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Dr Azman Abu Bakar MBBS;MPH;PhDDirector
Institute for Health Systems Researchwww.ihsr.gov.my
Patients’ Unvoiced Needs:Strengthening Doctor-Patient Communication
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Road-Map
• Definition• Relevance in Health Care• What do the Literatures say?• A “peep” into the Malaysian scenario• Where do we go from here?
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Introduction • Patient-centred care increasingly important
– in health care– important attribute of a good health care system– Pt’s right (MSQH guideline)– WHO Alliance for Patient Safety
• Vision of Health– promotes individual responsibility & community participation
• “Healing” relationship between Drs & Pts – essential to quality care
• Communication between Drs & Pts – remains the typical asymmetry of PATERNALISTIC Dr-Pt interactions
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A patient is deemed to have unvoiced needs
when concerns/problems that he/she had planned to share with the attending Health Care
Provider (HCP) could only be shared partially or not at all
Definition of Unvoiced Needs
Unvoiced needs = Unmet needs
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Relevance of Patients’ Unvoiced Needs in Context of Health care• It is all about doctor-patient (Dr-Pt) communication
DURING the clinical encounter• Affects both
– Health behaviour – Health outcomes
• Critical element of high quality care– Ensures provision of relevant information by patients– Influences pts’ ability to recall drs’ recommendations– Achieve better satisfaction– Improve compliance to treatment regimes
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Relevance of Patients’ Unvoiced Needs in Context of Health care• Effective Dr-Pt communication correlated with desired health
outcomes– Symptom resolution (e.g. control of headaches)– Functioning (e.g. asthma)– Physiologic measures (e.g. BP & blood sugar)– Pain control (e.g. cancer pain)– Emotional status (e.g. mood, anxiety)
• Poor Dr-Pt communication results in:– Failure to elicit important health-related information– Wrong management– Poor compliance
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Relevance of Patients’ Unvoiced Needs in Context of Health care• Macro-level
– Primary Health Care• Better health screening• Effective delivery of preventive health care services
– Secondary & Tertiary Care• Quality management resulting in
– Improved outcomes– Fewer iatrogenic complications
• Less wastage of resources
• Micro-level– Improved management of pt care & satisfaction
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Relevance of Patients’ Unvoiced Needs in Context of Health care
• Contributory factors– Patients’ culpability?– Doctors’ culpability?
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Relevance of Patients’ Unvoiced Needs in Context of Health care• Patients’ culpability
– Physical inability to hear information– Psychological unwillingness to receive unpleasant information– Anxieties & inhibitions stemming from perceived status differences– Problems of memory recall– Differences in what pts and drs know about disease– Social class or ethnic group membership– Differing role expectations pt & dr have of each other– Differences in ability to comprehend terms commonly used in medical
discourse
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Relevance of Patients’ Unvoiced Needs in Context of Health care
• What about Doctors’ culpability?
Food for Thought
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What the Literature Say…• Increasing amount of attention within health care
studies• Limited insight gained despite numerous studies• Main reason?
– doctor & patient relationship is one of the most complex amongst inter-personal relationship studies
– Involves interaction in non-equal positions, often non-voluntary, emotionally laden, and requires close cooperation
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What the Literature Say…• Vast body of literature on patients’ reasons for
deciding to consult but very few research on what patients have in mind while in waiting room regarding forthcoming consultations
• Simply asking people about their expectations of the consultation MAY NOT determine their actual purposes for seeing doctor
• Extent of unvoiced needs ranged from 9% in US to 88.6% in UK
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What the Literature Say…• Mixed feelings about the extent to which patients
feel their beliefs, experiences & preferences can be shared
• Doctors tend to dominate discussions in consultations
• Health care professionals’ behaviour can impede as well as enhance patient involvement
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A “peep” into the Malaysian Scenario
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Exploratory study in an outpatient MOH clinics in year 2006-2007
1 in 5 patients (20.9%, CI: 15.1, 26.7)
have unvoiced needs in Malaysia
Source: (Patients’ Unvoiced Needs: An Exploratory Study in an Outpatient Setting (2008))
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Low Lee Lan - Institute for Health Systems Research (IHSR)
Sondi Sararaks - IHSR
Azman Abu Bakar - IHSR
Maimunah A. Hamid - Ministry of Health
Goh Pik Pin – Selayang Hospital
Mohd Yusof Ibrahim - Department of Health Sabah
Muhammad Radzi Abu Hassan - Sultanah Bahiyah Hospital
Carol Lim Kar Koong - Likas Hospital
Abdul Jamil Abdullah - Sultanah Nur Zahirah Hospital
Ahmad Mardzuki Ibrahim - Sultanah Nur Zahirah Hospital
Loe Yak Khoon - Institute for Public Health
Nor Izati Abdullah - IHSR
Letchuman Ramanathan - Taiping Hospital
Research Team Members (2007-2009)
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Patients who sought treatment at clinic
Issue Planned:Not sure/cannot
remember
Issue Planned:None
Issue Planned:YES
Patients DID NOT share ANY of their planned issue with provider
Unvoiced Needs Patients PARTIALLY shared their
planned issues
Manage to share ALL issues with provider Voiced
After the doctor-patient consultation
** Issues Planned -someone who had planned to share or present his/her problems/ concerns to
HCP during consultation
** Unvoiced Need is based on the premise that patients have issues that they planned
to share with HCP
Operation Framework
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• To identify the extent and distribution of unvoiced needs in selected outpatient setting
• To design and evaluate the effectiveness of an intervention package to facilitate patients to voice their needs to healthcare provider
• To formulate recommendations for reducing patients’ unvoiced needs
Objective
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• A Community Trial study• Quantitative & Qualitative components
• Conducted in 10 MOH outpatient centres (specialist and primary health care)
4 centres, FTA intervention package 2 centres, Video intervention package 4 control centres
Research design
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Results
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Study Centre Pre Intervention
(%)
Post Intervention
(%)FTA
Centre A * 68.5
Centre B 15.1
Centre C 19.4
Video
Centre E * 43.0
Control
Centre G 45.9
Centre H * 27.4
Centre I 18.5
Study Centre Pre Intervention
(%)
Post Intervention
(%)
Centre D 22.3
Centre F * 45.8
Centre J 10.9
- Specialist Hospital - - Primary Health care -
Unvoiced Needs for Specialist Outpatient and Primary Health Care Centres
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• At baseline (pre intervention), unvoiced needs ranged:
– Specialist clinics: • from 15.1% to 68.5% (7 centres)
– Primary care settings: • from10.9% to 45.8% (3 centres)
Patients’ Unvoiced Needs at baseline
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Comparison with International Data
# Academic practice, * Qualitative study
Outcome Setting Malaysian study (%)baseline
US(Tjia J, 2008) #
US(Piette JD, 2004)
US(Bell RA, 2001)
US & Canada(Marvel MK, 1999)
UK(Frederikson, 1994)
UK(Barry, 2000)
*
Unvoiced Needs
Specialist clinic
15.1% to 68.5%
13.6 35 9 24.6 43 -
Primary Health Care
10.9% to 45.8%
- - - - - 88.6
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Are doctors aware that unvoiced needs exist? (qualitative study in Malaysia)• Excerpts from health care providers (FGD)
Source: FGD among HCP & patient_July 2008 (8 FGD sessions)
“most patients come to us needed explanation, we always talk to the
patients and explain what were their problems. I don’t see the problem
because we always talk to the patient.”
“What we always do is we talk, and patient will keep quiet first, and then after that we stop and we ask them, anything else that you want to know”
“Sometimes they keep asking the same thing that we already explain.
So, we have to re-explain.”
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Do Patients’ unvoiced needs exist? (qualitative study in Malaysia)
• Excerpts from patients (FGD)
Source: FGD among HCP & patient_July 2008 (8 FGD sessions)
“bila kita dah concentrate, benda lain sudah tidak masuk. Kadang2 doktor
cakap, kita nak mencelah pun tak boleh.”
“Kadang-kadang lupa, di rumah kita ingat nak beritahu, bila datang jumpa doktor dan doktor tanya lain, kita sudah
lupa apa yang kita nak cakapkan...”
”sambil kita tunggu tu kadang2 memang idea kita cukup banyak, bila jumpa doktor kadang2 kita lupa. Bila doktor cakap lain,
kita terus lupa”.
“Sometimes even you ask there is also no answer, so no point keep on asking the same
question…because I cannot get the answer then I ask again and then she (doctor) will say don’t
keep on asking the same question.”
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1) Forgotten issue
2) Perceived doctor’s/HCP’s attitude
3) Patient hesitancy (Embarrassment, nervous, do not want to waste HCP’s time)
4) Expect doctor/HCP to enquire5) Doctor/HCP did not give a chance to ask
“…saya ada merancang, tapi selalu lupa, bila jumpa doktor, bercakap-cakap dengan doktor, terus lupa dan bila dah keluar baru teringat...”
“…Saya pernah terkir mahu tanya doktor, tapi itulah kita takut dan rasa pertanyaan kitat itu tidak sesuai , takut kena marah dengan doktor...”
“…malu kalau doktor tu lelaki dan tidak berani cakap apa yang difikir, kalau saya jumpa doktor perempuan berani cakap (share)…”
“…pesakit lain juga mahu cerita itu ini kan, (jadi) tak boleh lama –lama dalam bilik (doktor) tu. Masa terhadkan...”
“…Kadang-kadang perkara yang telah dirancang ni tidak kesampaian, kadang-kadang kaku depan doktor...”
“…kalau doktor tanya kita jawab, semua kasi cerita, kalau doktor tidak tanya tak boleh la cerita…”
“…masa jumpa doktor , saya sakit perut , tapi bila saya bagitau sakit kepala juga, saya dapati doktor tu, dia laju, pantas dan nak cepat , macam seolah-olah dia tergesa-gesa. Jadi menyebabkan saya tak sempat bagi tahu yang saya ada sakit kepala juga ...”
Source: (FGD among patients_December 2006) – 6 FGD sessions
Factors Contributing to Unvoiced Needs:
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Interventions to
reduce Unvoiced Needs
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Two intervention packages were developed and implemented: A “Forgot to Ask” (FTA) slip comprising of a question sheet with instruction.
& FTA Poster – to promote the use of FTA slip.
Video with different scenario of messages.
Poster and pamphlet (fan) to promote awareness and tips on how to reduce unvoiced needs.
Training for health care provider (HCP) on implementation of the intervention.
Additional materials for HCP – Note books and stick-on notes awareness on unvoiced needs weredistributed to HCP and counter staff.
Intervention Components
needs
yourKeperluan
Anda
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Two intervention packages were developed and implemented: Centre used FTA A B C D
A “Forgot to Ask” (FTA) slip comprising of a question sheet with instruction.
& FTA Poster – to promote the use of FTA slip.
√ √ √ √
Video with different scenario of messages. - - - -
Poster and pamphlet (fan)to promote awareness and tips on how to reduce unvoiced needs. √ √ √ √
Training for health care provider (HCP) were providing on implementation of the intervention. √ √ √ √
Additional materials for HCP – Note books and stick-on notes awareness on unvoiced needs weredistributed to HCP and counter staff.
√ √ √ √
Components Used in Different Centres
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Two intervention packages were developed and implemented: Centre used VideoE F
A “Forgot to Ask” (FTA) slip comprising of a question sheet with instruction.
& FTA Poster – to promote the use of FTA slip.
- -
Video with different scenario of messages.
√ √
Poster and pamphlet (fan) to promote awareness and tips on how to reduce unvoiced needs. √ √
Training for health care provider (HCP) were providing on implementation of the intervention. √ √
Additional materials for HCP – Note books and stick-on notes awareness on unvoiced needs weredistributed to HCP and counter staff.
√ √
Components Used in Different Centres
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Study Centre Pre Intervention
(%)
Post Intervention
(%)FTA
Centre A * 68.5 39.0
Centre B 15.1 10.4
Centre C 19.4 20.1
Video
Centre E * 43.0 31.1
Control
Centre G 45.9 32.3
Centre H * 27.4 11.6
Centre I 18.5 22.8
Study Centre Pre Intervention
(%)
Post Intervention
(%)
Centre D 22.3 13.7
Centre F * 45.8 8.8
Centre J 10.9 22.9
- Specialist Hospital - - Primary Health care -
Unvoiced Needs for Specialist Outpatient and Primary Health Care Centres
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Discussion
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Intervention Package Local vs InternationalLOCAL (MALAYSIA)
Intervention: to reduce patients’ unvoiced needs during doctor-patient encounter
INTERNATIONAL Intervention: to increase number of questions
asked during doctor-patient encounter
FTA Intervention Package: 1 in 4 centres improved
FTA related intervention: 4 in 8 studies improved
Video Intervention Package : Both 2 centres improved
Video Intervention: 1 in 1 study – no change
Coaching of patients: 1 in 5 studies improved
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Shy
Pen/FTA slip not available
No reason given
Difficulty to read/see
Not ready to tell
No time
Prefer verbal instead of writen
Problem with the language
Don't know/had nothing to tell
0 10 20 30 40
0.61.01.72.52.9
7.825.626.0
32.1
As reminder (826)
As encouragement (826)
0%10%
20%30%
40%50%
60%70%
80%90%
100%
94.9
95.2
4
3.5
1
1.1
Useful
Not sure
Not useful
Aware of it (1659)
Received it (1428)
Had used it (1353)
0200400600800
10001200140016001800
86.1% 94.7%61.0%
13.9%5.3%
39.0%
NoYes
FTA Slip
Reasons for not using FTA Slip
Usefulness of FTA Slip
%
no. of patient
Evaluation of Intervention Package (by overall centre)
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Cant' see/hear
Not interested/important
No time
Problem with the language/understanding
0 20 40 60 80 100
2.4
3.5
14.1
80
%
Aware of it (700) Had view it (554)0
100200300400500600700800
79.1% 84.7%
20.9%15.3%
Se-ries3
No. of patient
As reminder (469)
As encouragement (469)
97.7
97.9
2.1
1.9
Not sureSeries3
Video Animation
Reasons for not view video animation
Usefulness of video animation
Evaluation of Intervention Package (by overall centre)
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Findings from FGD
Intervention material
HCP Patients
FTA Slip Require extra time Able to voice their concerns
Benefit for patient and HCP Create opportunity for patient to express their needs
Suggestion for improvement Suggestion for improvement
- Consultation more focused
Video Animation - Encourage patients to voice their concerns
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Quotation from FGD sessions:FTA slips
From HCPs:• “When they have the questions written down, for me I feel that consultation time is a
bit shorter because the question is already there. So, I just look, answer… look, answer…very fast. So, that’s helpful …”
• “It does open and guide me to the conversation and from there I know what is their concern and what they want”
• “I think the Form (FTA) actually helps in the sense that even though it does not give 100% answers to their questions, at least we can explore.”
• “Basically the paper (FTA) actually helps us; to help patients…. But then, at times… when they have ten questions… you will be catching up with time as well.”
• “Do whatever that you need to do like increase the patients' awareness of the need to voice out. Then, this will increase the success of your implementation.”
Findings from FGD (cont’)
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FTA slips
From Patients :• “…for me, first, I can talk freely, because we can write down each of my health problem.
Secondly, the consultation is faster, focused directly to illness (problem).”
• “...(previously) cannot deliver, but if with this form (FTA), all my illness, my problem, i can jot down on this form.”
• “Better (with FTA), we will take time to think what to write. Sometimes if seen by bad doctor (shouting) then we forget what to ask. It forces you to really think, think and remember…”
• “…what I planned to voice, I can write down there (FTA)…”
• “Even if the doctor didn’t even answer, at least we’ve already voiced out everything on the paper (FTA), doesn’t matter if they didn’t answer, sooner or later somebody will eventually read it, that is the good thing.”
• “Provide assistance to help illiterate patients & special counter for writing.”
Quotation from FGD sessions:Findings from FGD (cont’)
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Video Animation From Patients:
• “…for me, with this (message from animation), gives me the strong need to ask, because sometimes we worry, scared doctor will scold, so if with this (message) we are free to ask or get opinion and advice from doctor.”
• “ Video itu sentiasa mengingatkan tentang segala masalah yang kita hadapi, kita beritahu semua”
• ”Macam tujuan cerita (video) itu, pesakit sudah tidak rasa malu-malu beritahu masalah, sudah berani”
Quotation from FGD sessions:
Findings from FGD (cont’)
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Study Centre:- Study centres were conveniently selected - Of the ten study centres, we had only three
primary health care centres in this study- All primary care centres were located rural areas in
Sabah only- Video: only in 1 language (Malay) with English
subtitle
Limitations of Study
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• Patients’ unvoiced needs do exist.
• Patients may have trouble in voicing their concerns.
• Both FTA & Video intervention packages were able to reduce unvoiced needs
In Summary
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Where do We Go from Here?
• The interview is the most powerful, encompassing and versatile instrument available to the doctor
- G.L. Engel
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• Important medical practice trend worldwide is the increasing involvement of patients in their own care
• Growing recognition that patients’ wants ARE NOT capricious whims but LEGITIMATE needs in themselves
• Inter-personal communication is the PRIMARY TOOL by which Dr & Pt exchange information
• Important in situation of life-threatening diseases
Where do We Go from Here?
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• “We need to take time to save time”• WHO is really ignorant
–Dr or Pt or BOTH??
Where do We Go from Here?
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• Improving communication but more specifically it is about information exchange
• Partnership with patients– Treat patients as you would like to be treated
yourself• Well-informed patients wants your
– Knowledge– Listening (ears!)– Analysis– Opinion – BUT NOT YOUR DECISION!
Where do We Go from Here?
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• You NEED NOT be the all-knowing doctor of the past• Discuss and reflect with your patients• Create a calm, gentle and respectful atmosphere• Patients lose their autonomy when visiting a doctor and
duty of doctor to try restore the autonomy• The time of the consultation is the PATIENTS AND NOT
YOURS
Where do We Go from Here?
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• Where possible & feasible– Implement the interventions provided or any other
interventions you can develop
Where do We Go from Here?
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Thank You