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Section 10, Chapter 1: Effective Communication: Making the Most of the Consultation*

Lisa Roberts

OVERVIEW

In General

Communication impacts upon every clinical encounter and must be one of the most highly developed skills in any clinician’s toolkit. It not only has the power to influence patients’ experiences (often erroneously called “satisfaction”), but it can also significantly affect the outcome of healthcare. While it may not be possible to achieve excellent clinical outcomes every time, it should always be possible to ensure patients have a positive experience.

The core components of clinical communication are verbal content (what is said), non-verbal behaviors (how it’s delivered), and the interaction between the clinician and the patient and anyone who may be attending with the patient. Interestingly, the non-verbal component is considered to be the primary component, making up 55-97% of a message. Therefore, how you say something is even more important than what you say. Communication is most effective when there is no conflict between the two.

The key determinants of a “good” consultation have been described as:

  • Validation of the patient’s concerns
  • Explanation/diagnosis of the pain in clear and understandable terms
  • Patient-centered care
  • Reassurance
  • Review/discussion of the treatment options.1

Communication encompasses all of these and these skills need to be finely tuned and tailored for every patient, as it is not a case that one size fits all. Tailoring the consultation will influence how the introduction is made, how the history is taken, how diagnoses and prognoses are explained and any discussions and negotiations around investigation and treatment.

Patient experience is increasingly used as an indicator of quality2 and is equally important across public and private health sectors. Suboptimal practice (whether perceived or actual) has repercussions for clinicians. For example, “poor communication” has been cited as one of the top three reasons for hospital complaints, alongside errors in diagnosis and poor treatment.3

For such a key skill, it is surprising how little time clinicians dedicate to furthering these skills once they are qualified as compared to the time they spend honing their clinical skills. Reflecting on your practice, gaining feedback from patients, reviewing audio-recordings from consultations and performing peer reviews with colleagues can all provide insights that will help further develop the skills you already have.

Preparations

First Contact

Whether patients make contact directly or are referred through other healthcare professionals, how they make an appointment in your service is an important marker for what is to follow. The appearance and content of written materials, such as a letter or electronic confirmation of the appointment, is important. Again, asking patients for feedback can provide helpful insights into what it was like to receive the communication coming from your service, thereby ensuring instructions about where to be and what to bring are as patient-friendly as possible. It is important to remember that patients may have anxieties about the process of the appointment, as well as its outcome.

Many patients fail to get the best from their consultations because they arrive “unprepared and unequipped with the ‘right’ questions,”4 and services may benefit from reviewing the information given to patients ahead of time. Providing clear information can help with practicalities such as minimizing non-attendance, being in the wrong location, wearing inappropriate clothing, inability to recall medications, not bringing reading glasses, etc.

Preparing Yourself

A professional appearance is crucial in making a positive first impression. Many patients also welcome seeing clinicians washing their hands. In addition to any physical preparations, it is important for clinicians to be aware of any biases or assumptions they may have made from information given in the referral source. For example, do personal details impact your thinking? Consider the following:

  • Is the patient currently on sick leave?
  • Are the symptoms recurrent?
  • Is he/she a single parent with a young family?
  • Is it a sporting injury?
  • Does he/she work as a healthcare professional?
  • Has he/she had multiple previous appointments in your service?
  • Has he/she had previous treatment that was unhelpful?
  • Is he/she involved in litigation?

It is essential to ensure that you have key information about the patient available at the time of the consultation, especially details about this episode (including test results) as well as any previous episodes while in your service.

The Environment

Before inviting a patient into the clinical area, take a minute to check that the clinical space is tidy, there is clean paper on the examination couch and the furniture is arranged appropriately. This costs nothing and is all part of making the patient feel expected and welcome.

Be aware that a clinic room with solid walls versus curtains can influence the communication and trust that takes place. Patients may be more guarded if they think they can be overheard. Simple measures, like having a radio or playing music softly, can be an option, but you will need to check the law to avoid copyright infringement.

HISTORY TAKING

Introductions

You only get one chance to make a favorable first impression. It is reported to take only 39 minutes for a first impression to be made,5 and once made, it can be hard to change.

Welcoming a patient with a genuine smile can go a long way to making him or her feel at ease; its value should not be underestimated. If the patient is attending with someone else, greet him or her as well, ask how they are related and confirm that the patient wishes this person remain present for the consultation.

If there are other people present in the clinic (e.g., students, chaperones, other colleagues), it is important to explain to the patient who these individuals are and why they are there. Whenever possible, patients should be asked in advance if they are willing for others to be present, and they should be asked without coercion – in private, not in front of the other person or in a way that makes it hard for them to say no. How often do you see clinicians ask patients in front of students or junior colleagues if it is all right for them to be there? It is a simple courtesy that is often overlooked. Clinicians assume the appointment letter mentioned that it is a teaching clinic and others may be present, but this poor practice can easily be remedied.

Building Rapport

Rapport is influenced by non-verbal gestures such as offering a handshake on introduction, making eye contact without prolonged staring or maintaining an open and non-threatening body posture.6 Clinician posture can inhibit rapport. Sitting back or slouching may give an impression of disengagement. Meanwhile, a very forward-leaning posture can appear intimidating (particularly if you are relatively close in proximity to the patient). It is important not to invade a patient’s personal space.

At the start of an encounter, it is also prudent to be careful with small talk as this can be a barrier. Following an observation in our research, a patient reflected: “It didn’t start off well…when people say to me, ‘How are you? I hate it, because that is like saying, I don’t really care how you are actually, but I’m going to ask out of politeness.’” Similarly asking patients about their journey or if they found the department easily can lead to a litany of complaints, particularly if they have waited a while to see you and are being charged for parking.

Opening Questions

Communication within back care consultations is under-explored, and little attention has been given to how “best” to open discussion about the patients’ symptoms and the impact of symptoms upon their lives. Often referred as the “problem presentation,” how these questions are phrased can affect patient “satisfaction”7 as well as adherence to treatment.8 In a national survey in the UK, working with 11 examples from clinical practice involving initial consultations for patients with back pain, physical therapists identified their preferred key clinical question (i.e., the first specific clinical question asked after introductions) from the 11 offered as shown in Table 1-1. Their preferred key clinical question for follow-up encounters is as shown in Table 1-2.

TABLE 1-1. Results from the national survey showing the preferred phrasing of the key clinical question in initial consultations between physical therapists and patients with low back pain
Rank Score Phrase
1st 83 Do you want to just tell me a little bit about your back pain first of all?
2nd 77 I’ve had this referral through _________. Tell me what’s happened.
3rd 71 The referral says you’ve got back pain.  Is this correct?
4th 65 How can I help you today?
5th 57 What we’ll do today is just have a bit of a chat about your back pain, I believe it is. All right?
6th 45 It’s your back pain that you’re here for is it?
7th 35 What problem are you having at the moment?
8th 30 Do you want to tell me your story?
9th 29 Do you want to start off by telling me whereabouts you’re getting your pain at the moment?
10th 28 I know a little bit from the GP [General practitioner], when did this start?
11th 17 How long have you had back pain for?
TABLE 1-2. Results from the national survey showing the preferred phrasing of the key clinical question in a follow-up clinical encounter between physical therapists and patients with low back pain
Rank Score Phrase
1st 158 How have you been since I last saw you?
2nd 131 How did you get on with the treatment [e.g., exercises, hydro, injection, massage]?
3rd 82 How have you been feeling from a back painpoint of view?
4th 71 How are you getting on?
5th 54 How have you been?
6th 18 Are the back pain symptoms on-going?
7th 12 What was the take home message that you got from me last time?

Questioning Styles

Questioning skills are key to gaining information in a clinical encounter and enhancing the therapeutic relationship. It is important to keep questions simple and only address one issue at a time. Asking a closed question, such as “when did you start taking this medication?”, is likely to result in a short, focused answer. Meanwhile, an open question, such as “how did it start?”, can provide more detail about the onset of symptoms. If you really want to explore an issue in detail, TED questions (involving Tell, Explain or Describe stems) can be particularly useful. For example, “can you explain how these symptoms are affecting your life?”

Another practice that can help in building rapport is to phrase a question in a way that hands over control to the patient – for example, “you know your body better than anyone, so what do you think is going on in your back?” This shifts the balance of power to the patient and can help identify any concerns or beliefs he or she might have about the underlying cause of the symptoms. You can use this information to shape your explanations or reassurances later in the consultation.

It is worth giving thought as to how you ask questions about sensitive topics, such as possible cauda equina symptoms which involve bladder, bowels, sexual function, etc. Patients may feel embarrassed about divulging such details to a relative stranger, and this feeling is compounded in some cultural contexts. It can help to signpost your reason for asking these questions, perhaps with a statement along the lines of “sometimes back pain can cause serious damage to the nerves that supply the bladder and other organs, so we need to screen for these by asking a few safety questions. I’m sorry if they seem a bit personal, but they are important.”

Although clinicians usually have a core list of questions that they use in consultations to promote patient-centeredness, it can be illuminating to ask the following at the end of history-taking: “before we look at your back, is there anything else that we haven’t talked about that you think is important and want to raise?” This can help ensure the interaction addresses the patient’s agenda and can help avoid any unaddressed issues being raised during closure of the consultation that may require further physical examination.

Active Listening

As well as knowing what to say, a key skill for clinicians is to master knowing when to be silent. Even short pauses can provide patients with an opportunity to raise an issue that is important to them and can help shape the rest of the consultation.

It is also important to think about how to juggle the complex skills of history taking and actively listening to the patient, while recording important information about the consultation in real time, either manually or electronically. Many patients complain that the clinician did not appear to be listening, because they were “tapping away on the keyboard and I was just talking to the top of their head” or they were “looking away at the screen.” Simply explaining to the patient, “what you’re telling me is really important and I want to put it on record” can be helpful. Again, it is a case of signposting the reason you might appear to be otherwise engaged.

Consultation Content

We undertook a cross-sectional, observational study to measure the verbal communication in 25 back pain consultations in a UK physical therapy setting10 using the Medical Communications Behavior System,11 which categorizes 13 clinician behaviors, 7 patient behaviors and has 3 miscellaneous categories (with added examples from our research) (Table 1-3).

TABLE 1-3. Examples of the categories within the Medical Communications Behavior System (MCBS) after 11

Category

Includes

Example from research

Clinician
Content Behaviors 1. History/background probes “And did you have the back discomfort at the time or was it purely just the leg pain?” [Patient 5: line 33]
2. Checks for understanding information “When you were told about you having the sort of wear and tear and the arthritis… was it explained to you exactly what is going on?”  [Patient 1: line 412]
3. Advice/suggestion  “If you bring your leg up towards your chest for me and just hug the knee, can you feel that sort of stretching out the back here?” [Patient 5: line 781]
4. Restatement “Just to go back to when it started, you said it started to get worse about a year ago?”  [Patient 7: line 54]
5. Clarification Following a patient’s description of her recurring symptoms: “So it (the back pain) was sort of episodic?”  [Patient 4: line 37]
Affective Behaviors 1. Emotional probes “How would you feel about … me referring you to one of the Community Rehabilitation Teams, who can come out and see you in your home … and see if there’s anything that we can do to help you?”  [Patient 9: line 385]
2. Reassurance/support “So the fact that you can control it [the back pain] quite well – not to worry at the moment.”  [Patient 1: line 477]
3. Reflection of feelings Patient: “I’m just concerned it might be arthritis going into my back …”
Clinician: “Right. That’s what you, how you’re thinking?” [Patient 1: line 776]
4. Encourages/ acknowledges ‘I know what you mean.’ [Patient 1: line 547]
Negative Behaviors 1. Disapproval “Tsk.  OK.  OK.  So, I’m still trying to ascertain when the right hip pain came on.” [Patient 20: line 116]
2. Disruptions (Knock at the door).  “Oh sorry, do you mind if I just quickly answer that?”  [Patient 2: line 1011]
3. Jargon “I’m going to teach you an exercise … which is to work on your transversus abdominis, which is a deep, core stabilising muscle, OK?”  [Patient 4: line 605]
Patient
Content Behaviors 1. Content questions Responding to an answer on a health questionnaire to the question, “Do you have diabetes?”: “Did I tick that by mistake?” [Patient 10: line 81]
2. Content remarks “Oh well, I crouched down to get the bag from under my bed and you know, something went.” [Patient 3: line 39]
3. Checks for understanding “… What I’m gathering is, I have to re-strengthen the muscles that have become like an elastic band.  They’ve gone really thin?  Huh?” [Patient 2: line 1306]
Affective Behaviors 1. Encourages “I would say that was spot on.” [Patient 14: line 90]
2. Emotional expressions “I think it’s the old situation of, I’ve hurt myself, I’m a bit scared and I don’t really want to do anything again, yeah.” [Patient 2: line 585]
Negative Behaviors 1. Disapproval Clinician: “It’s too hot outside?”
Patient: “Well, it is when you’ve got to walk round in circles in this hospital.” [Patient 7: line 5]
2. Disruptions E.g., Knock on the door from another clinician enquiring whether the room contains a particular piece of equipment
Miscellaneous Categories 1. Social amenities “Come on in and have a seat. Right. Did you catch my name?” [Patient 6: line 4]
2. Silence
3. Unclassifiable E.g.,When the physical therapist and patient talk over each other.

Our results showed that clinicians spoke more than patients (49.5% versus 33.1%, respectively), and both groups spent little time overtly discussing emotions (1.4% and 0.9%, respectively).10 It was interesting to note the prevalence of advice given by the clinician in these first encounters, comprising 12.5% of the consultation.10

Interruptions

In a series of 264 primary care consultations undertaken in the US, 45.5% of patients were interrupted or “redirected” while giving their “statement of concerns,” and this was associated with fewer concerns mentioned by patients, late-arising concerns and missed opportunities to gather important patient data.12 Patients were given 23.1 seconds on average to itemize their concerns before being interrupted by the physician.12 Langewitz et al. report that patients will take, on average, 92 seconds to explain their problem in an outpatient setting if they are not interrupted.13 It can be hard to resist the urge to interrupt a patient in full flow, either to gain more detail about something they have said, to save time or to change the direction of the conversation. Two types of interruptions are identified in the literature: an “overlap,” which is an error in projecting when a speaker is planning to end; and an “interruption” or start-up at a point in a speaker’s talk where the thought cannot possibly be completed.14 It is important for clinicians to know the extent to which they interrupt patients and the impact this has on the interaction. Again, this can be examined in audio-recordings and with peer review.

Challenging Conversations

Sometimes clinicians are reluctant to ask patients about the social and emotional impact of their symptoms for fear it will increase the patients’ distress, take up too much time or threaten the clinician’s own emotional status. They may use strategies (consciously or unconsciously) to actively block further disclosure, and again, it is important to be aware of these practices and the consequences during a consultation.

Conversation can also be challenging when a patient displays signs of distress. It is essential to have a box of tissues that the patient can readily access should the need arise. In such times, a clinician may feel quite helpless and not know what to say, but sometimes words are not necessary; just being there and listening is a source of comfort. If given time and space to cry, patients will stop at their own pace. Ensuring privacy is important. It might help to use phrases like “I’m sorry this is so difficult for you” or “please take your time” to acknowledge their distress. This can be an opportunity to find out more about the patient’s coping skills and what has helped them in the past – knowledge that can be used to help them in the difficulties that lie ahead. In clinical correspondence, it is important to note the patient’s distress without judgement or prejudice.

PHYSICAL EXAMINATION

Preparation

It is important to recognize patients may feel anxious at having to get undressed, and they may have previously had negative consultation experiences. Simple measures, like leaving the cubicle while the patient undresses and providing a towel or blanket nearby to preserve dignity, can help. Also, explaining why it is necessary to ask them to remove an item of clothing shows courtesy.

Clearly articulating what you are looking at/seeing can help provide feedback and reassurance. These simple courtesies help to alleviate some of the patient’s anxiety and distress and avoid an unnecessary complaint.

THE DIAGNOSIS

Legitimization

One of the most challenging aspects of a clinical consultation is explaining to the patient the findings from the assessment in readiness for discussions about further investigations or potential treatment options. Patients essentially want to know what is causing the problem, what can be done about it and if /how quickly will it resolve. They want a simple summary of what is wrong so that when a family member, friend or employer asks they can legitimize their symptoms. This can be particularly difficult in back pain, as the label “non-specific back pain” is meaningless to most patients. It is preferable to just refer to their condition as “back pain,” because patients can think that “non-specific” means that either the clinician doesn’t know what is going on, the condition is not real or “they think I am making it up” –none of which are helpful.

Further challenges arise when investigations do not pinpoint a cause for the patient’s symptoms. Extra care needs to be taken when delivering the results of a scan that has not revealed any relevant pathology. Suggesting to a patient that the scan is normal when they still have significant symptoms can be particularly tricky. It can be helpful to explain that the scan is like looking at a photograph of the inside of the spine. You can see if bones or nerves have structural damage, but it doesn’t give many clues about “how”different structures are working. Therefore, its role is to rule out serious pathologies like tumors or pressure on nerves, which is reassuring.

Language

When situation becomes difficult, it is common for clinicians to regress to using jargon and to make assumptions about the patient’s level of knowledge. Jargon doesn’t necessarily have to be complicated. For example, the patient may misconstrue the term “chronic” to mean “dire” in everyday language; while in a healthcare context, it means that the symptoms have lasted more than three months. Likewise, using a term like “degeneration” is unhelpful – people don’t talk about the skin or hair “degenerating” with age and the notion of a “degenerative spine” can provoke fear that their spine is somehow crumbling. Discussions about degenerative changes are often complicated by using phrases like “wear and tear” that can leave patients wondering what is actually tearing. “Age-related changes” might be a less fearful option to use.

In the world of back pain, particular care needs to be taken with the label of “sciatica.” It should only ever be used in relation to radicular pain where there are clear signs of changes in myotomes and/or dermatomes and/or reflexes. It is NOT a term for any leg pain, and like the term “whiplash,” it can be hard to shake.

At all costs, clinicians need to avoid making patients fear-avoidant and the simple sentence, “you have chronic back pain; your spine is showing some signs of degeneration and you have a bit of wear and tear,” translates to “your back pain is dire; your spine is crumbling and structures inside are tearing.” Is it any wonder that when clinician then starts to talk about keeping active and exercising that the patient thinks they might do further damage? A less fear-provoking statement may be something along the lines of “you’ve had your back pain for a while, and your spine is showing some changes that are consistent with your age. Research has shown that it can be really helpful to keep active and….”

DECISION-MAKING

Shared Decision-making

Having reached a clinical diagnosis and communicated the findings, it is important to think about the complex process of negotiating treatment options through shared decision-making.

At present, there is no universally agreed upon definition of shared decision-making. One systematic review15 used 161 definitions and involved 31 concepts (most commonly “patient preferences” and “options”).

The principal components of shared decision-making16 have been described as:

  • Identifying and clarifying the issue
  • Identifying potential solutions
  • Discussing options and uncertainties
  • Providing information about the potential benefits, harms and uncertainties of each option
  • Checking that patients and professionals have a joint understanding
  • Gaining feedback and reactions
  • Agreeing on a course of action
  • Implementing the chosen treatment
  • Arranging follow-up
  • Evaluating outcomes and assessing the next steps.

Whilst there may be variations in the definition of shared decision-making, observational studies have found consistently that it is rarely implemented in practice. For example, our team measured the prevalence of shared decision-making in 80 clinical back pain encounters17 using the 12-item OPTION scale16 that was devised to rate general practice consultations.

The OPTION scale measures clinician-initiated behaviors from an observer’s perspective, scoring each on an ordinal scale from zero (“the behavior is not observed”) to four (“the behavior is observed and executed to a high standard”). Scores are summated and scaled to give an overall percentage and the higher the score the greater the shared decision-making competency attained, with 60% generally accepted to correlate with the lowest meaningful competency level.16 The reliability of the OPTION tool has been demonstrated with the inter-rater intra-class correlation coefficient (0.62), kappa scores for inter-rater agreement (0.71), Cronbach’s alpha (0.79) and intra-rater test-retest reliability (0.66) all above acceptable thresholds.16

In our study of 80 consultations (42 initial and 38 follow-up, ranging from 1 to 6 appointments per patient), the overall mean OPTION score was 24% (range 10.4%–43.8%) with 23.6% and 24.5% for the initial and follow-up consultations respectively, as shown in Table 1-4.

TABLE 1-4. The OPTION scale scores

Item

Shared decision-making behavior

Mean score (min–max)

0 (%)

1 (%)

2 (%)

3 (%)

4 (%)

1 The clinician draws attention to an identified problem as one that requires a decision making process. 0.7 (0-3) 48.8 33.8 16.3 1.3 0.0
2 The clinician states that there is more than one way to deal with the identified problem. 0.8 (0-3) 41.3 36.3 21.3 1.3 0.0
3 The clinician assesses patient’s preferred approach to receiving information to assist decision making. 0.6 (0-3) 58.8 27.5 10.0 3.8 0.0
4 The clinician lists “options,” which can include the choice of “no action.” 1.4 (1-3) 0.0 73.8 25.0 1.3 3.8
5 The clinician explains the pros and cons of options to the patient. 0.8 (0-3) 42.5 38.8 15.0 3.8 0.0
6 The clinician explores the patient’s expectations (or ideas) about how the problem(s) are to be managed. 1.0 (0-4) 41.3 27.5 22.5 6.3 2.5
7 The clinician explores the patient’s concerns (fears) about how problem(s) are to be managed. 0.3 (0-2) 77.5 17.5 5.0 0.0 0.0
8 The clinician checks that the patient has understood the information. 1.3 (0-3) 17.5 36.3 43.8 2.5 0.0
9 The clinician offers the patient explicit opportunities to ask questions during decision making process. 1.2 (0-2) 18.8 46.3 35.0 0.0 0.0
10 The clinician elicits the patient’s preferred level of involvement in decision making. 0.7 (0-3) 58.8 16.3 22.5 2.5 0.0
11 The clinician indicates the need for a decision making (or deferring) stage. 1.2 (0-3) 7.5 70.0 20.0 2.5 0.0
12 The clinician indicates the need to review the decision (or deferment). 1.7 (0-4) 5.0 42.5 31.3 18.8 2.5
Key16

0=The behavior is not observed
1=A minimal attempt is made to exhibit the behavior
2=The clinician asks the patient about their preferred way of receiving information to assist decision
3=The behavior is exhibited to a good standard
4=The behavior is observed and executed to a high standard

These results concur with Couët et al.’s systematic review18 of 2489 consultations across 29 international studies, involving general practitioners, cardiologists, psychiatrists, oncologists, dieticians and nurses, treating cancer, diabetes and depression, where the mean OPTION score was 23% (9-37%).

It is vital that clinicians involve patients appropriately in decisions affecting their healthcare in order to maximize non-specific treatment effects, reduce the potential for complaints and litigation, and enhance patients’ experiences. Our findings indicate that shared decision-making was under-developed in this cohort of back pain consultations, and with greater awareness of these 12 behaviors, it should be possible to improve shared decision-making competency.

CLOSURE

Leaving a positive final impression of the consultation is vitally important. Silverman et al. have proposed four main skills that contribute to a satisfactory ending of the consultation:

  • Summarizing the session
  • Contracting with the patient about what happens next
  • Providing a safety net – what to do if the plan is not working and when and how to seek help
  • Final checks that the patient is comfortable with plan and has the opportunity to ask questions or discuss any other items.19

If all has gone to plan, the patient leave the consultation with a clear understanding of the clinical diagnosis and any further investigations or potential treatment options. Importantly, they should have had a positive experience of the service.

CONCLUSION

Communication is considered the most important aspect of practice that health professionals have to master20 and should be optimized to give clinical skills the best chance of success. For such a key skill, clinicians need to invest time to enhance their skills in order to help optimize patients’ experiences and outcomes from spinal services.

PEARLS AND PITFALLS

Suggested professional development activities:

  • With express consent from your patient, audio-record a consultation. As well as considering what went well and any contributing factors, consider the aspects that perhaps did not go quite as well. Consider the patient, you, the patient’s problem presentation, the environment, as well as anything else. Identify any overlaps or interruptions made by you or the patient and analyze the consequences. Use the OPTION tool to score your performance with shared decision-making behaviors. Did you reach 60%?
  • Think about how you gain feedback from patients and families who use your service. Unfortunately, there is no universally accepted Patient Reported Experience Measure (PREM). However, a plethora of tools are in use across different professions and services.
* Material from this article was published in Principles of Musculoskeletal Treatment and Management: A Handbook for Therapists. 3rd ed, Petty & Barnard, Principles of communication and its application to clinical reasoning, 211-235, Copyright Elsevier (2017).

SUGGESTED READING

  • Roberts L, Langridge N. Chapter 9: Principles of communication and its application to clinical reasoning. In: Petty N, Barnard K, eds. Principles of Musculoskeletal Treatment and Management. 3rd ed. Amsterdam, Netherlands: Elsevier; 2017.

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