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