Randomized controlled trial of molnupiravir SARS-CoV-2 viral and antibody response in at-risk adult outpatients.

Viral clearance, antibody response and the mutagenic effect of molnupiravir has not been elucidated in at-risk populations. Non-hospitalised participants within 5 days of SARS-CoV-2 symptoms randomised to receive molnupiravir (n = 253) or Usual Care (n = 324) were recruited to study viral and antibody dynamics and the effect of molnupiravir on viral whole genome sequence from 1437 viral genomes. Molnupiravir accelerates viral load decline, but virus is detectable by Day 5 in most cases. At Day 14 (9 days post-treatment), molnupiravir is associated with significantly higher viral persistence and significantly lower anti-SARS-CoV-2 spike antibody titres compared to Usual Care. Serial sequencing reveals increased mutagenesis with molnupiravir treatment. Persistence of detectable viral RNA at Day 14 in the molnupiravir group is associated with higher transition mutations following treatment cessation. Viral viability at Day 14 is similar in both groups with post-molnupiravir treated samples cultured up to 9 days post cessation of treatment. The current 5-day molnupiravir course is too short. Longer courses should be tested to reduce the risk of potentially transmissible molnupiravir-mutated variants being generated. Trial registration: ISRCTN30448031.

The relationship between general practitioner movement behaviours with burnout and fatigue.

BACKGROUND: Physical inactivity is associated with feelings of burnout and fatigue, which in turn are associated with reduced performance among healthcare practitioners. This study explored movement behaviours of general practitioners (GPs) and the association between these behaviours with burnout and fatigue. METHODS: GPs in Northern Ireland were asked to wear a thigh-worn accelerometer for seven days and complete validated questionnaires to assess the association between daily number of steps, time spent sitting and standing with feelings of burnout and fatigue. RESULTS: Valid accelerometer data were obtained from 47 (77.0%) participants. Average workday sitting time, standing time and number of steps were 10.6 h (SD 1.5), 3.8 h (SD 1.3), and 7796 steps (SD 3116) respectively. Participants were less sedentary (8.0 h (SD 1.6)) and more active (4.7 h (SD 1.4) standing time and 12,408 steps (SD 4496)) on non-workdays. Fourteen (30.4%) participants reported burnout and sixteen (34.8%) reported severe fatigue. There were no significant associations between sitting, standing and step counts with burnout or fatigue (p > 0.05). CONCLUSION: GPs were less active on workdays compared to non-workdays and exhibited high levels of sitting. Feelings of burnout and fatigue were highly prevalent, however movement behaviours were not found to be associated with burnout and fatigue. Given the increased sedentariness among GPs on workdays compared to non-workdays, GPs should consider how they can improve their movement behaviours on workdays to help optimise their wellbeing.

Explaining a diagnosis of fibromyalgia in primary care: a scoping review.

BACKGROUND: Fibromyalgia is a common cause of chronic pain in the UK, with a huge individual and societal impact. Despite this, it remains difficult to diagnose and treat. The explanation of a fibromyalgia diagnosis can lead to difficult therapeutic relationships, with attitudinal issues and negative profiling of patients. This can lead to frustration, and have a harmful impact on health outcomes. AIM: To review how an explanation of a fibromyalgia diagnosis is provided in primary care in order to establish a model of best practice when educating patients on their diagnosis. DESIGN & SETTING: Scoping review of articles written in English. METHOD: MEDLINE, Embase, Web of Science, and grey literature were searched. Articles were extracted, reviewed, and analysed according to the inclusion criteria. RESULTS: In total, 29 records met the inclusion criteria. The following six overarching themes were identified: patient education; physician education; importance of the multidisciplinary team; importance of patient-centred care; the value of primary care; and useful resources. The literature illustrated that describing fibromyalgia using analogies to illustrate the pain sensitisation process can help patients understand their diagnosis better. This improves their willingness to accept management plans, particularly engagement with non-pharmacological therapies, which the literature suggested are best delivered within a multidisciplinary team. CONCLUSION: Key aspects of fibromyalgia should be explained to patients in order for them to gain a better understanding of their diagnosis. A 'one-size-fits-all' model for explaining the fibromyalgia diagnosis to patients is inappropriate because patients' experiences are individualised. Further research is required on whether different explanations impact patient outcomes.

Towards accountability-centred practices: governance in OSCEs subordinating patient and practitioner clinical experience.

New public management ideals and standards have become increasingly adhered to in health professions education; this is particularly apparent in high-stakes assessment, as a gateway to practice. Using an Institutional Ethnographic approach, we looked at the work involved in running high-stakes Objective Structured Clinical Exams (OSCEs) throughout an academic year including use of observations, interviews and textual analysis. In our results, we describe three types of 'work'-standardising work, defensibility work and accountability work-summarising these in the discussion as an Accountability Circuit, which shows the organising role of texts on people's work processes. We show how this form of governance mandates a shift towards accountability-centred practices, away from practices which are person-centred; this lens on accountability-centring during high-stakes assessments invites critique of the often-unquestioned emphasis of new public management in health professions education.

Are GP training opportunities in Northern Ireland widening or closing the gap on health inequalities? An analysis of Northern Ireland deprivation data.

BACKGROUND: Increasing the GP workforce will not necessarily level up healthcare provision. Instead, increasing GP training numbers could worsen health inequity and inequalities. This is especially true if there are fewer opportunities to learn, train, and build confidence in underserved, socioeconomically deprived areas. AIM: To investigate the representation of socioeconomic deprivation in postgraduate GP training practices in Northern Ireland (NI). DESIGN & SETTING: An analysis of socioeconomic deprivation indices and scores of GP practices in NI involved in postgraudate GP training. METHOD: The socioeconomic deprivation indices and scores of GP postgraduate training practices were compared against general practice in NI by examining the representation of practices whose patients live in areas of blanket deprivation, higher deprivation, and higher affluence. RESULTS: Of 319 practices in NI, 195 (61%) were registered as postgraduate training practices and had a statistically significantly lower deprivation score (3.02±0.21) compared with non-training practices (3.2±0.32), t(255) -2.02, P = 0.041. The proportion of training practices with blanket deprivation and higher levels of deprivation was underrepresented, with the current postgraduate GP training practices having more affluent populations. CONCLUSION: Postgraduate training practices had a statistically significant lower deprivation score and did not fully reflect the socioeconomic make-up of wider NI general practice. The results, however, are more favourable than in other areas of the UK and better than undergraduate teaching opportunities in general practice. Health inequalities will worsen if the representation of general practice training in areas of greater socioeconomic deprivation is not increased.

Essential workers? An institutional ethnographic lens on pandemic GP placements.

BACKGROUND: Clinical placements for medical students in the United Kingdom (UK) came to an abrupt halt in March 2020. The rapidly evolving Covid19 pandemic created specific challenges for educators, balancing safety concerns for patients, students and healthcare staff alongside the imperative to continue to train future clinicians. Organisations such as the Medical Schools Council (MSC) published guidance to help plan return of students to clinical placements. This study aimed to examine how GP education leads made decisions around students returning to clinical placements for the 20/21 academic year. METHOD: Data collection and analysis was informed by an Institutional Ethnographic approach. Five GP education leads from medical schools throughout the UK were interviewed (over MS TEAMS™). Interviews focused on the work the participants did to plan students' return to clinical placements and how they used texts to inform this work. Analysis focused on the interplay between the interview and textual data. RESULTS AND DISCUSSION: GP education leads actively used MSC guidance which confirmed students to be 'essential workers', an unquestioned and unquestionable phrase at the time. This permitted students to return to clinical placements by affording the GP education leads authority to ask or persuade GP tutors to accept them. Furthermore, by describing teaching as 'essential work' in its own right in the guidance, this extended what the GP tutors came to expect to do as 'essential workers' themselves. CONCLUSION: GP education leads activated authoritarian phrases such as 'essential workers' and 'essential work' contained within MSC guidance to direct students' return to clinical placements in GP settings.

(L)earning: Exploring the value of paid roles for medical students.

BACKGROUND: The Medical Student Technician (MST) role is a paid position established in Northern Ireland in 2020. The Experience-Based Learning (ExBL) model is a contemporary medical education pedagogy advocating supported participation to develop capabilities important for doctors-to-be. In this study, we used the ExBL model to explore the experiences of MSTs and how the role contributed to students' professional development and preparedness for practice. METHODS: A convenience sampling strategy was used to recruit a total of 17 MSTs in three focus groups. Semi-structured interviews were transcribed verbatim and analysed using the ExBL model as a framework. Transcripts were independently analysed and coded by two investigators and discrepancies resolved with the remaining investigators. RESULTS: The MST experiences reflected the various components of the ExBL model. Students valued earning a salary; however, what students earned transcended the financial reward alone. This professional role enabled students to meaningfully contribute to patient care and have authentic interactions with patients and staff. This fostered a sense of feeling valued and increased self-efficacy amongst MSTs, helping them acquire various practical, intellectual and affective capabilities and subsequently demonstrate an increased confidence in their identities as future doctors. CONCLUSION: Paid clinical roles for medical students could present useful adjuncts to traditional clinical placements, benefiting both students and potentially healthcare systems. The practice-based learning experiences described appear to be underpinned by a novel social context where students can add value, be and feel valued and gain valuable capabilities that better prepare them for starting work as a doctor.

Molnupiravir plus usual care versus usual care alone as early treatment for adults with COVID-19 at increased risk of adverse outcomes (PANORAMIC): an open-label, platform-adaptive randomised controlled trial.

BACKGROUND: The safety, effectiveness, and cost-effectiveness of molnupiravir, an oral antiviral medication for SARS-CoV-2, has not been established in vaccinated patients in the community at increased risk of morbidity and mortality from COVID-19. We aimed to establish whether the addition of molnupiravir to usual care reduced hospital admissions and deaths associated with COVID-19 in this population. METHODS: PANORAMIC was a UK-based, national, multicentre, open-label, multigroup, prospective, platform adaptive randomised controlled trial. Eligible participants were aged 50 years or older-or aged 18 years or older with relevant comorbidities-and had been unwell with confirmed COVID-19 for 5 days or fewer in the community. Participants were randomly assigned (1:1) to receive 800 mg molnupiravir twice daily for 5 days plus usual care or usual care only. A secure, web-based system (Spinnaker) was used for randomisation, which was stratified by age (<50 years vs ≥50 years) and vaccination status (yes vs no). COVID-19 outcomes were tracked via a self-completed online daily diary for 28 days after randomisation. The primary outcome was all-cause hospitalisation or death within 28 days of randomisation, which was analysed using Bayesian models in all eligible participants who were randomly assigned. This trial is registered with ISRCTN, number 30448031. FINDINGS: Between Dec 8, 2021, and April 27, 2022, 26 411 participants were randomly assigned, 12 821 to molnupiravir plus usual care, 12 962 to usual care alone, and 628 to other treatment groups (which will be reported separately). 12 529 participants from the molnupiravir plus usual care group, and 12 525 from the usual care group were included in the primary analysis population. The mean age of the population was 56·6 years (SD 12·6), and 24 290 (94%) of 25 708 participants had had at least three doses of a SARS-CoV-2 vaccine. Hospitalisations or deaths were recorded in 105 (1%) of 12 529 participants in the molnupiravir plus usual care group versus 98 (1%) of 12 525 in the usual care group (adjusted odds ratio 1·06 [95% Bayesian credible interval 0·81-1·41]; probability of superiority 0·33). There was no evidence of treatment interaction between subgroups. Serious adverse events were recorded for 50 (0·4%) of 12 774 participants in the molnupiravir plus usual care group and for 45 (0·3%) of 12 934 in the usual care group. None of these events were judged to be related to molnupiravir. INTERPRETATION: Molnupiravir did not reduce the frequency of COVID-19-associated hospitalisations or death among high-risk vaccinated adults in the community. FUNDING: UK National Institute for Health and Care Research.

Revised paper ASIM-D-21-00055R1: "Consulting properly rather than acting": advocating for real patient involvement in summative OSCEs.

BACKGROUND: In this "Advancing simulation practice" article, we offer an expose of the involvement of real patients in Objective Structured Clinical Examinations (OSCEs), inviting educators who traditionally involve solely SPs in their summative OSCEs to consider the practice. The need for standardisation in summative assessments can make educators understandably wary to try this, even if the rhetoric to involve real patients is accepted. We offer this as an instance of the tussle between standardisation and validity experienced throughout health professions education. MAIN TEXT: We offer our experience and empirical evidence of this simulation practice, based on an institutional ethnographic examination of the involvement of real patients in summative OSCEs from an undergraduate medical school in the UK. Our critique demonstrates the merits of this approach as an assessment environment closer to the real clinical environments where these soon-to-be doctors interact in a more authentic way with real patients and their illness experiences. We balance this against the extra work required for all involved and suggest the biggest challenge is in the reorientation work required for both Faculty and students who are institutionalised to expect standardisation above all in assessment. CONCLUSION: We advocate for involving real patients in summative OSCEs and hope that readers may feel compelled and empowered to foster this shift in mindset required to introduce this practice into their assessments.

Establishing a Deep End GP group: a scoping review.

BACKGROUND: GPs working in deprived areas, where all-cause mortality rates are higher compared to less deprived areas, face unique challenges. Despite 50 years passing since Tudor Hart's seminal 'inverse care law' paper, the health inequities gap remains wide. Deep End GP groups are frontline GP-led initiatives working to close this gap and improve the health and lives of those most in need. AIM: To use scoping methodology to map out the process of creating a Deep End GP group. DESIGN & SETTING: A scoping review using Arksey and O'Malley's framework. METHOD: MEDLINE, Embase, Web of Science, and CINAHL databases, as well as non-peer reviewed publications, were searched and articles extracted, reviewed, and analysed according to iterative inclusion criteria. RESULTS: From an initial search number of 35 articles, 16 articles were included in the final analysis. Key steps in starting a Deep End GP group were: quantifying patients and practices in areas of deprivation; establishing GP-led objectives at an initial meeting; regular steering group meetings with close collaboration between academic and frontline general practice, as well as the wider multidisciplinary team; and adopting a local Deep End logo. CONCLUSION: Deep End GP groups have made advances to reduce health impacts of systemic health inequities. Starting a Deep End GP group involves a multidisciplinary approach, beginning with the identification of patients and practices in areas of highest need. The findings and key themes identified in this scoping review will guide interested parties to start the journey to do the same in their locality and to join the Deep End movement.

Dermoscopy use in primary care: a qualitative study with general practitioners.

BACKGROUND: Skin assessments constitute a significant proportion of consultations with family physicians (commonly called general practitioners or GPs in the UK), and referrals to hospital dermatology departments have risen significantly in recent years. Research has shown that dermoscopy use may help GPs to assess and triage skin lesions, including suspected skin cancers, more accurately. However, dermoscopy is used by a small minority of GPs in the UK. Previous questionnaire studies have aimed to establish in a limited way some perceptions of dermoscopy among GPs: this study aimed to explore more deeply the factors influencing the use of dermoscopy among GPs. METHODS: This was a qualitative interview study set in UK general practice. A purposive sample was taken of GPs who were established dermoscopy users, GPs who had recently adopted dermoscopy, and those who did not use dermoscopy. A total of twelve semi-structured interviews were conducted. Audio-recordings were transcribed verbatim and analysed using a thematic analysis (Braun and Clarke). RESULTS: GPs' capability to use dermoscopy necessitated receiving adequate training, while previous dermatology experience and support from colleagues were also considered factors that enabled dermoscopy use. The impact of dermoscopy on patient consultations about skin complaints was generally considered to be positive, as was having an 'in-house' dermoscopy user within a GP practice to refer patients to. However, training in dermoscopy was not considered a priority for many GPs either due to other more pressing concerns within their practices or the perceived complexity of dermoscopy, alongside barriers such as equipment costs. Significant ethical concerns with posting patient photographs online for training and teaching purposes were also highlighted. CONCLUSIONS: Both GPs who use dermoscopy, and those who do not, consider it to have an important role in improving skin assessments within primary care. However the need for adequate training in dermoscopy and dermatology more generally was highlighted as a key barrier to its wider use. The development of competency standards for the use of dermoscopy could allow the adequacy of training to be assessed and developed.

GPs' perspectives regarding their sedentary behaviour and physical activity: a qualitative interview study.

BACKGROUND: General practice is a highly sedentary occupation, with many GPs spending more than 10.5 hours sitting each workday. This excessive sedentary behaviour and lack of physical activity (PA) is potentially detrimental to the health of GPs, as well as their ability to counsel patients regarding sedentary behaviour and PA. There is a lack of prior research examining the perspectives of GPs regarding their sedentary behaviour and PA. AIM: To explore GPs' perspectives regarding their sedentary behaviour and PA. DESIGN & SETTING: A qualitative interview study of GPs in Northern Ireland. METHOD: Semi-structured interviews were conducted with a purposive sample of 13 GPs who had previously taken part in a study to objectively measure their levels of sedentary behaviour and PA. Interview transcripts were analysed using deductive thematic analysis. The Theoretical Domains Framework (TDF) was used to facilitate identification of barriers and enablers affecting the ability of GPs to increase their PA. RESULTS: Key themes were categorised within six theoretical domains (environmental context and resources, social professional role and identity, goals, social influences, knowledge, and intentions) with sub-themes within each domain. CONCLUSION: Most GPs are unhappy with their current levels of sedentary behaviour and PA, and are concerned with how this is affecting their health. Numerous barriers and facilitators were identified affecting the ability of GPs to increase their PA, including working environment, and personal and professional responsibilities, among others. Addressing these could improve the health of GPs and their ability to counsel patients regarding sedentary behaviour and PA.

Exploration of sedentary behaviour among GPs: a cross-sectional study.

BACKGROUND: Sedentary behaviour, which may have increased among GPs due to increasing use of telemedicine, is associated with many illnesses and increased all-cause mortality. AIM: To explore levels of sedentary behaviour among GPs and General Practice Specialty Trainees (GPSTs). DESIGN & SETTING: Sequential, cross-sectional design (initial online sedentary behaviour questionnaire and subsequent thigh-worn accelerometer substudy) of GPs and GPSTs in Northern Ireland. METHOD: Self-reported questionnaire data were aggregated and compared with device-measured accelerometry data. RESULTS: Data from 353 participants (17.7% of GPs and GPSTs in Northern Ireland) revealed doctors in general practice self-reported higher workday sedentary time (10.33 hours, SD 2.97) than those in secondary care (7.9 hours, SD 3.43 [mean difference {MD} 2.43 hours; P<0.001]). An active workstation (for example, sit-stand desk), was used by 5.6% of participants in general practice, while 86.0% of those without one would consider using one in future. Active workstation users self-reported lower workday sedentary time (7.88 hours, SD 3.2) than non-users (10.47 hours, SD 2.88 [MD -2.58 hours, P = 0.001]). Accelerometer substudy participants underestimated their workday sedentary time by 0.17 hours (95% confidence interval [CI] = -1.86 to 2.20; P = 0.865), and non-workday sedentary time by 2.67 hours (95% CI = 0.99 to 4.35; P = 0.003). Most GPs (80.7%) reported increased workday sitting time compared to prior to the COVID-19 pandemic, while 87.0% would prefer less workday sitting time. CONCLUSION: GPs have high levels of workday sedentary time, which may be detrimental to their health. It is imperative to develop methods to address sedentary behaviour among GPs on workdays, both for their own health and the health of their patients.

Injury Reduction Programs for Reducing the Incidence of Sport-Related Head and Neck Injuries Including Concussion: A Systematic Review.

BACKGROUND: Sport-related head and neck injuries, including concussion, are a growing global public health concern with a need to explore injury risk reduction strategies such as neck exercises. OBJECTIVES: To systematically review the literature to investigate: (1) the relationship between neck strength and sport-related head and neck injuries (including sport-related concussion (SRC); and (2) whether neck exercise programs can reduce the incidence of (a) sport-related head and neck injuries; and (b) SRC. METHODS: Five databases (Ovid MEDLINE, CINAHL, EMBASE, SPORTDiscus, and Web of Science) and research lists of included studies were searched using a combination of medical subject headings and keywords to locate original studies which reported the association between incidence of head and/or neck injury and neck strength data, or included a neck exercise intervention either in isolation or as part of a more comprehensive exercise program. RESULTS: From an initial search of 593 studies, six were included in this review. A narrative synthesis was performed due to the heterogeneity of the included studies. The results of two observational studies reported that higher neck strength, but not deep neck flexor endurance, is associated with a lower risk of sustaining a SRC. Four intervention studies demonstrated that injury reduction programs that included neck exercises can reduce the incidence of sport-related head and neck injuries including SRC. CONCLUSION: Consideration should be given towards incorporating neck exercises into injury reduction exercise programs to reduce the incidence of sport-related head and neck injuries, including SRC. SYSTEMATIC REVIEW REGISTRATION: PROSPERO (registration number: 194217).

Sedentary behaviour among general practitioners: a systematic review.

BACKGROUND: Sedentary behaviour is when someone is awake, in a sitting, lying or reclining posture and is an independent risk factor for multiple causes of morbidity and mortality. A dose-response relationship has been demonstrated, whereby increasing sedentary time corresponds with increasing mortality rate. This study aimed to identify current levels of sedentary behaviour among General Practitioners (GPs), by examining and synthesising how sedentary behaviour has been measured in the primary care literature. METHODS: A systematic review was conducted to identify studies relating to levels of sedentary behaviour among GPs. Searches were performed using Medline®, Embase®, PscycINFO, Web of Science and the Cochrane Library, from inception of databases until January 2020, with a subsequent search of grey literature. Articles were assessed for quality and bias, with extraction of relevant data. RESULTS: The search criteria returned 1707 studies. Thirty four full texts were reviewed and 2 studies included in the final review. Both were cross-sectional surveys using self-reported estimation of sedentary time within the International Physical Activity Questionnaire (IPAQ). Keohane et al. examined GP trainees and GP trainers in Ireland. 60% reported spending in excess of 7 h sitting each day, 24% between 4 and 7 h, and 16% less than or equal to 4 h. Suija et al. examined female GPs in Estonia. The mean reported daily sitting time was 6 h and 36 min, with 56% sitting for over 6 h per day. Both studies were of satisfactory methodological quality but had a high risk of bias. CONCLUSION: There is a paucity of research examining current levels of sedentary behaviour among GPs. Objective data is needed to determine GPs' current levels of sedentary behaviour, particularly in light of the increase in remote consulting as a result of the COVID-19 pandemic.

Honoring Medicine's Social Contract: A Scoping Review of Critical Consciousness in Medical Education.

PURPOSE: To explore how the construct of critical consciousness has been conceptualized within the medical education literature and identify the main elements of critical consciousness in medical education so as to inform educational strategies to foster socially conscious physicians. METHOD: In March 2019, the authors conducted a literature search of 4 databases and Google Scholar, seeking articles discussing critical consciousness in medical education published any time after 1970. Three of the authors screened articles for eligibility. Two transcribed data using a data extraction form and identified preliminary emerging themes, which were then discussed by the whole research team to ensure agreement. RESULTS: Of the initial 317 articles identified, 20 met study inclusion criteria. The publication of academic articles around critical consciousness in medical education has expanded substantially since 2017. Critical consciousness has been conceptualized in the medical education literature through 4 overlapping themes: (1) social awareness, (2) cultural awareness, (3) political awareness, and (4) awareness of educational dynamics. CONCLUSIONS: Critical consciousness has been conceptualized in medical education as an intellectual construct to foster a reflexive awareness of professional power in health care, to unearth the values and biases legitimizing medicine as currently practiced, and to foster transformation and social accountability. Scholars highlighted its potential to improve sociocultural responsibility and to foster compassion in doctors. Adopting a critical pedagogy approach in medical education can help uphold its social accountability through an intrinsic orientation to action, but any enterprise working toward embedding critical pedagogy within curricula must acknowledge and challenge the current structure and culture of medical education itself.

Training Primary Care Physicians in Dermoscopy for Skin Cancer Detection: a Scoping Review.

In many countries, patients with concerning skin lesions will first consult a primary care physician (PCP). Dermoscopy has an evidence base supporting its use in primary care for skin cancer detection, but need for training has been cited as a key barrier to its use. How PCPs train to use dermoscopy is unclear. A scoping literature review was carried out to examine what is known from the published literature about PCP training in dermoscopy. The methodological steps taken in this review followed those described by Arksey and O'Malley, as revised by Levac et al. Four electronic databases were searched for evidence published up to June 2018. Sixteen articles were identified for analysis, all published since 2000. Ten training programs were identified all of which addressed dermoscopy of pigmented skin lesions, among other topics. Ten articles reported on a range of outcomes measured after training and showed generally positive results in terms of improved diagnostic performance, although no meta-analysis was conducted. However, it was unclear whether trained PCPs continued to use dermoscopy after training. Observational questionnaire data revealed that many PCPs use dermoscopy in practice without any formal training. The literature generally supports the use of dermoscopy by PCPs, but it is unclear whether current training leads to long-term change in PCPs' use of dermoscopy in clinical practice. Understanding this problem, as well as exploring PCPs' training needs, is essential to develop training programs that will facilitate the uptake and use of dermoscopy in primary care.

Dermoscopy Use in Primary Care: A Scoping Review.

BACKGROUND: Patients in many countries with new or changing skin lesions will first consult a primary care physician, often called a general practitioner (GP). With the dramatic rise in melanoma incidence over recent decades, dermoscopy offers a tool with an evidence base supporting its use in skin lesion assessment. How GPs use dermoscopy is unclear. OBJECTIVES: A scoping literature review was carried out to examine the current state of published evidence about dermoscopy use in primary care. METHODS: The methodological steps taken in this review followed those developed by Arksey and O'Malley, as revised by Levac and colleagues. Four electronic databases were searched for evidence published up to January 2018 describing the use of dermoscopy in a generalist primary care setting. Seven articles were identified for analysis. RESULTS: All included articles have been published since 2007. Most were questionnaire studies and revealed that generally a small minority of GPs use dermoscopy, although some jurisdictions such as Australia report greater use. Dermoscopy is generally used only for the assessment of pigmented skin lesions, but is not used consistently. Several perceived barriers to dermoscopy use, including the need for training, have been reported. CONCLUSIONS: There is a paucity of data on dermoscopy use among GPs, and diversity in questionnaire items prevents comparison between jurisdictions. Perceived barriers to dermoscopy use require more in-depth exploration, potentially including qualitative data, to evaluate them more fully. Understanding these factors, including how GPs train in dermoscopy, will be crucial in widening dermoscopy use in primary care.

Why institutional ethnography? Why now? Institutional ethnography in health professions education.

This 'A Qualitative Space' article takes a critical look at Dorothy Smith's approach to inquiry known as institutional ethnography and its potentiality in contemporary health professions education research. We delve into institutional ethnography's philosophical underpinnings, setting out the ontological shift that the researcher needs to make within this critical feminist approach. We use examples of research into frontline healthcare, into the health work of patients and into education to allow the reader to consider what an institutional ethnography research project might offer. We lay out our vision for potential growth for institutional ethnography research within the health professions education field and explain why we see this as the opportune moment to adopt institutional ethnography to meet some of the challenges facing health professions education in a way that offers informed change.