Learning to navigate uncertainty in primary care: a scoping literature review.

BACKGROUND: Clinical practice occurs in the context of uncertainty. Primary care is a clinical environment that accepts and works with uncertainty differently from secondary care. Recent literature reviews have contributed to understanding how clinical uncertainty is taught in educational settings and navigated in secondary care, and, to a lesser extent, by experienced GPs. We do not know how medical students and doctors in training learn to navigate uncertainty in primary care. AIM: To explore what is known about primary care as an opportunity for learning to navigate uncertainty. DESIGN & SETTING: Scoping review of articles written in English. METHOD: Using a scoping review methodology, Embase, MEDLINE, and Web of Science databases were searched, with additional articles obtained through citation searching. Studies were included in this review if they: (a) were based within populations of medical students and/or doctors in training; and (b) considered clinical uncertainty or ambiguity in primary care or a simulated primary care setting. Study findings were analysed thematically. RESULTS: Thirty-six studies were included from which the following three major themes were developed: uncertainty contributes to professional identity formation (PIF); adaptive responses; and maladaptive behaviours. Relational and social factors that influence PIF were identified. Adaptive responses included adjusting epistemic expectations and shared decision making (SDM). CONCLUSION: Educators can play a key role in helping learners navigate uncertainty through socialisation, discussing primary care epistemology, recognising maladaptive behaviours, and fostering a culture of constructive responses to uncertainty.

Is there ever a single best answer (SBA): assessment driving certainty in the uncertain world of GP?

Uncertainty is inherent in all areas of medical practice, not least in primary care, which is defined by its acceptance of uncertainty and complexity. Single best answer (SBA) questions are a ubiquitous assessment tool in undergraduate medical assessments; however clinical practice, particularly in primary care, challenges the supposition that a single best answer exists for all clinical encounters and dilemmas. In this article, we seek to highlight several aspects of the relationship between this assessment format and clinical uncertainty by considering its influence on medical students' views of uncertainty in the contexts of their medical education, personal epistemology, and clinical expectations.

Roadmap for achieving net-zero emissions in global food systems by 2050.

Food systems (FSs) emit ~ 20 GtCO2e/y (~ 35% of global greenhouse gas emissions). This level tends to raise given the expected increases in food demands, which may threaten global climate targets. Through a rapid assessment, evaluating 60+ scenarios based on existing low-emission and carbon sequestration practices, we estimate that intensifying FSs could reduce its emissions from 21.4 to - 2.0 GtCO2e/y and address increasing food demands without relying on carbon offsets (e.g., related to afforestation and reforestation programs). However, given historical trends and regional contexts, a more diverse portfolio of practices, including diet shifts and new-horizon technologies, will be needed to increase the feasibility of achieving net-zero FSs. One likely pathway consists of implementing practices that shift food production to the 30th-percentile of least emission-intensive FSs (~ 45% emissions reduction), sequester carbon at 50% of its potential (~ 5 GtCO2e/y) and adopt diet shifts and new-horizon technologies (~ 6 GtCO2e/y). For a successful transition to happen, the global FSs would, in the next decade (2020s), need to implement cost-effective mitigation practices and technologies, supported by improvements in countries' governance and technical assistance, innovative financial mechanisms and research focused on making affordable technologies in the following two decades (2030-2050). This work provides options and a vision to guide global FSs to achieving net-zero by 2050.

A Scoping Review: Mapping the Evidence for Undergraduate Concussion Education and Proposing the Content for Medical Student Concussion Teaching.

INTRODUCTION: Concussion is a common yet complex condition, with each new case requiring assessment by a medical doctor. Recent research has shown that doctors working in the UK have significant knowledge deficits regarding concussion diagnosis and management. AIM: The aim of this scoping review was to map out the evidence about how undergraduate medical students are being educated about concussion. METHOD: This scoping review involved seven research papers identified by searching five online databases in October 2020. Search terms relevant to concussion included: brain injuries, post-concussion syndrome, brain concussion and concussion, combined with search criteria for undergraduate education: medical students, undergraduate medical education, or curriculum. RESULTS: All seven papers were published in North America, with five papers recruiting medical students from single institutions (n = 590) and two papers surveying universities. Canadian medical schools have shown an upward trend in the quantity of teaching about concussion-specific teaching: from 0.57 to 2.65 h between 2012 and 2018. Lectures were the commonest mode of delivery of teaching, followed by problem-based learning and clinical rotations. The studies reach a common conclusion that medical students are not being adequately prepared for diagnosing and managing concussion, with insufficient undergraduate teaching, particularly exposure during clinical rotations, cited as the cause. CONCLUSIONS: Concussion: education of medical students is inadequate in North America. Medical schools should help address this by providing lectures and clinical presentations on concussion to learn from, particularly via problem-based learning. There is a paucity of evidence about concussion education in other geographical areas.

Canopy bird assemblages are less influenced by habitat age and isolation than understory bird assemblages in Neotropical secondary forest.

Secondary forest habitats are increasingly recognized for their potential to conserve biodiversity in the tropics. However, the development of faunal assemblages in secondary forest systems varies according to habitat quality and species-specific traits. In this study, we predicted that the recovery of bird assemblages is dependent on secondary forest age and level of isolation, the forest stratum examined, and the species' traits of feeding guild and body mass. This study was undertaken in secondary forests in central Panama; spanning a chronosequence of 60-, 90-, and 120-year-old forests, and in neighboring old-growth forest. To give equal attention to all forest strata, we employed a novel method that paired simultaneous surveys in canopy and understory. This survey method provides a more nuanced picture than ground-based studies, which are biased toward understory assemblages. Bird reassembly varied according to both habitat age and isolation, although it was challenging to separate these effects, as the older sites were also more isolated than the younger sites. In combination, habitat age and isolation impacted understory birds more than canopy-dwelling birds. Proportions of dietary guilds did not vary with habitat age, but were significantly different between strata. Body mass distributions were similar across forest ages for small-bodied birds, but older forest supported more large-bodied birds, probably due to control of poaching at these sites. Canopy assemblages were characterized by higher species richness, and greater variation in both dietary breadth and body mass, relative to understory assemblages. The results highlight that secondary forests may offer critical refugia for many bird species, particularly specialist canopy-dwellers. However, understory bird species may be less able to adapt to novel and isolated habitats and should be the focus of conservation efforts encouraging bird colonization of secondary forests.

An attenuated phenotype of Costello syndrome in three unrelated individuals with a HRAS c.179G>A (p.Gly60Asp) mutation correlates with uncommon functional consequences.

Heterozygous germline mutations in the proto-oncogene HRAS cause Costello syndrome (CS), an intellectual disability condition with severe failure to thrive, cardiac abnormalities, predisposition to tumors, and neurologic abnormalities. More than 80% of patients share the HRAS mutation c.34G>A (p.Gly12Ser) associated with the typical, relatively homogeneous phenotype. Rarer mutations occurred in individuals with an attenuated phenotype and less characteristic facial features. Most pathogenic HRAS alterations affect hydrolytic HRAS activity resulting in constitutive activation. "Gain-of-function" and "hyperactivation" concerning downstream pathways are widely used to explain the molecular basis and dysregulation of the RAS-MAPK pathway is the biologic mechanism shared amongst rasopathies. Panel testing for rasopathies identified a novel HRAS mutation (c.179G>A; p.Gly60Asp) in three individuals with attenuated features of Costello syndrome. De novo paternal origin occurred in two, transmission from a heterozygous mother in the third. Individuals showed subtle facial features; curly hair and relative macrocephaly were seen in three; atrial tachycardia and learning difficulties in two, and pulmonic valve dysplasia and mildly thickened left ventricle in one. None had severe failure to thrive, intellectual disability or cancer, underscoring the need to consider HRAS mutations in individuals with an unspecific rasopathy phenotype. Functional studies revealed strongly increased HRAS(Gly60Asp) binding to RAF1, but not to other signaling effectors. Hyperactivation of the MAPK downstream signaling pathways was absent. Our results indicate that an increase in the proportion of activated RAS downstream signaling components does not entirely explain the molecular basis of CS. We conclude that the phenotypic variability in CS recapitulates variable qualities of molecular dysfunction.