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 limited as well in what we can offer patients. So that must come out as a frustration as well, I'm sure.

Speaker B

00:06:58.650 - 00:07:34.310

Yeah, I think people. People were very aware that it just wasn't talked about with healthcare professionals.

And, I mean, it is really difficult because we know there are limited treatment options. But actually, a lot of people just said that they wanted it to be acknowledged and discussed.

So just a simple explanation of, you know, this is because of the inflammation in your skin it should settle as we get your condition under control. It might take months or years to settle.

An important thing that gps can do is sun protection is really important, so UV light can kind of exacerbate the pigmentation further. So even just a brief discussion about that I think patients would find really helpful.

Speaker A

00:07:34.790 - 00:07:40.790

And coming out of all this, were there any specific findings that really surprised you from these interviews?

Speaker B

00:07:41.400 - 00:08:27.550

Some of the issues I was sort of. I was sort of expecting just from my own clinical practice.

So the issues around delayed diagnosis and kind of lack of representation online, those were things I'd already come across.

But I think the main thing was just the profound impact that factors outside of the clinic room can have on patients that I think, as clinicians, we don't ask about or aren't aware of. So a big one for me, I think, was just misunderstandings within cultural communities about sort of what causes the skin condition.

And as I said, this then leads to kind of stigma and isolation and psychological problems.

So I think just the misunderstandings, which can be, you know, just through some simple education and community initiatives, we could really tackle this and improve people's experiences.

Speaker A

00:08:27.950 - 00:08:54.490

And you've touched upon this.

But this paper highlights big gaps in dermatology education and how clinical images are portrayed in textbooks, for instance, that we might learn from.

And I wonder, from your own perspective, how much do you think, think that that underrepresentation in teaching materials contributes to this diagnostic uncertainty that people have around what eczema might look like in a patient?

Speaker B

00:08:55.130 - 00:09:50.080

Yeah, I think it's a really important factor and certainly through kind of previous work I've done, we know that people just still aren't getting exposed to these images. Things are changing, so curricula are being diversified and textbooks, but it is still a big problem.

And we know that this then translates into kind of lower clinician confidence when assessing people with skin of colour. There are increasing resources out there, I think. So.

You know, websites like skindeet, there's something called the Global Skin Atlas, which has kind of freely accessible images that clinicians can look at to find examples in darker skin tones, you know, patient information leaflets. But as some of the participants said in the. In the studies, it still often is just a sentence.

So, you know, in black and brown skin, it might look less obvious and then that's it. So I think there's still a lot more work to be done for both patients and clinicians.

Speaker A

00:09:50.480 - 00:10:02.560

Yeah, and I guess that leads me to get your perspective on what do you think that good dermatology education in skin of color should look like just from your background in dermatology and teaching as well?

Speaker B

00:10:02.960 - 00:10:39.060

Yeah, I think just more images, more examples and just like an open discussion about how it can look different. And this is what it might look like in darker skin tones compared to white skin. So you've got kind of the whole how do skin conditions present?

But then obviously we do need more research on treatments. We know that, you know, people with skin of color are underrepresented in clinical trials.

So, you know, how do we know that all of these new treatments work?

So I think it's, yeah, it's like a multifaceted process, but just a good starting point is just incorporating lots of images, lots of discussion in undergraduate curricula and postgraduate training as well as.

Speaker A

00:10:39.610 - 00:10:53.690

And coming up from these interviews, were there any examples where patients described really positive consultations or what made those encounters work really well? So any sort of examples of good practice so people can sort of take those sort of pointers away as well?

Speaker B

00:10:54.010 - 00:11:29.500

Yeah, so definitely, you know, some people said that there wasn't actually a delay at all, you know, straight away they were seen and the clinician knew what it was. So yeah, it definitely wasn't all negative. And there was also some discussion about kind of preferences for healthcare professionals.

So both in terms of the type of clinician someone sees and also their ethnic background.

And certainly some people had really positive experiences in primary care and particularly kind of nurses, people had positive things to say, but it was quite a mixed bag. So, you know, everyone had different experiences, positives and negatives, to discuss.

Speaker A

00:11:30.380 - 00:11:46.680

And for gps listening to this, what do you think could be some key practical take home messages from this work for people to take back to their consulting room if they were faced with a bit of uncertainty around a diagnosis or if someone with skin of colour came to see them with a skin condition.

Speaker B

00:11:46.760 - 00:12:34.300

Yeah.

So as part of this work, so we generated kind of eight themes from the interviews and then condensed these into sort of seven practical points for primary care clinicians. So I would encourage people to have a look at the paper because we have a concise table with all of these points with examples for each one.

But just some examples would be looking out for and being prepared to discuss pigmentation changes with your patient.

So kind of recognizing that it's there, explaining what it is and just simple things patients can do to help, kind of asking about complementary treatments, being aware that use is more common in certain ethnic groups and you know, what potential driving factors might be. So there are just some quite quick and easy things that People can do, I think, to try and improve patients experiences.

Speaker A

00:12:34.910 - 00:12:50.510

And from your perspective in secondary care, how do you feel that this has sort of changed your practice or is there anything that you're particularly doing differently as a result of doing these interviews? I'm just interested to know sort of from your own personal point, whether you've picked up something in your practice that you've changed.

Speaker B

00:12:50.590 - 00:13:29.790

Yeah, 100%. Yeah. I think it's really difficult when you're in a busy consultation because you've got so many things to try and discuss and tick off.

But certainly when I'm seeing people with skin of color, I'm definitely more aware about, you know, have they got hyperpigmentation? Do they understand what that is? They're using any alternative treatments? Do they understand what's caused their condition?

Where are they looking for their information? Are they looking online? Because a lot of people trying to, you know, look on social media to find out stuff which has its pros and cons.

But yeah, I definitely think in secondary care as well, it's all really relevant and kind of highlights things that we should be doing. But it's easy to forget in the moment. But it is really important.

Speaker A

00:13:30.810 - 00:13:46.130

Absolutely. I think that's the thing.

It's just sometimes having a nugget or a thought in the back of your mind when you're faced with this, even if it's a busy consultation, sometimes you can add a lot just by asking one extra question or asking about one extra perspective or what really matters to the patient as well.

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?

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.

And you work in dermatology, is that right?

Yes, yes, I'm a dermatology registrar based in the Bristol Bath area.

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?

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.

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?

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.

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?

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.

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?

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.

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?

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.

And coming from a general practice perspective, it sometimes feels like the treatment options for dyspigmentation are really limited as well in what we can offer patients.

So that must come out as a frustration as well, I'm sure.

Yeah, I think people.

People were very aware that it just wasn't talked about with healthcare professionals.

And, I mean, it is really difficult because we know there are limited treatment options.

But actually, a lot of people just said that they wanted it to be acknowledged and discussed.

So just a simple explanation of, you know, this is because of the inflammation in your skin it should settle as we get your condition under control.

It might take months or years to settle.

An important thing that gps can do is sun protection is really important, so UV light can kind of exacerbate the pigmentation further.

So even just a brief discussion about that I think patients would find really helpful.

And coming out of all this, were there any specific findings that really surprised you from these interviews?

Some of the issues I was sort of.

I was sort of expecting just from my own clinical practice.

So the issues around delayed diagnosis and kind of lack of representation online, those were things I'd already come across.

But I think the main thing was just the profound impact that factors outside of the clinic room can have on patients that I think, as clinicians, we don't ask about or aren't aware of.

So a big one for me, I think, was just misunderstandings within cultural communities about sort of what causes the skin condition.

And as I said, this then leads to kind of stigma and isolation and psychological problems.

So I think just the misunderstandings, which can be, you know, just through some simple education and community initiatives, we could really tackle this and improve people's experiences.

And you've touched upon this.

But this paper highlights big gaps in dermatology education and how clinical images are portrayed in textbooks, for instance, that we might learn from.

And I wonder, from your own perspective, how much do you think, think that that underrepresentation in teaching materials contributes to this diagnostic uncertainty that people have around what eczema might look like in a patient?

Yeah, I think it's a really important factor and certainly through kind of previous work I've done, we know that people just still aren't getting exposed to these images.

Things are changing, so curricula are being diversified and textbooks, but it is still a big problem.

And we know that this then translates into kind of lower clinician confidence when assessing people with skin of colour.

There are increasing resources out there, I think.

So.

You know, websites like skindeet, there's something called the Global Skin Atlas, which has kind of freely accessible images that clinicians can look at to find examples in darker skin tones, you know, patient information leaflets.

But as some of the participants said in the.

In the studies, it still often is just a sentence.

So, you know, in black and brown skin, it might look less obvious and then that's it.

So I think there's still a lot more work to be done for both patients and clinicians.

Yeah, and I guess that leads me to get your perspective on what do you think that good dermatology education in skin of color should look like just from your background in dermatology and teaching as well?

Yeah, I think just more images, more examples and just like an open discussion about how it can look different.

And this is what it might look like in darker skin tones compared to white skin.

So you've got kind of the whole how do skin conditions present?

But then obviously we do need more research on treatments.

We know that, you know, people with skin of color are underrepresented in clinical trials.

So, you know, how do we know that all of these new treatments work?

So I think it's, yeah, it's like a multifaceted process, but just a good starting point is just incorporating lots of images, lots of discussion in undergraduate curricula and postgraduate training as well as.

And coming up from these interviews, were there any examples where patients described really positive consultations or what made those encounters work really well?

So any sort of examples of good practice so people can sort of take those sort of pointers away as well?

Yeah, so definitely, you know, some people said that there wasn't actually a delay at all, you know, straight away they were seen and the clinician knew what it was.

So yeah, it definitely wasn't all negative.

And there was also some discussion about kind of preferences for healthcare professionals.

So both in terms of the type of clinician someone sees and also their ethnic background.

And certainly some people had really positive experiences in primary care and particularly kind of nurses, people had positive things to say, but it was quite a mixed bag.

So, you know, everyone had different experiences, positives and negatives, to discuss.

And for gps listening to this, what do you think could be some key practical take home messages from this work for people to take back to their consulting room if they were faced with a bit of uncertainty around a diagnosis or if someone with skin of colour came to see them with a skin condition.

Yeah.

So as part of this work, so we generated kind of eight themes from the interviews and then condensed these into sort of seven practical points for primary care clinicians.

So I would encourage people to have a look at the paper because we have a concise table with all of these points with examples for each one.

But just some examples would be looking out for and being prepared to discuss pigmentation changes with your patient.

So kind of recognizing that it's there, explaining what it is and just simple things patients can do to help, kind of asking about complementary treatments, being aware that use is more common in certain ethnic groups and you know, what potential driving factors might be.

So there are just some quite quick and easy things that People can do, I think, to try and improve patients experiences.

And from your perspective in secondary care, how do you feel that this has sort of changed your practice or is there anything that you're particularly doing differently as a result of doing these interviews?

I'm just interested to know sort of from your own personal point, whether you've picked up something in your practice that you've changed.

Yeah, 100%.

Yeah.

I think it's really difficult when you're in a busy consultation because you've got so many things to try and discuss and tick off.

But certainly when I'm seeing people with skin of color, I'm definitely more aware about, you know, have they got hyperpigmentation?

Do they understand what that is?

They're using any alternative treatments?

Do they understand what's caused their condition?

Where are they looking for their information?

Are they looking online?

Because a lot of people trying to, you know, look on social media to find out stuff which has its pros and cons.

But yeah, I definitely think in secondary care as well, it's all really relevant and kind of highlights things that we should be doing.

But it's easy to forget in the moment.

But it is really important.

Absolutely.

I think that's the thing.

It's just sometimes having a nugget or a thought in the back of your mind when you're faced with this, even if it's a busy consultation, sometimes you can add a lot just by asking one extra question or asking about one extra perspective or what really matters to the patient as well.

Yeah, yeah, definitely.

Absolutely.

So any other thoughts about this paper?

Anything else you want to mention about it or this work?

I think it's.

Yeah, it's just great to get the message out there and you know, to acknowledge it is something that hasn't been done before.

And I think it hopefully will be a really impactful piece of work.

And I'm just really glad that I'm grateful to the participants for speaking to us and for sharing their experiences.

And I do think that we have created some really useful practical points.

So hopefully clinicians will find this useful day to day and easy to use and understand.

So that's the aim.

Absolutely.

And as you say, there's a really clear table in the paper about implications for practice and those really practical points that people, people can take back to the consulting room.

So I definitely recommend anyone listening to go back and listen, have a, have a read of that as well.

So.

Yeah, but I just wanted to say thanks very much.

I think that's been a really great chat about this super important piece of work.

And as you've mentioned in the paper, this is looks like it might just be the first time that someone's actually looked at this problem in this way.

So thanks very much for your time.

No worries.

Thank you for having me.

And thank you all very much for your time here and for listening to this BJGP podcast.

Eliza's original research article can be found on bjgp.org and the show notes and podcast audio [email protected] thanks again for listening.

And by.