| Code | Stakeholder | Stakeholder profile |
|---|---|---|
| R | Researcher | Clinical experience (<5 years) of treating LBP |
| Pa | Patient | Patient experience of LBP and related surgery (<5 years) |
| Ch | Chiropractor | Clinical experience (>1 years) of treating LBP |
| Phy1 | Physiotherapist 1 | Clinical experience (<1 years) of treating LBP |
| Phy2 | Physiotherapist 2 | Clinical experience (>10 years) of treating LBP alongside patient experience of LBP and related surgery (>5 years) |
Ad verbatim transcription
R Okay, so, um, this is a patient/ clinician focus group. So, I'm not specifically looking at your personal experiences, it’s more your ideas about the principle regarding the research that has been done on people with back pain, and how it's carried out in practice. Um, so it's really important that research works together with patients, together with scientists and with clinicians, so that everyone's got a realistic kind of outcome, because it's all very well people in universities thinking of great ideas, or even in hospitals, but if it doesn't actually apply to the population, it’s pretty redundant. So, using patients with, you know, together with everyone, is really important. So, it's definitely essential to have that meaningful research, okay? So, the first question then is really, going round in turn, can you introduce your name and give only an outline with regards to any professional or personal experience of lower back pain and sciatica- so that's those leg symptoms that sometimes happen. Should we start with you Liam?
Phy1 Um, my name's Liam, um, and my experience of back pain, honestly, mine was just, um, I just tried to pick something up I think, I can't really remember, and then I felt like my back was like AH! Oh! I'm cooking, because I tend to cook a lot, and then I'm standing for a long time, then I don't really do a lot of movements, and then I get pains in the morning. But mine goes away like for few days and after like, what, three days, or even two days, it doesn't really last for long.
R And what about your professional experience?
Ph1 Professional experience, I've seen a lot of people with back pain, a lot [group laughter] of people with back pain. And it's that kind of, like, same thing, picking up an object. Recently, I just had a guy who was working Amazon and then he was trying.. he picked up an object and he was fine, working … working. And then one time he just sat down and then stood up and then next minute his back just went, and he's been having that for over four months and then it's ongoing. And then quite a lot of people, same thing, picking up, and then waking up the next day, pain, and then since then it's ongoing back pain, that isn't going away, that it’s being, now classed, as chronic back pain, because it’s after three months.
R Okay, okay. Have you received any specialist knowledge or training about back pain?
Phy1 Um, yeah, from uni, but not too much… he he… and from here.
R Okay. Thank you. Okay. Great. Thank you.
Pa Hi, so my name is John. I'm in my 50s now, and I've had a few various, I guess, back incidents over the years. Um, most of them, up until three years ago, have been minor really, and silly things. I’ve picked something up wrong- I've hurt my back. Sweeping things- I've hurt my back. But normally that pain has gone away within a day or two, and there's been no significant problem. Three years ago, erm, I had an incident that came from jumping out of bed too quickly. It was ridiculous. The doorbell rang and I was in a hurry to go and get to the door, and jumping out of bed with suddenly crippling back pain. And, um, and that disappeared over a day or two, um, and it developed into something else completely different that I didn't understand at the time, which was I was starting to have problems with my leg. I was having numbness in my foot, and I was having various problems in my leg and, um, I honestly couldn't figure it out. I lived with it for probably two weeks or something like that before eventually going to see a physio, thinking I got a problem with my leg. Um, they did tests on me and said, no, no, no, you need to go and see your GP and or A&E, like urgently, you've got dropped foot, you've got a loss of strength, you've got loads other things going on in your leg. This is a problem. Um, and that situation developed over a period of weeks to get increasingly worse. So the pain wasn't in my back, it was in my leg but it was stopping me from sleeping, it could stopping me from moving, I was getting more and more disabled in my leg and in my foot, and ultimately having end up having back surgery to remedy that, and it all came from a herniated disk essentially, and problems, problems with that.
R Yes, yes, thank you.
Pa Sorry… very quickly, I'll go on, but that happened for years ago. that I recovered after the surgery, perfectly, but then about six weeks ago, I did the same thing again. Um, and exactly the same spot, and it was sort of sneezing this time. It's not been as bad, but I have had significant problems with mobility and significant problems with pain over the last few weeks, and I'm still suffering to a degree now.
R Yes, ok, thank you.
Phy2 Okay, so have you sought help?
Pa Er… yes, but most of that help has been in the form of medication that had given me to be able to me to sleep, because that was actually my biggest problem this time. Er, um, and sort of pdf’s of exercises to do each day.
Phy2 OK, so have been assessed and you don't have any like foot drop or anything weird and wonderful this time?
Pa I don't have any foot drop this time, the numbness that I have in my, I still have some numbness in my foot in my leg, but that seems like that's just what was left over from last time. It doesn't seem…
Phy2 Right, so you have not got any worse essentially?
Pa No, so I don't think that has got worse. and the sciatic pain has gradually got better over weeks. And so yeah, I've got to a point now where I'm still being super careful about certain things, I'm still changing my lifestyle because of it. Um, but I'm, as I sit here right now, I'm not in pain. Sleeping; I’m sleeping ok.
Phy2 Cool, OK so I’m Catherine. I worked in outpatients for about ten years, something like that, so I've seen lots of people with back pain and that radicular pain; bilateral leg symptoms where you thinking, oh OK get down to A&E; or just that mechanical back pain where it's a mechanical overload issue, and they just need to reintroduce that graded exposure to load. I've actually been on the escape pain class, but I'm not allowed to do classes here, which is hilarious.
R Ha ha [group laughter]. Too senior!
Phy2 Yeah. Uh, my own personal experience with back pain is I had a benign tumour since I was late teens, that didn't get picked up until I was 33, I’m 38 now. It went into cauda equina. That was fun times. I had like emergency surgery, and they didn't quite seal me up right, so I ended up having like low pressure headaches and horrendous leg pains that took them to two years to admit it was a problem and then they fixed it. Now I'm great. Living the dream!
R [Group laughter] That's quite a journey. Yeah.
Ch I'm Sarah, I work as a chiropractor, um, fairly new to the profession, like a year and a half. Um, personal experience of back pain has been very low- risk activity- related, um, nothing too severe, no neurological symptoms, but in terms of treating patients, seeing people with, um, sciatica, varying levels, varying risk presentations, always working within private practice.
R Okay, thank you great. Okay. So, as a group, using the post its and pens, could you map any events on a timeline for a person with lower back pain or sciatica? For example, you could put a phone call to the doctors. So, as a group, come up with different events on a timeline for a person.
Phy2 Oh, so we are not doing it as an individual?
R No, do it as a group. Okay? So yeah, please discuss as you, as you, do this, yeah.
Phy2 So, we just talk about a typical person and that goes to their GP and then slowly gets referred to somewhere else.
R Or it could be- it could be any route that they come through- treatment or no treatment. What's their journey from, presumably, when the pain starts? That would be one of them, wouldn't it? What kind of things happen on say, a typical person's journey? Yeah.
Ch Shall I do an ouch? [Group laughter]
Phy1 Self-referral?
Phy2 Or seeing a private clinician? It doesn't have to be physio, it could be osteopath, chiropractor, GP, could be literally anyone, or seeking help.
Pa There's definitely a stage where you don't really do anything. You’re kind of like, lie in bed, or stay on the sofa, you know, you might take time off work, but before seeking any medical attention.
Phy1 So wait and see?
Pa Yer. Exactly that. Yer.
Phy1 Uh huh.
Pa If you all could write nice and big, that would be amazing and use a new note. I will take a photo of your post its when I'm finished. Okay. cool. I guess that’s somewhere here, is it? [moving post it note] Anything else?
Ch People asking friends, family, ‘Is this normal?’
Pa Yer. Absolutely. Dr. Google.
Ch That's a big one. That is a big one.
Phy2 So searching for answers? Do you trying to put it as that one?
R [long pause , people writing] Okay. Is there anything that happens before the ouch point?
Ch That’s the mystery.
Pa I guess one thing I'm conscious of with my particular example, is like how much you look after yourself, I suppose. Which is, what core exercises are you doing? Are you doing yoga, you doing stretching or whatever, you are doing those kind of things. And if you had done those things, might none have staved off the ouch happening. Um, but for me personally, I think there's a sort of ‘life gets in the way’ and you stop worrying about it when you haven't got problems and so on and so forth. I’m not sure how to define that in a phrase or two, but…
R Self- care?
Phy1 Active lifestyle?
Pa Yeah, I guess so. Yeah, that's one way of dealing with it, an active, but in some cases, not an active lifestyle, it's actually can be quite sedentary and you're doing work and whatever. Then life gets in the way of being active and doing the exercises that you perhaps know you ought to be doing.
Phy2 So that’s everly more increasing in say the Western world where you sit on a toilet, you sit in a car, you barely move, you’re sat in an office. Not really being very active.
R So that is a non-active lifestyle then?
Ch So it could be active and non.
R Oh ok… yup... so we see self- referral…getting help… what goes on after that? Is that it?
Phy2 Get assessed. Potentially get advice. Do you listen to said advice?
Pa I would be more likely to speak to a pharmacist or someone probably, before I spoke to a medical professional as such.
Phy1 Ah ha, painkillers.
Phy2 Assessment, advice, education.
Pa And put one for pain relief.
Phy2 So I put at some point, so you've been referred to somewhere and you get an assessment, get advice, education, but you actually engage with it? [Group laughter] Query engagement. You can need a horse to water, you can't force it to drink. You know sometimes people come up with a load with mental gymnastics to explain things. and if you don't hit that expectation of what they were wanting to hear, they just won't engage. And you were saying, well, you seek, say before you do this bit [points to postit] you’d seek a sort of pharmacist sort of thing.
Pa Yer probably, yeah, save the grief.
R Okay.
Ch And then sometimes there's gonna be a waiting period.
Phy2 Yeah, sat on a massive waiting list, especially becoming if you are coming here.
Phy1 Hmm…. six weeks.
Ch Which, in my experience leads back to this stuff [points to post it note]
R OK, so the ‘the wait and see’ and the ‘Doctor Google’ and the waiting period after referral, self-referral, is interchangeable. Okay?
Pa mean, if you're not getting an emergency, GP appointment or going to A&E, you can easily be a week before you speak somebody or see someone face to face. And that's quite a long time if you're having real problems with mobility or sleep etc.
Phy1 I think for some people they end up going to A&E, even before they come in to...
Pa Its true, it's often the only way that you can get seen by someone, properly, quickly.
Phy1 Oh yer or the local minor injury unit.
Phy2 And then, alternative therapies.
Phy1 Or private massage.
Ch Yup.
Phy1 Hmmm… osteopath? chiropractors?
Phy2 You can get osteopaths on the NHS as well.
Phy1 Oh really?
R Okay, so, well, what’s coming after this, then? [points to last post it] What's sort of … is that the end of this sorting?
Phy2 Are you going down the engagement route? Or are they going down the ‘you didn’t tell me what you wanted to hear’ route?
[Group laughter]
R There could be two branches, I suppose.
Phy1 Yeah, so education too, if they engage, then this changes the pain or reduces the pain with a lot of education. If no changes then, you go for classes, and that's a six week period.
R [pause] Okay? Yeah, good. And what about the non-engagement then?
Phy2 They might seek alternate means, they might rely more heavily on medications, or they buy braces, they do all sorts of things or the alternative therapies or massage, where they feel they're having something done to them rather than just being spoken at and not listened to.
Ch I think, like you said, if they don't get that trust in that point, or that very specific way that they want to be spoken to, they quite quickly go back to other things. Looking sometimes for just what they want to hear. And I find that depending on how long that wait period is also depends on their receptiveness to what's being told.
Pa Yes, if you have waited several weeks and all you get is a sheet of exercises, you get a bit disheartened.
Phy2 Yes- it can be frustrating.
R Okay. So is that the end points then, for someone with back pain?
Phy2 What? Who is engaged?
Phy1 Once they were engaged, and they've been to back class.
Phy2 There is a miracle cure, post- back class? [Group laughter]
Phy1 Well, they, because of the education they get, they, um, kind of like carry on, managing their back pain, and then some people end up going to like the gym, for example. The last back class: when people gone to gym, some people gone to classes, some people have gone to things that would keep them active.
Phy2 So it is the long term behavioural changes you're looking forward to with the escape pain, isn't it? That's why there's so many sessions over that period of time, I think you have to have a minimum of 10 sessions out of the 12 to get that behavioural change, according to the evidence behind the class, I think. Which is why it's so heavy on advice and education, as well as exercise. You are trying to get them to listen, learn, and then think ‘how do I then deal with this long term?’ But again, it’s not for everyone, not everyone adheres to it. At the same time, it might not fix someone's pain or their perception of pain. And then it can lead into further chronicity.
Pa Yeah, I think the, yeah, the outcome if you like, the experience they're having if things are getting better, or if they're just staying exactly the same, its like changing people's perception and engagement with it. If you're doing these exercise every day for two months and you don't feel any improvement, I think you're quite likely to stop doing the exercises.
Phy2 It is a bit of a hard sell telling someone to do something they're not interested in doing, especially if they're in pain and it's not going the way they want.
R So, can we just focus back, we will definitely come back to these points. Happy to finish with this? Do we feel we've got all our ideas there for our timeline?
Ch I think you have to show with the bad side of, um, if people don't sort of finish in a good way. Just leading to…
R OK, yeah. Would someone be able to take a photo of these before me, please? Oh, we have got one to add. Liam’s got one to add [movement of post it].
Pa I don't know whether there's other things that people do and whether you need to cover off all of those, or if you are happy to generalise them, but I think people go to the gym, I think they go to physio, they go to I think someone mentioned chiropractors. There's all these weird and wonderful things you might try and do, so I don't know whether you need to capture all of those or just when you've got some of these alternatives
R Okay. Right, so on to our next question. When can it be harder for patients with lower back pain or sciatica to engage in treatment? So thinking about the timing.
Phy1 I think it is after, like for me, after they come in, and then they come in for a follow up and they see no improvement in their pain then that's when is a bit difficult, cos they're like, oh, I come to seek professional help and I’m expecting a miracle, and then they come back and then there’s, like, no changes in my back pain and I feel like it's getting worse, and then it is very difficult to get them to engage even more, because they are like, it didn't help the first time.
R Okay. So just after the follow up into the next, after the first assessment?
Pa From my personal experience, I don't think there's much given from the GP or wherever you get advice from as what the outcome should be. I think that's almost like half of the problem. If you were told, if you do this the outcome will be that, probably, or it could be this, but there's a range of options, whatever it might be, then you'd know where it's supposed to land, I suppose, and you might feel better if you're being told, ‘Well, it's gonna take at least six weeks to do anything’. Well, you'd know, have to four weeks, of course, its not done anything yet. But me personally, I didn't get that at all. It's just kind of do these exercises, come back in six weeks, if it's not improved, and that's all you get.
R So it's quite hard, it's quite hard early on in your first stage to engage,
Pa Yes, I guess so.
R Because you don’t know what your end goal is?
Pa There is, I guess, as a member of the public, there is ignorance over what my injury is, what the outcome should be for this, how long that's going to take, what does good look like, what does bad look like? A sheet of paper doing some exercise does not cover that.
R No. Any thoughts you two?
Phy2 Sorry, are you talking about when?
R Sorry, it is the question when could it be harder for patients with lower back pain or sciatica to engage in treatment?
Phy2 I think it all depends on the person and whether they're ready to receive what you're offering at that time. So a lot of people are looking for potentially imaging or some sort of firm diagnosis. But if you look at most of the evidence, you don't need that. If you don't need surgical management, you don't need to be scanned to see if you need surgical intervention. But trying to explain that to people is very difficult, especially if they've been going on with it for a long time, or they've not had their expectations met. So it's trying to address the expectation and explanations. So as you didn't get your explanation, you had no idea at what stage things would improve, and you just given one sheet of exercises, which typically says, do three sets of ten or something like that, with no progressive overload. Three sets of ten might have been way too hard to begin with, but really easy at the end, but at the same time it might just be too hard and you give up, cos you think ‘I'm in a lot of pain this is making things worse.’
R So it’s that sort of individualised sort of thing.
Phy2 You need to be given then a tailored program with advice and education, which isn't just, ‘here's my generic sheet that I hand out’ which often is what you get, in a rushed situation. It’s that, GPs, I feel sorry for them, you’ve got five minutes per patient, you’ve got to see, balance of probability, is this something serious or can I just give you the sheet and refer you on somewhere else? It’s very difficult.
Ch And I think like you said, pain being a massive barrier, and misunderstanding the hurt versus harm kind of rhetoric. That's quite hard to communicate to people, um, when they are in pain.
R Okay, so next question, patients can be stratified as low, medium or high risk of psychological responses to their back pain. This makes their condition more likely to be persistent. At what stage would a combined exercise and psychological programme be most beneficial for patients at medium risk of persistent back pain? So, shall I read that again?
Phy2 Is on this time-line, yer?
R Yes potentially, or if you thought of something new? Is it right after the first episode of pain, would that be a good stage to do a combined exercise and psychological programme? Or is it another stage?
Pa It really depends. For me personally, the second time I did it, psychologically it was actually really quite bad, because it was like ‘oh, I've done this again.’ It was incredibly bad last time and I ended up in surgery. I don't want that to happen again. And also this feeling that this is now something that's going to keep on happening the rest of my life, and perhaps get worse. And so, yeah, it would be beneficial very early on, I would say, in the process to get some kind of discussion on that.
R Yeah. OK. Are we all agreed? [pause] Yeah?
Phy2 Yeah, without the waiting lists and things like that, the sooner you can see someone, the easier life will be for them, whether it's chronicity or development of symptoms, it's the earlier you see something that better the outcomes typically would be.
R So that's early to see someone, but about how early you get a group programme? Would that be inappropriate early on?
Phy2 We are all weird and wonderful aren’t we, so like, if you're at a stage where you potentially be disruptive to that class or you've got a lot of negative thoughts in your head, and you're not appropriate for that group setting, yeah, you’d be bad. But if it's a case of you're an average Joe, you've got mechanical back pain, you're a little bit worried about it, but you're keen to engage and you’re keen to discuss things. Perfect. But it's that you know, we're all weird and wonderful, you can't just give out that one label for everyone. So you have to work out would they be useful in that class, in a way that they're gonna engage with it, or are they are gonna be a barrier to other people engaging, which is very difficult situation to find them.
Ch Yer, I think you're mostly to judge their initial engagement to see how they're gonna respond to the group based programme potentially.
Pa But for some people as well, and I know for me, there are stages of this process when you're in so much pain, you're not going to a group class to do anything. Like, you can barely make it across the room to go to the toilet. So you're not you're not going anywhere, have to do anyone or see anything. So, it's where, how would help like that, psychological help, might actually be quite comforting and useful at that stage, but you're not going anywhere to do that in a group setting.
R Yer, okay, so next question, can you discuss what factors overall would promote successful engagement of patients in a combined exercise and psychological programme? Repeat.
Phy1 I think a lot of education.
R Education about the condition?
Phy1 Yer, um, about back pain in general.
R Oh, ok, prior knowledge is really important?
Phy1 Prior knowledge…really important...
Pa And as I said, knowing the, having an explanation of it, and then knowing the expected days or outcome, is actually a really good thing to know. Yeah, it definitely needs to be communicated, I suppose, that this is the programme, this is what we do, this is typically how we treat back pain, we have a lot of successes with it, whatever it might be. From my experience, this has never really communicated at all. So, so, I wouldn't, I wouldn't know where to join a group because it's never been offered to me, and I wouldn't know the benefits of it because I've not been told it. So that could happen at any stage, but it needs to happen. And it doesn't need to come from an individual, it could be a web page, you know, it could be anything that you can read and go, oh yes, this is what I need to get involved with.
R Okay, so knowledge and prior knowledge, yup, okay.
Phy2 Yeah, so I would agree with the readability, and credibility. How accessible is that information? And then is it given in the correct manner? So there's lots of misinformation out there, isn't there? At the same time you read off a trusted source like potentially the NHS website or your doctor's websites, something along those lines, where they can stratify you’re potentially in this area, this will hopefully help you, and that will get the ball rolling a lot quicker than the ‘I'm sat at home, barely moving, everything sore, and I'm sort of fear avoidance’ which is that… People end up in that situation all the time, like, you know, when my bad back was bad, I waited to the point where I needed an emergency surgery, when I should have known better, but you do mental gymnastics to play it off as something that it isn't. Or you seek help from someone that potentially doesn’t know what they're talking about. There's loads of different reasons. At the same time, if that information is readily available, then people can access it freely, great.
Ch Yeah, definitely the accessibility. Um, and also just, is this before they go into care or when they're having the sessions? Sorry, I don’t understand the question.
R So what would promote successful engagement of patients? So we do have patients that drop out or can't attend. What could, what else, what could help with that?
Ch So it was, I would say, more simple stuff like a warm and encouraging environment where they feel listened to, is quite important for successful.
R Are there any personal factors that enable patients to engage? Do you think, um, so you talked about a warm environment, social contact, that sort of thing. Are there any organizational factors that help? I think we've talked about information sources.
Phy2 Are you talking about impoverished area, so you if you are from an impoverished area are less likely to be able to get up to somewhere, can't get transport, things like that?
R Access, yer yer.
Phy2 Is that what you are talking about?
R Yeah, yeah, that could be, that’s a barrier, isn't it, I guess. So, you could help with that.
Pa Are these things sometimes done digitally as well? So if someone is unable to physically attend, they can still get something else?
R No, not here no, but I think nationally yes.
Phy2 Nationally, yeah. It is a sort of postcode lottery, so depending on what services are set up in your local area, you can get very different options. Here, no.
R Ok. Good. So just to conclude then. Is there any anything important that we've missed that we should have included to discussed about? Anything you want to add?
Phy2 I think, with the access part of it. So, the outreach to sort of more sociable areas, so gyms, like village halls, things like that. Anything like that where you're getting people in a more sort of a local setting and they can outreach to it, I think it's far more important than having what this hospital model is, which is, let's have a central hub and everyone has to come to us. I think there should be outreaching into communities and making it easier and more accessible. Having smaller hubs, more spread out rather than one big hub, and thinking ‘you’re the clinical expert and everyone should come to me.’ Well so not everyone can, especially if you're struggling, if you knew there was something in your village hall just down the road, you'd probably struggle there, rather than let’s say, go and sit on a bus for 45 minutes or whatever, or get in the car, which I'm struggling to drive. What is your accessibility like, really?
Pa Yer, I mean I agree with some of the accessibility, and for me personally, I'm thinking about gyms- and a lot of people go to gyms- and they're already paying a subscription. They probably already have classes in that, and I don't know whether there's outreach from the NHS to those organisations, I suppose, and the trainers and instructors with them so that they could actually offer similar services.
Phy2 Some gyms do, but it's the gym that has to invest in it rather than the trusts, or the NHS trust that helps them. So, example, in Oxford, we outreached to the gyms and the council based gyms used to run Escape Pain and they used to do loads of classes, and we used to just feed into it like, perfect, you know, it was just a case of us giving them patients and then they would be encouraged to use the local equipment…
Pa Yer yer that’s right.
Phy2 …use the local facilities, meet people in their own area, who were struggling. Whereas up here, there's no real social engagement at all. But however, said that, if you are member of say Nuffield, things like that, they do offer classes and things like that, and have their own in-house physios. So it's all about what’s accessible to you locally. Unfortunately this hospital as a whole does not really outreach, whereas there are some gyms that have been sort of progressive and thought about that.
Phy1 I will say, definitely, accessibility in terms of like making it digital. Um, I remember Torbay they have like videos on, like a lot of information videos about what to do, how to do things, even like exercises in that videos, so that people can engage with them at home, so they're not having to come to a particular session to be involved or anything. So, I think putting them out there on like a website, as you already said, its really good and an ideal one to have.
Phy2 They have also got the reconnect to life website in Torbay which is really useful for the more chronic people. Torbay is very progressive compared to here.
Phy1 They are really good.
Pa And even if they are just giving out instructions, rather than a PDF, honestly, a richer media would be really helpful. Like, my wife does a lot of yoga, so when she sees me doing these things, she's like, ‘oh, that's that pose, you're doing it wrong, you need to do it like this’. I've never done yoga in my life, so I don't know what I'm doing. So, watching a two stage, you know, two photos of A and B isn't really enough, [group laughter] whereas watching videos from a few angles would be much more helpful.
Phy2 The sort of Chinese whispers that comes associated with giving someone a PDF. [group laughter] The amount of times, I have to give people PDFs because we have no real outreach or stuff. If I give you a set of exercises, I'll get you to come back and then see what you've been up to and I say two, three, four weeks, whatever its been, and the amount of times people have just doing random stuff, because that's their interpretation of what you've given them. Because they've got no concept of what you've actually given them. So it's then trying to get them to drill it in front of you and then say, ‘do you understand? Right, let's have a bit more of a chat and then show me that again.’ See if they actually understood it. But a lot of people, due to time constraints, don't have that ability to do that. So people go away and then potentially waste X number of weeks, or give themselves a bit of a mischief doing something they shouldn't have been doing. Or they get it right, and you're like, great, but it maybe it was a long set of exercises, try something else.
Pa Yer. Lots of issues.
Ch I was just gonna go back to that idea of trying to find the people, trying to implement the group based programmers early as possible, whilst also finding the people that might not help the group, um, which is difficult in an ethical way, I guess to do.
Phy2 It is certainly difficult trying to weed out people like that.
Ch Well yer, exactly.
Phy2 You can't get it right every time.
Ch And predict the future of whether they'll change their perspective.
R Okay. Good. Okay, thank you. So, um let's all stop there, I really appreciated your time. Thank you so much for ideas I didn't even consider- really, really good.
R Okay, so, um, this is a patient/ clinician focus group. So, I'm not specifically looking at your personal experiences, it’s more your ideas about the principle regarding the research that has been done on people with back pain, and how it's carried out in practice. Um, so it's really important that research works together with patients, together with scientists and with clinicians, so that everyone's got a realistic kind of outcome, because it's all very well people in universities thinking of great ideas, or even in hospitals, but if it doesn't actually apply to the population, it’s pretty redundant. So, using patients with, you know, together with everyone, is really important. So, it's definitely essential to have that meaningful research, okay? So, the first question then is really, going round in turn, can you introduce your name and give only an outline with regards to any professional or personal experience of lower back pain and sciatica- so that's those leg symptoms that sometimes happen. Should we start with you Liam?
Phy1 Um, my name's Liam, um, and my experience of back pain, honestly, mine was just, um, I just tried to pick something up I think, I can't really remember, and then I felt like my back was like AH! Oh! I'm cooking, because I tend to cook a lot, and then I'm standing for a long time, then I don't really do a lot of movements, and then I get pains in the morning. But mine goes away like for few days and after like, what, three days, or even two days, it doesn't really last for long.
R And what about your professional experience?
Ph1 Professional experience, I've seen a lot of people with back pain, a lot [group laughter] of people with back pain. And it's that kind of, like, same thing, picking up an object. Recently, I just had a guy who was working Amazon and then he was trying.. he picked up an object and he was fine, working … working. And then one time he just sat down and then stood up and then next minute his back just went, and he's been having that for over four months and then it's ongoing. And then quite a lot of people, same thing, picking up, and then waking up the next day, pain, and then since then it's ongoing back pain, that isn't going away, that it’s being, now classed, as chronic back pain, because it’s after three months.
R Okay, okay. Have you received any specialist knowledge or training about back pain?
Phy1 Um, yeah, from uni, but not too much… he he… and from here.
R Okay. Thank you. Okay. Great. Thank you.
Pa Hi, so my name is John. I'm in my 50s now, and I've had a few various, I guess, back incidents over the years. Um, most of them, up until three years ago, have been minor really, and silly things. I’ve picked something up wrong- I've hurt my back. Sweeping things- I've hurt my back. But normally that pain has gone away within a day or two, and there's been no significant problem. Three years ago, erm, I had an incident that came from jumping out of bed too quickly. It was ridiculous. The doorbell rang and I was in a hurry to go and get to the door, and jumping out of bed with suddenly crippling back pain. And, um, and that disappeared over a day or two, um, and it developed into something else completely different that I didn't understand at the time, which was I was starting to have problems with my leg. I was having numbness in my foot, and I was having various problems in my leg and, um, I honestly couldn't figure it out. I lived with it for probably two weeks or something like that before eventually going to see a physio, thinking I got a problem with my leg. Um, they did tests on me and said, no, no, no, you need to go and see your GP and or A&E, like urgently, you've got dropped foot, you've got a loss of strength, you've got loads other things going on in your leg. This is a problem. Um, and that situation developed over a period of weeks to get increasingly worse. So the pain wasn't in my back, it was in my leg but it was stopping me from sleeping, it could stopping me from moving, I was getting more and more disabled in my leg and in my foot, and ultimately having end up having back surgery to remedy that, and it all came from a herniated disk essentially, and problems, problems with that.
R Yes, yes, thank you.
Pa Sorry… very quickly, I'll go on, but that happened for years ago. that I recovered after the surgery, perfectly, but then about six weeks ago, I did the same thing again. Um, and exactly the same spot, and it was sort of sneezing this time. It's not been as bad, but I have had significant problems with mobility and significant problems with pain over the last few weeks, and I'm still suffering to a degree now.
R Yes, ok, thank you.
Phy2 Okay, so have you sought help?
Pa Er… yes, but most of that help has been in the form of medication that had given me to be able to me to sleep, because that was actually my biggest problem this time. Er, um, and sort of pdf’s of exercises to do each day.
Phy2 OK, so have been assessed and you don't have any like foot drop or anything weird and wonderful this time?
Pa I don't have any foot drop this time, the numbness that I have in my, I still have some numbness in my foot in my leg, but that seems like that's just what was left over from last time. It doesn't seem…
Phy2 Right, so you have not got any worse essentially?
Pa No, so I don't think that has got worse. and the sciatic pain has gradually got better over weeks. And so yeah, I've got to a point now where I'm still being super careful about certain things, I'm still changing my lifestyle because of it. Um, but I'm, as I sit here right now, I'm not in pain. Sleeping; I’m sleeping ok.
Phy2 Cool, OK so I’m Catherine. I worked in outpatients for about ten years, something like that, so I've seen lots of people with back pain and that radicular pain; bilateral leg symptoms where you thinking, oh OK get down to A&E; or just that mechanical back pain where it's a mechanical overload issue, and they just need to reintroduce that graded exposure to load. I've actually been on the escape pain class, but I'm not allowed to do classes here, which is hilarious.
R Ha ha [group laughter]. Too senior!
Phy2 Yeah. Uh, my own personal experience with back pain is I had a benign tumour since I was late teens, that didn't get picked up until I was 33, I’m 38 now. It went into cauda equina. That was fun times. I had like emergency surgery, and they didn't quite seal me up right, so I ended up having like low pressure headaches and horrendous leg pains that took them to two years to admit it was a problem and then they fixed it. Now I'm great. Living the dream!
R [Group laughter] That's quite a journey. Yeah.
Ch I'm Sarah, I work as a chiropractor, um, fairly new to the profession, like a year and a half. Um, personal experience of back pain has been very low- risk activity- related, um, nothing too severe, no neurological symptoms, but in terms of treating patients, seeing people with, um, sciatica, varying levels, varying risk presentations, always working within private practice.
R Okay, thank you great. Okay. So, as a group, using the post its and pens, could you map any events on a timeline for a person with lower back pain or sciatica? For example, you could put a phone call to the doctors. So, as a group, come up with different events on a timeline for a person.
Phy2 Oh, so we are not doing it as an individual?
R No, do it as a group. Okay? So yeah, please discuss as you, as you, do this, yeah.
Phy2 So, we just talk about a typical person and that goes to their GP and then slowly gets referred to somewhere else.
R Or it could be- it could be any route that they come through- treatment or no treatment. What's their journey from, presumably, when the pain starts? That would be one of them, wouldn't it? What kind of things happen on say, a typical person's journey? Yeah.
Ch Shall I do an ouch? [Group laughter]
Phy1 Self-referral?
Phy2 Or seeing a private clinician? It doesn't have to be physio, it could be osteopath, chiropractor, GP, could be literally anyone, or seeking help.
Pa There's definitely a stage where you don't really do anything. You’re kind of like, lie in bed, or stay on the sofa, you know, you might take time off work, but before seeking any medical attention.
Phy1 So wait and see?
Pa Yer. Exactly that. Yer.
Phy1 Uh huh.
Pa If you all could write nice and big, that would be amazing and use a new note. I will take a photo of your post its when I'm finished. Okay. cool. I guess that’s somewhere here, is it? [moving post it note] Anything else?
Ch People asking friends, family, ‘Is this normal?’
Pa Yer. Absolutely. Dr. Google.
Ch That's a big one. That is a big one.
Phy2 So searching for answers? Do you trying to put it as that one?
R [long pause , people writing] Okay. Is there anything that happens before the ouch point?
Ch That’s the mystery.
Pa I guess one thing I'm conscious of with my particular example, is like how much you look after yourself, I suppose. Which is, what core exercises are you doing? Are you doing yoga, you doing stretching or whatever, you are doing those kind of things. And if you had done those things, might none have staved off the ouch happening. Um, but for me personally, I think there's a sort of ‘life gets in the way’ and you stop worrying about it when you haven't got problems and so on and so forth. I’m not sure how to define that in a phrase or two, but…
R Self- care?
Phy1 Active lifestyle?
Pa Yeah, I guess so. Yeah, that's one way of dealing with it, an active, but in some cases, not an active lifestyle, it's actually can be quite sedentary and you're doing work and whatever. Then life gets in the way of being active and doing the exercises that you perhaps know you ought to be doing.
Phy2 So that’s everly more increasing in say the Western world where you sit on a toilet, you sit in a car, you barely move, you’re sat in an office. Not really being very active.
R So that is a non-active lifestyle then?
Ch So it could be active and non.
R Oh ok… yup... so we see self- referral…getting help… what goes on after that? Is that it?
Phy2 Get assessed. Potentially get advice. Do you listen to said advice?
Pa I would be more likely to speak to a pharmacist or someone probably, before I spoke to a medical professional as such.
Phy1 Ah ha, painkillers.
Phy2 Assessment, advice, education.
Pa And put one for pain relief.
Phy2 So I put at some point, so you've been referred to somewhere and you get an assessment, get advice, education, but you actually engage with it? [Group laughter] Query engagement. You can need a horse to water, you can't force it to drink. You know sometimes people come up with a load with mental gymnastics to explain things. and if you don't hit that expectation of what they were wanting to hear, they just won't engage. And you were saying, well, you seek, say before you do this bit [points to postit] you’d seek a sort of pharmacist sort of thing.
Pa Yer probably, yeah, save the grief.
R Okay.
Ch And then sometimes there's gonna be a waiting period.
Phy2 Yeah, sat on a massive waiting list, especially becoming if you are coming here.
Phy1 Hmm…. six weeks.
Ch Which, in my experience leads back to this stuff [points to post it note]
R OK, so the ‘the wait and see’ and the ‘Doctor Google’ and the waiting period after referral, self-referral, is interchangeable. Okay?
Pa mean, if you're not getting an emergency, GP appointment or going to A&E, you can easily be a week before you speak somebody or see someone face to face. And that's quite a long time if you're having real problems with mobility or sleep etc.
Phy1 I think for some people they end up going to A&E, even before they come in to...
Pa Its true, it's often the only way that you can get seen by someone, properly, quickly.
Phy1 Oh yer or the local minor injury unit.
Phy2 And then, alternative therapies.
Phy1 Or private massage.
Ch Yup.
Phy1 Hmmm… osteopath? chiropractors?
Phy2 You can get osteopaths on the NHS as well.
Phy1 Oh really?
R Okay, so, well, what’s coming after this, then? [points to last post it] What's sort of … is that the end of this sorting?
Phy2 Are you going down the engagement route? Or are they going down the ‘you didn’t tell me what you wanted to hear’ route?
[Group laughter]
R There could be two branches, I suppose.
Phy1 Yeah, so education too, if they engage, then this changes the pain or reduces the pain with a lot of education. If no changes then, you go for classes, and that's a six week period.
R [pause] Okay? Yeah, good. And what about the non-engagement then?
Phy2 They might seek alternate means, they might rely more heavily on medications, or they buy braces, they do all sorts of things or the alternative therapies or massage, where they feel they're having something done to them rather than just being spoken at and not listened to.
Ch I think, like you said, if they don't get that trust in that point, or that very specific way that they want to be spoken to, they quite quickly go back to other things. Looking sometimes for just what they want to hear. And I find that depending on how long that wait period is also depends on their receptiveness to what's being told.
Pa Yes, if you have waited several weeks and all you get is a sheet of exercises, you get a bit disheartened.
Phy2 Yes- it can be frustrating.
R Okay. So is that the end points then, for someone with back pain?
Phy2 What? Who is engaged?
Phy1 Once they were engaged, and they've been to back class.
Phy2 There is a miracle cure, post- back class? [Group laughter]
Phy1 Well, they, because of the education they get, they, um, kind of like carry on, managing their back pain, and then some people end up going to like the gym, for example. The last back class: when people gone to gym, some people gone to classes, some people have gone to things that would keep them active.
Phy2 So it is the long term behavioural changes you're looking forward to with the escape pain, isn't it? That's why there's so many sessions over that period of time, I think you have to have a minimum of 10 sessions out of the 12 to get that behavioural change, according to the evidence behind the class, I think. Which is why it's so heavy on advice and education, as well as exercise. You are trying to get them to listen, learn, and then think ‘how do I then deal with this long term?’ But again, it’s not for everyone, not everyone adheres to it. At the same time, it might not fix someone's pain or their perception of pain. And then it can lead into further chronicity.
Pa Yeah, I think the, yeah, the outcome if you like, the experience they're having if things are getting better, or if they're just staying exactly the same, its like changing people's perception and engagement with it. If you're doing these exercise every day for two months and you don't feel any improvement, I think you're quite likely to stop doing the exercises.
Phy2 It is a bit of a hard sell telling someone to do something they're not interested in doing, especially if they're in pain and it's not going the way they want.
R So, can we just focus back, we will definitely come back to these points. Happy to finish with this? Do we feel we've got all our ideas there for our timeline?
Ch I think you have to show with the bad side of, um, if people don't sort of finish in a good way. Just leading to…
R OK, yeah. Would someone be able to take a photo of these before me, please? Oh, we have got one to add. Liam’s got one to add [movement of post it].
Pa I don't know whether there's other things that people do and whether you need to cover off all of those, or if you are happy to generalise them, but I think people go to the gym, I think they go to physio, they go to I think someone mentioned chiropractors. There's all these weird and wonderful things you might try and do, so I don't know whether you need to capture all of those or just when you've got some of these alternatives
R Okay. Right, so on to our next question. When can it be harder for patients with lower back pain or sciatica to engage in treatment? So thinking about the timing.
Phy1 I think it is after, like for me, after they come in, and then they come in for a follow up and they see no improvement in their pain then that's when is a bit difficult, cos they're like, oh, I come to seek professional help and I’m expecting a miracle, and then they come back and then there’s, like, no changes in my back pain and I feel like it's getting worse, and then it is very difficult to get them to engage even more, because they are like, it didn't help the first time.
R Okay. So just after the follow up into the next, after the first assessment?
Pa From my personal experience, I don't think there's much given from the GP or wherever you get advice from as what the outcome should be. I think that's almost like half of the problem. If you were told, if you do this the outcome will be that, probably, or it could be this, but there's a range of options, whatever it might be, then you'd know where it's supposed to land, I suppose, and you might feel better if you're being told, ‘Well, it's gonna take at least six weeks to do anything’. Well, you'd know, have to four weeks, of course, its not done anything yet. But me personally, I didn't get that at all. It's just kind of do these exercises, come back in six weeks, if it's not improved, and that's all you get.
R So it's quite hard, it's quite hard early on in your first stage to engage,
Pa Yes, I guess so.
R Because you don’t know what your end goal is?
Pa There is, I guess, as a member of the public, there is ignorance over what my injury is, what the outcome should be for this, how long that's going to take, what does good look like, what does bad look like? A sheet of paper doing some exercise does not cover that.
R No. Any thoughts you two?
Phy2 Sorry, are you talking about when?
R Sorry, it is the question when could it be harder for patients with lower back pain or sciatica to engage in treatment?
Phy2 I think it all depends on the person and whether they're ready to receive what you're offering at that time. So a lot of people are looking for potentially imaging or some sort of firm diagnosis. But if you look at most of the evidence, you don't need that. If you don't need surgical management, you don't need to be scanned to see if you need surgical intervention. But trying to explain that to people is very difficult, especially if they've been going on with it for a long time, or they've not had their expectations met. So it's trying to address the expectation and explanations. So as you didn't get your explanation, you had no idea at what stage things would improve, and you just given one sheet of exercises, which typically says, do three sets of ten or something like that, with no progressive overload. Three sets of ten might have been way too hard to begin with, but really easy at the end, but at the same time it might just be too hard and you give up, cos you think ‘I'm in a lot of pain this is making things worse.’
R So it’s that sort of individualised sort of thing.
Phy2 You need to be given then a tailored program with advice and education, which isn't just, ‘here's my generic sheet that I hand out’ which often is what you get, in a rushed situation. It’s that, GPs, I feel sorry for them, you’ve got five minutes per patient, you’ve got to see, balance of probability, is this something serious or can I just give you the sheet and refer you on somewhere else? It’s very difficult.
Ch And I think like you said, pain being a massive barrier, and misunderstanding the hurt versus harm kind of rhetoric. That's quite hard to communicate to people, um, when they are in pain.
R Okay, so next question, patients can be stratified as low, medium or high risk of psychological responses to their back pain. This makes their condition more likely to be persistent. At what stage would a combined exercise and psychological programme be most beneficial for patients at medium risk of persistent back pain? So, shall I read that again?
Phy2 Is on this time-line, yer?
R Yes potentially, or if you thought of something new? Is it right after the first episode of pain, would that be a good stage to do a combined exercise and psychological programme? Or is it another stage?
Pa It really depends. For me personally, the second time I did it, psychologically it was actually really quite bad, because it was like ‘oh, I've done this again.’ It was incredibly bad last time and I ended up in surgery. I don't want that to happen again. And also this feeling that this is now something that's going to keep on happening the rest of my life, and perhaps get worse. And so, yeah, it would be beneficial very early on, I would say, in the process to get some kind of discussion on that.
R Yeah. OK. Are we all agreed? [pause] Yeah?
Phy2 Yeah, without the waiting lists and things like that, the sooner you can see someone, the easier life will be for them, whether it's chronicity or development of symptoms, it's the earlier you see something that better the outcomes typically would be.
R So that's early to see someone, but about how early you get a group programme? Would that be inappropriate early on?
Phy2 We are all weird and wonderful aren’t we, so like, if you're at a stage where you potentially be disruptive to that class or you've got a lot of negative thoughts in your head, and you're not appropriate for that group setting, yeah, you’d be bad. But if it's a case of you're an average Joe, you've got mechanical back pain, you're a little bit worried about it, but you're keen to engage and you’re keen to discuss things. Perfect. But it's that you know, we're all weird and wonderful, you can't just give out that one label for everyone. So you have to work out would they be useful in that class, in a way that they're gonna engage with it, or are they are gonna be a barrier to other people engaging, which is very difficult situation to find them.
Ch Yer, I think you're mostly to judge their initial engagement to see how they're gonna respond to the group based programme potentially.
Pa But for some people as well, and I know for me, there are stages of this process when you're in so much pain, you're not going to a group class to do anything. Like, you can barely make it across the room to go to the toilet. So you're not you're not going anywhere, have to do anyone or see anything. So, it's where, how would help like that, psychological help, might actually be quite comforting and useful at that stage, but you're not going anywhere to do that in a group setting.
R Yer, okay, so next question, can you discuss what factors overall would promote successful engagement of patients in a combined exercise and psychological programme? Repeat.
Phy1 I think a lot of education.
R Education about the condition?
Phy1 Yer, um, about back pain in general.
R Oh, ok, prior knowledge is really important?
Phy1 Prior knowledge…really important...
Pa And as I said, knowing the, having an explanation of it, and then knowing the expected days or outcome, is actually a really good thing to know. Yeah, it definitely needs to be communicated, I suppose, that this is the programme, this is what we do, this is typically how we treat back pain, we have a lot of successes with it, whatever it might be. From my experience, this has never really communicated at all. So, so, I wouldn't, I wouldn't know where to join a group because it's never been offered to me, and I wouldn't know the benefits of it because I've not been told it. So that could happen at any stage, but it needs to happen. And it doesn't need to come from an individual, it could be a web page, you know, it could be anything that you can read and go, oh yes, this is what I need to get involved with.
R Okay, so knowledge and prior knowledge, yup, okay.
Phy2 Yeah, so I would agree with the readability, and credibility. How accessible is that information? And then is it given in the correct manner? So there's lots of misinformation out there, isn't there? At the same time you read off a trusted source like potentially the NHS website or your doctor's websites, something along those lines, where they can stratify you’re potentially in this area, this will hopefully help you, and that will get the ball rolling a lot quicker than the ‘I'm sat at home, barely moving, everything sore, and I'm sort of fear avoidance’ which is that… People end up in that situation all the time, like, you know, when my bad back was bad, I waited to the point where I needed an emergency surgery, when I should have known better, but you do mental gymnastics to play it off as something that it isn't. Or you seek help from someone that potentially doesn’t know what they're talking about. There's loads of different reasons. At the same time, if that information is readily available, then people can access it freely, great.
Ch Yeah, definitely the accessibility. Um, and also just, is this before they go into care or when they're having the sessions? Sorry, I don’t understand the question.
R So what would promote successful engagement of patients? So we do have patients that drop out or can't attend. What could, what else, what could help with that?
Ch So it was, I would say, more simple stuff like a warm and encouraging environment where they feel listened to, is quite important for successful.
R Are there any personal factors that enable patients to engage? Do you think, um, so you talked about a warm environment, social contact, that sort of thing. Are there any organizational factors that help? I think we've talked about information sources.
Phy2 Are you talking about impoverished area, so you if you are from an impoverished area are less likely to be able to get up to somewhere, can't get transport, things like that?
R Access, yer yer.
Phy2 Is that what you are talking about?
R Yeah, yeah, that could be, that’s a barrier, isn't it, I guess. So, you could help with that.
Pa Are these things sometimes done digitally as well? So if someone is unable to physically attend, they can still get something else?
R No, not here no, but I think nationally yes.
Phy2 Nationally, yeah. It is a sort of postcode lottery, so depending on what services are set up in your local area, you can get very different options. Here, no.
R Ok. Good. So just to conclude then. Is there any anything important that we've missed that we should have included to discussed about? Anything you want to add?
Phy2 I think, with the access part of it. So, the outreach to sort of more sociable areas, so gyms, like village halls, things like that. Anything like that where you're getting people in a more sort of a local setting and they can outreach to it, I think it's far more important than having what this hospital model is, which is, let's have a central hub and everyone has to come to us. I think there should be outreaching into communities and making it easier and more accessible. Having smaller hubs, more spread out rather than one big hub, and thinking ‘you’re the clinical expert and everyone should come to me.’ Well so not everyone can, especially if you're struggling, if you knew there was something in your village hall just down the road, you'd probably struggle there, rather than let’s say, go and sit on a bus for 45 minutes or whatever, or get in the car, which I'm struggling to drive. What is your accessibility like, really?
Pa Yer, I mean I agree with some of the accessibility, and for me personally, I'm thinking about gyms- and a lot of people go to gyms- and they're already paying a subscription. They probably already have classes in that, and I don't know whether there's outreach from the NHS to those organisations, I suppose, and the trainers and instructors with them so that they could actually offer similar services.
Phy2 Some gyms do, but it's the gym that has to invest in it rather than the trusts, or the NHS trust that helps them. So, example, in Oxford, we outreached to the gyms and the council based gyms used to run Escape Pain and they used to do loads of classes, and we used to just feed into it like, perfect, you know, it was just a case of us giving them patients and then they would be encouraged to use the local equipment…
Pa Yer yer that’s right.
Phy2 …use the local facilities, meet people in their own area, who were struggling. Whereas up here, there's no real social engagement at all. But however, said that, if you are member of say Nuffield, things like that, they do offer classes and things like that, and have their own in-house physios. So it's all about what’s accessible to you locally. Unfortunately this hospital as a whole does not really outreach, whereas there are some gyms that have been sort of progressive and thought about that.
Phy1 I will say, definitely, accessibility in terms of like making it digital. Um, I remember Torbay they have like videos on, like a lot of information videos about what to do, how to do things, even like exercises in that videos, so that people can engage with them at home, so they're not having to come to a particular session to be involved or anything. So, I think putting them out there on like a website, as you already said, its really good and an ideal one to have.
Phy2 They have also got the reconnect to life website in Torbay which is really useful for the more chronic people. Torbay is very progressive compared to here.
Phy1 They are really good.
Pa And even if they are just giving out instructions, rather than a PDF, honestly, a richer media would be really helpful. Like, my wife does a lot of yoga, so when she sees me doing these things, she's like, ‘oh, that's that pose, you're doing it wrong, you need to do it like this’. I've never done yoga in my life, so I don't know what I'm doing. So, watching a two stage, you know, two photos of A and B isn't really enough, [group laughter] whereas watching videos from a few angles would be much more helpful.
Phy2 The sort of Chinese whispers that comes associated with giving someone a PDF. [group laughter] The amount of times, I have to give people PDFs because we have no real outreach or stuff. If I give you a set of exercises, I'll get you to come back and then see what you've been up to and I say two, three, four weeks, whatever its been, and the amount of times people have just doing random stuff, because that's their interpretation of what you've given them. Because they've got no concept of what you've actually given them. So it's then trying to get them to drill it in front of you and then say, ‘do you understand? Right, let's have a bit more of a chat and then show me that again.’ See if they actually understood it. But a lot of people, due to time constraints, don't have that ability to do that. So people go away and then potentially waste X number of weeks, or give themselves a bit of a mischief doing something they shouldn't have been doing. Or they get it right, and you're like, great, but it maybe it was a long set of exercises, try something else.
Pa Yer. Lots of issues.
Ch I was just gonna go back to that idea of trying to find the people, trying to implement the group based programmers early as possible, whilst also finding the people that might not help the group, um, which is difficult in an ethical way, I guess to do.
Phy2 It is certainly difficult trying to weed out people like that.
Ch Well yer, exactly.
Phy2 You can't get it right every time.
Ch And predict the future of whether they'll change their perspective.
R Okay. Good. Okay, thank you. So, um let's all stop there, I really appreciated your time. Thank you so much for ideas I didn't even consider- really, really good.