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Hi guys. Um Thank you all for coming. We've just um started the live now. We're just waiting a few minutes. So we're gonna start in like two minutes. So at five past, um just to make sure everybody can see Omar slides at the moment. Can everyone just maybe leave like a thumbs up on the chat just so that we know everything's working and then we can promptly start at five past. Ok, I think we'll get started. Um Thank you all for coming and welcome to our first part of our four part series of communication skills. Um This one focuses on history taking, um And the rest of our sessions will be advertised on meal as well and on our Instagram. So please do follow us there. Um I also want to say thank you to Roa for coming to this event, um which is the primary care lead. Um Our speaker for today is Omar who is 1/5 year medical student. Um And we hope that this will be an interacted session. Please do use the chat box as well if you have any questions and we'll try our best to answer them and at the end as well. So, Yvonne, thank you. Thank you very much. Uh Princess. Hello everyone. I hope you're all well. Um Thank you to the GPS for inviting me to uh deliver this talk on history taking um as part of a series about good communication. So just quickly the objectives of this session, I know there's some early clinical um students, um preclinical students, even I know there's some qualified healthcare staff, et cetera. So the a the main objectives are listed here. So um to help students understand the components of the medical history, teach effective communication techniques, which can be applied for history taking and for every single communication scenario you have from now until the end of time, share practical advice for and confidence during history taking um like real practical advice, not just the sort of thing that you just read. Um the cliche sort of stuff and address common challenges and how to overcome them. And at the end, there's a bit of interaction as well. So before I begin, um I'm gonna tell you what um I want from you and then what I'm gonna um give you in return. So the most important thing is I want interaction and I want you to be engaged. So um the chat is there, please do use the chat. But when I say engaged, I also mean put your phones away, just pay attention to this because I promise you that by the end of this session, your confidence in history taking and in communication in general will be so good that um you will be ecstatic, you'll be so happy. Um I hope this will be very constructive and beneficial for you. Um So please do pay attention with me, be alert with me, um, and engage even if you don't want to put anything in the chat per se, just mentally engage with me, think about everything I'm talking about. Um, and I promise this will stick with you, er, forever let me just put my phone on, do not disturb, I'm putting in my phone on your not so you guys put your phones as well. Um ok, right before I begin as well, can you just put in the chat box on a scale of 1 to 10? How confident are you in communication and history? Taking 10 being, you are the most confident in the entire world and one being you are not very confident. So I just need a few answers to see roughly where everyone's at in terms of how confident you are, how confident you are. 57.58477 six, ok, eight. So there is a mix overall 67. So I recognize some of the names that I put in the high numbers. Um, some of them are uh later clinical years. So that's a good sign. It means they're attending their placement and they're engaging and practicing very well, a few people that put forwards, um, which is completely fine. Um, when I started, I was probably a one. and now I'm a lot more confident. So by the end of this session, whatever you put in, I guarantee you'll go up at least by three. So if you start at four, you're gonna finish by at least seven. If you start at eight, you're gonna be 11 out of 10. And, um I have a little bit though. So just bear with me if I do uh cough, sneeze or sniffle, right? So intro, why is history uh taking important and why is effective communication important? Very good questions. Um Now as healthcare staff, firstly, if you want to answer in the chat chat box, be my guest. Um So give me a few ideas as why history taking is important. I know you all know the answers for this but just to create a bit of a live environment. So someone told me why is history important? History taking important and why is effective communication important? Answer one or the other or both or whatever. And whilst your answer, I am going to tell you the answer is real as it means the patient can be heard, figure out the problems for presenting complaint and patient satisfaction. Perfect. So the reason it's important is as a as healthcare staff, we have a big responsibility. We are actively getting involved in patients personal life, private life things that nobody else knows about them except themselves and us. So in order to do that, you need for the patient to trust you to believe in you um to trust your confidentiality, to trust your management and for them to engage in your treatment, you also need that trust. So trust is a very important thing. In order for the patient to trust you, they need to, someone just said for building report. In order for the patient to trust you, they need to, how, how are they going to trust you? If not from communication, they need to talk to you, you talk to them, um and you build a report and when you build a report, they trust you. Now, once they trust you, they will confide in you, they will tell you the truth. Um because sometimes patients are too shy to say something to you, they might think they're gonna get judged, they might think uh this is too embarrassing, they might think whatever. But at the end, we need to know these things because we need to treat them effectively. So we have to have very good communications so that the patients can trust us. And once they trust us, then they can tell us the real problems that they're having. Once they trust us, they will trust our management plan and then we can treat them um so that they can get better if they don't trust us, they won't listen to us. If they don't listen to us, they won't get better. So that's why it's very important. Now, why is history taking important? So over 80% of common diagnoses can be made just on history alone, forget examinations, investigations, all of these are important. But in terms of the most common conditions and the majority of conditions, you can just using the history alone, you'll be able to find the answer to the diagnosis. So a lot of people said rule out uh differentials to make the diagnosis, figure out the problem. History alone can get you 80 90%. Once you know, once you have maybe one or two differentials left or just to confirm 100% then you do investigations, examinations, et cetera. Now I know like I said, there's a few preclinical people here, er later clinical years, um other healthcare staff, nurses, et cetera. So this talk is tailored to everybody and I guarantee you will benefit you all. So before we begin, I'm gonna tell you a little story and I really like stories and I feel like stories are a good way to learn because rather than me just lecturing you, if I tell you a story, I'll stick with you more. So, um I was working on a ward um that had patients that had brain damage. Uh So it was almost like a rehabilitation ward and one of the patients. And this is why communication and having good communication and building report is important with patients. So I was on the ward and there was one patient with dementia. So there was some patients with brain damage, some some patients with stroke trauma, et cetera. And there was a patient with um with dementia. Very lovely patient. Very nice, very friendly to talk to. Uh just generally, just a sweet man and he was quite old. He had dementia and um that was his main diagnosis and that's why he was in care. Now, I'd see him every day. I'd spend many, I think it was 12 hour shifts. So I'd, I'd see him for quite a lot helping with eating, talking to him, keeping him company, et cetera. And everyone would say he has dementia. But when I'd speak to him because I spent so much time with him because I could, the other staff were a little bit busier so they couldn't spend as much time with him. I was more free. So I was spending a lot of time with him and we built a very, very good report together and, uh, I would talk to him and I would think they've diagnosed him with dementia. But when I speak to him and I see him every now and then, like, consistently, he doesn't forget what we talk about when I talk about his, like past, for example, he, he receives, he retrieves the, his memories and everything seems fine. So I was surprised he was diagnosed with dementia. Anyway, when I was speaking to his staff, he was like, yeah, he always gets confused on the ward. Um, every day when he comes to take his medications, they give him the medications. He always asks the same question. Why am I taking these medications? There's nothing, nothing wrong with me. And then they'd explain, you've got dementia and then he'll take his medications and et cetera. So once I was with him as he was taking his medications and he would, and as he was giving, taking the medication, he was, he looked at the drugs and he then looked at the nurse that gave him the drugs and he said, why am I taking this? And they said, because you've got dementia and then he looked at me and he winked and he cracked a small smile and then he looked back and he said, I don't have dementia. Uh, and then they said, yes, you do have dementia. You said this yesterday, but you do have dementia. And then he looked at me again and then he winked and then he cracked a smile and then he took his drugs and he moved on and I was like, are you doing this on purpose between him and I, and I was saying, are you doing this on purpose? Yeah. And he just laughed and he went away. And at that point, I was like, I don't know, I felt he was more just you know, he was quite old and he was just, he had a fun personality. He was just, he likes playing jokes. So, in my head, is it really dementia or is he just having, having a laugh and just trying to entertain himself? So then, um, I don't see him for a long while. Um, and then I come back, um, to the ward and I, and he's not there anymore. So I asked about him and it turns out unfortunately, he was taken to hospital and he had late stage cancer and he passed away. And when I was speaking to the staff with him, they were telling me I was telling them about, oh, like, did he really have dementia? Because when I'd speak to him, he was like this and he would talk to me and it almost felt like he was just almost putting it on just as like a laugh to have a joke, et cetera. Uh, very nice guy. And they were like, yeah, near the end, we actually suspected maybe he didn't have dementia and it was just mis misdiagnosed. Now, at that point, I was nowhere near qualified to say whether or not he had dementia or anything like that. But what this shows you is once you have such good communication with patients, when you build a rapport with them, you build a, a relationship where they can confide in you and be honest with you and stuff, you can sort of, um, they are more likely to open up to you. So, with me, he, he, he winked at me. He cracked a smile. But with all the other stuff, he didn't really do that. And the reason was because I had such a good bond with him because I spent so much time with him. I used to talk to him. I was honest open. Um, but the moral of the story is, is the importance of just having good communication and you can, it will open up doors for you and it will make your life so much easier. Um And patients were more likely to tell you the truth, um which is ultimately the most important thing because once you know what the truth is, once you know exactly what's going on with the patient, then you can provide the best service. And at the end of the day, that's what we want. So anyway, communication technique. So this is primarily focused at history taking. But like I said, this is gonna be useful for your everyday communication, communication with friends, with staff, amongst each other, with your colleagues. So what do we do before seeing the patient? Now this gets under and I'd never see anybody speaking about this. And when I was taught histories, no one really uh said this to me the presentation. When I say presentation, I mean, this is a little mini story. I like stories, but this is a mini story. I had, um, a friend of mine went to placement and he saw that some of the doctors were, were wearing, I think joggers or like tracksuit bottoms, but they didn't look like tracksuit or joggers. They looked a bit smart, but they were joggers and they were wearing trainers and they were wearing a scrub top. So then he went, um, he went to placement wearing joggers, white trainers and scrub top. And the consultant saw him before he saw any patients and this was a student. And he said, why are you just like this? You know, you are a doctor, you're, you're meant to be professional. You're seeking patients like this is the patients maybe worst days of their lives in hospital and they're going to look at you and they're gonna see you wearing joggers and trainers, it's not professional. So he sent him back and he got changed and he came back to the hospital. So presentation is so important the way you present yourself and body language, they tie two and two and two. So when you present yourself before you see the patient, you wanna make sure you are dressed appropriately, you wanna make sure that for example, you don't have stains on your top. You want to make sure that if you're wearing a shirt, a blouse or whatever, it's um ironed, it's um clean, it does not smell, your hair is done nicely. If you've got like a beard line up your beard, your shoes are clean, they are not scuffed and dirty, they are not ripped with holes. Um, it's very important because it's minor things like that is when a patient will look at you within the first few seconds, they'll decide whether or not you're somebody that they're gonna trust somebody they're gonna like, or if you're somebody that's, you know, doesn't exactly know what they're doing and that's instinctive, isn't it? Because through evolution, you look at somebody straight away, you know, whether they're a threat or whether they're a friendly person. Um And that protects us through evolution. So it's an instinctive thing, but it's something that doesn't get, um picked up on and I've never heard anybody else speak about this, but the way you present yourself and body language, when you walk into the room, for example, you want your chest out, you wanna have a confident posture because this patient is coming to you because they need your help. If you don't look confident and you look sort of all a little crowded and uncomfortable, they're not really gonna trust you, they're not gonna trust your management, they're not gonna trust the treatment, they are not gonna trust any of that. So you wanna have, you wanna look presentable, look professional and you wanna have good body language. And this is something ii uh I got positively commented on in psychiatry is um just having good body language when you see it as a guy, for example, you sit back, your, your knees are slightly apart, um, your hands are down, you've got open palms, for example, or you in a relaxed nonthreatening posture, which is very important in psychiatry, for example, with patients that have, uh, that have paranoia, um, they can feel threatened, for example. So if you're sat in, in a potentially threat, even if you don't mean it, if you're sat in a potentially threatening way or you know, you're crossing arms and you look like you're judging them or something like that. So you have to be aware of the way you present yourself and your body language. And this also ties in about mirroring. So if the patient is leaning forwards, then you lean forwards, you wanna mirror them almost, not too much, but you wanna make it look like you're similar to them when you mirror somebody, they like you. And the reason is because we like things that are similar to us. So if you look at your friend group, for example, you'll have a lot of similarities and that's why you're friends and you like each other. Likewise, if you're speaking to somebody, you wanna, you want them to like you as a, it's our job to make them like you uh to make the patient like us so that they can trust us and speak to us, um and agree to the treatment that we're gonna give them. And so that we can get the full truth from them. So you have to make them like you. And one of the easiest way is just to mirror them. If they're leaning forward, you lean forward, if they're leaning back, you lean back but not make it too obvious. If they lift their hand up, you lift your hand up as well. That's a bit, that's a little bit silly, but just to generally just mirror them. Um It creates like a connection. This is all psychology. I, I'm very fascinated by psychology. So uh this is one of the things. So this is what um most people will teach you. So what to do while seeing the patient now, active listening, active listening is basically listening, but you're actively listening and um you make it obvious that you're listening, that's basically what active listening is. So um keeping eye contact with the patient um nodding or mhm saying like these filler words sometimes, even if they tell you a line, repeat a few words from that line and all it does is just make them know that you're listening because um the biggest problem is if you feel like you're not listening, then they're just gonna stop talking. And that's not what we want. Empathy and nonverbal cues. Again, if they tell you something bad happened to them or you can see they, you know, their tone has changed or whatever you want to sort of match that mirror that show them that you're supportive, understanding, structured questioning. Now, that's the main one. Now, structured questioning is good. When you wanna be history, you want to be organized, you want to ask them these questions, you wanna be structured. But at the same time, more important than that is you want to maintain flow of conversation. So the perfect balance I have found is when you question a patient in your head, you should have structure. When you're speaking to the patient, you want them to feel like they're just having a normal conversation, just like you walk into a cafe and you see somebody sitting in and you talk about and then what people talk about with the weather and how nice the coffee is and all of that. If you're having a conversation, you go from one topic to another another and it just feels so casual. That's what you want, except medically history taking related. So you want them to feel like um you're having just a normal casual conversation with them about. So make it feel like they're having a conversation, but in your head, you're structuring exactly what you're saying. And everything you ask is for a purpose and then clarifying and summarizing this is important both ways. Um A to make sure that you understood what they're saying for them to understand what you said. If you're explaining a treatment, for example, you want to make sure that they understood what you told them. And likewise, when they tell you a lot of information. It's good to every now and then clarify if they are not 100% sure to summarize as well. Um Just so that you don't forget and then uh after you see the patient again, so you've spoken to the patient for 10 minutes, five minutes, 15 minutes, whatever it is. Now, there's a lot of information in your head. So what you want to do is you want to structure it again and we'll go all through all this. So don't worry. Um And then of course, you're gonna have to summarize. So whether this is a exam or an OSK situation, you're gonna have to repeat the information back to your senior or if it's an actual practice where you have to relay the information or write it down in your notes, you need to summarize it. You can't go with the patient said Xy and then quote them word for word. So um top tip. So before I go to, I see a lot of people, they write on a piece of paper, they grab a piece of paper and then they write, you know, everything you need from a history. So presenting complaint, history, presenting complaints, uh you know, uh past medical history, drug history, et cetera and then they go and speak to the patient. Now, I don't like that personally and that's something I never did. So the reason is, is because when you do that you become reliant on that. So, um so when you, when it comes to taking histories, it becomes dependent on this piece of paper that structures everything for you what you want. Whenever you look at a, a very good consultant or a very good doctor or a very good nurse or whatever and they speak to patients, it, they just speak and they just, it feels like they know everything but they are not looking and reading from a sheet. And the way they are able to do that is because they actually have so much experience that to them, this is just like, uh, you know, just like a walk in the park because they have experienced it so much. So, um, the problem with writing it down is you become dependent on writing it down and it makes it harder for you to, to sort of improvise or to, um, be able to acquire the skills to take a good history just from yourself. You become like, oh, no, I need my paper, I need to write it down. Otherwise I'll forget otherwise, I'll forget. I guarantee you if you, next time you take your history, you just go, you know, you have a rough idea of what you want to talk about and you just don't write anything down. Just try and retain as much as you can if you are in early clinical years. There is actually no problem with that. You should do that. So much because by the, by after a few more histories, you realize that everything just comes to you, you ask a question and then it reminds you of the next question. You remember the next question and it becomes second nature to you. Um Whereas if you write everything down, it takes a bit longer for you to, to, to acquire the skill of taking a history because you are so dependent on writing everything down. Whereas what you should do is you should just go into it and remember everything you need to ask in a history, just remember whatever you can ask the questions. And then um if you've forgotten something, you're still a early clinical year student. So it's not that big of a problem. You can either go back to the patient or you can say next time I will um ask them this, this and this and I missed it out. And then you'll realize that the next time you do it, you will never forget the things you ever miss missed out. And then you take another history and then you, you forget a few things. The next time you take it, you remember those things, do you know what I mean? And then eventually your history technique will be like perfect. And that's the biggest thing you feel like you might forget, but you actually don't forget, you remember everything. So that's my biggest advice. If you, if you, if you tend to write everything you need to write on a piece of paper, try and er build the habit and the skill of not doing that. And it'll help you a lot. Everything just comes and clicks and I promise you by the end of this, um you'll all be on this level, hopefully. So stay organized systemic approach. So you wanna have an organized sort of thought coming into this. If the patient, if you have an idea what this patient has, what the patient doesn't have, you wanna make sure that for you, it comes across as organized the patient, they rarely really care. They, they don't know that you need to ask about the, the history of presenting complaint and then you have to move on to the um other medical history and then you have to ask about their family history. The patients don't know that all the patients know is the doctors come in to speak to me as long as they're comfortable, as long as it feels to them, like you're having a conversation, whatever order you go in, it doesn't matter. So what when it says they're organized, that means for you in your own head so that you don't get mixed up so that you don't forget any red flags so that you remember to ask all the important questions. That's what when we say stay organized, that's what we mean. The patient doesn't expect you to stick, stick to a specific um sort of um first question, it has to be this. Second question has to be this and then systemic approach is good. So you don't get lost. So systemic approaches, for example, regardless what the symptom is, for example, it could be about anything. But you go for example, if someone has chest pain, now you can ask systemic approaches. So it could be musculoskeletal, it could be cardio, it could be respiratory, could be traumatic, et cetera. So having that structure will mean you're less likely to forget other things. So I know I'm talking a lot but I promise you by the end, every everything. So I'm talking a lot, I'm talking about by the end, we're gonna close everything together and everything is just gonna click for you. So handling differ, difficult patients uh may come across angry, emotional patients or family emphasize care, compassion patients. Now, when you speak to a patient, you know, the the textbook way is that a patient, you'll ask them questions, they'll answer you perfectly. And then that's it. Reality is there's a lot of we're, we're emotional human beings, we're emotional creation. So um when you speak to patients, it won't always be that they're just, you know, happy and jolly and yay, I'm so excited to speak to the doctor. Sometimes they'll be angry, sometimes they'll be upset, sometimes they've had a long waiting time. So they're frustrated, sometimes they're breaking bad news. Sometimes they've had a previous bad experience with the trust or with the ward or whatever with another doctor somewhere else. And now they're talking to you. So the important bit about good communication is you're gonna be equipped to handle all of that. Um And the way you speak to the patient, that's why mirroring is important in the sense that if the patient looks angry, I'm not saying mirror them and look angry as well because that's not gonna help. But if you can acknowledge that they're angry, you're not gonna be happy. Do you know what I mean? You're gonna be more neutral in that sense. Time management. Very important for exams. Very important in practice. If you're on a GP, you have 10 minutes for the entire consultation. So if you take a 10 minute history, you're not gonna have time for examinations or treatments or anything like that. Yeah, if you're on the ward likewise, you're gonna have, you're gonna be, be, you're gonna be uh people calling you to help them. You don't have much time. So, but with practice at the end of the day, with practice, you're gonna become, this is gonna become way more easier and uh we will practice at the end and overcoming nerves, everyone gets nervous, everyone gets er worried. What if I forget? What if the patient is angry or what if the patient doesn't give me the answers? What if I forget what I need to ask them? What if they tell me information and then I go home and I forget it. Um And that's something that again will come with experience. That's not something to worry about. Acknowledge that it is normal. One thing that helped me get over nerves, especially when I first started. And obviously this was all a new experience is the concept of fake it till you make it. You know, tell yourself that you're not, you're not nervous. Tell yourself that you're confident, tell yourself that you're ready. Um believe in yourself and your abilities. If you're, if you're, for example, the 3rd, 4th, 5th year medical student, you've been in me studying medicine long enough that you have this knowledge, you have a whole bank of knowledge and techniques and everything. So you're, you're, you're able to do it. You just need to believe and trust in yourself and every single one of you has had a conversation with other people. So every single person watching this, you know how to talk to people, you know, how to converse, you know, how to uh just speak. So if you know how to speak, then you know how to take a history. It's just speaking, but you're asking medical questions as well. So you're, you're fully qualified and capable, you need to acknowledge that you are qualified and capable of speaking to patients and speaking and asking you the right questions and just be believe in yourself. And at the end of day, no one expects you to be perfect. Especially when you're in early years, you're gonna make mistakes, you're gonna forget things. You're gonna maybe word things not the best way and then, but you, it's the learning from these mistakes, that means you'll never make these mistakes again and your skills will improve every single person that is very good at. History is very good at communication. Never started that way. They tried and they did, uh, mistakes and they failed and they, and then they worked on it and they improved and they changed and then they become better, be better and better. So, and also when I was talking about like dressing well and being confident, you have all heard that concept of if you look good, you do good. Um If you look good, you feel good and then you do good. It is the same concept. If you look professional, if you look good body language, um open body language, you are gonna look good, you are gonna feel good. And then when you feel good, you are gonna be good and it is gonna stop you from being nervous. So this is the uh this is the meaty part of the history, which is the actual t of the history. Everything that we talked about before this is stuff to get you ready to take a history and uh techniques that we are using within this history taking to make your history a very good history. And when I say that I'm talking specifically about communication so that you're able to talk to the patients effectively and efficiently get exactly the answers that you need. And then um being able to basically ask the right questions and have them feel confident and trust you enough that they open up to you because that's what it's most important thing. Once they trust you and open up to you, then they will engage in the history properly. They will engage in the treatments, et cetera. So, breakdown of medical history and just put in the chart. Have you all seen, seen this before? And is there anything you would add onto this that you think we, I haven't added on the slides that you would add? I actually won't answer. This wasn't an excuse to drink qu ice it ice. I think the water was a hit anybody. OK. Firstly, just say whether or not you've seen this sort of um presenting complaint, history, presenting complaint past medical history, et cetera. Ice can and then if there's anything else you would add. So ice is a good one. Consent, of course, very important. Yes. Have seen. OK. So concern is, is, is OK. So um breakdown of medical history. Now, when you, we're gonna think logically uh by the way, just right has everyone memorized these. Like if I if you had to close your eyes and say all of these has everyone in this chat memorized these or do you struggle and be honest, I'm hoping some of you say you struggle because I'm gonna help you or are you all just so good at history is that you memorized every single one of these as in, you don't write them down on a piece of paper. You just go in, you know. Exactly. I'm going to ask about this and this and this and this and this a few more answers and now we won. OK? So no one struggles with it. Everyone's memorized this, straight off. Not even one person struggles with history taking. I have each question I want to ask in the paper. OK. Thank you for being honest. Sometimes forget surgical history. OK? So we're gonna approach this in a very logical way. Um And that's gonna help you that you don't need to memorize this and this technique will make sure you'll never ever forget the important things you need to ask in the history. Now, when you approach a patient to speak to them, regardless of the setting, what's the most important thing you're gonna do? What's the very first thing you're gonna do to a patient? Like as soon as you walk into the, er, the room or the ward or whatever and you see the patient and the patient sees you. What's the very first thing you're gonna do? I assume you look presentable. You've got good body language. You've got a nice smile. Well, what's the very first thing after that you're gonna do exactly say hello and introduce yourself and confirm details. You want to introduce yourself logically when you go and speak to somebody on the street, you are gonna say your name. You're gonna be like, oh, hi, I am. So and so I'm Samantha MBAA. You're going to introduce yourself. It is logical because they do not know who you are. Even though you are wearing scro you got a lanyard, you might have a stat on your neck. They don't know who you are. So the most important thing is you are going to introduce yourself. And um this is OK. What is the next thing you are going to do? So you Jesus. So, hi, my name is Omar. Hi, my name is Samantha. Hi, my name is David. What is the very next thing you are gonna do? Someone said, someone said uh confirmed details. Ah OK. So hand hygiene, you know, II was gonna laugh at this hand hygiene but I was in an O station and uh it was just a history taking and one of the feedback I got was I should have washed my hands. I didn't touch the patient. I was at least a meter and a half away from the patient. But in, in the uh recommendations for, I don't know if they just didn't have anything much to say. So they just added that but they said wash your hands before any patient interaction So that's a good habit to do. So I thought how you right explain what you're going to do. Uh What the one I want is I expected most people to say is confirm the patient details, but I don't wanna put you your name. Jungin said, how are you today? And that's something that gets so overlooked when you can speak to a patient or especially in an osk setting. Er So in an examination setting, they're gonna expect you to be. Most people are robotic. They're like, hi, my name is Omar. Um, could you please confirm your name and date of birth? Like you sound like a robot. And the problem with that is a, you feel like a robot b they feel like you're a robot and the examiner feels like you're a robot. So how did you break this cycle? Because that's what most people do and something as simple as how are you today? It, it lowers their guards because most people expected to say hi. My name is Omar. Can you please confirm your name and date of birth? Especially in Osteo Center where time is critical, like you don't wanna waste time. So most people just get straight on with it and you can do that. But the better way to do this is something as simple as how are you today? And the reason you do that is it ca catches them off. God, I've spoken to patients before where I've said something like that or made like a small comment or whatever and it's almost taken them back. Um It's, they surprising a bit because they were expecting me just to go straight into it. And instead I took an extra second out of my time and ask them a personal question or ask them, how are you or ask them something of that and that shows that you care if I come up to you and I say hi, my name is Omar. Could you please confirm your name of the date of birth? You're like, ok, so this is robots coming up to me and he's talking to me and he's, he's just a robot. This is a I but in reality, if you're like, hi, my name is Omar. How are you today? They're like, oh, he's asking me about me like this guy actually cares about me. He's, he's asking how I am or he's asking have I had a long weight or, and drink some water or something like he actually cares about me. So from the get go the first two seconds of seeing the patient, they're already starting to think, oh, this guy actually or this girl actually cares about me. What's that gonna do? It's gonna help you, help them trust you more like you more so that they can open up to you and you know, comply with the treatments and whatever you're gonna talk to them about. Ok, so now you've done that, you're going to uh confirm who they are, uh expose purpose of your action. Exactly. Um So you're gonna confirm who they are, at least for the NHS, you name, date of birth. Uh So far as that and then, um, you wanna sit down, stand whatever you're doing. Now, uh we're gonna go into this little bit. So, presenting so logically a patient has come in, they've got a problem. You've done this introduction now, logically, what are you gonna do? So what brought you in today or why, why, why you're here essentially is what you wanna find out. So you target the presenting complaint and this, they call the golden minute and the reason it's called the golden minute is because the patient has a lot going on. You have no idea what the patient has, but the patient has a lot they wanna say. And so you just let them talk. It's that simple. You just give them the time and you'll find that in this one minute, they usually tell you most of the things you need to know. So you just ask them what brought you in today or how can I help you today or what's the problem? And they'll just talk and they'll tell you this and this and this and this and this and this. Now, the problem. If you write on your piece of paper that his uh present a complaint history, present a complaint past medical a lot of times you're limiting yourself to a specific, specific structure. Now, if you paid attention to what I said at the start is one of the most important things is to make them feel like they're having a conversation. So if they're talking about something and, um, they're talking about, for example, the medication they're on and halfway through, you interrupt them and you ask them, oh, wait on, on here. I haven't got into that, but I'm still on family history. So you make them go back to the family history and then later bring them back to their drug history. It's not gonna feel like conversation. It's just gonna feel like you're, you're too robotic again, you're, you're sort of too in your system. So this golden minute allows you to sort of get a big over overview of what's going on now. OK. So the patient said I've come in, I've got a tummy ache, blah, blah, blah, blah, blah. OK. So you've listened, you've given them a, a minute to speak, they express most of what they have to say. Now, they said they've got a turmeric. Now, what is a TME TME is very subjective, isn't it? Um For a patient that could mean any part of the abdomen, it could be the side, it could be um maybe somewhere else that's radiating to the tummy or they'll say I've got stomach pain, do they actually mean the stomach? Do they mean the colon, do they mean the liver? Do they mean et cetera? So you need more information, right? And that's where the history of presenting complaint is because they said they got a tummy ache. That was their presenting complaint. But that's not enough for me because what is, what is a tummy ache to them? So, now you need more information about the tummy ache and that when you think like that, you know, ok. so I've done the, the, the presenting complaint. Now I'm gonna do the history of presenting complaint. Now, has everyone here heard of Socrates for getting extra information on the presenting complaint. Yes, yes. Or has anybody used a different uh Pneumonic when it comes to asking specific questions about the presenting complaint, because there's a few of Pneumonics. Socrates is the main one that we use. So what is Socrates, the Greek philosopher? Yes, the Greek philosopher. But in this context, we are talking about the Mnemonic Socrates. OK. So no, so what Socrates is just because it's a easy word um to remember, I'll break it down for you. So s so each letter in the word Socrates refers to a word that basically gives you all you need to know about the pre the history of presenting complaint. Just this word Socrates, every letter in it represents a word that tells you everything you need to know about presenting complaint. So what does the s stand for Socrates is sight so logically when someone says I've got a tummy ache, you need. The first thing everybody's curious to know is where, where in your tummy, you know, your torso is quite a big region. So what is the sight s for at sight? So they're gonna tell you here or here. The best way I find is, can you just point to where it hurts the most rather than tell them which area and then they have to tell you, you know, the top right area or the, the bottom left, but closer to the middle, just say, can you point to where? So that's the site? So, no, OK. So logically, we've, we've established that they've got a tummy ache and it's in this region wherever it is. What's the next thing we wanna know? How long have you had this for? Like when did this start? So that's what o stands for onset. So as the site, oh, is onset? So the onset, when did this start? Oh, this started? Because it's important if, is this a problem that's been going on for years? Is it a problem that has been on for seconds for minutes, for hours? For, has it come on before and come back again? So, so first you find out where it is, that's the site and then the onset. So when did this start? It started two hours ago, it started three hours ago, it started last week and then it went away and then it came back. So it's important. Ok. So they've got a tummy ache and they've said that it's in this region and it started this morning. What else we need to know? Like, what does it feel like? So see, for characteristic. So we know it's here and it started this morning. So what is it, is it a sharp pain? Is it a stabbing pain? Because different types of the, the characters, different types of characteristics of pain can tell you what the differential is like a crushing pain in your chest or maybe like a AAA sharp stabbing pain or um like a numb pain. All of these have different reasons as to sort of give you an idea of what it could be. Um You know, what can somebody in somebody that knows what Socrates is for the, to help other people? Do you want to just write out what Socrates is? So s equals something or equals, so equals onset, see these characteristics and then, um that will help people that uh would rather have it written down. Ok. So we've done, we've done so the patients come in, they've got so much pain and um when did it start? It started this morning? Ok. Cool. So what does it feel like? Characteristic? How, because you won't know what it feels like? So you need to ask anybody can do it, you know, like someone put it and deleted the site. You are right. So, um, So they told you it happened this morning and it's like a stabbing pain or it's like AAA sharp pain? OK. So then you go on to RR is radiation, meaning what meaning that does the pain go anywhere else. So history present this Socrates can be used for pain but it can also be used in general. So where does it radiate to? Is it? So you said it starts here but does it go to anywhere else again, that can give you hints? Is there inflammation? Is it a different region or is it um uh somewhere that's spreading a problem that's spreading and then a a is associated symptoms. Thank you, Mira A is associated symptoms. So for example, if they have abdomen pain, which in this scenario, they do you want to ask them about other things like for example, um have their bowel habits changed? Has their water work? So their urine has changed. Have they had any weight loss? Um Have they had any bloating, for example, so things that are that could be linked to this, have they had a fever? So you ask about those sort of whatever it could be if it's a a head injury, for example, have they had uh visual problems, hearing problems, taste problems, et cetera. So tea is timing T and O are usually used interchangeably but tea is, for example, um has the timing changed? So has it, for example, started as a very achy sharp pain and then it went down a little bit and then maybe it came back but it came as a different type of pain. And does it go away and come back or is it constant? So you, it's, this is just trying to get more information. E is exacerbating factors slash alleviating factors. So, does anything make it worse? You often find patients, for example, um, er, they, they'll do something and it will help them, for example. Um, so in epiglottitis, for example, in the inflammation of the epiglottis, you'll find them in a tripod position. They lean forwards. Why? Because that helps them, er, breathe a little bit more better. So these sort of things, um, and then, er, severity, severity, er, which is just as simple as on a scale of 1 to 10. How bad is the pain and pain is subjective. So a, that gives you an idea of whether you need to manage the pain right now or not. And b, if you ask them now and they say it's a six and then you ask them in an hour and they tell you it's a 10, you know that, ok, this has gotten a lot worse. Their 10 could be, for example, a three to you, but for them, they started as a six and they became a 10. So for them, that means it's gotten a lot worse. So that's why. So that's what Socrates is. So logically, we've come in, spoke to the patient introduced ourselves, asked them what's, you know, what's going on? They told you you got tummy ache very broad. So you ask specific questions. Now, from this alone, you have a pretty good idea of what this could be. I promise just from these first two things. So using sos, you know, exactly, pretty much what the patient has. But you know what, now that we've established sort of the, the characteristic of this presentation. What, what else do we know? Do they have any problems, medical problems already that could be, um, causing this? Like, for example, you take all this history and then it turns out, for example, they've got inflammatory bowel disease and this is just AAA, sort of a, um, a flare up of it, right? If it, so this would put your job. So you don't need to think of so many differentials if you sort of have a pretty good idea of what it could be because they've already had this before. So, yeah, ask the past medical history. Um, often you ask someone, their past medical history, they might say I don't have any and then you ask them, oh, what about your BP? And they'll be like, oh, yeah, it is a bit high. Do you take any tablets for it? Yeah. Ok. So they have hypertension but they might not think of it as a, as a, or they might think. Oh, because it's controlled I don't really have it. Um So you have to be specific. Likewise with their stomach, for example, do you have any, anything? Uh do you have any medical history? If your asthma is too broad, they might, they might forget to be honest. Uh They'll be like no, yeah, any respiratory problems. Oh, yeah, I do have asthma. So it is important uh to be specific. So if they have abdomen, ask specific, do you have any other problem? Do you have any problems in your abdomen that you're aware of any conditions? No. Ok. Anything in your heart? Depending on the age of the patient, you should always ask about heart lungs, et cetera. And uh someone said earlier, they forget surgical history. This is the perfect time to ask surgical. It's not, you can put it as its own bracket, but you can include it in past medical history and they had previous surgeries if say they have abdomen pain and then uh they had a previous surgery in their abdomen. You could think, oh, maybe this previous surgery has caused adhesions to happen now. And that's what's causing their abdomen pain. So it's a surgical history is very important because a it means that um they had a problem of some sort before that had to be surgically fixed. And b it could mean that this repair, this surgery has caused them, these symptoms next family history. So, ok, you ask them about their abdomen, they tell you, they've got, you ask them why they're here. They tell you your abdomen, you get specific information about the pain and what the pain is like. Then you ask them, do they have any other medical conditions that could be related to this, that could cause this et cetera? And also it helps you in. If you wanna give them treatment, you wanna make sure that you're not giving them something contraindicated to what they're being treated for. And then to make your life easier, you want to say like maybe this is something they've had in the family, they have abdomen, abdo pain for whatever reason in the family. So you ask family history, any family history of any medical conditions. And again, you can be specific, anything of the abdomen, um anything with the heart, the lungs, etc and avoid using a medical drug. And like there's no need to say respiratory, just say any problems with your lungs. Um And then social history. Now this is just a generic. Um So GPS. So this is just a message members will receive cheat sheets at the end of this workshop. Uh So be sure to fill out the feedback form to receive this. If you aren't a member, leave us your email address and we'll get back to you. Ok. So um social issue is one of the most important things um that people usually only ask, do you smoke and do you drink? But there's a lot of things that you should ask that are quite important. So, social history is basically everything that's not what's in here already that we've spoken about. So, smoking and drinking are very important. Um, and when you ask them, you need to be specific. So if they say they smoke, ask exactly how many cigarettes and for how long they smoked and drinking likewise, they might say, oh, only occasionally and then you ask them. Uh, so how much do you drink? And they'll tell you, oh, I drink four bottles of beer every day. For example, um, I don't know if that's a lot. Uh, six, we'll say 10 bottles a day, but that's for them. That's occasional, that's light. Um, but, uh, for example, objectively in a medical sense that might be a lot. So you need to quantify exactly. And not just how much they drink what they drink. So, different alcohols, for example, have different concentrations. So it's important to ask what they drink and how much they drink. And then you can calculate, is it above the recommended limit or below the limit? Diet? Again, diet is very important. What type of food they eat? Um, because their diet can, has a big effect on a lot of medical conditions. Um, so this is also important for the treatment. Usually a lot of treatments you can tell them if you just control your diet. Um, this will help in your condition. So it's good to ask in the history what their diet is like and likewise, that ties in with activity levels and occupation. Why is occupation important is because a if they're ill, can they still work? Um if they can't work, how are they going to survive without an income? Do they have sick pay? Do they not have sick pay? How are they gonna manage, you know, with their kids and all of that if they can't, if they can't work, um, because of this medical condition b has their job now or in the past caused them to, um, to develop a medical like asbestos exposure. Er, so they have respiratory problems and they used to work, for example, in demolition of houses. So there's a risk they were exposed to asbestos or a farmer, for example, er, exposed to fertilizers with chemicals in it. Um, or like a pilot, for example, um, they need, for example, good vision. So have that problem with their eyes. You need to know their, because you need to know whether or not uh, they need to inform their employer pets as well. Pets. So there's a lot of parasites you can get from pets, er, from their feces, um, that affect the eyes and the brain and the, and the lungs as well. Uh, any allergies and stuff like that. So, pets is a good one and holidays, does anyone know why holidays is important to ask if they have been on holiday recently? Why is that important? Like why is it, are you, are you just being nosey or is there a medical reason why you ask? Have you been on holiday recently? Pe Yes, what else can holidays do? Endemic conditions? So, when they go in different countries, so different countries have different infections, different countries have different. So they're all right, essentially um diseases. So you can have different countries have different rates and levels of certain diseases. So for example, um you can go to another country that has parasites included. Yes. TB. So some countries have high prevalence of a certain condition that you don't have it in this country. So for example, we don't vaccinate for it cos it's very, very, very low rate. They go to abroad and they catch something there and they come back, you ask them where it is and then they tell you, oh, I went to so and so country and then, you know, in so and so country they have high rates of this disease. So then you do some tests for it. So it's important to know where they've been. Um because then you can sort of see what have they caught if they have caught anything from abroad and likewise pe and stuff like that as well. So, drug history. So now that we've spoken to the patient, we sort of have a good idea of what the problem is. We have a good idea of um er, their current medical conditions for the medical state, their medi past medical history and their surgical one, they, you know, their family, whether or not they have any diseases in the family, you know, you have a good idea of their social history. You need to know that. Do you take any medication? Uh, so you ask them about medication and so a lot of times you'll ask them, um, what medication are you on any medication? And they'll tell you a medication and then it, when you, when they tell you what this medication is, you realize that they have another medical, uh, condition that they haven't told you to begin with. So you asked about their past medical history, they told you, for example, I'm on nothing. And then you ask them for their drug history and tell you, yeah, I take a blue inhaler every day, for example. And then, you know, oh, so do you have problems with your lungs then, and then, and then that helps you remember if you missed to ask about anything specific in the past medical history and allergies is very important. Never forget allergies. Allergies are very important. You need to know. Um, it's hard to mess up though because when you're doing, uh, a drug chart, you have to take the box for allergies. So you either have to say they have allergies or you have to say they don't have allergies. So it's something that you'll just you won't forget and you have to ask about over the counter as well because a lot of people, when you ask them, are you on medication? They'll think of prescriptions. But in reality, a lot of, a lot of medication you can buy over the counter over the counter and these can have interactions with medications that you want to prescribe. I purposely being very generic of not being specific. A because I don't want to confuse people. Um B um this is like such a good sort of foundational er history breakdown that you can apply for everything. When you do psych history, there's extra things that you need to ask. When you do a pediatric history, there's other things you ask as well, but this is like a fantastic foundational sort of history. Um Like for example, a 90 year old patient could be taking Ibuprofen every day over the counter to her. You asked to do, are you on any medication? She says no, because she's not prescribing anything. But then when you ask her, do you take anything over the counter? She tells you I've been taking Ibuprofen and she's come in with Abdo pain. OK. You got to think or maybe she's got ulcers um systemic review. So red flag. So this is usually something you would ask anyway. So when we talked about assoc associated symptoms, you would ask it there. Um But it's its own thing because it is very important. So, a systemic review. If you wanna be very generic, you can ask them about every single. So you can ask about their cardio, their vascular, their respiratory, their musculoskeletal, et cetera, et cetera, their renal. Um You can do that. Um Usually though you'll be more, you'll ask a systemic but more relevant. So if um so you ask it more relevant to whatever the condition. So if it's abdomen, you usually, you, you, you will ask about their renal, you'll ask about their livers, you'll ask about their intestines, et cetera. Like you will be specific in that sense. Um and red flags stuff that chances are, it's not this, but we have to rule this out because if we don't, then it's detrimental to the patient. So when we say red flags, like for example, asking questions about cancer, um that doesn't mean the patient has cancer, the majority of patients won't have cancer when they come see you. But it is something you absolutely have to rule out because if you miss it, it's detrimental to the patient. So we rule it out as standard, even if it's unlikely the patient has uh has this red flags like a cancer. OK. So I hope this was like a very sort of specific uh in depth. Um And I know it's a lot of information, but if you try and train yourself to just look at this be like, why are we asking these questions? Understand? Why are we asking these questions, then it will help you in. Um um So that you, when you don't write it, cos if you do write it, you're gonna stop writing it from today. So you're not gonna write everything, you're just gonna remember it and this will help you remember it by asking logically. So if they have any medical histories, past medical history, does their family, what about their social history? Do they smoke? Do they drink? Have they been abroad? Et cetera? Uh So just think logically about it and I promise you, you won't struggle so common or is missing red flag symptoms again, red flag symptoms, that it just means that if you miss it, it's detrimental. Um but it doesn't mean that the patient is gonna have that. Uh but it is something we ask to rule out failing to ask about key parts of history. If that happens, it's not a problem initially because especially as preclinical, you can just go back and you can double check with the patient. You can come back even in practice if everyone makes mistakes, no one's perfect, you're gonna go back and you're gonna speak to the patient again, asking leading questions or being too focused on the diagnosis. That's a problem you have especially early on. They tell you they got abdomen pain, for example, right, lower quadrant, you're gonna take appendicitis and that's all you're gonna think about. That's a problem. You wanna, you wanna have that, put it in the corner of your brain and then ask them other questions and be generic. Open questions. Don't try and make them say they sort of come to your conclusion. You wanna sort of be as, er, as, er open as you can not balancing open and close questions when you first start good rule of thumb when you first start open questions. So what have you come in for? Can you tell, tell me a bit more about your abdo pain, et cetera? And then when you ask and then later on the consultation, are you on any medication? No? Yes or no. Are, are you taking anything over the counter? Yes or no? Do you have any allergies? Yes or no. So you start usually with open questions and then you go on to closed questions. So interactive time. So we're almost near the end 58 year old male with chest pain. What uh what are you going to want to ask and find out? So, just comment uh a few important things. So what are you gonna want to ask and find out if someone comes in with chest pain? You always want to start with a red flag. I, you're gonna do Socrates? Yes. So that alone will tell you where, how long they've had it for? What does it feel like? Um Socrates is really fantastic. How long they've had it for? Has it changed? What's the characteristic of it? And then when you go into differential diagnoses, what are you thinking of when you say chest pain? Just quickly write out a few comments. We're almost done. Socrates. Yes. Past medical history. Give me some, give me some differentials. Heart attack. That's a red flag. Then the best way to tackle this is you got to think you all know enough lung cancer. Am I angina? There's so many ways, but the problem is there's so much going on cost, costochondritis pe M IC O PD. Anxiety. So there's so much going on. How do you sort of um how do you organize these thoughts? Just remember your anatomy? So someone comes in with chest pain, what do you have there? You have the heart. So it could be cardiac, you have blood vessels, it could be vascular, you have your lungs there, it could be um respiratory, you have muscles, it could be muscular. God, esophagus. Is there your stomach sort of lies there? So systems review. So that's that, that is exactly what I was going for. You go, you do a systems review basically. So you to determine your differentials just know what is there. So if this h this area hurts what an anatomically is there and then just ask questions about that. Ok. Fantastic. Like every single person who has, has said the right things. I think there's only one or two more examples. So a 78 year old female with loss of consciousness? What are you gonna find out if a 78 year old think of the age loss of consciousness, even the gender that can give you a hint. What are you going to ask and find out? So if someone comes in with old age and loss of consciousness, were they alone? We did someone witness them lose conscious? How did, well, who found them? Who did someone call an ambulance? Did they hit their head? Was it a witness loss of consciousness? Hypoglycemia dehydration. These are all differentials, epilepsy when it happened. How did she fall? Her her? Exactly. So you need, you need more logically. If someone comes in and they old female lost conscious, you need to ask a lot of questions about what you know, you need more context. How when exactly red flags did she hit her head? Has this happened before duration? What were they doing? Yes. Medication. Exactly. So there's a million reasons. These are very broad but it, it helps to make you think, try and organize your thoughts. So if someone said lost conscious, what does that even mean? Loss of conscious? Did she fall and lose conscious? Did she lose conscious and then fall or did she hit her head? Did someone see her? Did she just lose balance? Did they, do you know what I mean? So you want, you basically, you, you wanna be like a detective always asking why how, what happens? Give me specific details sometimes you feel like, oh, I'm asking too many questions. You're not. There's no such thing you ask as much questions as you can because the more details your questions are, the more you ask about, the quicker you get to an answer. Diabetes is exactly all differentials. Now, uh fourteen-year-old female with change in bowel habit, what, what, what do you need to know? So when they said change in bowel habit again, these are very broad questions. So you want to narrow it down? What do you mean by a change in bowel habit? What exactly was your bowel habit before? What is it now, how long has this going on for? What are some differentials? C A? Why are some differentials for someone with a change in a young girl change in bowel habits? In fact, tell me what the red flag is. What's a red flag? IBD, IBD? What's the red flag with this one weight loss? Ibs, blue mucus. So Marina said the C A blood mucus, celiac, Celia blood in stools, diarrhea. So exactly. So basically these are very, very, very generic. All of these are right? Ce celiac is very common in this age group in young weight loss. Yes, blood, yes. Um, like for example, cancer is very unlikely in a 14 year old female though very unlikely, but it is something you have to cross out why? Because it's unlikely. But if it was, then you wanna rule it out straight away because you don't want it to progress. What is it most likely? Ok. It could be, it could be CIA it could be IBS IBD uh gastroenteritis. There are more probable glucose intolerance. Those are more probable, but you have to rule out the red flags first. Oh, conclusion. So what we have learned today and I hope you've all found this beneficial whilst I tell you the conclusion, can everyone just write? Um, So when we first started a lot of people wrote us on, on a scale of 1 to 10, how confident they are. There was a few eights, a few fives, a few fours, sixes just write roughly where you are. Now when it comes to history taking. Um when it comes to history taking and communication in general, it starts from the very 1st 2nd they speak to you cos communication isn't just about the words you say, it's about how you, how you hold yourself, how you carry yourself. So it starts straight away from just how you present your body language. That's, that's still part of communication. You wanna speak. You wanna introduce yourself, you wanna be friendly, don't worry about it. Make jokes if you can not like you're not a comedian, but you can make jokes, you can be easy, you can be comfortable, lean back, sort of be relaxed because that's gonna help you. Um And then you wanna ask, you wanna have structure in your head, but you want the patient to feel like they're just having a normal conversation. So if the patient goes on and they talk about, you know, a bit of family history, a bit of drugs, a bit of XYZ and they lead at the conversation on with that, carry on with it and then go back to what you wanted to ask, let them carry the conversation and then let them, but you also have to control the conversation so that you can not a waste time. And b they don't want him to go on a big tangent. You wanna come back glucose intolerance at 14 years of age, a female, 14 years of age unlikely to have glucose intolerance. Um, at 14 uu, unless you mean diabetes. Um, is that what you're referring to be? Oh, diabetes. Yeah. Ok. Yeah. Would it cause abdo pain? That wouldn't be the main symptom. So if they come in with just a sorry, a change in bowel habits, it probably wouldn't be diabetes. Um, there's other things that they'll have, usually they'll have, uh, DK or something like that metabolic, er, symptoms before they'll have change in bowel symptoms. But it can, they can have change in bowels, but that wouldn't be the main symptom of it, but there's no harm in thinking that, um, and ring that out, but back to the conclusion. So you present yourself, you speak to the patient, you talk, um, um, you, you, you, you let them sort of. So if the patient starts talking about something and then they mention something else, you can elaborate on that something because it helps them think they're just having a normal conversation. And then obviously you go back to what you need to Socrates is very important. Um But the most important of all this is just practice. If you practice, I guarantee you you'll get better. The reason why consultants are very good at history. Taking it takes them two minutes to do to take a history while when you go to your GP placements you'll speak to. You'll see the GP in a consultation within three minutes. They finish the history within two minutes. They've done the examination, they've submitted investigations and they've given them a treatment before nine minutes. Why? Because they've done this so many times. So just with practice, take on board, what I've said and then just practice and I guarantee you you'll feel so much more confident. Um And I believe that is the end of the talk. So is there any questions, write them down? No worries if there's any questions, write them down and um, Princess or read, I wanna close up the, I do apologize. I run up a little bit but we started five minutes later as well. Thank you so much, Omar for this wonderful talk. Um Thank you. Also everyone for coming and engaging and participating with us tonight. Um Please do fill in the feedback forms which will be available to you now. And you'll also get your certificates when you've done that um crib sheets will be available to our members and this will be sent over the next few days. Again, please do follow us and medo and also our Instagram and to keep updated with everything that we do with our future events and also our future um communication skills workshop and we look forward to seeing you again next week. Uh The feedback form will be sent over. Yeah. Thank you again, Rona. All right. Thank you, everyone. All right. Thank you, everyone. Hope this was beneficial for you. Make sure to fill in the feedback form um which will be sent automatically after the session ends. Uh take care and hopefully you will all be amazing doctors and healthcare workers.