BJGP Interviews

Today, we’re speaking to Andrew McClarey, who works as a GP and Education co-ordinator Lead for General Practice in the Scottish Centre for Simulation and Clinical Human Factors.
Title of paper: “Quick wins” vs “eating the frog”: Exploring general practitioners’ prioritisation dilemmas
Available at: https://doi.org/10.3399/BJGP.2025.0628
Link to tactical decision making games: https://archive.johs.org.uk/article/doi/10.54531/svvw4195
This is the first study to look at the factors which experienced GPs consider when prioritising their acute workload. Several themes have emerged which highlight the importance of prioritisation training in General Practice. These themes could be used to teach prioritisation decision making to GP registrars or in the creation of continuing professional development resources for experienced GPs.

Transcript
This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.Speaker A
00:00:00.400 - 00:00:56.560
Hi and welcome to BJ GP Interviews. I'm Nada Khan and I'm one of the Associate editors of the Journal. Thanks for listening to this podcast today.

In today's episode, we're speaking to Dr. Andrew McClary.

Andrew is a GP partner and he also works as Education Coordinator, Lead for General Practice in the Scottish Centre for Simulation and Clinical Human Factors. We're here today to discuss the paper that he's recently published in the bjjp.

And the paper is titled Quick Wins versus Eating the Frog, Exploring general practitioners Prioritization dilemmas. So, hi, Andrew, it's really nice to meet you.

And this paper really stood out to us, I think, because prioritisation is something that gps do every day, but it's not really something that we discuss explicitly. I'm just interested in what made you do this work and made you interested in studying it.

Speaker B
00:00:57.200 - 00:02:00.600
It's interesting, I think, that for me, I finished my GP training just after the pandemic and therefore I did a lot of my training during the COVID pandemic. And around then the face of general practice, like most things in life, changed completely overnight.

We moved on to telephone consulting and being encouraged to have empty waiting rooms.

And I think around the same time we realized that we probably couldn't continue doing what we had been doing, which was being everything to everyone, which brought us on to prioritizing our workload. We have to decide who needs seen, who does not, and when are they seen. And that was a real gap for me in the training that I was provided.

And I found myself going into working as a fully qualified GP without really an awareness of how to prioritise in a, in a sensible way. And I think that's where this interest was born out of.

Speaker A
00:02:00.760 - 00:02:42.050
And before we get into what you found, it's probably worth saying a little bit about how you approach the study. So this was a qualitative interview study involving gps from a range of practices and career stages.

And what you did was you really explored how they prioritized work during the course of a typical surgery.

And then I guess through those interviews you looked at sort of the strategies and influences and trade offs that shaped those decisions in everyday general practice. But one of the things I found really interesting was that prioritization wasn't just about clinical urgency.

And I wonder if you could talk through some of the other factors that GPs are weighing up quickly, I suppose, when they're deciding what to tackle first.

Speaker B
00:02:42.690 - 00:06:17.800
Absolutely.

It was very interesting, the themes that emerged from the data and also actually how much agreement There was amongst the gps in the focus groups, as we're not traditionally a group of people who agree about very much. So one thing that GP is particularly interested in, there's five main themes. One is about the system awareness.

So we're aware about our own surgeries and where the pressure points are.

For example, we're low on particular acute slots today, or there's a certain type of patient that is coming in more frequently at the moment, so we're aware of that. But it's not just having that awareness, it's also being able to adjust how we consult based on the pressures that the system are under.

For example, if there are a lot of children or fevers coming in, we want to see them all face to face. We ask the admin team, just bring them all in face to face and we'll see them that way, rather than setting everything up over the phone.

So it's not just an awareness of the system, but actually adjusting ourselves to that demand. Another one is the time management. What's the most efficient use of my time?

How am I going to get out on time this evening for nursery pickup or whatever else I have to do in the evening? But it's not just our time, it's also the system's time.

So what I mean by that is, I know if I try and refer to a hospital service in the afternoon, they'll probably be at capacity. If I do that in the morning, I am much more or first thing, except an afternoon surgery.

I'm much more likely to have my patient accepted and managed in a way that I think is most appropriate for them. Also, third theme, familiarity with our patients.

We are more familiar with our patients and therefore we don't have to go trawl through their histories. We know, right? I know that patient, I know what that's about. I spoke to them about it last week. Let's just phone them first and move on.

That's an easy thing for me to do. Then relationships.

Fourth theme, relationships with patients, in that we develop a trusting relationship, particularly if you've been working in a practice for a long period of time.

For example, we might be able to have a conversation on the phone saying, well, are you as bad as you were the last time, for example, when you went to hospital with your copd? Is it as bad as that? Well, no, no, Doctor, not as bad as that. And you know these patients and you trust them to tell you the story like it is.

But we also not only prioritise relationships with our patients, but also with other staff members.

For example, if you're interrupted during a duty doctor session and it's the practice nurse who is needing help with something, that person is there in front of you. They're a valued member of your team and you want to be able to provide input for them in a timely way.

And I guess that takes us back to system awareness. We know that that nurse has also got lots of patients to see, and if there's a delay in that, then the whole system is suffering from it.

And then lastly, fifth is this idea of personal preferences. Some of us like doing hard things first, so that's eating the frog.

Some of us like the quick wins and the endorphin release, of actually seeing all of the columns or all of the slots in the IT system changing a different color, we get a bit of a rush from that. There's no right or wrong answer with this, but actually a lot of it does come down to that.

But it's also about looking after ourselves, but also balancing that against good patient care and what needs to be done first from a clinical urgency perspective.

Speaker A
00:06:18.360 - 00:06:45.170
And the title of the paper is Quick Wins versus Eating the Frog.

And I find that really interesting because from my own clinical practice, sometimes I feel like I'm telling myself off if I'm only taking off the easy tasks, because I know then at the end of the day I'm going to have all the long referral letters, the things that I've really been putting off. And I think, gosh, why did I leave it to this point, really?

But I wonder if you can explain what that means a bit more generally, and why it captured something important about GP decision making.

Speaker B
00:06:45.570 - 00:08:12.210
I think ultimately, for me, it's about when we are at the trainee stage. We are actually honest about how we approach prioritizing our workload. And I think ultimately that comes down to personality.

Some of us like doing the more difficult things first, and then we feel that we've got the wind at our back and we're able to go on about our afternoon knowing that the most difficult thing in that list is done. In fact, the quote goes, eat a live frog first thing in the morning and nothing worse will happen you for the rest of the day.

And I think that's probably paraphrasing a little bit, but I think that's the thing. If the worst thing is out of the way, the afternoon suddenly seems much better versus actually some of us need that endorphin release.

And the highs, I guess, of actually seeing, feeling that we're going through our afternoon at a Good rate. And we are managing things well and some of us like that.

But I think ultimately, if we can have that conversation at the trainee stage to say, look, you're either a frog eater or you're a quick winner and you have to decide which you are. And maybe actually you're at the point in your career where you have the opportunity to actually try these out.

Say, right, we'll do the hardest thing first, how does that feel? Versus, you know, take off a few easy things, how does...

Today, we’re speaking to Dr Tom Purchase, a GP and Health and Care Research Wales NIHR doctoral fellow.
Title of paper: Co-generating ideas for safer paediatric care in general practice with parents and stakeholders
Available at: https://doi.org/10.3399/BJGP.2025.0690
Research has highlighted the important role parents play in in paediatric patient safety, for example, through mitigating safety incidents in general practice, yet their perspectives have rarely shaped system-level improvements. This study co-generated and prioritised ideas for change with parents and key stakeholders, identifying feasible and impactful strategies to improve paediatric safety in primary care. These strategies centred around practice communication, accessing care records and results, and fostering a culture of shared learning and development. Parents are willing and able to contribute meaningfully to safety improvement efforts, and their insights align with national patient safety priorities. Clinicians and policy makers can use these findings to strengthen collaboration with families, tailor safety interventions to local needs, and embed parent voices into the design of safer care systems.
Transcript
This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.
Speaker A
00:00:00.480 - 00:00:49.500
Hello and welcome today to BJGP Interviews. I'm Nada Khan and I'm one of the Associate editors of the Journal. Thanks for listening again to this podcast.

In today's episode, we're talking to Dr. Tom Purchase. Tom is a GP and a health and Care Research Wales NIHR Doctoral Fellow.

We're here today to talk about the paper he's just published in the bjgp and the paper is titled Co Generating Ideas for Safer Pediatric Care in General Practice with Parents and Stakeholders.

So, hi, Tom, it's really great to meet you and to talk about your work, but before we talk about the study itself, I'm interested to know what first got you interested in pediatric patient safety in general practice.

Speaker B
00:00:50.060 - 00:02:26.850
Thanks. It's born, I think, out of an extension of the work that we've been doing within the patient safety team within Cardiff University.

So a lot of what we do is looking at incident reports, safety incident reports, and trying to pick out what are the, you know, high level key learning points and takeaway messages from those.

And then within the team, we started to think about, as well as the types of incidents and the types of harms that are occurring within pediatric incidents. For example, how are parents involved?

And it was a bit of a novel approach to what we normally do, trying to have that extra aspect within the incidents and figuring out how parents were either helping to contribute or to mitigate against the incidents, not just looking at the incidents themselves. So that was the starting point, really.

And then once we'd started digging into that data and identifying that, actually the majority of the time, which is in one of the papers that was published last year in BJGP, 77% of the reports we were looking at specifically around general practice showed that parents were taking these mitigatory actions that, you know, positive actions that were able to prevent harm or further harm from occurring to their child, for example, chasing results or chasing referrals or importantly, being able to speak up. And then that highlighted, I think, the importance of parents being able to have a voice and advocating on behalf of their child.

And that really sparked, I think, the interest, and therefore this part of the.

Speaker A
00:02:26.850 - 00:02:46.490
Project, and I think that's a really interesting thing about this paper, is that it focuses on parents and parents not just as observers of care, but as active contributors to safety. And I wonder what your thoughts are about why that's an important shift in how we think about these things.

I think you've touched on it a bit, but yeah, I'm interested to know a bit more about that.

Speaker B
00:02:46.810 - 00:03:55.980
I think it is a really important aspect of care, but also particularly safety, which maybe is untapped in terms of parents as a resource as to how we can keep children safe.

We know that children on the whole are more, maybe not more vulnerable, but certainly are a vulnerable group when it comes to patient care in general and patient safety.

And that's because they're so heavily reliant on others to speak on their behalf, to make sure somebody else is looking out for their healthcare needs. And therefore they are probably playing a part within the world of patient safety.

And there are good studies from hospital relating to incident reports that show that parents are capable of picking up issues early on. They're able to detect issues that maybe other parts or people within the system aren't detecting.

And as I mentioned, our paper from last year specifically looking at general practice showed that parents are able to prevent harms from reaching their children. So they're playing a substantial part already.

And from a systems perspective, that is mainly parents figuring out workarounds within a system that really isn't, I don't think, designed to support them as well as it could be.

Speaker A
00:03:56.460 - 00:04:33.810
And I guess that's kind of the crux of what you were doing here.

So I guess before we get into findings, just, you know, a quick word about the methods because you worked here with groups of parents to develop ideas for improving pediatric patient safety in, in general practice, in primary care, and then you explored those ideas with a wider group of stakeholders and that included clinicians, managers and policymakers, and then brought them all together to co generate ideas for safer care. And it was really interesting because the parents generated 16 different ideas for improving safety.

And were there any that particularly surprised you and jumped out at you?

Speaker B
00:04:34.450 - 00:05:33.980
I don't think necessarily any were too surprising on the basis that we. I don't think I really had any thoughts going into it as to what they might say.

But I guess what did surprise me more was that some of the ideas that we then took forward to the stakeholder group kind of highlighted some disparities or some clear disagreements between the parents who were accessing our services and the people who work within the services. And how we viewed, I suppose, viewed what's actually happening, that kind of work is imagined and how we think things are going and the work is done.

I guess what the parents were trying to do to come up with the idea is to bridge that gap unknowingly. I suppose maybe what's surprising is that none of them, I didn't think any of the ideas were necessarily too resource intensive.

You know, I think what was quite reassuring is that lots of what the parents were saying were actually relatively simple things that we might be able to enact or at least adopt or adapt, you know, to our own environments.

Speaker A
00:05:34.540 - 00:05:47.730
And a lot of the ideas seem to center, I think, around communication, access to records and test results, and actually just helping parents to speak up. And why do you think those themes emerge so strongly?

Speaker B
00:05:48.450 - 00:07:24.990
I think that comes back to maybe that difference between how we like to think the system's functioning and how parents think the system's functioning as healthcare professionals and parents.

Because we know from a thematic analysis we did, which is also going to be published in bjgp, from these discussions we've had with the parents, that a lot of them said they felt the need to fight in order to be heard.

So although within, say, pediatrics and GP training programmes and CBDs and everything we have to do for revalidation, taking ideas, concerns, expectations, collateral histories, making sure we're really considering that the holistic approach is all considered clinically, what you're then getting, I suppose, from the parents is that maybe we're not doing it as well as we could be.

And one parent within the workshop said, I know as a parent you are expected to advocate for your child, but what it surprises me is how regularly you have to do it and sometimes it feels like a full time job.

And I think that one really struck a chord in terms of really emphasizing how much extra effort and how much work parents are feeling they need to put in. And I think that also implies that the system isn't making it as easy as possible for them to be able to do the right thing.

So I can't necessarily explain unfortunately why they feel that those areas needed to be targeted.

I guess it's because there are barriers that we are not tackling correctly in order to help parents to speak up more efficiently and certainly to be listened to.

Speaker A
00:07:26.840 - 00:07:35.160
And one of the stakeholder priorities was this idea of a designated parent advocate. Can you tell us a bit more about that idea and why it resonated?

Speaker B
00:07:35.640 - 00:09:21.810
Yeah, sure.

I really liked that one and I thought it was an interesting one because again, it...

Today, we’re speaking to Dr Garth Funston, a GP and Clinical Senior Lecturer in Primary Care Cancer Research at Queen Mary University of London.
Title of paper: Using large language models to identify pre-diagnostic clinical features of ovarian cancer from healthcare records: a population-based case-control study
Available at: https://doi.org/10.3399/BJGP.2025.0366
Most women with ovarian cancer present with symptoms, but many symptoms are recorded only in free text healthcare records and missed by studies and clinical decision support tools that rely on coded data. We found that using large language models (LLMs) to extract symptoms from free text records substantially increased symptom detection and strengthened associations with ovarian cancer. Incorporating LLM-extracted symptom information into research and clinical decision tools may support identification of women at higher risk of cancer and aid appropriate investigation.

Transcript
This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.
Speaker A
00:00:00.800 - 00:00:50.940
Hi and welcome to BJGP Interviews. I'm Nada Khan and I'm one of the Associate editors of the Journal. Thanks for listening to this podcast today.

In today's episode, we're talking to Dr. Garth Funston, who is an academic GP and clinical senior Lecturer in Primary Care Research at Queen Mary University of London.

We're here to talk about his recent paper in the BJDP which is titled Using Large Language Models to Identify Pre Diagnostic Clinical Features of Ovarian and Cancer from Healthcare Records.

So, Garth, thanks so much for talking to us again today, but I wonder, just before we get into the AI side of this paper, can you briefly explain the clinical problem you're trying to address here with ovarian cancer diagnosis in general practice?

Speaker B
00:00:51.500 - 00:01:55.010
So most women with ovarian cancer are diagnosed after they develop symptoms and see their doctor. The challenge is that most symptoms are really non specific. There's no real red flag symptoms for ovarian cancer.

That makes it a real clinical challenge for the GP to kind of recognize it and perform tests.

So the symptoms are things like abdominal and pelvic pain, persistent bloating, urinary urgency and frequency, things that we see really frequently in gp. So knowing when to consider ovarian cancer is the big challenge.

And we know that certainly a proportion of women see their GP multiple times before the diagnosis. Now we're lucky for ovarian cancer in that we have reasonably good triage tests and CA125 and transvaginal ultrasound.

So the challenge really is to identify women with these non specific symptoms early so as we can work out who to test and hopefully improve early diagnosis and on outcomes in that way.

Speaker A
00:01:55.250 - 00:02:14.530
Yeah, and I'm sure you're well aware of sort of the body work around this area and people like Willie Hamilton, who's done work around early diagnosis of ovarian cancer, along with Claire Bankhead, and they did some really interesting work around things like bloating, didn't they? But that was slightly different, I think, and a little bit that's some time ago now, isn't it?

Speaker B
00:02:14.930 - 00:02:39.230
Yeah, it was some time ago. I think all of that is, you know, fundamental and still holds true.

And they did a lot of work around things like IBS and in women over, over 50 and things like that that are kind of these subtle signs that we need to be aware of with ovarian cancer.

So, yeah, we know there's lots of features that are associated with ovarian cancer, but it's recognizing when to invest to get those features because they're so common.

Speaker A
00:02:39.630 - 00:02:49.310
Yeah. And do you think that's why it's described as difficult to diagnose early in general practice? Is it because the symptoms are so common?

What are your thoughts on that?

Speaker B
00:02:49.390 - 00:03:48.750
I think there's a few reasons.

I think ovarian cancer used to be called, certainly in the media, the kind of the silent killer and terminology, which I really, really frustrates me, because we know it's not. We know that most women of symptoms for diagnosis. We actually know that from this paper and other papers that are symptoms in early stage cancer.

But that kind of thought around ovarian cancer still holds. Secondly, the symptoms are nonspecific, they're reasonably common. I mean, you know, I probably see a.

A patient with abdominal pain most days and it's kind of working out which ones to investigate for ovarian cancer. Yeah. And so I think those are the main things. And thirdly, it's, you know, it's not the most common common cancer.

GP will see people probably only encounter a case of ovarian cancer every three to five years, a new case. And that's the extra challenge. It's kind of suspecting it when it's a rare thing in primary care.

Speaker A
00:03:49.100 - 00:04:03.500
Yeah. And one thing I found really interesting about this work is that you're using free text clinical records rather than just coded data.

So can you tell us a little bit about the data you accessed here and why it was so important to use this free text data?

Speaker B
00:04:04.220 - 00:05:09.600
So a lot of the work that we do with primary care data focuses on coded data and certainly within the uk, because that's really the data we can actually access within UK for research purposes. But up to 80% of clinical information is not in that coded format, it's in the free text.

And work from people like Sarah Price in the past have shown that often subtle things that we need to pick up are in the free text and GPS don't code that.

So it's something I've been really keen to use in research for many years now to try and look at what extra information is there in the free text that could help us in both research and clinical practice and kind of picking up these cancers. And the data we accessed was from the United States, it was from healthcare clinics associated with the University of Washington.

And that included kind of coded data, but also the free text medical records of patients which had been anonymized and were accessed in a kind of a safe and appropriate way.

Speaker A
00:05:10.000 - 00:05:40.140
Yeah.

And I think a lot of clinical staff listening to this will certainly, certainly appreciate that a Lot goes into the notes that we just type in that doesn't really get coded. So it's phenomenal that you're able to access that data.

And this paper uses large language models or LLMs, which some people might associate, associate with tools like ChatGPT, but just at a very basic level. Can you just talk us through what actually is a large language model and what sort of it was used for in this, in this study?

Speaker B
00:05:40.950 - 00:06:49.130
Large language models, lots of people use them on a daily basis. Absolutely right.

Things like ChatGPT, they're essentially a tool for our purposes which we use to extract information from the free text medical records. Now natural language processing approaches have been used actually for many years, kind of rule based approaches.

Other models, these require lots of training. You need to lots of highly annotated records and notes to train the models.

Advantage of large language models, things like GPT, is they need less annotated notes and we did still do some of that, but they require less and that makes them much easier to apply and use in practice. We use them in this setting to effectively pull out key information on symptoms.

We predefined a list of 17 symptoms from the literature which were associated with ovarian cancer and we used the large language models to go through the notes, pull out information on those symptoms that we could use in the study alongside the coded data.

Speaker A
00:06:50.090 - 00:07:03.350
And I think that as we've been discussing, these large language models are probably really useful for this kind of data. I think especially because a lot of general practice is narrative and contextual as we've been discussing as well.

Speaker B
00:07:03.350 - 00:07:38.940
Yeah, I think, I mean there's two challenges with using free text data. One is access requirements because there's lots of concerns around confidentiality. The other is just the volume of it.

You've got these massive records that you know, contain lots of information, lots of writing, go back years. How do you actually process that to find the key information that you need?

I think large language models are a really useful tool here because with a bit of training you can use them to actually extract the information that's pertinent to your kind of question.

Speaker A
00:07:39.340 - 00:07:48.620
So let's go into what you found and I'm really interested to know about what kind of patterns or features was this model able to identify before an ovarian cancer diagnosis.

Speaker B
00:07:49.180 - 00:09:06.690
So we looked at 17, 17 features. We find actually that 14 of the features were more frequently recorded within the free text and coded...

Today, we’re speaking to Dr Clare Macdonald, an Academic Clinical Lecturer in General Practice based at the University of Birmingham.
Title of paper: Complex social needs and maternal postnatal care: what can primary care do?
Available at: https://doi.org/10.3399/BJGP.2026.0069
Throughout the discussion we use the terms ‘woman’ and ‘women’, but we know that not all those who give birth will identify as women and intend this to mean all those who give birth.
Transcript
This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.

Speaker A
00:00:00.480 - 00:00:51.740
Hello and welcome to BJ GP Interviews. I'm Nada Khan and I'm one of the Associate Editors of the Journal. Thanks for listening to this podcast today.

In today's episode, we're speaking to Dr. Claire MacDonald. Claire is an academic clinical lecturer in general practice, and she's based at the University of Birmingham.

We're here today to talk about the editorial she's just published in the May issue of the bjgp, and it's titled Complex Social Needs and Maternal Postnatal Care. What Can Primary Care Do?

So, hi, Clare, it's lovely to meet you and to talk about this brilliant editorial, but before we get into the editorial itself, I wonder if you can just talk us through what you actually mean by complex social needs in the context of postnatal care.

Speaker B
00:00:51.980 - 00:02:21.290
Yeah.

So I think when we talk about social complexity in the postnatal population, we're talking about women who have multiple factors that might be influencing how they can access care or influencing the clinical and social risks that they have. So for most people, the time after they've had a baby results in some social change.

Even in the most straightforward, most brilliantly supported, most physically well person, there are big social changes. And that is a period of a complex time to navigate and finding your way and your identity as a family with a new baby and so on.

When we talk about complex social needs, we're talking about women who face other aspects of adversity.

So it might be that they have housing instability, it might be that they have experienced domestic abuse or they continue to experience domestic abuse, that they have a history of safeguarding issues, safeguarding for themselves or safeguarding concern, concerns about other children or other family members.

And when we see women who have overlapping social risk factors that produces this kind of network of complexity that puts them at compounded additional risk and they need additional help in navigating their health needs in that time.

Speaker A
00:02:21.450 - 00:02:47.310
And I wonder why you felt that this was an important issue to highlight right now. So is there anything in particular that makes you think that this is the right time to sort of look into this?

I know that there's a complex picture in terms of sort of maternal care, and if we look at things like the cost of living crisis, which is compounding a lot of the pressures that people are facing. But talk me through what your impetus was in thinking about this as a now issue.

Speaker B
00:02:48.110 - 00:05:26.470
Yeah, that's right.

So maternity services are really high profile in the news a lot at the moment, but from a secondary care perspective, and quite rightly, there's a spotlight on the poor care that some women and their families and their babies receive from secondary care. And there are, you know, huge pieces of work being done to improve that, to improve outcomes and to improve people's experiences.

But that focus tends to be on intrapartum care.

So the care that people receive in hospital around the time of birth, sometimes there's a little bit of focus on antenatal care as well and reducing risk during pregnancy, there's a lot less focus on what looks like the less exciting time of preconception care and then postnatal care. So after women get discharged from maternity services, we know that they're often left feeling a little bit isolated in the healthcare context.

Some qualitative research that we've done in the past, looking at women's experiences of postnatal care, women told us that they were surprised about they'd had so many appointments during pregnancy and then so much healthcare retention in the first few days after birth, and then they were just surprised. No, you know, they had a baby and no one was really interested in their health anymore. And that genuinely came as a surprise to them.

We know that maternal mortality in the uk, which, thankfully, in absolute numbers, is. Is quite small, but it's certainly higher than it could be and maybe should be, particularly compared to other kind of similar European countries.

And there are actually more maternal deaths postnatally, so in the sort of later postnatal period, six weeks to a year after birth, than there are in that sort of antenatal, intrapartum and early postnatal period. And all of the political drive tends to be about reducing maternal mortality in its traditional definition of being up to six weeks after birth.

But as GPs, where we can really have an impact is in those late maternal deaths.

And of course, very few of us, thankfully, will be involved in the care of a woman who dies in that period, because they are small in absolute numbers. But there are all the women who do not die, but have those risk factors and have that complexity.

And the longer they live with those sort of adverse health conditions and adverse social conditions, that is dramatically reducing their quality life course health. And we can really step in, in that postnatal period to look at how we can influence that.

Speaker A
00:05:26.870 - 00:05:49.080
Yeah, and you've mentioned about the kind of care that women get in during their pregnancy. And sometimes, I'm sure for some women, the postnatal period can feel already pretty fragmented for those reasons.

But how do you think that that fragmentation can become amplified for women with complex social needs? Do you have any thoughts about that?

Speaker B
00:05:50.280 - 00:08:25.320
Absolutely. So a Lot of people will know how to contact their gp, right?

I think if you ask people, most people have probably got that number saved in their phone or they know where their GP practice is.

But after you have a baby, women are then given all these kind of new healthcare professionals who are interested and involved and it's impossible to know how that all fits together.

So the midwife will typically follow women up for that kind of, you know, 10 to 14 days postnatally, usually just at the time the midwife is giving you the final sign off appointment. Within a day or two, you have an appointment with the health visitor, which again is somebody new, and then you might have a follow up.

For example, if a woman's had a third degree tear or is having some additional hospital follow up because of hypertension or gestational diabetes, then the hospital are involved and then they come back to the GP.

And I often feel like, for us as GPs, women, as soon as they're pregnant, they can generally self refer to the midwife and they get kind of lifted out of the primary care system to an extent.

We might not see them through their whole pregnancy, then they have a baby, we might or might not get a discharge summary that gives us some details about the birth and then we invite them for their postnatal consultation and in that time, you know, they've had an entire pregnancy, a huge life changing event, and then we get to see them for this one appointment. And it's so complicated.

Often for women who are not sure where they're going to get their next meal from, how can they be giving any kind of cognitive time to figuring out if the midwife told the health visitor and if the health visitor told the GP and if they're worried that their bleeding's gone on for a bit too long, do they try and phone the woman who came on Thursday or the woman who came on Monday, or do they come back to their gp?

We're asking a lot and we also place a lot of burden on women to retell their story because information transfer is not always timely, it's not always sufficiently detailed.

And again, for women who are living in more precarious social situations, that burden then of having to, you know, they're juggling and the, you know, the mental load of everything they're trying to figure out. And then we're asking them, can you remember if your blood pressure was high during your pregnancy?

Whereas we should know that we should have that information from those other services. So that fragmentation in services really means that the burden is unduly placed on women to kind of patch that up.

And we need to find a better way of dealing with that.

Speaker A
00:08:25.640 - 00:08:38.260
One of the things I think that comes through really strongly is that some of the women with the greatest needs often face the biggest barriers, care. And what kind of barriers are we talking about here that these women are facing?

Speaker B
00:08:38.980 - 00:10:06.270
The Embrace report, which is well, well worth a look at at least their infographics, I think for every gp, it's just a...

Today, we’re speaking to Dr Eliza Hutchinson, a dermatology registrar and academic clinical fellow based at the Centre for Applied Excellence in Skin and Allergy Research at the University of Bristol.
Title of paper: Eczema, acne, and psoriasis in people with skin of colour: a qualitative UK-based study
Available at: https://doi.org/10.3399/BJGP.2025.0720
This study is the first, to the authors’ knowledge, to explore the experiences of living with an inflammatory dermatosis specifically in people with skin of colour. We generated eight themes important to participants: delayed or missed diagnosis; preferences regarding healthcare professionals; lack of online information and social media use; misunderstandings in cultural communities; concerns about treatment and lack of research; complementary medicine use; experiences and impact of dyspigmentation; and challenges with structural racism. These findings offer insight into the complex experiences and challenges faced by UK adults with skin of colour living with eczema, acne, and psoriasis. Our practical points for primary care clinicians are a step towards facilitating mutual understanding and improving care for people with skin of colour.

Transcript
This transcript was generated using AI and has not been reviewed for accuracy. Please be aware it may contain errors or omissions.

Speaker A
00:00:00.560 - 00:00:53.150
Hi and welcome to BJGP Interviews. I'm Nada Khan and I'm one of the Associate editors of the BJGP. In today's episode, we're speaking to Dr. Eliza Hutchinson.

Eliza is a dermatology registrar and an academic clinical fellow and she's based at the Centre for Applied Excellence in Skin and Skin Allergy Research at the University of Bristol. We're here to talk about the paper she's just published in the bjgp and the paper is titled Eczema Acne and Psoriasis in People with Skin of Color.

A Qualitative UK based Study. So, Eliza, it's lovely to meet you and thanks again for joining us to talk about this paper.

But before we talk about the paper itself, I'm just wondering what made you specifically interested in researching skin conditions in skin of color?

Speaker B
00:00:53.550 - 00:01:34.700
Yeah, thank you so much for having me.

So I think people with skin of color have been and still are massively underrepresented in kind of medical curricula, learning resources, clinical trials. And I certainly remember when I was at medical school, I don't think I had any teaching on diverse skin tones at all.

And so it was as I sort of learned more dermatology, I just became very aware that they are so underrepresented. And I think earlier work in this area, I really tried to improve education for medical students and healthcare professionals around skin of color.

That was kind of my starting point.

And then I realised actually there's very little, if anything actually on the experiences of people with skin of colour, which is kind of what led me to this project.

Speaker A
00:01:35.820 - 00:01:38.380
And you work in dermatology, is that right?

Speaker B
00:01:38.460 - 00:01:42.300
Yes, yes, I'm a dermatology registrar based in the Bristol Bath area.

Speaker A
00:01:42.540 - 00:02:06.890
Great. So it's wonderful to have your expertise in this especially.

And we may get into this sort of about sort of your perspective from secondary care as well, looking back into general practice as well. But this paper focuses on eczema, acne and psoriasis and these are conditions that we see a lot as gps.

So why did you feel that this was an important area to look at for people with skin of colour?

Speaker B
00:02:07.290 - 00:02:41.470
Yes, I mean, as you said, we know that skin conditions are super common.

They make up over 14% of GP consultations and eczema, acne and psoriasis are some of the most common inflammatory skin conditions we see and we know that they have a significant burden on everyone that experiences them.

But I think particularly in people with skin of colour, we already know that these people experience kind of increasing things like Dispigmentation, so skin tone getting lighter or darker from their skin condition. And yeah, I think I just wanted to focus on some of the more common conditions that are seen kind of day to day in primary care.

Speaker A
00:02:42.110 - 00:02:54.890
And this was a qualitative study and you emphasized that you really wanted to understand the experiences of people here. So talk us through a bit what you did. You spoke to people who had these conditions and had skin of colour?

Speaker B
00:02:55.050 - 00:03:26.060
Yes. So we recruited using online methods for a couple of reasons, but really wanted to get kind of diverse range of experiences from across the uk.

So we started off with an online survey and that was open to people of all skin tones. And we have written this up as a separate paper which should be out hopefully in the next few months.

But based on these responses, we then kind of purposefully recruited people with skin of color to take part in an online one to one interview. And so we spoke to 20 different people with skin of colour as part of this.

Speaker A
00:03:26.460 - 00:03:40.300
And I think one of the really interesting things that came out and is running as a strong theme through the paper is that skin conditions can present really differently in skin of colour. Can you explain a bit about what that means in practice as well?

Speaker B
00:03:40.700 - 00:04:49.210
Yeah. So we know that skin conditions can look and behave very differently in people with skin of colour compared to white skin.

So for example, eczema is typically in a kind of flexural distribution in people with white skin, so like in the elbow creases behind the knees.

But in people with skin of colour it might be more likely to be on the extensor surfaces, it might be in a sort of discoid type pattern, so kind of well defined round patches or sort of a follicular pattern is another one we see. So if you look at medical textbooks and what we're taught at medical school, we just don't see pictures of these presentations.

And I think another big thing is obviously redness is much less obvious in skin of colour. So that's typically what we would associate with skin inflammation is redness and it is much less obvious.

And instead in darker skin tones it might look kind of purpley. Brownie might not be as obvious. And certainly in the interviews we found that patients were aware of this as well.

So they were looking at their own skin and not picking up that it was kind of actively inflamed. They didn't know what it was and they'd go and see a GP or another healthcare professional in primary care and they also wouldn't know.

And then it's just kind of leading to Delayed diagnosis, misdiagnoses.

Speaker A
00:04:50.140 - 00:05:16.780
Yeah, And I think that's certainly something. So the people you spoke to described these delays in diagnosis and also this uncertainty from clinicians.

And I do wonder if that is reflected in what we learn and what the wider public understand is what inflammation might look like as well. So I wonder what really stood out to you from these experiences.

So how did people and clinicians sort of navigate those delays and uncertainty as well?

Speaker B
00:05:17.320 - 00:05:44.760
What was quite shocking was in terms of the misdiagnosis a lot of the time, infection and infestation.

So, for example, scabies was a big one that people were misdiagnosed with, and that in some circumstances did lead to kind of stigmatisation, psychological distress, embarrassment, and then people were more afraid to seek help. Further delays in diagnosis. Yeah, I think that was the thing that struck me the most in terms of this problem.

Speaker A
00:05:45.240 - 00:06:00.040
And you've mentioned this, you talked about dyspigmentation, and that came through as well very strongly in the interviews. And I think that's probably a problem that's specific to skin of color as well.

And can you talk through why that came up as such an important issue for patients in this study?

Speaker B
00:06:00.760 - 00:06:46.890
Yeah, of course. So I think we already know that dyspigmentation.

So skin tone usually getting darker, but sometimes lighter as a result of skin inflammation, we know that it is more common in darker skin tones just because they've got more melanin there to start with. But the thing that struck me in these interviews was just the profound impact that this can have on patients.

So embarrassment, isolation, body dysmorphia. There's a lot of misunderstanding as well, kind of within certain communities about what causes it.

And some people experience negative comments from within their own community, from friends and family, which really exacerbated that kind of psychosocial impact even more. And obviously, skin tone is massively tied into kind of identity, and the impact on people's wellbeing was just. Yeah, it was huge.

Speaker A
00:06:47.690 - 00:06:58.490
And coming from a general practice perspective, it sometimes feels like the treatment options for dyspigmentation are really...