dr azman abu bakar mbbs;mph;phd director institute for health systems research

Definition Design ConclusionResults Discussion Intervention Evaluation Qualitative AppendixMethodDevelopment Table

Dr Azman Abu Bakar MBBS;MPH;PhDDirector

Institute for Health Systems Researchwww.ihsr.gov.my

Patients’ Unvoiced Needs:Strengthening Doctor-Patient Communication


Road-Map

• Definition• Relevance in Health Care• What do the Literatures say?• A “peep” into the Malaysian scenario• Where do we go from here?


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


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


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


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


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


Relevance of Patients’ Unvoiced Needs in Context of Health care

• Contributory factors– Patients’ culpability?– Doctors’ culpability?


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


Relevance of Patients’ Unvoiced Needs in Context of Health care

• What about Doctors’ culpability?

Food for Thought


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


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


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


A “peep” into the Malaysian Scenario


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))


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)


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


• 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


• 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


Results


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


(%)

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


• 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


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


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.”


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.”


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:


Interventions to

reduce Unvoiced Needs


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


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.


√ √ √ √

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. √ √ √ √


√ √ √ √

Components Used in Different Centres


Two intervention packages were developed and implemented: Centre used VideoE F

A “Forgot to Ask” (FTA) slip comprising of a question sheet with instruction.


- -

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. √ √


√ √

Components Used in Different Centres



(%)

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


(%)

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


Discussion


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


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)


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)


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


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’)


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’)


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’)


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


• 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


Where do We Go from Here?

• The interview is the most powerful, encompassing and versatile instrument available to the doctor

- G.L. Engel


• 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



• “We need to take time to save time”• WHO is really ignorant

–Dr or Pt or BOTH??



• 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!



• 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 possible & feasible– Implement the interventions provided or any other

interventions you can develop



Thank You

dr azman abu bakar mbbs;mph;phd director institute for health systems research

Documents

health systems

health carewhat

context of health careit

health careimportant

drs pts essential

patientsinfluences pts

doctors culpability

quality carecommunication