Background
Methods
Individual interviews
Observation of training session and huddles
Analysis
HP Eng | HP Chen | HP Ho | HP Wu |
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HP Eng gave a limited account of the purpose and ethos of CSP: “let patient talk a bit more… so that we can understand the patient more” and so “help them manage their chronic condition better than the usual approach”. He saw CSP as “quite similar” to usual care but with less reliance on medication and more attention to diet and exercise. In both interviews, HP Eng referred to CSP as “patient-centric”. In w1 he explained this meant “patients realize that all this is for their own good” and that “they also had to take care of their own health”. In w2, he linked the concept to listening to patients’ concerns and giving advice relevant to their situation. HP Eng valued the graphs in the CSP letter as making it “easier for [patients] to understand” “the target we are aiming for”. He said in w1 “one of the things I’m hearing about the idea of the CSP is perhaps that it’s the patient’s ideas about what they can do” but had no examples of this. In w2 he more confidently described going through each indicator in the letter, using the graphs to give patients “a clearer picture” and provide a focus for goal setting. HP Eng routinely asked patients about their “diet, exercise and then whether they comply with the medication, any side effect or not”. HP Eng thought the few patients he had seen by w1 were “not that interested”, because they had not completed the results letter. At w2, he still found most patients “not interested”, perhaps because they had financial worries with which “we can’t help the patient”. HP Eng thought CSP could help him understand a patient’s situation and so tailor advice-giving. However, it was “not so helpful” if patients “don’t give you much” or “are not so willing to work with you”. HP Eng saw no impact of CSP on empathy, rapport or respect in his communication with patients. He said he rushed CSP conversations because “the queue builds up and we can’t afford” 30 minutes. HP Eng saw it as a limitation of CSP that patients were often not motivated to modify their diet or exercise to improve diabetes control. HP Eng did not directly answer questions about continuing with CSP but emphasised that it was difficult given clinic time pressures. | HP Chen regarded improvement of diabetes control, and especially HbA1c, as the purpose of PACE-D and focus of the CSP conversation. He thought CSP could be “quite helpful” for patients with poorly controlled diabetes who come prepared and motivated. However, he “rarely” saw such prepared and motivated patients, especially through to follow-up. At w1, HP Chen had not seen any clear examples of improvement in HbA1c. By w2, he had seen one or two patients “that really achieve their goal” of improved sugars or weight. HP Chen found CSP “tough” and “tiring” in the busy polyclinic with the stress of the patient queue and the challenge of changing pace between usual and PACE-D consultations. This did not improve with experience. HP Chen admitted “cut[ting] patients short” in the telling of their concerns, finding mentions of non-life-threatening problems an unhelpful diversion. He sometimes skipped to goal setting. When reviewing CSP letters with patients, HP Chen prioritised blood sugar, blood pressure and cholesterol levels. When the patient queue allowed, he tried to “pause a little” to ask patients about family, work and what is important to them before sharing “some sad stories” about patients with uncontrolled diabetes who didn’t listen to advice and suffered complications. Although some patients would “just keep quiet” he could “try to push” those “able” to say “of course they wanted to be still independent” to help them set goals and achieve targets for sugar control. If time allowed, HP Chen would ask about their routine so his advice could be more practical for their situation. HP Chen thought patients could feel more respected when given time to share their concerns but saw the time it took to hear these as a disadvantage for staff. HP Chen favoured the faster resolution and lower resource use of usual consultations but thought neither these nor CSP made much difference for patients with poorly controlled diabetes who did not take prescribed medicines. For HP Chen, the main challenges of CSP were time constraints and patients’ lack of motivation. With uncertainty about CSP’s impact on diabetes control and concern about staffing levels and resources, HP Chen was not inclined to recommend continuing CSP for all people with diabetes but perhaps not averse to continuing with a more select patient group. | HP Ho talked very positively about CSP training as having “opened up” for him a new way of consulting. He saw CSP as an approach that could help him “understand the patients better”, work “together” with them “toward a common ground” and so improve their care. It took time for HP Ho to get beyond consciously telling himself to “change mode” for CSP and get comfortable using the approach. He also needed to remind himself about CSP after time away from the Teamlet. His self-reminding focused primarily on “shared decision-making” the “OARS” skills and “patients’ goals”. HP Ho found some patients were reluctant to say much, perhaps because they were not used to the CSP approach. However, he could usually “fish out” something useful in a conversation and valued coming to understand the patient even a bit better. With CSP, HP Ho heard things that he didn’t used to hear, including what people were concerned about and why. If he learned about a difficult home or work situation, he could at least show empathy and not suggest or expect impossible diet or exercise changes. HP Ho used CSP type questions in other consultations as well as designated CSP conversations. His reflections on goal setting with patients who found this difficult led him to suggest that sometimes “starting” something might be an appropriate goal. HP Ho thought CSP gave health professionals a better chance of improving healthcare and outcomes (he had a keen interest in reducing cardiovascular risk). CSP could help him increase patients’ motivation – for example supporting someone to lose weight because they wanted to feel better about themselves. He also appreciated that CSP could ensure patients felt more listened to and respected. Even if the agreed action was only to keep medications at the same dose, he could be more confident that was what the patient wanted. HP Ho was not sure that CSP had benefitted all the patients he saw (he lacked evidence, including about patient satisfaction) but he was confident it benefited some. He would “strongly encourage” continued use of CSP and the incorporation of its principles into daily consults. He stressed that the CSP system depended on the ongoing support of PACE-D co-ordinators and extended consultation times. | HP Wu stressed the collaborative aspects of CSP. It “made a lot of sense” to her that patients got their lab results before consultations, and she valued how CSP “flipped” the conversation to ask what was important to the patient. HP Wu had started using what she learned from CSP training immediately and found patients responded positively to open questions about what they thought. She now finds it “difficult to not” use this approach in her consultations. HP Wu emphasised a need for the collaborative ethos of CSP to be followed through between the main CSP conversations. She prepared carefully for CSP conversations and follow-ups and had found a way to search medical records for panels of lab tests to help find notes from the CSPs that followed. HP Wu admitted struggling with long patient stories that she thought she could predict the end of. “Speed is a thing” in the polyclinic and professional training had taught her that good doctors diagnose and act quickly – but she had learned to listen and see where the story took her. HP Wu gave detailed examples of different kinds of benefit derived from hearing what a patient would have been less able to share in usual consultations HP Wu appreciated that various forms of progress might be made in a CSP conversation even if no goals were set or actions plans made. She stressed a need to avoid imposing a tick-box process orthodoxy for CSP on health professionals: sometimes, for example, goal setting and action planning was less necessary or appropriate. HP Wu also reflected that as a deeply personal process, goal-setting could make patients feel vulnerable so needed to be supported carefully. HP Wu considered CSP beneficial for both patients and health professionals. Even at its worse a CSP conversation would be no worse than a usual consultation for patients. She favoured continuing with the approach but noted that while some health professionals spent time on CSP with some patients, others would be working with a queue of patients who would receive less contact time. |
Results
Understandings and reported enactments of CSP
When CSP goes well: ‘ideal’ patient behaviours and outcomes
Commonality and variation in professional enactments of CSP conversations
Benefits of CSP beyond improvements in health behaviours and biomedical markers
Illustrative Quotation | Summary |
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“It didn’t exactly go that well, but it was a case of when I looked at the patient’s problem in an open-ended manner and allowed her to speak, she said something like ‘this condition is something that I need to work on myself, it’s not something that other people can do for me’. And I think ‘Yeah’. And even though at the end of that conversation, there wasn’t a goal set or a plan made, I think it was a good step…. So previously it would be ‘OK, these are your results, these are your medications, I think we should shift, we should adjust the medications this way, I think these are what you should be working on’. Now we have flipped it around and ask ‘What is important to you?’, ‘What would you like to work on?’. I think that makes a lot of difference. When you throw the ball into the patient’s court, I think it forces them to think about what it is about their conditions that they want to work on. Whereas I find that if the doctor is the one telling you, ‘OK, this is what you should do’ the patient just reverts to being defensive, say ‘OK, I don’t want to do that’.” (HP Wu, w2) | When patients are asked openly, they may start to think about what is important to them and what they can do in relation to their condition (even if they don’t get as far as making specific plans). |
“I will get to hear more about what really concerns the patients. Yeah. So maybe they feel that now they have more time, or more of an opportunity to voice out their concerns… or they were more likely to talk about it compared to a normal consult where they might feel they were a bit rushed… So I get to understand the patients more.… Spending a few minutes to find out what their preferences are, what their values are, this gives us a better idea of what we’re dealing with and then how to manage these patients subsequently… (HP Ho, w1) I do get a feeling that they feel that if for once they have been given the opportunity to talk more to the doctor, and let the doctor know about their side of the story, how they feel about things, they will get more satisfaction from that. Yeah. And the doctor is listening [laughs]. I think from the patient's point of view, they always like it when the doctor is listening [laughs].” (HP Ho, w1) | Patients have time and opportunity to voice concerns. Health professionals can better hear and understand. Patients may be more satisfied. |
“What was interesting about this particular conversation was it turned to his things about [home situation], family matters. Things that weren’t purely about diabetes but they mattered to him. So it was positive in that sense because it allowed him to speak quite freely about these things… He is not with family, so the opportunity to be listened to would probably, I’m guessing, be quite precious to him… I listened to him, yes, I did, and I think he appreciated being listened to” (HP Ang, w1) | Patients can talk about what matters to them. Patients may appreciate being listened to. |
“I have conducted some non-PACE-D consults where I was too engrossed in HbA1C… we have only that 5 minutes and I will just go straight to that point, ‘Okay, HbA1C is going up. It's not just going up, it's already in the terrible range’, and you could see how the patient responded and patient obviously had previous consults where the doctor has hunted them down, made them so demoralised and they just hate coming to the clinic… If we are going to venture into … asking them, ‘Why are you so upset?’ and things like that… that would need more time in the normal consults. So, often time we will be quite dismissive, … we will just say, ‘Okay, let's do this. Let's increase the medicine’ and things like that… Overall, it's yet another, I would say, negative consult, and patient get more and more depressed. So that doesn't help with the diabetes. But what I see from PACE-D … I don't see any patients going out of the room feeling downcast or adverse to this consult.” (HP Seow, w2) | Health professionals can avoid demoralising patients. Health professionals can investigate rather than dismiss sources of upset. |
“I think the approach is sort of quite novel lah. Actually useful lah. Because I mean we used to think differently. So now at least we think that maybe we shouldn't be saying too much. Let the person talk. And if possible we try to sort of examine their ambivalence and if they got something, we don't argue, we try to roll with them. Maybe next time then there's more confidence and trust that - listen to them more, maybe it will help. So, CSP help us at least to learn some of these skills lah.” (HP Toh, w2) | Health professionals can avoid unfruitful arguing, work with patient to explore their reasoning, and build therapeutically useful trust. |
“CSP makes me feel like I'm doing what a doctor should do... We have been trained to help people, we have been trained to listen to patients with open ended questions, to get a story out of them, to understand individual circumstances, to deliver individualized treatment… But because of systemic issues, because of timing issues, we have been always limited in the ability to deliver that. And therefore, our practice has evolved into a more paternalistic kind of approach, which, in my opinion is effective, is fast, but not the most ideal. CSP allows me to do what I've been trained to do: to work with people, not to dictate people's life.” (HP Boon, w2) | Health professionals can listen, understand and work with people in the ways they think they should. |
“I have more time to show empathy to the patients and to really care for the patients rather than just mundanely go through the steps of the targets and the numbers. And often times, we can hear what patient is sharing. Even though it is not something to do with the illness itself, I feel that the consult is more joyful and it’s probably more education for me… I feel that if they benefit from it, even if just emotionally, I feel that that makes my day in that sense … I mean, you see patients 5 days a week, 8 hours a day. Sometimes, you can get so it's just like a chore. We just see patient and patient and patient - it's just like a factory. But this adds more meaning to what we do. And sometimes we just need to take it slow and value what we do… I think that helps with our own, I would say mental health, to a certain extent… maybe it helps us to look forward coming to work to spend time with patient… I mean it helps us to know that the patient knows that they are cared for… there is a proper doctor-patient relationship, there is rapport … So, that's way, way different from just seeing numbers, seeing patients as just clearing the queue.” (HP Seow, w2) | Health professionals can listen to and learn from patients. Health professionals can show empathy and develop rapport with patients. Health professionals can enjoy work more; this way of working can benefit professional wellbeing. |
Perceived challenges to achievement of CSP’s potential
Summary of challenge | Illustrative quotations |
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Variations in patients’ ability and willingness to engage | |
Many patients come to CSP conversations unprepared and perhaps reluctant to share their views | “So, some patients come in they might not be prepared, even though we mailed them the results, they [PACE-D coordinators] have told them that they are supposed to write out their thoughts to discuss with us, but many come in just [pause] is in blank lah. Yeah, so they are not prepared… they never really think of what are they going to do to help with their own conditions. Then I think that is a bit of the challenge as well. Even though we tried to stimulate them during the CSP itself, but some patient just doesn't really open up to me.” (HP Chen, w2) “If they really feel that they don’t want to know about how their conditions is, I will leave that and just continue back to the normal consult pattern, rather than continuing the CSP session, because I feel that it will be like hitting a stone wall for that session, lah. (HP Foo, w2) “Sad to say the majority of patients will come in, they have no idea what they are in for [despite the CSP process having been explained]. “Have you seen your results?” - “Yeah, I looked at my results.” “So what do you think about your results?” - “I don't know, you have to explain it to me”. And when you ask them about, “have you thought about your diabetes being poorly controlled…?” well, it's the same: the unpreparedness will show. And when you try to engage them into thinking about what they can do in their life, asking them to describe a day of their life, they sort of become hesitant, a bit withdrawn, like “This is not the kind of consult I'm expecting”.” (HP Boon, w2) |
Health professionals or patients may lack the language skills needed for CSP conversations and important aspects of communication may be lost in translation when interpreters are required | “Most of the time we speak whatever language the patient prefers. That's the first thing lah. But that's where the problem is, because you know there's some things that is very hard to explain, and then sometimes when we try to transcribe, it actually loses the meaning, becomes sort of not what we intended for it to be… And you see for us, for example it's not only Chinese. We have to speak in Mandarin, Dialect, then Malay, ah? So I'm quite proficient … but it's that conversational, not at that kind of level where I can explain this word exactly, what it means”. (HP Toh, w2) “In a delivery model like that of CSP, the accuracy of message is very important … If I were to do a reflection and the translation comes out to be something else then it totally defeats that purpose. Yeah. So that is the biggest challenge I have when it comes to a language that's not native to me … I may not be able to deliver it effectively… The other way is also true. So when we ask patients, “What do you think about your diabetes control?” … when we talk to them in English, or if they're not efficient in the language that they use, they may just give us a very ambivalent answer. And that doesn't really reflect the concern or the worries that they have with regards to the condition because they don't know how else to express it.” (HP Boon, w2) “I can’t speak Malay, so if the patient can speak simple English, we can still communicate. But, if the patient cannot, I would need a translator. And a lot of times during translation, empathy gets lost I think. It’s very hard for me to tell the patient “I see you are really angry and then to get a translator to say that in Malay”. Yeah. So, I’m not sure what to do about that.” (HP Yeoh, w1) [In response to a question about what could help ensure CSP works well for patients and health professionals] “A translator that can translate empathy!” (HP Yeoh, w2) |
Local medical culture has habituated patients to expect to be given medication and told what to do | “Some elderly… with a background of poorly controlled diabetes… not so forthcoming… of the mentality like “I’m here to get the medicine and being told what should be done” [and] when I try to ask in another way, then they kind of become a bit frustrated and they start to say, "Eh, you are the doctor, you tell me lah! Why am I here if you are not going to tell me?" (HP Lai, w2) “So the different thing [about CSP] will be like I ask them rather than I tell them lah… So I try to ask. “So you tell me, what you want to do?”, and “What are you going to do to achieve this or this?” So they will, they will say something, but … if at the beginning you ask, they are a bit scared. So you need to like a bit warm up. After warm-up, I find that's more better [laughter].” (HP Deng, w1) |
Organisational arrangements and policy priorities shaping delivery of CSP | |
CSP training scenarios were easier than those encountered in practice | “So, I thought that training was interesting, actually it was conducted very well. But it’s just that when I came out of the training and started practising it, it was really quite different.” [Interviewer: Can you say a little more about what’s the difference?] “The patients are not rehearsed [laughter]. The patients don’t come in with a script and then tell me what I want to know [laughter]. Right, it’s not like I ask a question and they will give me the answer that I want. So, sometimes they don’t want to talk or don’t answer my questions the way - they don't give me the answers that I was looking for. So then in those cases I will feel a bit stuck, so I’m not sure how to bring the conversation forward” (HP Yeoh, w1) |
Clinic session pressures: long patient queues mean health professionals feel time pressures | “Because of the time constraints, lah, sometimes we have to rush through the consultation. So we can't really wait a lot and listen to all the patient's concerns … so sometimes we are rushing through. So some people, the proper CSP probably not enough time.” (HP Eng, w2) “If there is a lot of CSP patients for that day and there is a lot of patients waiting outside not for CSP, then I might actually shorten the CSP consult if I do not really have the time to go through. So yeah, so it might tend to go back to the old way of consult if let's say we are short of the time.” (HP Chen, w2) “More of a problem is time constraints. Because we have so many patients. So sometimes we tend to rush. … I must admit that sometimes, I tend to rush because I thought I still need to clear all the cases, the full pile of thing behind. Yeah. So that's one of the major challenges lah.” (HP Lai, w2) “While I try to honour the CSP process which is really listen to the patient, I think that there is an underlying part of me that tries to make it efficient.” (HP Ang, w2) “Sometimes I also get stressed about … whether I’m doing the CSP properly or whether I’ve been too rushed because there are ten patients outside and then I have to finish this CSP quickly… So sometimes I wonder whether if I had really more time, or less time pressure, whether the CSP would have gone a little bit better?… I think if given less pressure on the time and the queue, I would be in a better mood and then I can empathise better [laughs]. So empathy. And then I probably would have time to think about what they say… reflect better about what has been going on so far during the consultation. Yeah, otherwise sometimes I feel like there are a lot of things going on in my mind… during the CSP itself. (HP Yeoh, w2) |
Appointment scheduling issues: CSP conversations are interspersed with usual consults (some health professionals struggle to change mindset or pace) | “Not every patient is PACE-D, so we have to change our mode of consultation in between. So the patients for PACE-D come, then we slow down. But then after patient go out, we have to go back to our usual way. Very tough.” (HP Chen, w1) “When we are seated in that hot seat, seeing that CSP patient, how prepared are we to really spend the time with them? … I think from my own personal experience there is a certain degree some sort of a barrier. Because it's about like switching head, as I am seeing my common queue patients, regular patients who – I might spend about five minutes with them and off they go. Suddenly a CSP comes in, I need to switch my head and say ‘This is a CSP patient, I need to sit down, calm myself down and not hurry, listen to them’. That's sometimes a bit difficult, especially when I am really in that mode of seeing patients.” (HP Boon, w2) |
Teamlet working: staffing arrangements limit relational continuity, which can constrain conversation, impede development of rapport, and obscure health professionals’ view of how patients progress after a CSP | “It is not like a GP in the western countries where they have one doctor and every time they see the doctor it’s like they know them very well. For our patients here, we see doctors in a team and not every time is the same doctor. So they might not be too familiar with us to tell us such an in-depth history” (HP Foo, w2) “I’m sort of handicapped by the fact that I don’t always get to see the same patients because of the way that clinics are run. But I find that within the consultation there is a sense of positivity… I think that [challenging a patient’s expressed acceptance of poor diabetes control] is an option if you have a … certain rapport with the patients. In this case I think it was the first time I’m seeing this particular patient so I realised, it was probably not a good time of doing this. (HP Wu, w2) “Very rarely we see this kind of motivated patients. Unfortunately, I haven't got a chance to see back the patients who is so motivated, to see how is their HbA1c… probably it's followed up by my colleagues... So I don't know whether the HbA1c really improve after that, even though they do a full preparation.” (HP Chen, w2) |
Medical record systems do not facilitate quick identification and review of notes from CSP conversations. | “We have no system to tag the patient to the doctor that saw the CSP. If we had, then maybe it's a bit better. Because sometimes, although the records are all there, it's very difficult to see through so many records when was the last CSP. Because in between, after the CSP, there may be a lot of other consultations for other things… I got to look at 10 different clinical entries before I reach the actual thing that I want for to launch our discussion.” (HP Toh, w2) |
A systemic focus on biomedical markers and diabetes: Biomedical norms are prioritised in performance indicators and as the PACE-D primary outcome measure (a) this can be in tension with what matters to patients | ”So, I would say that the sugar, pressure and the cholesterol is the 3 most important thing that I would try to like to make sure they are within the target first before I talk about others, other parameters. Yeah… because that's our KPI [laughs]. That's our clinic KPI.” (HP Chen, w2) “We want to succeed. And if you see ten patients and everybody ends up with a HbA1c of 8 and your friend ends with a HbA1c of 7, definitely you will think something is wrong.. That means you won't be CSP-orientated, but more medications driven lah… Of course, the actual clinical parameters is very important lah. But at the end of it, I think if the patient goes off satisfied, meaning that he thinks that you listened to him, you tried to do the best for him, I think that is success lah. Of course, it's not measurable, but there is a form of success to me.” (HP Toh, w2) “One of the questions [doctors were] concerned about when it comes to leaving things to the patients is that while we have our clinical performance indicators, quality indicators to look after, if we don’t push, and patients don’t meet this, then the scores all suffer and that kind of thing. So that was one of the concerns … I realised … that if you’re trying to push the patient to go a mile, okay and the patient wouldn’t go along with it, then the patient is at zero. But if you make this a more a collaborative thing and the patient says ‘Oh, okay I may not be able to go a mile with you, but I’m willing to go half a mile’ then the patient is half a mile further from zero.” (HP Wu, w2) “[The results letter] sort of spells out for the patients what their goals would be… because… green is the goal that each table is pointing the reader to. And in fact all the goals in the traffic light are very biomedical, like weight target, blood pressure target and HbA1c target. So very naturally, when a person goes to the page to talk about what your goals are, they will tend to think about medical targets for their goals. And that's why, when I ask them about a life target for their goals, they seem as if it's a long shot away from what they were expecting any doctor to ask them… So I think that frames how our patients think about goals… Whereas when I speak to them, I'm trying to get them to think about the bigger story of what they really want and how these are really just surrogate measures of how to get there. So it does constrain.” (HP Ang), w2 |
A systemic focus on biomedical markers and diabetes: Biomedical norms are prioritised in performance indicators and as the PACE-D primary outcome measure (b) this can raise questions of what is relevant to include in a CSP conversation. | “[Hearing long stories] is something that I struggle with I would say. Because one of the things in polyclinic is that speed is a thing. And I think it’s also something in the training of a physician… being able to come to a diagnosis and offer a solution quickly is considered a good thing, right? … So, I think this is something I struggle with, when the patient starts the story and I sort of think I already know how the story ends and all that … So I suppose I learn not to cut them off, just listen and yeah, see where it takes you” (HP Wu, w2) “So the time that has been budgeted ends up being about talking about life, for example… Is it a loss? No, I don’t think so. I think it’s just about getting to know my patient better. And, yeah, we don’t exist for diabetes alone, I suppose, as doctors” (HP Ang, w1) “I basically base my questioning, perhaps not as widely as I expected it to be in terms of - for example, when it comes to the goals of living better with diabetes, which is the language we use, I kind of narrow it down because at the end of the day, it turns out to be that the reasons why people want to be healthy turns out to be - in [my] mind … about three, four or five reasons … (avoidance of complications… avoidance of being a burden to the family… independence and freedom and being able to do what I want to do… seeing the grandson grow up – the family relationship matters…). So when … I want to ask for the goals, if the patient is a bit not in the habit of reflecting or thinking of possible answers, I would, after a bit of waiting, give some examples… I found that if I talk about these life goals as opposed to disease focused goals, they tend to find some kind of synchronicity … For the blue collar workers, the elderly types, sometimes they are not given to thinking about these things… and maybe the language to describe their goals may not be as rich… I try to solve the problem with them by giving them some model answers I know of: “Do any of these apply to you?” (HP Ang, w2) |
A systemic focus on biomedical markers and diabetes: Biomedical norms are prioritised in performance indicators and as the PACE-D primary outcome measure (c) this can raise questions about where it is acceptable to end a conversation. | This example involved a woman who attributed a significant worsening of her HbA1c to the fact she had been making a herbal drink for her family because of the haze (high levels of air pollution) and had to add sugar before they would drink it. She realised while telling the story that she could take her portion out before adding sugar, but seemed disinclined to make a change: “So at the end of it, she said “I’m happy with my blood sugar control.” Even though I wasn’t. And “I’m happy with my lifestyle.” … I suppose pre PACE-D it would have been a bit harder for me to accept… I mean there’s like “You shouldn’t be happy with this”, right? I could understand if you’re happy with your lifestyle, but you shouldn’t be happy with your results. I think post PACE-D there is - it changes I suppose the clinician also. So, I find it easier to accept because I sort of understand that there is no point in trying to force the patient to change his or her mind. Because it probably wouldn’t work. And … I think … from what she said and probably by the way she said it, I also understood that … maybe she’s happy with the lifestyle, but I think she probably wouldn’t be happy with her control. It was probably something she said in the sort of self-rationalisation, sort of denial thing. But … with the PACE-D training, I thought it wouldn’t be (how you say?) profitable to push the point, you know. It was just enough to accept that, and to not close the doors and keep the conversation going. So, I think that’s something I learnt from the PACE-D year of care training” (HP Wu, w2) |
Variations in patients’ ability and willingness to engage
Organisational arrangements and policy priorities shaping delivery of CSP
Health professionals’ evaluations of CSP
Discussion
Strengths and limitations of methods
Contribution to theoretical understanding
Less conducive to broadly effective enactments and positive experiences and evaluations of CSP | More conducive to broadly effective enactments and positive experiences and evaluations of CSP | |
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View of purpose of CSP | Improve HbA1c and other biomedical markers or risk factors for diabetes, supporting patient to work on these. | Improve health and broader wellbeing, working with person’s own perspective on these. (This can include, but is not limited to, biomedical markers and risk factors). |
View of CSP conversation as ‘causal’; expected timeframe of success | As a discrete intervention, with an expectation that it will impact directly and relatively quickly on relevant behaviours and (biomedical) health outcomes. | As an intervention that is part of a long-term process in a complex social environment. It may have various benefits, but impacts on health may take a long time to become evident. |
Understanding of how motivation features in CSP | Patient should come in prepared and motivated to improve their health; practitioner works with a motivated patient to set goals and action plans to improve their diabetes. | Patient ideally comes in prepared and motivated to improve their health, but practitioner role includes working to identify and develop patient’s motivation and support them, when appropriate, to set goals and action plans to improve some aspect of their health and wellbeing that matters to them. |
Why listen to patients and find out about their lives? | Attend to patient’s views about their test results and elicit practical details of their life in order to identify scope for them to act to improve their diabetes. | Attend to patient’s views about their diabetes, perspectives on what matters and key features of their life in order to understand them better and to find appropriate ways to support them to address their own priorities for diabetes or broader health and wellbeing. |
Emphases in professional interest | Strong interest in disease, bioscience and/or epidemiology; less drawn to psychosocial aspects of healthcare | Strong interest in people and the psychosocial aspects of healthcare as vital for good use of biomedicine |
Relevant prior training | No or little prior training with motivational interviewing or similar. | Some (perhaps extensive) prior training and experience in motivational interviewing or similar. |
How CSP relates to previous practice | CSP perhaps involves a significant change, but the difference is seen mainly in terms of allocated consultation time, consultation stages, the kind of questions the health professional asks and the balance of who talks. | CSP allows space for and perhaps gives a formal structure to approaches to working with patients that were already of interest or being tried. Or CSP involves a significant change in approach involving a shift in values towards more sharing and a greater appreciation of working with what matters to the patient. |
Presumptive comparator in evaluative judgements of CSP generally | ‘Ideal’ account of CSP Or The most positive examples of substantial improvements in patients’ biomedical markers following CSP. | Pre-CSP arrangements, including ‘usual’ consultations. |
Implications for policy, practice and research
Recommendations for organisational systems and policy development: |
• Investigate scope to improve language matches between health professional and patient for CSP conversation appointments • Review appointment systems to improve relational continuity through CSP consultations and follow ups • Consider establishing dedicated clinics for CSP conversations or clearly demarcating and protecting a block of time for these within mixed clinic sessions. • Review the medical record system for scope to facilitate identification of notes about CSP conversations and follow-up (progress review) discussions • Review Key Performance Indicators and associated incentives to reduce emphasis on biomedical markers and reflect commitment to person-centredness and broader wellbeinga • Strengthen post-training support for health professionals delivering CSP (see below) • Perhaps consider staff assignment to CSPs to reflect interests and skillsb |
Recommendations for CSP leads and trainers |
• Review the CSP letter as modified for Singapore with a view to more clearly encourage patients and health professionals to reflect on what matters in the patient’s life and for their health and wellbeing (including psychosocial issues beyond the biomedical markers for which test result trends are provided) • Refer to the CSP letter as a ‘preparation’ or ‘planning’ letter or similar, rather than as a ‘results’ letter to help encourage preparation and with a broader focus.b • In training and follow up support for health professionals who deliver CSP: ◦ Prepare health professionals more explicitly and practically for some patients coming to CSP conversations ‘unprepared’ and, for various reasons, being not very forthcoming with their ideasb ◦ Encourage health professionals to check and reflect on their interpretive emphases and if necessary consider whether a shift to positions more conducive to broadly successful enactments of CSP would be appropriate. Table 4 could be the basis for a tool to support this. Meanwhile we note it might be particularly important to: • Debunk expectations that CSP will mostly go according to the ‘ideal’ model with quick wins in biomedical improvementsb • Encourage health professionals to keep in sight a bigger picture of how diabetes impacts patients, to adopt a broad view of the purpose of CSP (enabling people to live well with their condition) • Encourage recognition and appreciation of the ‘softer’ relational and experiential benefits of CSP – both in their own right and as possibly intermediate to longer term health benefits. • Promote the underlying ethos of CSP as valuable in its own right and attend to this as the basis for the ‘usual’ process steps (a hollow or inflexibly dogmatic tick box approach to CSP steps may be counterproductive, there needs to be an underpinning interest in the person’s wellbeing and life and orientation to a collaborative and continuing supportive approach) • Discourage viewing the CSP conversation as a ‘one-off’ intervention • Encourage recognition that one can do ‘a good job in the circumstances’ • If possible, offer occasional ‘peer review’ by a skilled trainer who can observe consultations and support individual health professionals to reflect on and improve their practice |
Recommendations for interpretations of trial findings and further research |
• Be aware of outcomes (including experiences that may mediate longer term health outcomes and are broadly relevant for wellbeing) that are not assessed • Be aware of varying fidelity to the intervention (and recognise that the adverse effects of some shortfalls in fidelity may be compounded in some circumstances) • Be aware of potentially modifiable systemic challenges and shortfalls in some professional enactments of CSP conversations and follow up that have likely limited the impact of CSP on health outcomes. • When inviting or interpreting health professionals’ evaluative comments and thoughts about whether an approach they have tried should be extended, check their reference comparator (an unrealistic ideal or previous usual practice?). If possible elicit and bear in mind how they have understood and enacted the approach, and in what circumstances. • Be aware that simple rating questionnaires about the value of CSP are potentially misleading if health professionals are making different assumptions about patient populations, working contexts (including organisational support) and the skills of the health professionals involved. • Qualitative studies of health professionals’ perspectives can add value |