intervention to support people while maintaining standards.
We also challenge the idea that kindness is simply an individual quality, and consider how we can build kindness into the way our workplaces and organisations are designed.
A practical conversation about supervision, leadership, feedback and creating workplaces where people can learn, speak up and do their best work.
Practical clinical pearls.
First, kindness is not the same as niceness. Sometimes the kindest thing we can do is have the difficult conversation, set a boundary or give honest feedback.
Second, kindness is something we build into our systems. Protected supervision time, clear expectations and regular check-ins create the structure for people to do well.
Third, trust is built before it is needed. The small, everyday interactions are what make difficult conversations safer when they eventually need to happen.
Fourth, silence is not neutral. Avoiding a difficult conversation may feel easier in the moment, but it can leave people anxious, prevent learning and allow problems to continue.
Fifth, different situations need different conversations. Coaching, feedback and intervention are not the same thing, and knowing which one is needed is an important part of good supervision.
Sixth, directness can be kinder than vague reassurance. Be specific about what happened, the impact it had and what needs to happen next.
Lastly, Good supervision is a shared system responsibility. Power matters in supervision. The person with less power should not be expected to carry the burden of fixing a poor supervisory relationship. Supervisors and organisations have a responsibility to create safe, supportive and accountable supervision.
If the relationship is not working, seek support outside the immediate supervisory relationship. A professional mentor, another supervisor or a trusted peer can help you work out what is happening, consider your options and decide how best to move forward.
Resources:
· Macklin N, Lee TH, Edmondson AC. Why kindness isn’t a nice to have. Harvard Business Review. 2025 Jul 29.
· Macklin N, Rapana N, Wilkinson-Meyers L, Dowell A. He Aroha Whakatō, He Aroha Puta Mai. Embedding kindness in organisational practice: lessons from a kaupapa Māori primary care team. Kōtuitui. 2026;21(3). doi:10.1002/kot2.70056.
· Macklin N, Wilkinson-Meyers L, Dowell A. Defining kindness in healthcare: perspectives from international experts. SSM Health Syst. 2026;7:100270. doi:10.1016/j.ssmhs.2026.100270.
· Goode S, Hodge G, Cross D. A guide in undertaking core clinical supervision: supervisors’ experiences in implementing core clinical supervision in general practice. Practice Nursing. 2025;36(1):19-25. doi:10.12968/pnur.2025.36.1.19.
· Ingham G, Johnson C. GP supervisors in Australia: a cornerstone in need of repair. Med J Aust. 2022;216(4):178-181. doi:10.5694/mja2.51411.
· Wearne S, Dornan T, Teunissen PW, Skinner T. General practitioners as supervisors in postgraduate clinical education: an integrative review. Med Educ. 2012;46(12):1161-1173. doi:10.1111/j.1365-2923.2012.04348.x.
· O’Sullivan B, Hickson H, Kippen R, Wallace G. Exploring attributes of high-quality clinical supervision in general practice through interviews with peer-recognised GP supervisors. BMC Med Educ. 2021;21:441. doi:10.1186/s12909-021-02882-7.
· ten Cate O. Entrustability of professional activities and competency-based training. Med Educ. 2005;39(12):1176-1177. doi:10.1111/j.1365-2929.2005.02341.x.
· Dwyer M, Griffin P, Rouhi M, Waddingham S, O’Brien L, Prior S. Junior doctors’ experiences of workplace bullying, harassment and discrimination in Australia and Aotearoa New Zealand: a scoping review. ANZ J Surg. 2026;96(1-2):37-47. doi:10.1111/ans.70323.

About Dr Nicki Macklin:
Nicki is a researcher, consultant, and speaker who explores how organisations can design systems and structures that sustain kindness and human connection at work.
Her PhD, through the University of Auckland's Faculty of Medicine and Health Sciences, was among the world's first doctoral studies on organisational kindness in healthcare. She is a former occupational therapist, with a background in quality improvement management and innovative service design in primary care, and has spent many years as a patient and whānau advocate both in Aotearoa and overseas. Nicki is currently an Associate Editor at BMJ Leader, where she leads its Kindness and Human Connection stream, and a visiting scholar and guest lecturer at the University of Toronto's Rotman School of Management. Her work has been published in peer-reviewed journals including the British Medical Journal Leader and Social Sciences and Medicine, and in outlets such as the Harvard Business Review, where her article with Amy Edmondson and Tom Lee was named one of HBR's top ten management insights of 2025.
Through her consulting practice, KindFrame, Nicki works with leaders, teams, and governance groups across healthcare, legal and business sectors, including extensive work with the health and legal professions in New Zealand and Australia. She speaks regularly on kindness as designable infrastructure rather than personality, and on what it takes to build the conditions for people to do their best work.
Listen here:
https://podcasts.apple.com/nz/podcast/kindness-supervision-leadership-w-dr-nicki-macklin/id1845748299?i=1000791893728
https://open.spotify.com/episode/5jO3CN4zlQSwytaVUAg0rS?si=d0235c0804a7438d

In one of my most challenging conversations of the year, Dr Diana Kopua asks us to slow down and look differently at ADHD.
Equity CME poinst can be claimed.
We meet Wiremu, a 22-year-old Māori man who comes to primary care with his auntie after his boss suggests he might have ADHD. He is struggling to stay focused at work and complete his apprenticeship theory, and it would be easy to move quickly towards a diagnosis.
But Diana challenges us to pause.
What happens when we start with the relationship rather than the diagnosis? What does context really mean when we are assessing ADHD? And what might we miss if we focus on symptoms without understanding whakapapa, whānau, culture, identity and the lived experience of the person sitting in front of us?
This is not a conversation about finding a different checklist for diagnosing ADHD. It is a conversation about questioning whether the way we currently approach assessment is always serving our patients well.
Diana shares how Māori models of health, including Mahi a Atua and Mauri, can change the way we think about distress and wellbeing. We talk about the role of whānau, culturally safe assessment, diagnostic labels and the uncomfortable possibility that our own clinical practice can sometimes contribute to inequity.
We also ask a difficult question: when is an ADHD diagnosis actually helpful, and when might we be too quick to assume that a diagnostic label is the answer?
There are no easy answers here. Instead, Diana asks us to be curious, to sit with some discomfort and to think more deeply about what we are doing, why we are doing it, and who our approach is working for.
For GPs and other primary care clinicians, this episode offers practical ways to rethink ADHD consultations, while challenging us to look honestly at the assumptions we bring into the room.
Sometimes better care starts with being willing to stop, listen and see the patient differently.
Practical clinical pearls:
Start with the relationship, not the diagnosis. Name the purpose of the consultation, establish what matters to the patient, and check how they want to approach the conversation.
Bring whānau into the conversation early. Where appropriate, invite whānau participation from the beginning rather than treating it as an add-on to the consultation.
Use a culturally appropriate framework. Frameworks such as Mauri can help explore wellbeing and the wider context of the patient’s experience alongside diagnostic assessment.
Ask what the diagnosis will change. Before pursuing a diagnostic label, ask how it will benefit this patient, at this time. Consider whether the focus should be on potential, strengths and support as well as symptoms.
Check how the consultation felt to the patient. Before finishing, ask whether they felt respected, heard and understood. Be willing to sit with discomfort, reflect on how your own practice may contribute to inequity, and stay curious about where you can do better.
Feeling out of your depth? Upskill- see resources below.
Resources:
Te Kurahuna – Mahi a Atua – Official website for Mahi a Atua, including information about the approach, training, publications, and resources.
Kopua, D., & Skirrow, P. (2023). Racism, Mātauranga Māori and ADHD: An Interview With Dr Diana Kopua. Journal of the New Zealand College of Clinical Psychologists, 33(1), 72–78. https://doi.org/10.5281/zenodo.8187808 (Mahi a Atua)
Kopua, D. M., Kopua, M. A., & Bracken, P. J. (2020). Mahi a Atua: A Māori approach to mental health. Transcultural Psychiatry, 57(2), 375–383. https://doi.org/10.1177/1363461519851606 (Sage Journals)
Te Kurahuna Publications & Resources – Collection of Dr Diana Kopua's publications, reports, and additional resources on Mahi a Atua, Indigenous mental health, racism, and systems transformation.
About Dr Diana Kopua: (Ngāti Porou) is a consultant psychiatrist, co-founder of Te Kurahuna, and the developer of Mahi a Atua, an Indigenous approach to mental health grounded in Māori pūrākau, whakapapa and mātauranga Māori. Originally trained as a nurse before studying medicine at the University of Otago, she completed specialist training in psychiatry in 2014 and has led the development of innovative kaupapa Māori mental health services, including Te Kūwatawata and Te Hiringa Matua. Through her clinical work, teaching and research, Dr Kopua has become a leading voice on Indigenous mental health, racism in healthcare, and culturally grounded approaches to ADHD and wellbeing.
Listen here:
https://podcasts.apple.com/nz/podcast/adhd-maori-lens-w-dr-diana-kopua/id1845748299?i=1000789362552
https://open.spotify.com/episode/7AHwjYFtJqcRYl4cY5syoi?si=85d7210fdc074d69

Varicose veins are common presentation in primary care, but knowing who to reassure, who to investigate and who to refer isn't always straightforward. Today we are doing something different- we are going work through five real-world quick-fire cases to highlight practical assessment and management of VV’s. I am joined by Dr Sam Dunn.
Practical clinical pearls:
1. Pregnancy- Treat the symptoms, not the veins.
Compression, movement, avoiding prolonged standing and leg elevation are usually all that’s needed. Reassess 3–6 months postpartum.
2. Examine varicose veins standing up.
They can disappear when the patient lies down. Look for oedema, pigmentation, eczema, lipodermatosclerosis and ulcers—and check the pulses before compression.
3. Compression isn’t automatically benign.
Check arterial circulation first. If pulses are reduced or arterial disease is possible, assess further before prescribing higher-grade compression.
4. Know who needs referral.
Symptoms, oedema, skin changes, ulcers, thrombophlebitis or bleeding mean this is more than a cosmetic problem and warrants referral.
5. A bleeding varicose vein is an emergency waiting to happen.
Lie down, elevate the leg and apply firm pressure. If it doesn’t stop—or starts again—seek urgent medical care. Even when it stops, arrange urgent referral.
Bio:
Dr Sam Dunn. Sam is Medical Director at Palm Clinic and an experienced cosmetic medicine and vein physician. After beginning his career in emergency medicine, Sam has spent almost two decades practising phlebology and cosmetic medicine. He holds Diplomas in Procedural Phlebology, Skin Cancer Medicine and Community Emergency Medicine, and is a Fellow of the New Zealand Society of Cosmetic Medicine.
Resources:
https://www.palmclinic.co.nz/vein-care/what-to-expect
https://www.anzsvs.org.au/patient-information/varicose-veins/
https://medlineplus.gov/varicoseveins.html
Listen here:
https://podcasts.apple.com/nz/podcast/varicose-veins-w-dr-sam-dunn/id1845748299?i=1000786889860
https://open.spotify.com/episode/4gP40UOpbqu4p48SmCD4rm?si=721f49e4bd68454c

Frailty is a common but often under-recognised clinical syndrome that has significant implications for health outcomes in older adults. In this episode, we explore how frailty develops, who is most at risk, and why early identification matters. We discuss practical approaches to assessment in primary care, the consequences of frailty, and evidence-based strategies to help patients maintain function, independence, and quality of life with specific discussions around Te Ao Māori perspective.
Practical clinical pearls:
Watch for the frailty pattern: unintentional weight loss, reduced activity, fatigue, slowed gait, and falls.
Use the corridor as part of the consult: gait speed, chair rise, grip strength, and how they move tell you a lot.
Ask family/whānau for collateral history, because gradual decline is often noticed there first.
Think multifactorially: frailty is linked to sarcopenia, multimorbidity, polypharmacy, social isolation, nutrition, and environmental barriers.
Prioritize resistance training and adequate protein intake; those are among the most effective preventive strategies.
Review medications carefully, especially sedatives, anticholinergics, and overly tight diabetes or blood pressure treatment.
Use frailty to change decision-making: shift from disease-only management to goals-of-care and whole-person planning.
Keep care strengths-based and culturally grounded, especially for Māori patients: focus on what matters, what supports them, and what gives them mana.
Don’t wait until someone is clearly frail; midlife is the right time to start prevention.
Frailty is not just a label — it’s a signal to act.

Resources:
Health Quality & Safety Commission New Zealand. Frailty | Te Wairuhi: Frailty care guides 2023 [Internet]. Wellington: Health Quality & Safety Commission New Zealand; 2023 [cited 2026 Jun 17]. Available from: Frailty | Te Wairuhi: Frailty care guides 2023
Healthify. Clinical Frailty Scale [Internet]. Auckland: Healthify He Puna Waiora; [cited 2026 Jun 17]. Available from: Clinical Frailty Scale
Gee S, Bullmore I, Cheung G, et al. It's about who they are and what they can do: Māori perspectives on frailty in later life. N Z Med J. 2021;134(1535):17-24. Available from: ResearchGate article

Biography:
Dr Helen Kenealy is a dual-trained General Physician and Geriatrician with extensive experience in the care of older adults. She is currently Chief Clinical and Risk Officer at Metlifecare, where she oversees clinical quality, governance, risk management, health and safety, and digital health innovation across retirement living and aged care services.
Helen is passionate about delivering high-quality care for older adults and supporting people to maintain independence, function, and quality of life as they age. She brings extensive expertise in frailty, healthy ageing, comprehensive geriatric assessment, and the healthcare systems that support older New Zealanders.
Listen here:
https://podcasts.apple.com/nz/podcast/frailty-w-dr-helen-kenealy/id1845748299?i=1000783687000
https://open.spotify.com/episode/5jbMGUOgMGMDTzBONMuOsS?si=6ef1d31419394317
#frailty #CME