Table 3 Challenges to health professionals’ enactments of CSP and achievement of CSP’s potential

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about what they can do in their life, asking them to describe a day of their life, they sort of become hesitant, a bit withdrawn, like “This is not the kind of consult I'm expecting”.”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)