nm0338: er [0.9] i i have been or-, dist-, did just distribute er evaluation 
sheets [0.4] they're actually the ones that are used for the Master's in 
Medical Education course but [0.3] please do fill these out as you go along 
what we would really like [0.4] on the reverse of the sheet [0.3] is some sort 
of text comments as well of of the day and [0.4] whether you would like it 
repeated i was just talking to my colleagues from namex whe-, whether you would 
like [0.5] one of [0.3] the other sister universities perhaps to host the event 
[0.4] next time 'cause i think people have appreciated the sort of [0.4] the 
small group [0.5] the other thing is i don't know if everybody's actually 
signed in has anybody not signed in [0.3] can i just send this form round just 
nm0339: thank you 
nm0338: for for people to to sign in [0.3] and introduce our next speakers 
we've got three speakers from [0.3] namex University from the Department of 
Primary Care and General Practice [0.4] Interactive Skills Unit [0.5] er namex 
namex and namex as stated and they're going to 
talk to us about er [0.3] consultation skills research [0.2] thank you very 
much [0.7] 
nf0340: yes but fear not by the miracle of m-, rehearsal and careful 
timekeeping [0.2] the three of us are going to present within the fifteen 
minute time slot [0.6] [laughter] that's the challenge 
nm0348: 
nf0340: [laughter] [0.7] we're doing [laughter] [0.4] we're doing something for 
you that's er a little different from the previous presentations we're not 
doing er an in-depth presentation on a particular research ini-, initiative or 
methodology [0.5] er what we thought might be interesting er if we've got an 
opportunity [0.4] er [0.3] while we've got a group of colleagues here from from 
different sides [0.4] that we might just give you an overview of some of the 
research themes that we're looking at within the Interactive Skills Unit at the 
moment [0.3] and that will be a very quick zip through er what's 
happening at namex [0.4] er and then [0.2] namex myself and namex will speak 
for just two or three minutes each [0.3] er on our own personal favourite area 
of research [0.5] er questions are welcome on anything that er we discuss [0.4] 
and given that it is going to be a romp through a number of topics rather than 
an in-, in-depth [0.4] er we're giving everybody a [0.2] handout if you'd like 
to have one with supporting information [0.3] and a business card on top so 
that if there is an area where you think [0.7] i'd like to know a bit more 
about that or that's something we should be talking about together [0.2] please 
feel free to give us a ring [0.6] that's us [laugh] [1.1] 
nm0341: that's us 
nf0340: [laughter] [0.9] that's us [laughter] [0.3] and the next slide that 
namex is about to put up for me lovely thank you namex [0.4] er is er just an 
overview of the research currently un-, being undertaken by the 
Interactive Skills Unit [0.3] and the type of areas we get ourselves involved 
in [0.8] the Interactive Skills Unit is essentially a unit based at namex 
University primarily concerned with consultation [0.2] and communication skills 
[0.2] teaching and assessment [0.7] and that's across primarily medicine but 
also nursing and dentistry [0.6] and we start wo-, doing communication skills 
work with the undergraduates when they ooh two weeks after they arrive [0.6] 
then they pass through our careful hands until year five [0.5] er and then 
we're responsible for a number of training initiatives within the region [0.4] 
er well we do a lot of work with er qualified health professionals [0.5] 
including the areas that you would expect clinical consultations [0.3] 
communication skills subjects but also a lot of management and leadership [0.4] 
i'm not going to er read the list out for you you can see the range of work 
there [0.3] just a couple of quick things to draw your attention to [0.3] the 
contracted work that we do with the I-S-U [0.2] that's things that 
are commissioned through the er postgraduate dean's office [0.6] our very good 
friend namex [0.4] engages us in that range of work [0.3] er [0.2] non-
contracted is when the phone rings and people ring us up with weird and 
wonderful requests for programmes workshops and [0.4] video work [0.6] and the 
undergraduate programme's on the other side there [0.2] and the areas marked 
with an asterisk are areas in which one or more members [0.4] of our 
multidisciplinary team are currently researching [2.1] so there's quite a bit 
going on at the moment [1.1] and when we get our three-hundred-and-ninety first 
years next year there's going to be a lot more going on [1.0] [laugh] [0.5] if 
anybody's got any theories on how to make walls into rubber [0.4] [laughter] i 
would like to hear about them at the end [laughter] 
nm0341: that would be terrific thank you [0.2] 
nf0340: that's what we're up to at the moment next one please namex [3.6] this 
is my [0.4] personal area of my main personal area of research at the moment 
i've got a few things going on but this is the big one [0.4] er 'cause this is 
my PhD which hopefully i'll be handing in t-, [1.1] sometime in the next few 
weeks [0.6] er [0.3] my particular area of interest is assessment er in 
particular how communication skills are assessed [0.5] and there's been some 
references this morning to the interesting areas about [0.2] consistency in 
assessing the candidate interview candidate's communication [0.4] how can we 
start to begin to make [0.2] judgements about attitude and professionalism [0.
4] this ties in i think quite nicely with that [0.5] er [0.8] it's a five year 
project that i'm going to attempt to describe in two minutes so [0.2] in its 
briefest form [1.9] in a in in year five as part of their final general 
practice exam [0.7] our students have to undertake [0.4] a long station OSCE 
effectively [0.4] and two of those stations are full role played consultations 
[1.0] we're a mit-, we're a multidisciplinary team in the Interactive Skills 
Unit which means that we're a mixture of [0.3] commissions non-commissions 
linguists [0.3] and a big 
team of role players er from different teaching training and [0.4] theatrical 
backgrounds [0.9] er and the role players are a great resource we use them for 
teaching right through the curriculum [0.5] and the most experienced ones er 
are used for assessment [1.3] and the way that our [0.3] voices examination 
works on the communications i mean on sorry on the stations where role play's 
happening [0.6] is er a t-, an observing G-P examiner will score the students 
for [0.2] clinical topics and areas of clinical management [0.7] but the 
communication skills score [0.7] which is [0.4] worth a fifth of the station 
mark [0.4] is negotiated between the examiner and the role player [2.5] the 
scoring system that we use i've actually given you a copy of we use a banding 
system we we [1.2] we abandoned checklists and rating scales er [0.9] a while 
ago because they they don't work for communication in our experience [0.4] 
we're trying to move towards this sort of more [0.3] positive assessment er and 
that's our banding system is A to F and you've got a sample there of a b-, band 
B [0.3] which i'm happy to talk to anybody about afterwards if they want to [1.
4] basically my PhD is looking at the way that negotiation system takes place 
[0.2] and a lot of data was collected [0.4] over a four year period [0.5] where 
i was recording [1.2] independent [0.4] score perception of every role player 
[0.2] independent score perception of every examiner [0.3] and then the mark 
that they finally agreed on which was the score awarded in the finals to the 
students [0.3] and as you can guess basically looking for reliability [3.0] 
next one please namex [2.3] that's the very briefest summary of the most 
interesting areas of the results that i came across [0.5] er across a sample of 
over a thousand consultations er [1.1] irrespective of whatever variables er we 
we looked at [0.7] female students performed consistently higher [0.7] or if 
you like were awarded consistently higher scores depending on how you choose to 
frame that [0.6] er right across the sample [0.4] and the that's that female 
student gender [0.2] 
significantly higher score [0.2] was irrespective of [0.5] the year of study 
the age of the examiner the experience of the role player [0.2] the time of day 
the month of year [0.4] all of the exam variables that we looked at [0.5] that 
was the one that stayed significant [1.5] we found that students perform less 
well on some role play stations than others [0.7] and we're starting to work 
towards some theories from that that there is a relationship [0.4] between [0.
6] a student's communication skills performance [0.3] and the content of the 
consultation [1.8] found that the students are getting higher marks when 
they're discussing lifestyle issues [0.3] than when they're required to [0.3] 
discuss a new diagnosis [0.4] for example [0.8] 
nm0343: namex did you [0.2] you said they did perform better did you say how 
much better what percentage or how did you score [1.2] 
nf0340: er i've i i can give you a lot of detail about that i-, i-, in a few 
minutes do you do you mind because there's 
nm0343: 
okay 
nf0340: three of us in a very short time would you mind awfully 
nm0343: okay 
nf0340: if i if i let my colleagues [0.6] finish and we can discuss that 
afterwards [0.4] i mean i've i've got i've got a PhD thesis of of which a third 
of it is the is the type of data that you're talking about [0.4] and i mean yes 
i can pin that down to exact percentages for you if you wish no problem [0.7] 
er [1.7] performance factors er those were just some variables that we looked 
at to find out whether [0.4] things like seeing eighteen candidates back to 
back [0.2] had a significant impact on the scoring dynamic and found that it 
did [0.4] so we're making changes around that [0.7] er experience er age and 
year [0.2] were just some other factors that we looked at again i can give you 
more detail of those things that interested you [0.6] and the overall result 
thankfully was that er [0.7] the system was consistent there were over seventy 
assessors involved in this study over four years [0.5] and we did find the [0.
3] awarding of initial marks and 
the awarded marks and the negotiation process [0.3] to be consistent [0.2] and 
it is reliable [0.5] across the study period [0.5] and there are some small 
areas that we're going to be tweaking and modifying and revising [0.4] er but 
on the whole we're happy that this form of communication skills marking [0.3] 
is currently running without bias [0.7] thanks namex [1.0] 
nm0341: you're welcome [1.0] can i have the microphone [0.4] 
nf0340: you can [0.6] 
nm0341: hello [1.8] say hello namex [0.2] 
ss: hello namex [laughter] [0.2] 
nm0341: thank you very much [0.7] er the actor in me will never die it er i was 
reflecting on the way here today that [0.6] that my journey the journey that 
brings me here today started back in nineteen-eighty-one September nineteen-
eighty-one when i joined the Theatre Studies department just down the road [1.
1] and was one of the people who did Theatre Studies and Dramatic Arts B-A 
honours back between nineteen-eighty-one and eighty-four subsequently became an 
actor [0.5] millions of other things and bits and pieces in between but over 
the last seven years [0.3] have been working with er [0.3] namex and the team 
on the communication skills course at namex so that's some of my background [0.
5] my particular research area is cross-disciplinary [0.9] it causes all kinds 
of difficulties because it's not quite qualititative it's not quite 
quantitative it adds to knowledge in er [0.6] hopefully in three different 
areas [0.5] i'm not quite sure most of where or what [0.4] er it's er currently 
a Master's looking for transfer to a PhD and we're going through that process 
at the moment so it's far earlier inter-, in the process than [0.4] than y-, 
we're at with namex at the moment [0.4] but effectively i'm looking at doctor-
patient communication skills [0.5] i'm applying a linguistic model to look at 
contextually [0.2] what is happening [0.4] within doctor-patient communication 
skills [0.5] and then i'm looking at 
finding a visual representation of what a consultation looks like [0.9] and 
applying [0.5] a chaos theory measurement [0.9] to that visualization to then 
say okay well what does this tell us about it so [0.4] those of you who are 
aware of what a fractal is and what a fractal does will understand that those 
of you who don't [0.4] i can give you three or four hours later to talk through 
it is that all right [0.8] [laughter] that'd be great [0.5] er those of you 
with in the University of namex who are aware of Frances Griffiths will perhaps 
know that this is a big research area of Frances' [0.4] and i've presented 
before the complexity in primary care group on a number of occasions [0.3] on 
this particular area [0.3] i don't propose to go into any great depth of it 
today for [0.2] for for quite obvious time [0.4] limitation reasons [0.4] my 
hope is that ultimately where this will be leading will be to move towards [0.
3] looking at doctor-patient communication ultimately in terms of complexity 
theory [0.3] and this if you like is a doorway in [0.5] what what is actually 
happening where is it working [0.4] okay [0.5] what's it look like [1.8] those 
are consultations [0.7] done in this way [1.0] those are visualizations of 
consultations [0.6] and what you can actually do is you can say [1.1] a fractal 
very very briefly is the measurement of irregularity it is the statistical 
measurement of irregularity of that shape [2.1] if you think about the 
coastline of Britain [0.6] that has a fractal measurement of one-point-two-
seven [0.6] it's in between the first and the second dimension [0.9] [laughter] 
are we getting into Doctor Who yet [0.4] do you like it [0.2] okay [0.5] so the 
fractal measurements there are represented by er the [0.2] the [0.6] signified 
D-F equals one-point-three-one so we've got a smaller fractal [0.4] value on 
that one than we have on that one my study is looking at why that is what that 
means what the implications for that are [0.8] i think given the linguistic 
model that i've chosen what i'm looking 
at at the moment and what i'm developing is something that measures [0.3] style 
[0.2] consultation style [0.7] right [1.1] it's looking at er what i call the 
topography that's the mathematical relationship to to chaos theory so we're 
looking at the topography of a consultation what is the rocky road that takes 
you from [0.3] hello good morning come in sit down how can i help you through 
to yeah thanks doctor that's brilliant [1.0] what is that road what does that 
journey look like is it smooth is it rough [0.6] what does the roughness mean 
is the roughness appropriate is it not there are all sorts of issues around 
that [0.6] er [0.2] consequently [1.3] variance of style how important is that 
how does that work what sort of level of flexibility have we got [0.5] that is 
almost a measurement of flexibility that one [0.4] has great flexibility that 
one has less so [1.4] lot more in this what's the application [0.5] reflective 
practice [0.6] it's not an assessment tool it can't be done in that sort of way 
because it's largely a qualitative 
study [0.4] and the volume of information that would need to be sat behind it i 
think would be a problem [0.6] my hope is to develop something that a doctor 
can sit down and look at and say hang on a minute [0.6] why are these 
particular why do i work in these particular areas more than in other 
particular areas dependent on the circumstances [0.5] of the consultation what 
the presenting condition is how long the consultation is how long the 
relationship has been with the patient and all those other variables [0.5] so 
really [0.3] that's kind of where i'm going at the moment [0.4] so er [0.6] 
almost within time i'm going to hand you over for a far more rigorous approach 
to er [laughter] namex 
nm0342: i'm [0.4] doing discourse analysis of [0.2] recorded consultations [0.
4] and basically what i'm looking for [0.5] is why do patients make initiations 
in consultations [0.4] so why do they initiate new information [0.5] in a 
consultation [0.6] and i'm using something called the I-R-F model which was 
developed at 
namex in the seventies for educational discourse [0.6] and I-R-F stands for 
initiation response and feedback and if you look on your handout on the first 
page [0.4] you will see that [0.4] an initiation [1.7] basically is when a 
speaker [0.3] attempts to engage a listener [0.7] and then you get a response 
[0.3] and [1.2] what's quite unusual about educational discourse is you get 
feedback in [0.2] so you get the teacher evaluating [0.4] the response of the 
pupil [0.9] and this also happens according to literature in medicine [0.2] so 
you often get [0.2] a doctor [0.2] evaluating what the patient has said [0.5] 
so an example from my corpus [0.4] does it hurt a bit if i d-, does it hurt if 
i do that [0.2] does it okay good [0.4] now why did the doctor say good 
[laughter] [0.4] when [0.6] when the patient said it hurt [1.0] is kind of 
strange to me [0.4] and i wondered why this would be and as i'm not a G-P nor a 
doctor [0.6] in another specialty i don't really know why [0.3] a doctor would 
say good [0.3] when a patient had said i've got pain [0.7] but maybe he has a 
reassuring technique i'm not sure so and i'd 
be interested to know what people think afterwards [1.5] what i've tried to do 
then [0.5] is [0.9] categorize [0.8] c-, the communication into exchanges [0.6] 
okay which are basically [0.9] communicative function [0.4] and each new 
initiation [0.2] is also a new exchange [0.2] so every time you have a new [0.
2] initiation in a consultation [0.4] it's a new exchange [0.5] and i've come 
up with eight categories which i've also put [0.3] on your handout [1.0] er i 
think most of them are self-explanatory [0.4] er [0.8] informing exchanges are 
when [0.2] the doctor or the patient gives information [0.4] checking exchanges 
[0.6] usually when the doctor usually is checking to make sure the patient's 
understood [0.3] but sometimes the patient will initiate a check [0.5] to make 
sure they have understood the doctor correctly [0.7] directing exchanges [0.3] 
that's when [0.5] usually the doctor is [0.5] giving a direction to the patient 
to facili-, to facilitate diagnosis so would you please take your shirt off for 
example [1.4] advice exchanges [0.4] usually when the doctor is talking about 
[0.3] prescribing you 
know i want you to take this [0.5] once a day twice a day [0.3] and so on [1.9] 
okay [0.7] could you move on to the next slide 
nm0341: sure 
nm0342: thanks namex [0.7] okay [0.7] so my main question for my PhD is why do 
patients initiate [1.5] but we're also videotaping the consultations because [0.
2] from pilot studies of audio data [0.4] we realized we were missing an awful 
lot [0.3] of what was happening because a lot of the [0.6] responses [0.2] are 
non-verbal [1.0] so in some cases we had lots of initiations by the doctor [0.
3] but there didn't seem to be a response [0.3] so we had to assume therefore 
that the [0.2] response was a non-verbal one that the audio tape didn't pick up 
[0.5] so we're videotaping for that reason [0.8] we're also combining this with 
a patient enablement instrument [0.6] to see [0.2] if [0.5] there are certain 
exchange categories [0.3] that influence high enablement scores so we're using 
John Howie's patient enablement instrument [0.4] for that purpose [0.3] because 
most [0.5] discourse analysis studies [0.2] are 
based [0.3] just on observation [0.2] we don't actually use a measure of 
satisfaction [1.1] okay [0.6] we're also using this technique for [0.2] a few 
other projects [0.5] i've done a comparison of general practice with simulated 
emergency medicine [0.3] consultations [0.4] and what was interesting there [0.
9] we found [0.6] for closed questions [0.2] that in emergency medicine [0.2] 
the doctors tended to stack [0.2] the closed questions ones for the [0.2] one 
on top of the other [0.4] and they didn't wait for the patient to respond [0.6] 
so they may have they may have asked four questions [1.2] and [0.2] it was 
sometimes puzzling for the patient [0.5] which question do i answer first [0.4] 
and that didn't really happen in general practice [0.4] it was much slower so i 
would say [0.3] that in emergency medicine [0.3] a consultation is far more 
dense [0.4] you have lots more closed questions coming at flying out at a 
patient [0.4] whereas in general practice it's often more reflective [1.5] 
we've also used this technique for evaluation of undergraduate role play [0.6] 
and finally [0.4] we've just finished a project to do with 
evaluation of training interventions for early intervention in psychoses [0.8] 
er [0.5] which is interesting too [0.5] er if you have any questions i'll [0.2] 
i'll answer them afterwards and that's it [0.2] thanks namex [1.0] cheers [1.2] 
nm0341: thank you again [1.9] 
nm0338: thanks very much could i bring namex back to the front as well 'cause 
i'm sure there'll be lots of questions for [0.8] the three of you assembled [0.
4] or individually 
nm0342: sorry can i sit down [laughter] 
nm0341: of course you can 
nm0341: [laughter] no it's all right i'll take that chair [laughter] 
nf0340: give the patient the chair [1.5] 
nm0338: would any of you like to to to lead off with a [0.8] a question [4.1] 
nm0343: namex can i take you up for that [0.5] er part i raised [0.4] in during 
your talk sorry to 
interrupt you there [0.6] but if you teach people separately [0.4] er [0.6] 
there are studies to show if you teach [0.4] females separately and males 
females [0.7] do better than male students 
nf0340: yes 
nm0343: this is at high school level 
nf0340: there's a lot of parallels in education yeah 
nm0343: right in er n-, now what is go-, what is [0.5] what do i say going 
wrong [0.5] i think the females are superior class of beings i definitely 
[laughter] have no doubt about that [0.4] but why does it happen does it wh-, 
what what's the microanatomy behind it why is it student you know female 
students are [0.7] perform we find that our housemen [0.3] student er female 
students do better than our male 
nf0340: mm-hmm 
nm0343: now what what is the [0.9] 
nf0340: well 
nm0343: what do you find in your research 
nf0340: i i i mean i've run into i mean [0.6] my my my my actual hard 
research is is looking at really [0.3] is looking at the numbers and looking at 
the statistics [0.4] i haven-, i i i'm not an expert on [1.5] some of the 
clinical factors that lie behind gender gender performance [0.5] i have a i 
have a theory from having looked around at other educational sources like er [0.
3] recent government studies on [0.6] school performance [0.4] i have a theory 
that [0.2] with er er [0.4] girls maturing faster and apply themselves at an 
earlier age [0.3] to learning perhaps in a way that some of their male peers 
don't and that may continue into higher education [0.6] but i think we have to 
be a little bit careful about making generalizations because [0.4] what we have 
here [0.3] is evidence that female students [0.3] are scoring higher [0.2] in a 
communication skills tests [0.2] than their male colleagues [0.3] and that's 
usually by a margin of [0.2] one-and-a-half to two-and-a-half marks [0.6] out 
of a hundred [1.0] across the board [1.4] what we don't have yet but i'm 
collecting is comparative data and what i'd like to know is are those same 
female students [0.7] 
performing [0.9] better on machine marked tests [0.7] or might we find that 
this is a particular style of examination [0.6] that suits our female students 
and there are other areas of the test [0.2] like audit where perhaps our male 
students are doing better [0.4] so what this has sparked off for me as a single 
result [0.6] is the need to do [0.3] a load of comparative studies around 
voices and around other areas of the curriculum [0.5] to try and provide the 
data [1.0] that you're talking about [0.6] i mean there's all sorts of 
speculation could be made as to [0.4] why the girls do better in this situation 
[0.7] it may be because it's just a [0.4] a situation where they're they're 
being er er er assessed on a number of skills simultaneously [0.5] and that 
perhaps some of our female students find it easier to [0.2] think about a 
number of things consecutively [0.6] i read er i [0.2] read something by a 
psychologist suggesting [0.4] that men are much more focused in their thinking 
[0.3] that women perhaps are more apt at multitasking [1.1] that's one view [1.
8] i 
don't have er i mean i i don't think myself or any psychiatrist or psychologist 
or commissioner in the country can give a definite answer to [0.7] why has this 
female student done better at this task than this male student [0.9] what we 
have got is evidence that it's happening and and what we're realizing is that 
it's important [0.4] to find out what teaching and learning methods are suiting 
which groups of students [0.3] so that we can make sure that we're offering an 
appropriate range [0.5] of teaching and testing methods [0.2] to give all our 
students the chance of being the best that they possibly can be [2.9] 
nm0341: hello 
nm0344: can i ask namex about er [0.5] the way you tried to map the 
consultation [0.4] 
nm0342: mm-hmm 
nm0344: the process itself [0.2] i mean you say it's very useful as a 
reflecting which i agree but how complicated is to map that [0.7] sort of chart 
[0.2] 
nm0342: er it's very time-consuming because 
nm0344: it is mm 
nm0342: 
you have to sort of every utterance you have to give [0.3] a category to [0.6] 
er [1.0] and it takes and what i tend to do is i code [0.9] a consultation on 
one day [0.3] and then i will leave it two weeks and then i will code it again 
[0.3] on a blank piece of paper and compare the two [1.2] er so i so i try to 
get some kind of reliability in my coding system and then i also ask other 
people to code [0.3] as well [0.6] 
nm0344: so [0.5] i'm just thinking about one other function that your 
nm0342: okay 
nm0344: your unit uses for poorly perform [0.5] doctor [0.5] 
nf0340: yes 
nm0344: er yeah [0.5] so if i got a poorly perform doctor 
nm0342: mm-hmm 
nm0344: i want to look at his communication 
nm0342: yeah [0.2] 
nm0344: or consultation skills one of the aspect [1.2] you will have [0.5] one 
person look at the consultation yourself chart it and then leave it for a 
couple of weeks then another person to chart it [0.2] and then reflect it back 
to the doctor 
nm0342: 
er i don't 
nm0344: i just wonder how complicated the process 
nm0342: i don't use the i don't i haven't used my [0.5] the system for er to 
rate a poorly performing doctor [0.2] 
nm0344: okay [0.2] er 
nm0342: er [0.3] 
nm0344: but you can apply all it [0.2] 
nm0342: yeah i'm i'm i'm sure there has i'm sure there is an application then 
yes [0.3] er [0.9] it's i mean this form of discourse analysis is quite well 
known in educational circles and can be taught to [0.5] to people quite easily 
[0.3] 
nm0344: so people can easily learn how to do this 
nm0342: er i i think probably with er [1.2] gosh a day training they'd be able 
to code quite [0.3] do simple coding yes [0.2] 
nm0344: because particular for poorly perform doctor i find [0.3] is actually 
make them [0.4] 
appreciate they're poorly performing [0.2] 
nm0342: mm [0.3] 
nm0344: er 
nm0342: well it's [0.2] yeah 
nm0344: if you can have this sort of scoring system it's much easier to for 
them to look at yes i didn't do very well [0.3] rather than than you know [0.3] 
subjectively somebody criticizing 
nm0342: one [0.2] one problem i've noticed with [0.3] this system [0.4] is that 
[0.5] it's very initiation focused [0.4] it's it focuses on the initiation so 
the exchanges are dictated [0.3] by the initiations [0.2] and because [0.3] in 
my corpus of data [0.5] over eighty per cent of the initiations are made by the 
doctor [0.3] it means the patient's voice is kind of [0.3] not heard [0.2] so 
what i'm what i'm doing now is 
nm0344: 
nm0342: going back [0.6] and looking at the responses because the responses are 
what the patient does most of all [0.3] so that's what i need to do [0.2] and 
i'm trying to work with a framework of responses [0.2] that works in the same 
way that a frame-, framework initations with this 
nm0344: thank you very much 
nm0342: thank you 
nf0340: 
we do [0.2] sorry can i if i just pick up very briefly on that [0.4] er we do 
use audio recording er w-, we're referred doctors particularly when the when 
the difficulty's a language problem [0.4] er or a verbal communication problem 
[0.4] and er our professor namex who's a a [0.2] a a linguist with a lot of 
expertise in this area [0.4] he does record consultations to play back to [0.6] 
er doctors that are referred to us [0.3] but our primary method is role play [0.
8] or er referred doctor coaching [1.3] 
nm0345: er i just wanted to ask namex er [0.6] the the the topic of your 
nm0341: i'll stand up 
nm0345: your work is is only it's a like n-, like nothing i've ever heard 
before [0.5] er [0.4] and and i 
nm0341: really [laughter] 
nm0345: 
nm0341: completely familiar with [0.2] sorry 
nm0345: er what i was wondering is i-, is this something that is established 
and has been done 
nm0341: mm 
nm0345: a 
great deal of or is this something that you're sort of [0.2] beginning the 
pioneering process of [0.8] and if so [0.2] or or or or you know where has it 
been used before and for what reason [0.3] 
nm0341: well that's time up isn't it [laughter] [0.4] er i-, no it hasn't [0.3] 
is the answer to your question the er whe-, where i'm where i'm at with this is 
[2.6] th-, the short answer to your question is that visualization of [0.3] 
consultations in the kind of way that i'm doing that's a radar graph in Excel 
it's nothing more complex than that but visualization of consultations is not 
something that appears to be regular in the literature [0.6] if it is it's 
looked at in quite a different way it's bandings around which particular 
clinical areas are being picked up [1.1] my journey to reach the point that i'm 
at at the moment is an interest in complexity theory which is the i-, which 
which is an idea that [1.0] very briefly the sum of a whole bunch of entities a 
whole 
bunch of individual things put together [1.2] gives you a whole and that whole 
is far greater than the sum of its parts now that to me is a human interaction 
[1.1] finding a way back from that [0.4] is trying to find a way that is 
meaningfully representative rather than me standing here and saying to you oh 
no it's very important because of this this this and this [0.3] it's finding a 
diagrammatical representation that's fast and easy to use [0.4] the traditional 
measurement of that representation [0.4] within [0.2] complexity theory which 
is what's underpinning my feeling about how [1.0] discourse works [0.8] what er 
traditionally underpins that is [0.3] a series of mes-, mathematical 
measurements of which fractals is one [0.9] it's a hap-, it's a happy 
circumstance that you can measure the irregularity [0.5] of something that is 
travelling through different types of contexts [0.5] visually [0.3] and then 
pick up a measurement that expresses [0.2] philosophically [0.8] its complexity 
and irregularity which i think is what a human interaction is about 
rather than a series of [0.5] rather than a series of very basic exchanges [0.
3] as i'm saying that i'm aware [0.5] of a parallel with what namex's saying 
but i'm looking at it in a different kind of way [0.4] and that's no reflection 
on [0.8] er on that does that sort of answer your question [1.1] 
nm0345: mm [0.3] probably won't sleep tonight 
nm0341: but it e-, 
nm0345: but er 
nm0341: [laughter] [0.4] well taped it and er [0.2] [laughter] i mean but no 
it's a but but no i don't think anything quite like it has been done and i 
think that's one of the things that [0.2] one of the things that A makes it 
very interesting to me but B makes it extraordinarily difficult [0.4] 
nm0345: mm 
nm0341: within the health professionals' culture to describe it because it's 
largely qualititative [0.4] in terms of where it's going [0.3] with a 
quantitative output [1.4] so it's a it's it's quite difficult to match the two 
things together really [0.7] 
nm0338: er g-, i was just going to say can we just have two more questions 
namex and er namex [0.2] is that 
all right 
nm0346: i think that maybe the talk alluded to this anyway but sort of [0.3] an 
extension of namex's point i think is [0.4] do you ev-, envisage a problem with 
what you're doing really is you're you're men-, you're [0.5] coming out with 
some very theoretical results about communication 
nm0341: absolutely [0.6] 
nm0346: do you envisage a problem with actually transferring that back into [0.
6] er i mean what are you going to do with your results apart from saying this 
here's the theory this is very interesting but what in real terms a doctor's 
going to do when you say that to him 'cause it's all so theoretical [0.4] do 
you see a problem with going back into [0.8] practical side 
nm0341: i don't i don't don't see a problem with going back into it really 
because it's it's around where it's around where the diagrams are coming from 
because [0.3] the key to the key to it is and this is what where there wasn't 
time to explain i'll very briefly [0.3] say it's based on [0.4] four different 
elements of a consultation which very briefly are meet and greet [0.6] er 
patient explaining the problem [0.2] doctor exploring the plob-, [0.2] problem 
[0.4] and consultation resolution so where are we going so which [0.2] of those 
areas are we in [0.4] visually you can tell from that graph [0.4] which of 
those contexts the consultation spends most of its time in [0.9] that i think 
is a helpful in tool for self [0.3] er reflection [0.3] on the pilot study 
which has looked at thirty consultations of which those are two [0.7] one of 
the things that has become very clear and it echoes something that namex was 
saying about initiations [0.3] is that an awful lot of time is spent in the 
area of the doctor exploring the problem which feels to me is kind of how it 
should be [0.2] okay tell me a bit more about that when did the pain first 
start [0.2] those sorts of questions where you're exploring what you've been 
told by the patient [0.7] now what it's saying is if [0.7] contextually 
depending on what the presenting condition is [1.1] is it useful to be spending 
i'm not 
saying is it right i'm saying is it useful to be spending as much time in that 
area i think at the moment it's a tool for reflection [0.4] it's very very 
early days in developing the idea because as namex's just [0.3] pointed out 
done it [0.5] so [0.4] i i can't say further than that but that's the way the 
thinking's going and i do think it has a practical application in terms of 
coding the data [0.3] that can be done very quickly and again it would be a 
fast training process because you're not looking at [0.3] an eighty-five point 
hierarchy or whatever the calibre of scale is in terms of marking up a 
transcript [0.6] does that [0.3] m-, sort of make sense [0.5] 
nm0346: thank you [1.8] 
nm0347: er it's not precisely a question but i hope in some ways it's an answer 
to your question [1.0] communication skills of course are only one domain [0.2] 
of consultation skills 
nm0341: absolutely 
nm0347: 
and [0.6] my experience with undergraduates er at namex is that the domain our 
students third and fourth year students struggle with most is in their problem 
solving [0.4] so it's the cognitive aspects of the consultation 
nm0341: mm-hmm [0.3] 
nm0347: and [0.4] what limited work i've done with [0.3] er [0.4] qualified 
doctors also [0.3] i think that applies too [0.3] so when consultations go 
wrong [0.3] i think it o-, it often is rooted [0.4] in the problem solving [0.
8] and [0.2] it [0.7] so i think [0.8] that's why it's sometimes quite 
difficult for non-commissions to evaluate what's happening in the consultation 
nm0341: absolutely 
nm0347: which is why i have the immediate answer to your question the reason 
why the doctor says oh good [0.4] is because at the point [0.4] that the 
information he gathered the fact it hurt then [0.2] helped him confirm his 
diagnostic reasoning at that point [0.3] so what he's saying is oh good i now 
know what the diagnosis is 
nm0341: mm-hmm 
nm0347: not oh good i've hurt you [0.5] er and it's i think 
it's the fact that all of this happens in an integrated way [0.5] makes it i 
mean it's a particular skill 
nm0341: mm 
nm0347: analysing [0.3] anybody's consultation skills 
nm0341: absolutely 
nm0347: because [0.2] in a sense you have to have an equal level of skill if 
not higher [0.3] in order to make those kind of judgements [0.7] and [0.3] 
certainly i think [0.4] that's you know where most undergraduates [0.3] er are 
really struggling [0.4] er 
nf0340: yeah i think that's really interesting i'm [0.3] thinking what you're 
saying 
nm0341: mm 
nf0340: might link in to this this this thing we're finding about [0.3] the 
communication marks for the students varying according to the content of the 
scenario [0.7] and they're s-, definitely more confident and better at 
communicating [0.4] when they're discussing [0.5] a lifestyle 
nm0347: mm 
nf0340: issue or [0.2] counselling somebody talking to somebody that's [0.2] 
got a known long-term illness that the patient has had for a long time [0.4] 
put them in a situation where you give them a test result [0.3] and they have 
to interpret the 
test result work out the plan of management [0.2] and then explain and 
negotiate with the patient [0.2] those communication marks are poorer [0.2] 
nm0347: yeah [0.4] 
nf0340: and i i'm i'm i'm thinking what you've said is 
nm0347: 
nf0340: very interesting and perhaps 
nm0347: mm 
nf0340: looking at that in terms er i'm going to revisit those questions [0.3] 
and actually think about what you've said and revisit them in terms of [0.5] 
are the lower scoring questions more heavily based in problem solving than the 
higher scoring questions [0.9] and if i find that i shall give you a ring 
'cause i shall want to talk to you about that some more [laughter] absolutely 
[0.6] i mean we have [0.4] what we've done in our in i don't know i don't know 
if you know how namex assesses its students in the Clinical Methods course but 
what we have got is a 
wealth of data [0.4] because we actually code what their strengths and 
weaknesses are 
nf0340: mm [0.2] 
nm0347: and [0.4] we so over about six-hundred seven-hundred [0.2] assessments 
we now know [0.3] what [0.2] namex er [0.2] and some namex students do well and 
do less well [0.3] and problem solving is usually where they struggle 
nf0340: mm [0.3] 
nm0347: and certainly [0.5] my anecdotal experience is that [0.2] that if the 
student doesn't really know what the diagnosis is [0.3] their scores on 
management are going to be quite low 
nf0340: yeah 
nm0347: er 
nm0341: is that awaiting publication or 
nm0347: er hopefully yes [0.4] 
nm0341: i was going to say c-, 'cause th-, that would be very interesting would 
be [0.2] very interested to 
nm0347: yeah 
nm0341: see that seriously if you would send 
nm0347: yeah [0.2] i mean we have a sense that within this huge mass of data 
because most students end up with about ten or fifteen codes for which they're 
either strengths or weaknesses 
nm0341: yeah [0.4] 
nm0347: 
er that we may be able to identify patterns of strengths and weakness amongst 
students so you might identify the student as a poor problem solver [0.3] but 
who has quite good communication skills 
nm0341: yeah [0.2] 
nm0347: and you might have a student whose basic problems lie perhaps more in 
in in interviewing and history taking they're just so bad at talking to people 
[0.3] 
nf0340: mm-hmm 
nm0347: the information they get back is rubbish [0.3] and so [0.2] you know [1.
2] 
nf0340: yeah absolutely 
nm0341: that's right thanks very much [0.6] 
nf0340: 
and er if i reiterate what namex said about thank you for having us today it's 
been a 
nm0341: yeah it's lovely 
nf0340: a really interesting day so far and we look forward to the rest of it 
[0.4] 
nm0338: thank you very much [5.9] [laughter] one of the things that we hope 
will come out of today is that we've sparked some collaborative [0.4] 
initiatives [0.5] because the way we teach students [0.6] at namex and namex [0.
2] in relation to the consultation is obviously different to [0.4] or slightly 
different to what happens at namex so [0.7] i'm [0.4] i hope we've sowed those 
seeds of [0.2] collaboration and we'll be able to to take those forward