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Home > MSAA Publications > The Motivator > The Motivator: Spring 2008 > Cover Story - Partners in Wellness: The Importance of a Positive Doctor-Patient Relationship
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Cover Story

Partners in Wellness: The Importance of a Positive Doctor-Patient Relationship

By Susan Wells Courtney, Richard Blanck, MD,and Jack Burks, MD

A Doctor's Style

Every doctor has a certain style, philosophy, and way of communicating with his or her patients. Finding the right doctor-patient match is not always easy, but when successful, patients and doctors may enjoy a long-term relationship with open communication and mutual understanding.

Dr. Richard Blanck is a neurologist who specializes in MS, and has been seeing patients for more than 30 years. One of Dr. Blanck 's most urgent objectives has been to spread the word about the importance of doctor-patient communication. By openly speaking with a patient – and perhaps more importantly, listening closely to what the patient has to say – a solid rapport will likely develop. This helps to bring about a correct diagnosis more quickly, as well as encourage better treatment adherence and compliance.

Dr. Blanck believes that much of a doctor's personality and ability to communicate is developed while growing up, and not all doctors are able to show compassion and speak comfortably with a patient. Reports of seemingly impersonal and uninterested doctors are not uncommon. While these individuals may be highly qualified and extremely knowledgeable, they may lack the interpersonal skills necessary to develop a supportive relationship through communication and compassion. Some physicians may be better suited for a career in research versus daily patient care just for this reason.

In addition to a doctor's personality, other limitations such as time constraints placed on him or her by the workload, can greatly contribute to reduced interaction with the patient. Some patients have grown accustomed to a rushed style of patient care. After a few brief questions and a quick diagnosis, the doctor vanishes, leaving someone else to wrap up the details. With this type of care, patients often leave feeling alone, dissatisfied, and frustrated.

The Initial Interview

Fortunately, not all doctors have a rushed bedside manner. Some doctors will spend as much time as needed with a patient so they may fully understand the patient 's complaints and the degree to which they are affecting his or her quality of life. Particularly during the initial interview process, Dr. Blanck finds that a full hour or more may be required.

The initial interview is vitally important, not only to work toward an accurate diagnosis, but also to lay the foundation for a positive rapport and ongoing treatment plan. According to Dr. Blanck, a good rapport begins with a heartfelt greeting. Making eye contact, shaking hands, smiling, and leaning in to show a sincere interest, all work toward making a patient feel welcome, relaxed, and comfortable. One of the first goals is to reduce anxiety, which a new patient often experiences.

During the initial interview, Dr. Blanck spends most of his time inquiring about the patient 's symptoms and their impact on daily life. He points out that learning a patient's history is the most important part of the neurological exam. The first part of taking a patient 's history is to ask about his or her chief complaint. In neurology, this often falls under one of three categories: cognitive (thinking and emotion); motor function (such as weakness, coordination, and involuntary movements); and sensation (pain, numbness, and other changes in feeling).

When a patient talks about pain or other discomfort, Dr. Blanck asks a series of questions to understand the nature of the symptom. He uses a mnemonic of six letters (PQRSTU) to guide him through the series of questions. To follow is an explanation of this system:

P: Where is the pain positioned? This gives the location of the pain.

Q: What is the quality of the pain? This describes how the pain feels, i.e., if it is sharp or dull, aching or throbbing, etc.

R: Where does the pain radiate? This explains if the pain stays in one place, or if it continues to other locations – such as a headache that may start in the front of the head and radiate to other areas of the head.

S: What events might precipitate, aggravate, or relieve these symptoms? The physician may learn about outside factors that may worsen the pain, as well as treatments that may relieve the pain.

T: What is the time sequence of events? Also known as the "temporal profile" or "chronology," this specifies if the pain comes on gradually or suddenly, how long it may last, when it first began, how often it appears, and if the frequency is increasing or decreasing.

U: Have I come to an understanding of the symptom, and the degree to which it is affecting the patient 's life? Doctors need to understand how the symptom affects the patient's activities of daily living, including work, recreation, and relationships. This is the most important piece to the puzzle.

Of course, these questions need to be asked in a compassionate manner. The doctor needs to show that he or she cares and is truly interested in the thoughts and feelings which the patient is experiencing.

These are the types of questions that should be asked during the initial interview, and according to Dr. Blanck, he can often make a provisional diagnosis based on the history given verbally by the patient.

Also while listening, the neurologist is able to assess other functions. For instance, if a patient can tell the doctor a full history of symptoms in great detail, he or she may have a good mental status; if the patient talks about his or her senses – such as seeing, hearing, tasting, and smelling, then the doctor may infer that the cranial nerves are not affected.

Following the interview process, Dr. Blanck then conducts a neurological exam, orders lab testing (to rule out other disorders), a magnetic resonance imaging (MRI) scan, and possibly an analysis of the spinal fluid. These are done to support his initial findings suggestive of MS.

Delivering the Diagnosis of MS

Delivering a diagnosis of MS is a very sensitive issue. Dr. Blanck is passionate about the importance of delivering a diagnosis in the best manner possible. He believes that the messages should be clear and precise, using understandable terms. The physician should also show compassion and convey hope for the future. To follow are the eight ideals which Dr. Blanck strives for when delivering a diagnosis.

1) Deliver the diagnosis in person... giving someone a diagnosis over the phone, leaving a message on an answering machine, or having a nurse deliver the news, is not acceptable.

2) Include others when appropriate... since this can be a stressful time, having a family member present, such as a spouse or significant other, is very helpful for the patient in terms of understanding and remembering what is said.

3) Communicate properly... the doctor needs to listen to the patient, understand his or her concerns, and address those concerns.

4) Allay anxiety... while every patient is different, a doctor needs to "read" a patient's personality, working to reduce anxiety and building a rapport.

5) Deliver the information clearly... doctors need to use understandable language and avoid medical terminology as much as possible, providing definitions whenever needed.

6) Never play God... patients need to know that only God may predict the future; physicians can only make educational guesses and offer appropriate treatment options.

7) Educate the patient... doctors are responsible to answer specific questions about treatments (detailed later in this article). When a patient knows the answers, he or she may make informed decisions about his or her own treatment.

8) Have a sense of humor... lighter moments enable doctors and patients to enjoy one another, and to serve as a momentary escape from the more serious issues surrounding MS. Everyone needs laughter.

Despite the need to provide as much information as possible to newly diagnosed patients, care must also be taken not to overwhelm a patient with too many details. Dr. Blanck tries to provide information in manageable amounts, allowing individuals time to digest what they have heard and to prepare questions for the next visit.

Successful Doctor-Patient Communication

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In the book, How to Talk to Your Doctor: Getting the Answers and Care You Need (Quill Driver Books, 2006), author Patricia Agnew states:

"If you are to be successful in communicating with your doctor, first you must have a doctor with whom to talk. The choice of your primary-care physician, the doctor you call first in case of illness or accident, is critical. You will talk to him more often than any other physician or surgeon involved in your health care.

"You should develop a relationship of mutual trust with this doctor. You must feel that you can trust him with your health care, and he will need to trust you to follow his directions. It is imperative that he be open to questions and not bristle when you question his treatment or suggestions. "

Dr. Blanck explains, "Doctors often don't realize the impact they have on their patients. Once a doctor crosses a line, the patient never forgets. A patient may leave a doctor 's care and not give a reason, so the physician never knows that he or she has done anything wrong or has been remiss in any way.

"Often doctors learn about patient relationships after becoming a patient themselves. Doctors don 't always view themselves as advocates. They need to ask themselves, 'How would I approach this if the patient was a relative of mine with MS? Where would I go for help? '

"Doctors need to convey that they genuinely care about the concerns and wellbeing of their patients. Listening intently to what a patient has to say, learning about the impact of their symptoms, and asking the right questions, will go a long way toward forming the initial diagnosis and guiding patients through ongoing care and long-term treatment. Additionally, research shows that a patient needs to be able to talk without interruption to fully communicate his or her concerns. "

In The Intelligent Patient's Guide to the Doctor-Patient Relationship: Learning How to Talk So Your Doctor Will Listen, by Barbara M. Korsch and Caroline Harding (Oxford University Press, 1998), the authors note:

"Why do we complain about our doctors? Why do they complain about us? What makes the doctor-patient relationship so complex?...The medical setting itself creates many basic barriers to open, effective, and mutually satisfying communication. In addition, many small misunderstandings contribute to dissatisfaction on both sides, waste time, and ultimately adversely affect outcomes. Each individual in the interaction has perceptions of the other 's behavior and very often the twain don't meet."

Dr. Blanck continues, "Doctors are human, and they need to reflect the emotions that are appropriate to how a patient is feeling. Doctors need to convey compassion, show support, and help their patients know that they are not alone. Doctors need to step back to see how they appear to a patient. Not making eye contact, folding their arms in front of them, or asking insensitive questions, can make a doctor appear impersonal and uncaring to the patient. "

A good rapport will positively affect a patient's adherence to ongoing treatment. Without this rapport, patients are more likely to stray from their doctor 's recommendations. With MS, this can greatly impact one's quality of life as well as long-term disease progression.

Nonverbal communication is also important. Dr. Blanck explains, "A comprehensive understanding of the patient's problems requires me to study his behavior, observe his general appearance, listen to his manner of speaking and tone of voice, and note whether or not he makes eye contact with me. Other observations include his facial expression, gestures, and body movements. All of these nonverbal signs can indicate various issues, including a display of emotions or tearfulness, which can help me to understand the impact of the symptoms on the patient. "

Author Nancy Keene, in her book, Working with Your Doctor: Getting the Healthcare You Deserve (Patient-Centered Guides, 1998) comments:

"You need to be involved to get the best medical care. A crucial first step is to invest the time to find a doctor who is smart, caring, and up to date. You 're also more likely to trust a doctor who really knows you – one who knows your medical history, understands your needs, and talks to you about your likes and dislikes. Research has shown that patients who work as partners with their physicians feel more in control, tolerate treatments well, and take more responsibility for their health. Moreover, if you have a close relationship with your doctor, you are more likely to be diagnosed accurately and recover quickly. "

Preparing for Doctor Appointments

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Having at least one family member, friend, or care partner present at a doctor's appointment can be extremely helpful and may enhance communication. Often a new patient may feel overwhelmed, anxious, or confused, and the support of a loved one – who observes the patient everyday – can usually shed light on various symptoms and behaviors. A family member can also help by noting what the doctor says and assisting the patient at home with remembering the details.

Preparing questions and recording different symptoms are important for patients to do prior to the office appointment. This ensures that the doctor will address any questions that the patient may have, as well as be aware of any changes in symptoms. It also helps the doctor to recommend the best possible treatment options for the patient at that time.

From a doctor's point of view, the book titled, YOU: The Smart Patient: An Insider's Handbook for Getting the Best Treatment, by Michael F. Roizen and Mehmet C. Oz (Free Press 2006) states:

"Most people think they communicate with their doctors just fine. Better than fine, in fact. Fantastic. Given that most of the communication consists of nodding or a request for antibiotics, there 's little to find fault with. That's the problem, of course. Most patients don't do a great job of communicating with their doctors because patients often give us too little pertinent information to go on (remember, just like the detective, we 're looking for the facts). At the same time, they may also give us too many distracting or off-topic details. It reminds us a little bit of what a mechanic must think when we try to explain a noise in our car. We 're not sure when it started, we're not sure what makes it worse, we think it's a whining sound but aren't sure... We bet this becomes a tedious monologue for those earnest professionals trying to help us. An almost identical conversation goes on in doctors ' offices every day..."

For guidelines to help patients prepare for a visit with their doctor (and a wealth of other topics relating to healthcare), readers may visit www.healthcarecoach.org and search for "Maintaining a Good Relationship with Your Doctor," for more information (this is an article under the "Your Health" tab, in the "Get the Care You Need" section). For maintaining a good relationship with their doctor, patients are given several tips, such as "choosing the right doctor," "preparing questions and concerns in advance," "knowledge is power," and "speak up for your right to understand." Many of these topics have links to specific articles for more details.

"Preparing for a Visit to Your Doctor" is a separate article listed on the Health Care Coach website. It lists questions to consider, including:

  • What is my main problem?
  • What do I need to do?
  • Why is it important for me to do this?

Other questions relate to one's health in the recent past. Sample questions include:

  • Have you noticed anything different in your sleeping, eating, or other daily habits?
  • Have you noticed any new or unusual pains, aches, lumps, or bruises?
  • Have you seen any changes in your moods?
  • Do you have more trouble getting up in the morning?

If seeing a doctor for a particular problem, Health Care Coach lists these questions:

  • How and when did you first become aware of the problem?
  • How would you describe what you are feeling or how the problem felt at that time you noticed it?
  • Does it tend to happen at certain times of the day or when you are doing certain activities?
  • What other patterns have you noticed, if any?
  • What did you do when you noticed the problem to try to make it better?

The article also suggests that patients make a list of any medications they are taking. They should check their own health records to see they are due for any immunizations or tests. An excellent form for tracking medical history may be found at www.realage.com. Readers may download a copy of "Your Health Journal" by searching the website or at http://utility2.realage.com/ media/pdfs/SP_HealthJournal.pdf for a copy of the detailed, patient-friendly chart.

In addition to preparing for the doctor visit with a list of questions and concerns, Dr. Blanck encourages his patients to take advantage of reliable resources to learn about the disease and its treatments on their own. The authors of Making Informed Medical Decisions: Where to Look and How to Use What You Find (by Darol Joseff, Nancy Oster, and Lucy Thomas (Patient Centered Guides, 2000) agree:

"Regardless of your treatment outlook, when you are newly diagnosed with a medical condition, you are likely to feel yourself thrust into a world of medical jargon, tests, personnel, and processes that are unfamiliar and frightening. On top of being emotionally and physically stressed, you have to learn a new language and way of thinking about disease. Doing research can provide a way of gaining clarity and getting back some sense of control over your life. You may want to find out more about your condition, the range of treatments, or where to find the best doctor or treatment center for this condition. "

"Patients need to assert themselves," notes Dr. Blanck. "It's crucial for any patient who does not feel comfortable with their present physician, to know that they may look for a second opinion, and possibly consider changing doctors. I encourage my patients to go for a second opinion if they have any doubts or unresolved concerns. " (Readers may find more information by visiting www.healthcarecoach.com and searching for "second opinions." It provides a general overview with several links to other articles on the topic.)

"People with a chronic condition such as MS should not visit a doctor and go away feeling as though their questions have not been answered. Long-term treatment requires an ongoing rapport of mutual understanding with not only the treating physician, but with the entire healthcare team. Patients need to know that they are not alone, and they must receive support, guidance, and hope for the future. "

Physician Models of Care for
Patients and their Families

MSAA Chief Medical Officer Dr. Jack Burks has written about some of the vital issues involved with the doctor-patient relationship in MS. Dr. Burks wrote a chapter entitled, "A Dynamic Model for Understanding the Physician's Relationship with Patients and Their Families," which appears in the book, Multiple Sclerosis and the Family (edited by RC Kalb and LC Scheinberg, Demos Medical Publishing, 1992). The following information was taken from this chapter.

Traditional Models of Care

According to Dr. Burks, the traditional role of the physician has been to consult with and examine the patient, determine a diagnosis, and prescribe or discuss a treatment to provide a cure. This type of relationship is categorized as one of two established models of care.

The first model of care is referred to as the "Acute Model," representing a paternalistic type of relationship where the doctor sees the patient, makes a diagnosis, and prescribes a treatment. The thoughts and values of the patient and his or her family are given little consideration in this model of care.

With the second model of care, known as the "Functional Model," the patient plays more of a role in his or her treatment plan. In this model, the doctor provides information on treatment options, so the patient may decide how to proceed.

Both the Acute and the Functional models of care exclude any involvement with the needs and dynamics of the patient's family. Information is kept confidential. While these models may work well in some instances, this is not the case for an ongoing condition such as MS, which at this time has no cure and the symptoms impact not only the patient, but the entire family.

The Evolving Educational Model of Care

With MS, the initial symptoms and diagnosis can be overwhelming for everyone involved. Once any urgent medical issues have been addressed, the physician can begin an educational process to inform the patient and family members of treatment options available. Over time, as symptoms are treated and life becomes more balanced, the patient and family may then play active roles in choosing treatments and making plans for the future.

This type of care plan is referred to as the "Evolving Educational Model." It allows the patient and family to have an interactive, open, and ongoing relationship with an entire healthcare team.

Dr. Burks explains, "While the Evolving Educational Model incorporates aspects of the earlier approaches – including the initial diagnosis and treatment recommendations – it also provides the patient and family with a more equal, active role in the long-term planning and decision-making process. The healthcare team, patient, and family members work together to decide who will give and receive medical information, and who will be involved in the treatment planning. At the same time, careful attention is still given to issues of confidentiality, privacy, and autonomy. "

As the name implies, this model is designed to evolve according to the changing needs, roles, and issues of the patient and family. For instance, if the patient is under 18, his or her patients will be the primary decision makers until the child becomes an adult. Additional issues arise as parents worry about their child, who is becoming more independent and may be making his or her own decisions. Another example of changing roles occurs when an adult with MS experiences cognitive or other changes, which may require other family members to take on a more active role in the decision-making process.

"One of the most important features of the Evolving Educational Model," notes Dr. Burks, "is the concept of the entire healthcare team working in conjunction with the patient and family, to provide the most appropriate and effective care options at that time. Recommendations will change according to the patient and family's current needs and medical issues."

Healing is a Process

When stress, depression, or other emotional factors arise – often affecting the relationships and family functioning, and possibly aggravating the symptoms of MS – members of the healthcare team may recognize the hidden emotional problems behind the physical complaints, and recommend interventions such as counseling to resolve these issues. Without this model of care, unnecessary medications or hospitalizations may be prescribed to address what might otherwise seem to be a symptom of MS.

Dr. Burks continues, "The initial contacts between the patient and doctor can set the stage for the entire therapeutic relationship. Using a supportive and educational approach, the physician should engage the family in the treatment process and create an atmosphere that encourages open communication and cooperation over the course of the relationship.

"Medical treatment per se is only one component of the ongoing doctor-patient relationship. Healing is the process component, which takes place with the patient and family, as they understand and appreciate the changes they are experiencing. The doctor and healthcare team create a safe, respectful, and nonjudgmental place for the patient and family to cope with these changes. The doctor and healthcare team help to make the fears, uncertainties, and negative feelings more manageable by serving as a supportive presence and a role model. "

Giving Treatment Options

Once the diagnosis of MS has been established, Dr. Blanck's next step is to provide information to the patient about the treatment plan. He envisions the treatment as having four arms:

First arm: Optimization of General Health... Patients may help themselves by: not smoking; eating healthy foods and maintaining an ideal weight; participating in moderate and appropriate exercise; and seeking help for emotional issues, such as anxiety or depression.

Second arm: Managing Symptoms... Dr. Blanck asks his patients and their families to give him a list of symptoms they are experiencing, and to put them in order of most impairing to least impairing. From this list, he is able to create a treatment plan that addresses the various problems, giving greater attention to those symptoms having the greatest impact on quality of life.

Third arm: Treating an Acute Attack... Also known as an exacerbation or disease flare-up, Dr. Blanck explains that the most commonly prescribed treatment for an acute attack is intravenous steroids, which work by reducing inflammation. While this treatment can help to speed one's recovery from a flare-up, he also points out that no long-term benefits have been observed; studies show that after approximately six months, patients have similar outcomes, regardless of whether or not they received steroid treatment. Dr. Blanck recommends treatment if the symptoms are severe enough that they interfere with one's activities of daily living. If symptoms are mild, he feels that patients may be better advised to "ride out the episode," reserving treatment for a more severe disease flare-up.

Fourth arm: Modifying the Course of the Disease... This area encompasses the six medications approved by the Food and Drug Administration (FDA) for the long-term treatment of MS. As many know, four medications may be self-injected at one's home; these include Avonex®, Betaseron®, Rebif®, and Copaxone®. The latter two medications (Mitoxantrone® and Tysabri®) are each given via intravenous infusions at hospitals or infusion centers.

Dr. Blanck informs his patients of the American Academy of Neurology (AAN) position on the value of early and aggressive treatment of individuals diagnosed with MS (or a "clinically isolated syndrome"). Studies show that patients with relapsing forms of the disease may experience reduced disease activity (as shown on MRI, as well as fewer and less severe exacerbations). Dr. Blanck's personal philosophy is "to treat the patient with the best available agent, until something better comes along. "

In regards to any type of specific test or treatment recommended by a doctor, Dr. Blanck believes that he or she has an ethical and professional obligation to answer the following five questions.

  • Why is the test or treatment recommended?
  • How is the test performed or the treatment administered?
  • What are the risks, both short term and long term?
  • What are the benefits?
  • What are the alternatives?

Without answers to these questions, patients and their families do not have the information necessary to make their own decisions and ultimately receive the best care. In a world of uncertainty, doctors need to enable patients to make informed decisions. He advises patients to be proactive and ask the right questions.

Making Every Day Count

Dr. Blanck wants patients to know the power of the human mind, noting the placebo effect, and the concept of harnessing the power to help heal one's own body. Making every day count is vital, and MS can be a springboard to make life more meaningful.

He also emphasizes hope. He sees much hope for the future, in terms of treatments that may one day offer restorative properties to reverse lost function, as well as research into potential cures for MS. His dream is that one day, MS may be prevented from ever developing.

Dr. Blanck remarks, "I believe that MS, as well as life in general, is like walking through a minefield. An unexpected flare-up or new problem can burst onto the scene at any time. People need to be'artfully dodgeful,' and doctors must serve as guides to help people through their challenging times. As a physician, I am privileged to be invited into people's lives, to share their sorrows and secrets, while assisting them to become happy and fulfilled. "

Additional Reading

How Doctors Think, by Jerome Groopman, MD; Mariner Books (2008)

How to Save Your Own Life, by Marie Savard, MD; Warner Books Trade Paperback Original (2000)

How to Survive Your Doctor's Care, by Pamela F. Gallin, MD, FACS; LifeLine Press (2003)

How to Talk to Your Doctor: Getting the Answers and Care You Need, by Patricia Agnew; Quill Driver Books (2006)

How to Talk with Your Doctor: The Guide for Patients and Their Physicians Who Want to Reconcile and Use the Best of Conventional and Alternative Medicine, by Ronald L. Hoffman, MD; Basic Health Publications (2006)

Making Informed Medical Decisions: Where to Look and How to Use What You Find, by Nancy Oster, Lucy Thomas, and Darol Joseff, MD; Patient Centered Guides (2000)

Making the Patient Your Partner: Communication Skills for Doctors and Other Caregivers, by Thomas Gordon, PhD and W. Sterling Edwards, MD; Auburn House Paperback (1997)

Multiple Sclerosis: A Guide for Families, by Rosalind C. Kalb, PhD; Demos Vermande (1998)

Patient Self-help Guide: How to Talk to Your Doctor, by Jane Williams; Principle Publications (2006)

Special Treatment: Ten Ways to Get the Same Special Health Care Your Doctor Gets, by Kevin J. Soden, MD, MPH and Christine Dumas, DDS; The Berkley Publishing Group (2003)

The Essential Patient Handbook: Getting the Health Care You Need - From Doctors Who Know, by Alan B. Ettinger, MD and Deborah M. Weisbrot, MD; Demos Medical Publishing (2004)

The Intelligent Patient's Guide to the Doctor-Patient Relationship: Learning How to Talk So Your Doctor Will Listen, by Barbara M. Korsch, MD and Caroline Harding; Oxford University Press (1998)

The Most Unhealthy Relationship of All: A Guide to Better Doctor-Patient Communication, by Dr. Mark A. Hertzberg; iUniverse (2003)

The Savard Health Record, by Marie Savard, MD; Time-Life Trade Publishing (2000)

The Savvy Patient: How to Get the Best Health Care, by Mark C. Pettus, MD; Capital Books (2004)

What to Ask the Doc: The Questions to Ask to Get the Answers You Need, by Margaret Fitzpatrick, RN, Linda Burke, RN, and Daryl Lee, RN; RN Interactive, Inc (2003)

Working with Your Doctor: Getting the Healthcare You Deserve, by Nancy Keene; Patient Centered Guides (1998)

YOU: The Smart Patient: An Insider's Handbook for Getting the Best Treatment, by Michael F. Roizen, MD and Mehmet C. Oz, MD; Free Press (2006)

Your Doctor Said What? Exposing the Communication Gap, by Dr. Terrie Wurzbacher; LifeSuccess Publishing (2006)

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Dr. Richard Blanck is a neurologist who specializes in MS at Neurology Associates of Long Island, PC, in Great Neck, New York. For the past 31 years, he has held the positions of instructor of neurology and clinical associate professor at the Cornell University Medical College in New York, and clinical associate professor at the New York University Medical College.

Dr. Blanck has been seeing patients for more than 30 years, and from this experience, has authored several articles. He is also active with the National Multiple Sclerosis Society – chairing committees, speaking at events, and serving as a patient advocate.

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Last Updated on Monday, 25 March 2013 11:07