Monday, 28 July 2014

Doc, could you speak slower, more simply?

Spotlight on helping patients, especially the elderly, comply with medical instructions
By Salma Khalik, The Sunday Times, 27 Jul 2014

If only patients followed their doctors' orders, fewer would land in hospital or complain that they never seem to get better. That's a lament often heard in medical circles.

Various studies have shown that as many as half the patients with chronic ailments do not take their medicine as instructed - resulting not only in much waste, but even worse, avoidable deaths.

So an article by Associate Professor Chin Jing Jih in the May issue of the Singapore Medical Association (SMA) News is not just timely, but also refreshingly honest.

The SMA president, a senior geriatric medicine specialist at Tan Tock Seng Hospital (TTSH), described an encounter with a patient while he was still a junior doctor and the valuable lesson he learnt.

In his piece titled Excuse Me Doctor, Can I Record Your Instructions Please?, Prof Chin recounts how the patient told him: "Do you realise that you doctors have a tendency to just rattle off a long list of instructions and treatment plans, often in some technical jargon which I have to check my medical dictionary to understand?

"And because there are many instructions to follow, I really cannot remember them even if I want to be a good and compliant patient."

For the young doctor, that was the Eureka! moment when the truth of what the patient said hit home.

"Doctors tend to overload patients and caregivers with a flood of information. This is then followed by a long list of directives and advice," he said. "No wonder so many of them suffer from recall failure and end up being labelled 'poorly compliant patients' despite their best efforts."

That particular patient had whipped out a tape recorder so he could listen to the instructions later at leisure - an act Prof Chin described as a "way of crying for help".

He suggested that doctors use "appropriate memory aids (that) will go a long way to ensure compliance, avoid medical errors, and help patients play an active role in taking care of themselves".

Older patients with more medical problems are the most likely to have problems following doctors' orders, so the problem is likely to get worse as Singapore's population greys.

Today, more than 10 per cent of people here are aged 65 years and older. The number is projected to rise to 18.5 per cent by 2030 - or about 900,000 people.

Prof Chin, who is director of TTSH's Institute of Geriatrics and Active Ageing, told The Sunday Times that the hospital has put in place tools to help with patient communication and education.

These include providing printed, illustrated information on certain procedures.

For example, the one on colonoscopy - to check for colon cancer - tells the patient of the risks and benefits, as well as how to prepare for the procedure and what to expect when it's over.

There are also audio-visual clips that help remind patients how to do a blood glucose test at home, or the proper way to transfer a stroke patient. Patients and their caregivers can watch these video clips again and again if they are not quite sure how to do it.

Prof Chin's article hit home, especially for those who deal with older patients.

Mr Lim Mun Moon, pharmacy director at the Singapore General Hospital (SGH), said SGH uses sun and moon symbols to help patients understand when to take their medicine. Those who are unsure of their medicine schedule can call the pharmacy to clarify, using the number printed on their medicine label.

He noted however that some patients don't follow doctors' instructions about taking their medicine because they think treatment is expensive, and not because they don't understand what to do.

Dr Terence Tang, a senior geriatric consultant at Khoo Teck Puat Hospital (KTPH), said many things contribute to non-compliance, such as language differences, poor vision, hearing loss or having little understanding of medical treatment.

He added that the occasions when a patient changes medication or the time when he takes his medicine are "always anxious moments" for doctors.

"It is not uncommon for mistakes to occur due to miscommunication, especially during the initial period of the change," he said.

So pharmacists at KTPH print out written instructions for the patient. The printout lists the medicine and dosage, what each drug is for, and advice on what to do should the patient suffer side effects - all in the language the patient is most comfortable with.

Dr Tang said these printouts are given to all chronic patients, and patients with acute problems may also request them.

Dr Tang said doctors at KTPH try to have family conferences to explain the patient's care plans, but this can be "challenging in busy Singapore".

He added: "Managing an elderly patient is a fine balance between respecting his personal rights and recognising that assistance may be required from family members."

Prof Chin told The Sunday Times that doctors need to customise what they do with different patients. "For some of my patients and caregivers, I may write down the information on a piece of paper to ensure accurate compliance," he said. "For some, I may direct them to a particular website, while for others, they may prefer to just repeat the instruction to me in the clinic as recall is less of an issue than accuracy."

The National Healthcare Group Polyclinics, in the same health cluster as TTSH, has gone one step further in helping patients get their dosage correct.

All nine of its polyclinics offer patients the option of having their medicine packed into sachets. These come in the order in which they are to be taken - so the night dose will follow the morning dose, with dates and times printed so patients know if they have missed taking one.

But patients need to pay $3.50 for a week's supply of pre-packed sachets.

The group also provides patients who "show signs of confusion" with in-depth counselling and written instructions.

Dr Lew Yii Jen, the senior director of the group's clinical services division, said patients who get different types of medicine from different doctors, such as specialists and general practitioners, tend to be even more confused.

So the polyclinic pharmacists go through all their different types of medicine to remove duplication, and recommend how and when to take their various drugs.

Also on hand are health attendants who speak a range of dialects, to ensure that language is not a barrier for patients.

Nurses trained in managing chronic diseases act as care managers and call patients known to have problems with compliance, to see how they are coping. This gives the patients a chance to ask about anything they are unsure about.

Dr Lew said family support is vital in helping patients manage their disease. One in four of the group's patients is 60 years or older.

Prof Chin agrees. "The key point is that we are sharing with many of our patients and caregivers instructions that consist of many crucial steps that need to be followed quite precisely," he said. "We should explore various ways to help them with accurate recall, which is the first step of good compliance and desirable treatment outcomes."

Singapore nurses develop hospital app that 'speaks' in dialect
Nurses use smartphone app to give elderly patients instructions, advice
By Kash Cheong, The Straits Times, 26 Jul 2014

WHEN nurse Sheree Ye needs to communicate with a patient who speaks only Cantonese, she no longer needs to play charades or wait for a colleague to translate.

The 22-year-old can now whip out her smartphone and use a new app that translates the health-care instructions she has to give patients, especially elderly ones who communicate only in Cantonese.

"It's so much more convenient," said the nurse from Changi General Hospital (CGH). "Patients do not have to guess what I am saying. Nurses can communicate more efficiently and attend to more patients as a result."

Called the Integrated Healthcare Communicator (iCOM), the Android app contains 100 Cantonese translations of phrases commonly used in a hospital setting. The phrases include "Please put this tablet under your tongue" and "Please do not get out of the bed alone".

App users just tap on the appropriate phrase displayed in English, and it gets read out in Cantonese. For more complex actions, the app calls up images to help convey what is needed.

If a nurse wants to, say, put a patient on an intravenous drip, a picture of a drip will appear as the instruction is read out in dialect.

Nurses can also switch to the phonetics option and listen to dialect voice-overs, so they can learn Cantonese in their own time.

The app helps overcome a longstanding problem in the nursing industry, said CGH nursing informatics deputy director Wong Kok Cheong.

"I joined nursing some 22 years ago, and the language barrier issue has not gone away," he said. "It could become worse with a younger generation of nurses."

About half of the nurses at CGH are under 35, and few speak dialect. The hospital says that, every day, two in five nurses call on a colleague to help them with translation.

iCOM is the brainchild of nine CGH nurses who developed it with the help of Integrated Health Information Systems and a $10,000 grant from the Eastern Health Alliance's Centre for Innovation. It is believed to be the first smartphone app for hospitals to feature a local dialect.

Currently, it is available only in Cantonese and on Android, but there are plans to expand it to include Hokkien, Hakka and Hainanese as well as Malay, and to add 300 phrases. CGH plans to develop an iPhone version as well.

iCOM will be available for all CGH nurses from Nurses Day, which falls on Aug 1 here.

Madam Kan Wan Sin, 83, who speaks mainly Cantonese, says the app is a godsend when she visits the hospital. "At least now I understand missy (the nurse)."

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