 Welcome to this workshop about communication. In this case, patient-doctor communication in context. With the question in the back, is there only one solution about how to communicate well? I'm Evelyn van Veel from Nijmegen in the Netherlands, and I'm giving this workshop on behalf of each International Association for Communication and Health Care. Thank you very much to the hosts, Wonka, for inviting me to give this workshop. I'm very happy that so many of you are still taking the time in this one before last session to join us. And I'm aware of the fact that the people who are coming in now missed my first words, so I'll say welcome again. And this presentation is given on behalf of the collaboration between Wonka and each International Association for Communication and Health Care. This was originally meant to be a plenary workshop, and let me see what's in the chat. Ah, okay. That was my question asking you to please put on your videos. It doesn't seem to be working because I don't see any faces. But let me proceed anyway. I see many nice pictures of familiar and less familiar faces. I was asked to give this workshop when we were still hoping to meet alive in person a year ago in Abu Dhabi, and then now in Abu Dhabi in person again. It would have been a 90 minute workshop. It has been reduced to an online workshop for 60 minutes. And I'm going to try and do as much as I had intended to do when we met live, although some of the format will not be possible. But I'm going to still try and make it as interactive as possible. So sharing my plan with you, first of all, welcome to all of you. We'll be introducing each ourselves to each other in a minute. I'm going to do that through the chat and ask you a question in a quiz. Then I will be introducing each. I'll give a few slides on effective communication in general. And in this case, not interprofessional like Lawrence Dormans, but professional patient communication. We'll do a skill spotting exercise. I will show a video for that. Talk a little bit about structure and giving information. And then the main discussion will be on context and on cultural differences and the consequences for communication. So let me proceed and I will be doing this alternating PowerPoints, but I will keep the PowerPoint slides up with questions for answering in the chat. So you can answer everyone personally can answer in the chat and we can all see the answers. If you open the chat function, which will either be you will find it by hovering over the bottom or the top of your screen depending on the settings on your computer. Sometimes we'll have large group discussions and I see it's already quite a large group. So that's great. And sometimes I'm going to ask the organization to allocate breakout rooms. And then you can chat with your colleagues about something that I'll ask you or give you an issue to discuss. But let me move on first to the introduction so we can familiarize ourselves with the functions I'm going to use in the chat function function. Could you please write your name and the country you're from your front and I'll do the same. So I'll go to the chat myself now and write my name and my country. So if you could please do that as well. And then press the enter button. And make sure you send this to everyone. So I already see Joseph doing it. And I hope a lot of others case from the Netherlands is their high case. And Sirot from Thailand. Fantastic. And keep on doing this while I'll talk on because it's great for others to see what countries are represented in this workshop. Somebody from Italy. Great. So I'll move on but keep filling out the chat. Then as I said, I will also use breakout rooms. And when I use breakout rooms, you will see this icon. And in this I when you see this icon, you will be automatically allocated to a room when I asked the organization to do so. And also brought back into the plenary session when it's time. And I will give you a question to talk about in the breakout room. And what I want to do is ask you during this first breakout that we'll have in just a few seconds to appoint a scribe or a speaker, whatever you want to call that person to answer the questions either in the chat or in the plenary when I invite that person to do so. And of course there's also this little hands up function, because I had hoped that I could see your faces or your hands coming up but doesn't seem to work. So if you put up a hand, then we can also identify who is described and who would like to speak on behalf of the whole breakout group. Before, before I am going to ask the organization to send you to a breakout group in this first breakout. I'm going to show you a quiz question. And I'm going to show you a diagram for that. And in that diagram, you will see four groups. And this is the slide and you can draw a quick diagram yourself. This was a study performed in the Netherlands among GPS family physicians if you want treating patients with depression. And in this study the GP the family physicians were divided into two groups though skilled in communication and those not. And the other intervention they looked at was the, if the GPS applied the intervention for treatment of depression adequately. In this case, they made an accurate diagnosis prescribed antidepressants in a correct dosage and for exact length. And of course these were four groups then GPS were skilled in in communication combined and not skilled combined with the other two. So in your breakout room and I want the organization I hope the organization can allocate those present over various breakout rooms please discuss this and for each of the boxes one, two, three and four discuss if you think they were effective or they were not effective and which boxes were effective. Okay, great. Welcome back. And I was informed by now I'm getting videos as well that's great to see your faces. So that's wonderful. I was informed that room three was quite full. So I would like to ask them scribe of room three to inform us about what they thought I hope you had a lively discussion first of all. But I would like to know what the outcome in your group was of the four quadrants of the diagram. So who is the scribe of room three. Can you wave your hand on top there is or on the bottom there should be a wave hand thing. So, Karim can give you the microphone. Yep, so now all participants are able to unmute themselves so please if if you if you have a response for Professor Evelyn please just unmute yourself. So who was going to speak from room three. So what we think how Dr. Maria Alexander. Hello. Hello. Good morning. And thank you for the topic is, I think it's really important for each of us as a primary care physician to know how important is communication in our daily life. What we conclude is communication is the most important part for the GP skill in communication, because it's the step one in every treatment that we provide for our patients. Even if the patient know the treatment that he's going to receive but if we don't communicate well to explain the why and what we're going to give. So we cannot obtain a better outcome. So you thought that which which quadrants were positive were effective. The first one. Okay. Actually, the first one is also applying medical content correctly, because it's sort of bringing together the top ones. Okay. Because we have a little lack of time and some technical problems at the start I'm going to move on and then when I have other questions I'll ask another scribe to report. So I'm going to show you the outcome as the study was done. You were entirely right. As you can see here in this study, the group of family physicians who were skilled in communication combined with applying the intervention adequately. Those were the only ones who were effective after three and 12 months. So, actually the messages you need both your medical content, right, as well as your communication. So you cannot just apply the intervention adequately without communicating well because then you won't be effective. That wasn't this study, of course, but that's the main message. So I would like to continue with introducing each now because communication is so important. A number of years ago this organization was founded initially as a European organization. Now it's an international. It's called each international association for communication in healthcare. And it's a worldwide organization with the overall aim of promoting effective evidence based patient centered healthcare communication between patients, relatives, and healthcare practitioners. I'm not going to read the rest of the slide because I'm going to invite you to visit our website when the conference is done and you see the website address down here. And before I forget to say whoever is interested to receive the presentation and perhaps other information you can drop me an email my email address will be at the end of this workshop. So moving to another slide about each. Again, I'm not going to read everything but each offers a lot of resources on communication. It brings together teachers researchers and practitioners and the arrow I've put there because we collaborate with existing relevant next works and associations. That's in fact the reason why I'm here because there is a collaborative relationship between Wonka and each and we've developed projects together. And that's what we hope to continue doing and probably you've seen on the Twitter account courses coming through from our organization etc etc. So again, I'm inviting you to visit our website after the conference. To make this a sales talk so I would like to move on to the content subject and talk a little bit about evidence about why communication is important and what makes it effective. And Lawrence Dorman was talking about interprofessional communication. I'm now talking about professional patient communication. And like in this case, I mean, I know I'm talking to the already converted because as family physicians you will always try to communicate in a patient centered way with your patients. The system has changed so much. There are so many things we have to do at the same time, often lack of time. So sometimes communication effective communication gets a bit lost in all the things we have to do in a day. So it's good to once and then talk about it in detail again and go back to basics and that's what I'm doing now. Of course you all know that adequate doctor patient communication and of course I mean professional patient communication contributes to a more accurate diagnosis you already concluded that from the quiz question I gave you. You get a better adherence to treatment and more effectiveness, less problems in patient safety, less legal issues and lower costs and there is evidence for all of these aspects. And it's the quality of the communication that has that effect. And it's not just about satisfaction, but you can really measure better outcomes on a lot of these outcomes when you communicate effectively. And it also reduces costs and there are studies that show that costs are lower because of fewer diagnostic texts because of fewer referrals. So our recent body of research I would like to point that out to you is that fewer contextual errors are made when you communicate well. And I would like to point you to a very nice video that you can find on YouTube. And again, if you ask me for the presentation you can find the link. These are studies performed by Saul Wiener. And this specific video is a talk he gave for our past each ICCH conference in September where he talks about studies done on these contextual errors very interesting studies. So the quality of the physician patient communication is important throughout every encounter you have with your patient, but it's only effective if there is a mutual understanding of each other's exploratory model of illness and disease, taking into account that patient perspective. And of course the expectations of the patient, the patient's ideas concerns and expectations and you find a common ground that counts for information gathering, shared problem definition, and for information giving as well with a shared plan. So communication is not just soft. Even in this conference I heard a lot of people talk about soft skills and I don't really agree that communication is soft, because words really have healing power. Words and how they are used cause cognitive and emotional changes in body and brain. For those of you who are interested, please have a look at some studies done by Benedetti and his group in the placebo studies and it's fascinating to see what he shows really happens in that body and in that brain when you use words differently. So for example, empathy, expressing empathy in a really genuine way helps patients with better outcomes and they recover more quickly. This was a study done by a few of my colleague researchers in the Netherlands and they showed that effective statements reduce anxiety and uncertainty and temper emotional arousal. So you all know that if you're less emotional, there is an increased recall of medical information. So you remember things better. And in this case it only took 38 seconds more. I hear a bell I don't know what it is. I hope I'm not overlooking something but I'm not getting a signal from the organization. May I kindly request all participants to ensure that they're muted please. Thank you. Okay, I think I can move on now. In fact, everyone always says it takes so much time but in this study, these effective statements only took 38 seconds more and what's 38 seconds on a lifetime. But still, in a busy practice in busy health care systems, you're a lot of doctors and definitely your colleague specialist will still say that it costs too much time. And I would like you to become active again and answer these two questions in your chat function. Take two minutes minutes to answer this question personally. Do you think personally that responding to cues your patient sent takes too much time yes or no. And how much longer in process in percentage. Do you think that your consultations will take if you respond to cues and I'll give you two minutes to answer this in the chat. You'll see that it's working. If you look at the chat you can see your colleagues a lot think it doesn't take longer personally. And some think that consultations might be a little bit longer sometimes 20 to 30 seconds sometimes four to five minutes. And of course, when you do a study like this. There are every consultation but they looked at averages. They just keep writing. We're always done almost done with our two minutes. So I'll show you the solution please keep writing it's no problem I'll show you the solution now. Actually this where some studies done you probably all know the studies done back in the past by Moira Stewart, and also by Kaplan who said patient centered consultations are not longer. More recent studies somewhere consultations of GPS and of surgeons were tested and actually responding to cues made their consultation shorter GP consultations by 12 and a half percent surgical consultations which are usually already short by 10 and a half percent and also an oncology between 10 and 12 and a half percent shorter. So that's really worthwhile and might be because patients don't have to repeat each other. They listen better to what you say, et cetera, et cetera, but it's worthwhile to respond to cues. And if you want to do so. It's also important that you don't get lost in a patient narrative and to be able to capture medical and patient perspective and of course the contextual data and use your communication skills adequately. You sort of need a structure in your mind. So again, please go to the chat function and think of those core basic communication skills you're doing this every day. Can you take a moment? I don't know. It's mine now. Apologies. I'm going to stop the bell. Can you take, let's say one and a half minutes to write as many core communication skills you think of that you use every day in the chat function because you're doing this every day so it shouldn't cost you much time to do this. And just imagine a patient, an average patient that comes to you with a new complaint. What skills will you be using? What core communication skills will you be using? I see listening. Definitely. Questions like how can I help you? So that's an open question. Listening, clarify, empathetic attitude. Great. So while the answers keep coming in, I'm going to show the next slide. So these are a number of the skills you already have mentioned. So open questions, of course, moving along your consultation to more closed ones, attentive to listening, facilitative responses, pick up on cues, clarifying, time framing, et cetera, et cetera. So yes, this is actually what you need to do, but what is also important while doing so is not getting lost in the patient narrative. So get your structure. And I think that's the next slide I would like to show you, it's that you sort of need a model of structure in your mind. And this one is on the left side providing structure on the right side, building that relationship using the communication skills. While you go through a sort of the structure of a consultation where you start, you initiate the session, you gather information, if necessary, you do a physical examination or another kind of testing. And then you inform the patient about what you think is going on and do more planning. And then you close the session that counts for every consultation where it's information gathering or information giving it might be only part of this. You provide structure on the left hand side and at the same time you build a relationship with your patient using appropriate nonverbal behavior, developing a rapport and involving your patient as much as possible. And of course that means shared decision. This model is called the Calgary Cambridge model but there are many other models out there as long as you have a structure as well as core communication skills. So I'm moving on to the next one, well done. Of course there are lots of challenges there. You have patients of a different culture when patients are very emotional for example when you're breaking bad news. In effect you use the same core communication skills, but you just use a little bit differently sometimes you need a little more time. Sometimes you need more time, more silences. Sometimes there are other things you need more you need other help. AIDS and everything. So a lot of things you might do a little bit differently but it's usually just dividing your skills and your time a little bit differently but using the same basic core communication skills. I don't know about it a bit more when we're talking about culture, but I would very much like to have a little bit more time in the breakout rooms and I can't see a clock unfortunately about how I'm doing for time. So I hope Karim can inform me when you are in the breakout room, because what I want to do first now is show you a video it's a four minute video we'll watch that together. I'll give you a little instruction and then you go to the breakout rooms. So first, Karim will show you a video and that will run for four minutes. It's between physician and a patient with a mental health problem. It's only four minutes of a longer consultation. So you won't get the full picture. But what I would like you to do while you're watching the video is right into the chat. You can see the communication skills you see this physician using and the symptoms he is collecting because he is using these communication skills. And that's the only thing you have to do while writing, and then we will now start showing the video and after that we've seen the video will go to breakout rooms but I'll repeat the question. So while you're watching the video please also write into the chat. Karim, can you please show the video to all the participants. Mr. Rounds. Yes, hello. Hello, my name is Dr. Tarbek. Nice to meet you. Thank you very much for coming up today. What I'd like to do over the next 10 minutes or so is just to talk with you and find out a little bit about your problems and how you've been recently. Would that be alright? Yeah, okay. Perhaps we could start off just by talking about what's been the trouble at the moment. What's been the worst problem for you? I'm not sleeping very well. I wake up a couple of times during the night and it takes me a long time to get back to sleep if I can get back to sleep. I'm usually wide awake by five or I'll pass five in the morning. Alright, alright. And can you get back to sleep again after that? No, I usually just lay in bed and get up a little while later. I used to sleep like half past seven or eight o'clock. So that's two hours earlier than you wouldn't usually wake up. Yeah. I don't feel any more tired. Just wake up and I don't know why. Get back to sleep. I can't. Are there any particular things that are worrying you at the moment? Well, I wake up and think of Dorothy. What we achieved together and our life together and then I start to miss her. And I feel all upset. Yeah, upset. Could you tell me a little bit about Dorothy? Who is she? Oh, she was my wife. Been married nearly 50 years. She died six months ago. Oh, I am sorry. Yeah, it was all very sudden. She had a stroke and was unconscious and never recovered. That must have been a very difficult time for you. Yeah, it was. But our Linda, she was a good girl. She came around and she helped a lot. Linda is your daughter? Yeah, she's our eldest. Yeah, she lives locally so that was quite useful. She came around and helped my hand if I needed it, which I did. Still do sometimes. My Dorothy. You must miss her a great deal. Yeah, I do. She's still sort of in my mind and my heart, but just not there physically. So, unfortunately, you lost your wife six months ago? Yeah. Can you tell me a bit about how you've been feeling since then in yourself? I think I lost interest in most things. I used to go fishing and bowling with my pals, but not really interested anymore. I don't see much. They keep asking me out and I say, yes, I look in my diary and see when I can come, but I forget or don't want to get back to them. Right. So you've become rather more isolated recently? Yes. I see the boys occasionally and Linda comes over a couple of times a week. She's very helpful. She helped me do the housework and I've got no enthusiasm for anything anymore. It's strange. I never thought I'd be like this, but... Can you take any interest in life at the moment? When you turn the television on, what is it? Murders, stabbings, war, muggins, fires, riots? It's also depressing. So, in the small group, could you please discuss what you think was going on and also what symptoms were gathered and if you have an idea about what's probably going on. It's not the full picture. What skills you would use to explain this to the patient. And again, I think we can go to breakout rooms and maybe we make it a little bit shorter because I think we're probably a little bit short of time and I'll have to cut down on some of the activities later on, but can you allocate breakout rooms to these people now where they can discuss this? Yes, of course. Would two minutes be okay? Yeah, it's fine for me. I know it's short, but then we can continue in the large group. Ladies and gentlemen, I'm assigning you all to the breakout rooms. Please accept to be inducted into them. Thank you. They won't hear me talking. Will they know? Whoever is still with us and has not joined the breakout rooms will be able to hear you. Okay. I just wanted to know how much time I've left because we started late and I'm a little lost in how much time I have. That's okay. Let me just follow up because after this session we have the opening ceremony and we need a little bit of time to set up for that. So initially we're supposed to end your session at 7.30, which is less than that. No, yeah, 12 minutes. And we have a 15 minute buffer. So I will try to extend as long as I can. Okay. But if we can end it by 7.30, that'd be great. If not, then I can push up to 7.35. Okay, so 17 minutes. I'll try to skip the detailed slide. And because there was one more discussion item that I would like them to discuss. I said 10 minutes on the slide, but it will be much shorter, but at least so they can add some cultural differences in the discussion. And I think that's probably better because then we won't lose time. So I'll do that and try to get back on track as much as I can, but I might need a few minutes more. So if you can allow me a few minutes more, that would be great. If not, then I'll just promise them that they, but they have to send me an email because when this closes, I can't see the chat and take out their addresses from there. Right. Okay. I'll do what I can from my set to extend. Great. Thank you so much. Workout to the breakout rooms. The time was over. Would you like me to bring them back? Bring them back. Please do. So they'll be in, in 25 seconds. Yeah. That's great. I will let you know as soon as they've done. Yeah. For your reference. Rooms number one, three, six. Seem to have enough participants for a conversation. So I would address my questions to them. Yeah. That's one, three. Six. Six. So I'll go to one then because that's different group. Okay. Okay. Yep. Just every, tell me when everyone's back. Everyone has his back now. Okay. So can welcome back. I hope you had a nice discussion. I know it's short and I'll have to cut down on the breakout rooms because we're short of time. And I would very much like to discuss. Discuss culture as well. But first I would like someone from one. To report on what they thought was going on and what skills they were. Would use in their group to share that with the patient. So information giving. Is there someone from group one who would like to. Inform the whole group. About this. So open your mic. If. You're willing to do that. If you're willing to do that. If you're willing to do that. If you're willing to do that. You're willing to do that. Can you see Kareem if somebody is coming in or otherwise somebody from another room who is willing to talk. Maybe that's maybe any of the video participants. Yeah. The participants for their videos open at the moment. Would you like to speak on behalf of your group. Dr. Larry. Dr. Seirat. So I think I waited long enough. So then let me just. Move on. Not as not to lose. That much time. I believe Dr. Seirat has. Answer your question. Okay, great. Great. Please do them. Yeah. We think that he's going through the assessment of his. Last. Of his wife. Whether he has depression and whether he will. What kind of treatment the patient will need. Whether medication or supportive. Supporting system. It seems that he has family close to him. Who can be supportive. And. It's need to be assessed. Better not. Any medication to. For his illness. Yeah. So actually what you're saying is that he gathered a lot of symptoms and it might be a depression. Of course, this was not the full consultation. And then he needs to explain this. And. Come up with a plan. And I think the most important thing is that the patient is involved in everything of this. So thank you very much for your. Suggestions. What I would like to do now is show you. The skills for information giving. Of course, there are broader areas. And if you have attended the plenary lecture in which Lawrence Dorman. Talked about the patient that was. Number five in his 10 point communication plan. It was, it is about giving as much information as possible. And in this case, it's not. As much as possible, but it's as much as possible for every patient. Because you need to provide the correct amount and type of information that helps with an. Accurate recall and understanding. And of course it means that the patient has to understand what you're telling them. And you have to go back and forth in a dialogue to make sure that happens. And for your plan, you also need to do this in a shared decision. There's a lot more to be said about this. I have some handouts about the details. And I had a slide, but because we're short of time, I'm not going to discuss this in detail because I would very much like to discuss the detail of the cultural issue, which was the most important part of this workshop. And I'm not going to do it in a breakout room because again, that costs a lot of time. And I had, I need to finish on time for the last session. I was required to do so. So I'm going to take the risk. And I know it's a very big risk in this, in this context to have a large group discussion rather than a breakout session with you. Because I'm going to ask the question is. I've talked about basic communication skills, core communication skills with open questions and expressing empathy and silences and all of this. I've talked about giving information and giving information, making sure that you do this in a, in a dialogue with your patient, then that you chunk and check and give information and palatable chunks and that your patient is involved. So you know what he does understand and you continue your information giving from there. So a lot of things you need to do, but a lot of what you do might also depend on your own setting, the context you're working in, the cultural setting you're working in, et cetera, et cetera. And of course on that individual patient, you are discussing this with at that particular moment. So normally I would have had you discussing this in a 10 minute breakout, but we just don't have the time. So I want to open the floor and ask you to unmute yourselves and everyone who wants to add something that is different in their culture. So in your culture, what communication skills do you use in a different matter because of the context you are working in? And just to give you a little lead to make you understand what I mean. So when I worked in Japan, and I'll show you the projects when we almost finished the presentation in let's say five minutes, it was very necessary to use, to express empathy in a different way. Because in Japanese, in Japan, they use many more words when they express empathy. Then for instance, in my own culture where you have a lot of silence and allow the patient to come in with feelings and express feelings, et cetera, they really needed more words. So that's a different way of doing the same thing, but correct in that specific context. So who wants to add something that they do differently in their context? Please open your mic and add it in words, so we can all hear it. Is it possible, Karim, can they unmute? Yes, professor, everybody's able to unmute. Okay, so don't feel shy. Please add because we can really learn from you because we only communicate in our own context with our patients and can learn from your examples. When we work in Uruguay and China, I learned that many times patients will simply would like us to guide them or give them what to do rather than them leaving or sharing their thoughts. So this happens a lot in certain context. Yes. The interesting thing is that the same was the case in Indonesia, but then when you ask patients and invite patients to contribute, they sometimes do, but of course it depends on the hierarchy of that specific person with you. If there is a lot of hierarchy, they probably prefer you to tell them what to do, even if in their heart they would like to be involved. That's very, very, very interesting. So I would love to read more about your cultural context. Is there anyone else from another setting who would like to contribute? Africa perhaps or I don't hear anyone. So let me move on then. Is there someone who was trying to share? Yes, this is Bola Fatusi from Nigeria. Okay, great. I just want to share that in my practice setting, if it were to be a patient with an opposite sex to the doctor, maybe a female to a male doctor, who are not expected to look at her face, not touch her, maybe when you are communicating, you want to show sympathy or empathy. Don't touch. You can have some other doctor with the same sex, maybe a female doctor, to talk to her. She will be more open to that doctor. But if it is a male doctor, if a female with depression is seen as a male doctor, it will be very difficult to really help her in my practice setting. Thank you, that's very interesting. Great to hear more about that. I don't think we have the time now, but please share your information on chat or over email. Thank you so much. I would like to move on to the last few slides. The question at the beginning was, is there only one answer to effective communication, how to communicate effectively? And in fact, there is and there is not. I would say yes, because you all use the same core skills, but the other thing is that you might want to organize them differently. And like we just heard from a colleague in Africa, with a female patient, she will have more effect, but she will be using the same communication skills. So the other answer is no, because you have to sometimes use them in a different way. So it's yes and no, there are more than one way, there are more solutions, and it all depends on the context about how to use your communication skills. And I think that's important. We need to keep listening to that and to keep being aware of that. I'm moving on to the last few slides now. For the ones who asked the presentation, they can read the other slides in detail. What I want to point out to you is that because of the collaborative relationship, we have shared projects. And we've done a few, we've been working together for a number of years now, and there are two projects, one in Moldova and one in Japan that we have actually published about. And if you're interested, read these publications in PEC, patient education and counseling that report on the difficulties and the barriers and obstacles, but also the successes we had there. And for those of you who are interested in these projects, are definitely still possible in your country as well, if you want to collaborate and have a collaborative relationship with each. You can become a member. Wonka members get a reduced membership of each. So that can encourage you to do so. And the other thing I want to do is invite you to join each and to visit our next conference, hopefully in person in September next year in Glasgow. Otherwise we also had two online conference like this one, but we hope to be meeting each other in Glasgow next year in September. And I hope we can have some colleagues from some new colleagues from Wonka joining each and perhaps set up some projects together where we always try to combine medical content with effective communication. I know this was very short. If this would have been a live workshop, I would have had at least 15 minutes more and see your faces and be much more effective and efficient than I was now because of the technical problems. But I'm very happy that so many decided to join this workshop at this difficult hour at the end of the conference. So thank you so much. And I'm moving to my very last slide. If there is a final question, send that to me over email because I can always enter the answer over email. I can't see the chat anymore then. And if you can also over email, send me one communication aspect that we discussed during this workshop that you would like to remember and apply in your practice. And if not, that's okay too. Because as I said, I was preaching to the already converted. I know you're using many of these skills all the time. And still it's interesting to learn more from each other and that's why I wanted to point out the two publications for you because we learned surprising things in co-creating training and discussing these things with each other. So thank you very much for your attendance. I hope many of you will drop me an email on the email address below so I can send them the presentation and be in contact with them. And thank you all for being here and also Karim for guiding me through with all the technical problems and making this at least work for most of the attendees. Thank you and have a pleasant closing rest of the conference. Bye-bye.