Inaugural Lecture : Putting Patients Back at the Heart of Care

adambakkam Rosamond the Dean Faculty of Medicine you know CI a– who will chair this afternoon’s lecture and professor dr. engine Department of primary care medicine faculty of medicine university of malaya can we please stand for the national anthem and you end zone No Oh Oh Oh gah ah the park i love Oh yup oh gosh ha son but haha good afternoon professor dr. adiba comoros amin Dina faculty of medicine university of malaya professor dr. Tunku Camaro zaman Benton cause I know Abaddon director newsteam liya Medical Center his Excellency’s ten threes that talks respected professors distinguished guests professor dr. intelligent management of the faculty of medicine university of malaya ladies and gentlemen welcome to the inaugural lecture by professor the antigen and title putting patients back to the heart of care without further delay I would like to invite professor adeeba cameras Amin to chair the lecture and to introduce professor at the intention dr Dina good afternoon everyone and thank you for coming to the first of the series of inaugural lectures for this year 2016 and I can’t think of anyone better to start the ball rolling for this year than in Chechen I guess I you know in reading your your CV perhaps first uncheck Jen could be best described as the one who almost got away and what I mean by that is you know we have this rivalry with our twin our

cousin or with stepbrother whatever you want to call an us because Chuck Jen did his first degree at nus and subsequently also stayed on to do masters in family medicine and fortunately for universiti malaya chose to come back to malaysia and universiti malaya not many of our graduates who go down SAS choose to do that and certainly I think the faculty and um are so much richer and better for it because chuck jen has been one of the shining stars in the faculty combining his clinical progress with his certainly his academic achievements I think Chuck jen has been one of the leading academic staff in in a small but very productive department of family medicine they’ve probably got one of the highest ratios of clinical clinicians to PhD compared to many of the other clinical academic departments so it certainly is a tribute to the department but also to check Jenn who’s been leading many of the research projects and programs in Department of Primary Care as as an internist as an internal medicine ah I always admire people who choose to do primary care because really you are the consummate doctor you have to know everything from from from pediatrics all the way to terminal care and and I for one has never spent a day doing general practice really really admire those who do do primary care and and check Jen and colleagues are really leading the university as well as the primary care facility as a whole in trying to to build up the specialty of primary care and I think at last count we put the task at you having to produce something like 20,000 primary care physicians for the country no small task but with his background and his his contribution actively to the Academy of Family Physicians of Malaysia I’m sure that Chuck genin and colleagues eventually we’ll be able to achieve this 20,000 primary care physicians for the country but I think we’re Chuck jen has really made his mark is in driving research in from primary care and he has sadly established close collaboration with researchers from the UK Australia and many parts of the world and he was also asked recently and has done an admirable job of putting hopefully blended learning open-source learning for clinical research which we hope to well we will retrying it at the moment but we hope to expand to the rest of the faculty and to those who are doing other clinical masters program for for the requirement to complete a project so he’s been a busy man and on top of that he’s not taking on the big task of being the deputy chair of the ethics committee so we and and I’m glad to see the title of your top putting patients back at the heart of care I think it’s very easy to lose sight of what we do and who we are and i look forward to hearing how province research into patient decision-making has will leaders into better patient care so over to you thank you very much profitable for the kind introduction distinguished guests friends colleagues family members it’s an honor for me to be here speaking to all of you today and I know many of you having busy shadows and clinics and you have to cancel them to come to this lecture I’m just thinking considering

the men hours that we have here the cost must be tremendous right um before I start I’d like to thank many people here or not here who have made this possible for me first of all I to thank the organizing committee the icr the dean’s office the department’s particular pond nor and wounding or putting this all together I like to thank my teachers both in years of schooling in nus as well as in um particular profit share is not here today I also like to thank my colleagues from department where we can from other departments we’ve helped me along the way and as well as of course my students we have a key me on my toes and keep going and love all of these my patients who have inspired me to route to put up this title today putting patients back at the heart of care okay let me start as a primary care physicians I will attend my clinics quite regularly but this day’s a bit less now about once a week used to be one every day so and i tend to hurry across to my room consolidation room i think was a ton done looking at my patients I just walk into my consultation room and get my patients consolidation started usually there’s a long list and have to rush them through so sometimes I wonder what’s happening to the patient’s ups like my consultation group like this particular man what is going through his mind what has he thought about before he even come to see me in this clinic is he going to say think that I’m going to see my regular doctor so I’m going to admit he’s not going to be around because attending meetings I’m going to get my test results today once the results going to be okay the doctor said that I’m supposed to start in saline this time if my blood sugar level is not good so but I don’t want to because a lot of concerns or maybe I have lots of work waiting for me in my office and I just want to get through this as fast as i Kenned so many things goes to the mind but how much do we know about what’s going on in the mind of this particular patient but this patient’s not too bad is alone I don’t think he has the weight for too long to get his turn more likely is this okay this is um I think any department so long queues and there will break out well hopefully less now right under the guidance of profitable tomorrow and the waiting times cutting shorter but still you have to wait a long time but when they get in the doctors for this thing signed about 10 minutes 15 minutes at most you see them so are we really achieving what we set out to do is to help patients with their illness this is a if those of you who have been to recur DePalma primary care medicine this is a typical consultation room and this is my x collection of the thin who is from Myanmar and this is a nice Chinese lady let’s call her madam tan okay obviously dr. thin doesn’t know how to speak Mandarin neither does Madame turn knows of this Vinglish so most of time they will converse in Malay because dr 13 knows Malay so well madam tan has lots of problems she has diabetes on insulin she’s hypertension dyslipidemia just osteoarthritis of the knee she’s slightly pale she’s vegetarian so any make and of course she has just the husband just passed away she’s this you know just deceased and she’s coping with greeting lots of these problems that are typical patients that we see envirocare really so dr. teen has to deal with all these things so the patient typically spend 15 minutes with us at most 20 minutes per consultation so it’s each year they see us for four to four times a year so that is about an hour per year what happened to them the rest of the year twenty sixty four days in 23 hours how much do we know their life beyond the consultation and every day madam plan has to grapple with and that’s just the health just 2 diabetes about her diet about monitoring her sugar about remembering Deepika tablets and medications and injections at night once a day so but this is just part of a life this is just a health part of her life how about the rest of the latter social part of a life we don’t know a children her grandchildren she’s through after

the grieving now losing her husband so how much do we know about patient really and when we try to manage our patients all this comes into play because all these affects her her life including your health this is a paper that went in dig for her monsters and fishery near myself co-authored why do some people with type 2 diabetes who are already on insulin still have poor glycemic control is the exploratory qualitative study and these are my attempt to try to show you some of the voices of patients that needs what’s happening in the life at home this is an exit lorry driver he was a lorry driver until he had to start on insulin and he kept having hypos and then he has to stop driving every time he’s fought in Canton essentially every time the doctor asked me to eat brat can you eat bread every day for sure you were headed they were asked you to eat vegetables every day cannot like that you know as much as as doctors part of the things that we do is to advise patients about diets and but to the patient’s you know diet is just part of their life and they enjoy eating so you asking them eat bread you know go on cereals milk and all that it just doesn’t work do we know what they are doing at home this 40 all US officer government officer I don’t quite like insulin actually I’m very afraid of needles and the pain that follows in a week I would say at least three times I would skip the insulin injections these are interviews from patients and doesn’t wonder the sugar is high but we can’t solve their hyperglycemia the fresh sugar unless we deal with the root of the problem that is afraid of the needles and is painful this is another paper that we published with one may and and prov cha barriers and facilitators to self monitoring of blood sugar in people with type 2 diabetes and decide voices of this 61 year old retired teacher living with diabetes for 20 years if the blood sugar reading is a bit say one or two unit higher I get frustrated why is the blood sugar not coming down that’s frustration I pray 100 times I pray pray pray that it must not be more than that before they dictate blood sugar monitoring then I prick and see oh it is more than what’s expected before diabetes kills me the mental torture will kill me and that’s why I just couldn’t be bothered to check my blood sugar at all so this is exactly what happening in the real world despite the fact I said you must monitor sugar is very important then you can gauge that can adjust her insulin blah blah blah but that’s exactly what’s happening in the mind unless and until we address that the highest blood sugar level will not be soft and let’s go back to this lady again and poor dr. thin has to deal with all these things sugar is high that’s the cost which is not monitoring she isn’t skipping injections you know three times a day and she just cannot control her food because she just enjoys food eating bread vegetables no go so how is dr. didn’t going to help her should we because for us as medical doctors who are trained to use evidence-based to try to help this person try to use the best available evidence based on scientific research and scientific research say that diet is important medication is important insulin is the way to go but this patient is telling you that that’s not the most important thing to her I started off as a junior house officer in Singapore General Hospital attended my first evidence based medicine workshop and I was really happy because finally I see the light because I feel that that’s probably the best way I can you know method I can use to trying to manage my patients because I’m just looking at the scientific evidence for those of you who are not familiar evidence-based medicine it basically means that you try to integrate whatever scientific research together considering your experience your familiarity of the patients and then taking concentrations patients values but it’s important to them and then practice as such but most of the time previously people just focus on the scientific evidence without actually looking into the patient values so when I was happy seeing that because it’s black and white there’s evidence I practice it no evidence I don’t practice it it’s so easy for me especially for junior doctors that’s why we stick strictly to clinical practice guidelines as if the other Bible but little do we know that these guidelines are just guidelines they are

not black or white there’s a lot of gray in between this is sorry for the confusing map and if you think about it if evidence-based medicine is practiced by the doctors worldwide and this is embraced as the way we should practice medicine are we doing we should see that those patients who require some treatment should be receiving it but just look at this map i’m using the US data hopefully one day malaysia will have the same kind of data it’s a Dartmouth Atlas Project some of you may be aware we basically map out the practices across the whole United States and try to see whether there’s variations in how doctors practice medicine the darker the red the Raider it is means that the more mastectomy is being done for women with breast cancer as you know mustek to me for early breast cancer you can either do mastectomy which means to remove the whole priced or you can you do lumpectomy which you just removed a small part of the breast with radiotherapy so and you can see that the yellow means that it is very it’s not so commonly practiced or else red means very commonly practice and can see the variations even even if you look at this even Chicago just with in Chicago itself the second one you can see that yellow there’s red and does that rate that means even within that small little area there’s variations in how doctors decide whether to do must act to me or not it’s not because the fact that the woman’s are different because summer early summer late is not and also not because patients are don’t want to do mastectomy well maybe a portion of them but majority actually leave it to the doctors and the doctors basically make a decision this is just mastectomy which means that the decision is made based on the doctor’s discretion and the doctors know for factor if you think about it if mastectomy and lumpectomy are equally effective in treating cancer that should be equal there should not be so much so but in this case there’s overwhelmingly a lot of mastectomy in one area versus the other so I think this is something for us to really think about and why are we practicing differently if evidence-based medicine should guide us juanita properly you myself Renee did a study looking at GPS views and experiences about practicing evidence-based medicine and these are conclusions just been accepted for publication the GPS set that they lacked knowledge and skills and it really depends on the workplace culture whether the workplace promote this kind of evidence-based medicine culture or not is more in academic institutions like in ummc but when go to private GPS in clinical sahar turn then the skills and the culture completely different and they don’t they practiced Agnes business that’s unless it tends to depend on more experts opinion the shocking thing we found was that ebm perceived as a threat to good clinical practice when we look at it I was like why is they think are they thinking that ebm should be perceived as a threat and the reason is because this is from a GP if use that evidence based medicine people tend to focus on research scientific evidence and neglecting what the patient’s think if we want to be embracing patient-centered care then we should be thinking about patients rather than just using the scientific evidence but actually in real in real in actual definition evidence backs and patient values are actually important is how we practice it but this is what people perceive evidence-based medicine s so going back to the topic of the day is about patient-centered care when we practice evidence-based medicine I think we tend to neglect patient values which is an important part and if ultimately whatever outcome of the treatment is patients are the one who are going to benefit or to suffer or get a home so i think when we practice so-called evidence based medicine we really have to look at patients values which are what’s important to the patient what are the preferences what’s important to them this is a study that’s conducted by lee uconn my first fugitive student who is nelson election or department he explored what patient values means in the medical decision making concept and

when we look at patient values is not just talking about the treatment specific values for example it about diabetes we’re not just talking about is um avoiding complications important is hypos something that would consider as important to me but we also have to think about the light goals and five philosophies because a busy person who is in the you know in the early stage of their career career the family money is much more important than health it was sacrifice hell for that so when we explore patient values i think is very important to take considerations their life goals what’s important at that stage of life and of course the last circle is actually personal and social cultural background sometimes a religion take precedence over it it is suspect that the insulin is not Hollow for example they will not take it so I think this is a broader context of how we should see patient values not just about the treatment but also the live goals and their social and cultural background this is just an example I showed you that for example starting insulin type 2 diabetes we are patients values which are I’m afraid of the pain is that is expensive I may faint because they look at many movies when you start instantly and you may have high ball you may faint will I get more complications they think that by studying inslee indigent can get get kidney failure for example whereas for the doctors sitting on the other side of the table yeah well more worried about the blood sugar control we’re worried about our we achieving our audit targets of hba1c of less than six point five percent because that’s what our boss want us to do fewer complications so you can see a mismatch between the two the patient values and doctors values and we know that they are not the same so that’s a clash there so when there’s a clash you can see that the consolidation will not go well and this is the reason why I think if I went for my PhD was pretty frustrated because I was trying here to help you the patience to convert to con insulin because I want you to save your limbs save your eyesight and prevent you from getting heart attack but the patient’s saying no no no and then one year later they are still not on insulin so if you really frustrate that but only when i discovered that actually does this mismatch that we need to deal with then i can live with that so acting in the best interest of patients may not hold true all the time i think we need to listen to the patients more and interesting of medicine now it’s called the National Academy of Medicine define patient-centered care as providing care that’s respectful of and responsive to individual patient preferences needs and values and ensuring that patient values guy all clinical decisions and I really like this definition but this is not saying that we don’t need to have competent clinicians we must and that’s a prerequisite but that’s not enough we need to take patients values and needs into our considerations when making clinical decisions with them and how to operationalize this I mean this sounds very so very nice very self philosophical can you actually convert it into something concrete something interventional something that we can actually practice in our daily clinical consultations no point talking about it if you have done do anything about it this is a concept of shared decision-making which is introduced by Katie Charles in McMaster Canada and on the one hand is the paternalistic model which is something that Maxim is quite used to the means the doctors being the expert knows what is best and then decide for the patients what is the treatment option on the other hand is the other extreme is where that doctors provide informations give the patient’s informations and the patients just make the decisions without actually needing to ask the doctors what his or her opinions is which is not usually happens in our context but shared decision-making is in between whereby patient provides information about the values and preferences practitioners provide the clinical expertise based on scientific evidence and the clinical experience and both parties discuss negotiate and agree on that decision this sounds very ideal and it can be anything in between it’s not three concrete blocks but somewhere in between also happens so what is with this that interventions are being developed to help patients make informed decisions so if you look at madam tan and dr. thin on one hand is the expectations who knows about the values the health believes the

health knowledge and psychosocial background these days and age internet is very easily accessible patients with search for informations before they go into consultation room perhaps not Madame time mr. but some of the younger generations they were definitely such before they go in and ask you the questions also on the other hand of course are the clinicians with the clinical expertise as well as having the experience of managing patients and knowing these patients health stages throughout because they’re falling up them across so they know these patients sort of preferences and they also know the health resources where to refer the patients where the cheaper drugs in oh and all this and through this in the consultations together with other family members as well as the nurses the dietitian support dieter is the pharmacist that they come to a decisions as you can see is actually very complex that is a journey that go through but truly I mean do patients wants to be involved in decision making isn’t it easier if doctors made a decision after all the doctors should be in the position to advise the patients so this is a study conducted by Angela Coulter in 2005 but I think it still holds true until now that does wide variations in different countries whether the patient’s people actually wanted to make their own decisions or wanted the doctors to share decisions with them and this is where by they want to make their own decisions or the doctors share with them rather than doctors making for them you see in Switzerland Germany UK very high particular Switzerland and in poland and spain much less in Spain less than fifty percent they wandered doctors to make a decision so so I was quite excited when I came back from a PhD in 2009 when you share this concept of shared decision-making so I presented it in the hospital conference and attend if I quite a few people and about we should do this check decision-making and that’s when I got a question ash is one prof son Jeff actually who raised this question cho-jen this cells were all very nice very Western you know but does it work actually our patients most of the time may want us to guide them in need a decision or even want us to make decision which is still true i think many ways so i was really upset with sanjeev because i said what how could you say that but when I went back and reflect I say is true and this is I mean the previous slide just showed that isn’t it so I I asked myself you know I said I had this you know hospital-based clinicians in order Don you know but maybe he has a point there so I actually went back and seriously think about it and then I decided to do this study and then a ranjini wisdom graduate and all the family physicians in Penang did study when she was was the students in 20 2012 actually patient involvement in decision making a cross-section study in malaysian prime cos plane but very modest is primary care clinic this is not in the world this is not in clinical a hard time okay and this is what we found more than seventy percent ok this is comparing japan but you just look at malaysia 50 plus 20 above almost three quarter want to be involved in decision making this is all the walk-in patients in Crooker including those with chronic diseases only about twenty-five percent want the doctor to make decisions for them so i got the answer right and then we also found that only thing that’s associated with a preference is actually the household income means that those who are poorer tends to want the doctors to make decision for them because they do not perhaps have much options and this is the only place they can come to because it’s cheaper for example and we also found that we ask the doctor to predict whether they can guess what the doctor patient wants do they want a more autonomous role or something they wanted doctors to predict whether i know that whether they want the doctors to will make decisions for them we found that the doctors feel terribly when they ask them to try to predict whether the patient’s want to be involved or not so which means that we are not very good we meaning the doctors and the health care professionals are not very good actually in understanding what patients want so i think this really is also a wake-up call but we just completed another study but this time in a rural setting unfortunately just we just analyze the data and it was done in a koala longer to somewhere near bunting but in a rural setting and we found actually opposite meaning that 75% of them wanted doctor to make decisions for them okay i need to be balanced otherwise i was just telling you the positive findings right

and then the other quarter actually did not want the doc the only a quarter wanted to take them to be involved in decisions making themselves so there is variations so but we don’t know who are the ones who wanted who are the ones who don’t want so i think more needs to be done on this and then we went on a group of us really Istavan shared decision-making this came together and then did what we call a situation analysis a scoping review whereby we want to know what’s happening in Malaysia so we published this paper and overview of patient involvement in health care decision-making we look at the clinical practice the teaching in undergrads and postgraduate we looked at the research done in this area we look at the policies with look at the laws and legislations very little done and very little in the club curriculums is about decision-making patient-centered care is also assumed under communication skills consultation skills it’s all in the hidden agenda a curriculum it’s not explicitly sort of tested as such so there’s a gap there’s a gap there is actually a sort of a policy of sort that’s already published by MMC saying that we must involve patients in decision-making and it’s quite explicitly laid out but that was already about 15 20 years ago and is still not being implemented until now so what’s happening and let’s go back again so with all this with the gaps and all that so how are we going to help madam turn in this consultation can we do something about it or are we going to just live with it and there are actually different ways of helping patients to make decisions i’m sure some of us have made difficult decisions in our lives not necessary health but in terms of health decisions these are the three ways that people have actually done research on and found to have some evidence first is patient decision aids which i’ll tell you more about it second is the district coaching whereby the healthcare professionals or counselor teach people how to make decisions third is actually training the healthcare professionals in communication skill consultation skills so that they engage patients in decision-making which one do you think is the most effective I wish is the third but actually this is the one with the list evidence okay it’s been found to be actually not so effective decision coaching some evidence the one with the most evidence is actually the patient decision aids which actually is what I’ve been doing for the past I would say seven or eight years study with my PhD didn’t know what our patients musicians at all bar is a natural literature review i discovered that and those early phase of this patient decision it’s research and then now i’m doing a bit more and you may ask what patient decision aids are is basically an evidence-based tool the missus based on scientific evidence and it tell patients about the risks and benefits of the treatment for example the recent benefits of mastectomy versus lumpectomy insulin versus no insulin questions to explore what’s important to patient something that we don’t usually ask in or explore in education pamphlets for example it facilitates the doctors or the nurses in consultations but not replacing them and it should not buy right influence one person to choose one options over another because most of the time as clinicians we tend to influence the patients to choose one options over another so if you are truly patient-centered then we should actually leave it to them to sort of make their decisions without undue influence and this is a cluster randomized control study that I’ve done in UK involving 150 patients about 33 practices in the general practices and we try to find out whether a patient decision aids there is helping patients to make decisions about insulin starting insulin helps them to make a better decisions or improve your blood sugar level and it’s been found to this cluster randomized control trial that it improved patients knowledge how they perceive risks of getting a particular complications involving they improve the involvement in decision-making and also reduces the conflict whether to make these decisions or that decisions but there’s no difference in terms of the blood sugar level because some people may say if you let them make the decisions then they won’t start insulin in which case the sugar level may actually go up but actually far there’s no difference and the consultation time again people may worried that by doing this engaging talking to them you actually prolong the consolidation time by using this decision it but actually

there’s no difference as well in terms of consolidation time so decision arroz y is actually how did you make your decisions about your diabetes treatment as you can see the treatment group that those with patient decision aids are more involved in decision making whereas those who are in the control group twenty one percent of them still getting sort of decision made by the health care professionals so there is an impact in terms of the decision role after using the decision it with a p-value of less than 0.05 same thing for those who have distinct decisions how many of them actually persist with the decisions we know that sometimes patients say yes I’ll start insulin but at the end after six months they stop using it because they got all the side effects complications because the decision is not informed one again you can see that those who are using patient decision aids actually persist sixty-eight percent of them persist at your decisions where are fifty six percent of those in the control persistent that is a stats quiz infant difference between the two but of course decision it is not the key although everything is not the answer to everything it has its limitations as well as we have written in this the latter two bmj that however use of this aids is only one component of transformational change needed to promote an embed patient-centered care into usual clinical practice we cannot replace a sort of patient-centered care with just using like decision if and that’s it it requires the change of the health system the change of the doctors and nurses the health care professionals attitudes towards patients this aids are not aimed at just saving treatment costs but can also help change the relationship between clinicians and patients particularly in the management of long-term conditions the routine so patient decision is a part of whole system change can also facilitate the introductions of other patients can send it care initiatives such as shared decision-making support for self-management and care planning and this led me to the projects they’ve been doing for the past 78 years we call it the D meet project or the decision-making on insulin therapy whether we try to develop decision aids to support patients in decision-making as you can see this is now this is a website actually and is now limit 3 was 12 and then I’ll three so now this is an implementation phase at the first was the development phase the second was actually at developing in the health innovations and the third phase now is the implementation phase and this decision aids was developed based on a specific framework whenever we do develop an intervention I think is very important to keep in mind that these interventions it’s not because we like it is useful but because it must be developed based on the needs of the stakeholders so we actually interview patients doctors nurses pharmacists policymakers in the process of developing this decision eight and something that I learned is that you must we must we must involve the patients in research in telling us what is important what is needed in research at the early phase they don’t come in as a participants of your research but coming as the development of your research and the more and more we are doing that and nowadays I think most of the projects would have a patient’s involved where we develop an intervention and we find it very useful we need to train them and I think one of my patients actually I think mr. Chong you know my patients who has very good give us real feedback about some of the interventions we have done and we really thank him for that and from this we published quite a few papers and I’m going to show you some of the lessons we have learned from this and all the key things that’s different from the other decision is developed other countries I’m going to summarize it for you actually is the cultural difference when we develop a decision eight when we try to develop something that is something’s import something from the Western world I think we have to be very careful we should not just import it and implement it and this we learned also from this particular study I’m going to share with you some of the things that we must consider where we sort of develop and interventions particular for patient center interventions language barrier I think you all know this very well language barriers were common especially when healthcare professionals did not know the patient’s preferred language this particular male man in clinker certain set duppy bahasa english site up for humsafar hamsika ski bahasa melayu

moonkin belief aha fortunately most our patients are doctors and nurses can speak Malay right when they is not very good so something I struggled but but it’s very important to speak the lingo same goes for dialect speaking Mandarin speaking or tamil-speaking patients all this decision making is very difficult if you don’t speak the language a doctor said a medical officer in clinic offensive language I feel is very important Barry you have to overcome I managed to get lots of Indian stuff to be in the clinic so basically when we improve the communication the patient can accept it better so they already implemented it by getting more healthcare professionals of that particular ethnic groups so for that we actually develop the decision is in four languages so we struggle with Tamil but we did it eventually it’s a struggle and we also develop health care professional guides for them the other issue is this paternalistic health care model there’s very commonly practice there were concerns that patient decision aids was developed with a hidden agenda to persuade patients to start in saline this is a tool whenever a doctor give our patients at all the patients ultimately will think that oh you want me to start in saline you’re giving this tool you must be trying to persuade me to something but actually it’s not the case for example this university based primary care doctor said they find that this is a tool for us to persuade them as the insulin I think perceive it that way rather than for them to see which treatment is good of which is bad about this particular patients in ummc at the rate they’re going that means the doctors are going they have so many patients I overheard them saying today alone 250 patients actually we are more like did get 506 I’m sure you know all this tech time is a good deal idea but how are you going to see it through is another thing and the doctor must be committed to want it or do they feel like it is a waste of time and this is exactly what we found any when we interviewed doctors they’ll think is a good idea but can we implement it in a busy clinic setting clinical setting well for that we have two trained sorry it’s a bit dark and there’s me in the training with workshops we have a guidebook and now we have an e-learning module that they can go online and learnt because as you know workshops is not sustainable and you want to disseminate why we can’t be conducting workshops all the time so I think within your ways to help to implement this the teaching and training the trainers use of complementary and alternative medicine other hubs or the jammu you know or the Chinese medicine keep coming up again and again and we know some of us are also thinking ourselves this Malaya taxi driver after seeing dr. X I was feeling the tension meaning that she has to start the incident right I was approached by this salesperson just below the clinic right he gave me this 44th types of vitamin like ice blend that kind of thing I don’t know I just drank it and he’s a taxi driver and for one year he has been drinking days every day is almost like like TB patients coming back for the drugs or something like that dots or something and it’s effective you know why he lost weight by drinking this the salesperson also said you if you drink this you cannot take a lot of meat you have to cut down your dries you have to eat healthy only this juice will work of course it worked because he lost 10 kilos is obese and now is 10 kilos so of course it worked and but he could not you didn’t continue on because it’s expensive and I guess to drive that every day and do it so but this is what happens perhaps that might be by what in fact is not the Jews as you know is the advice that goes with it and which we have been telling the patients is the perceptions of the patients about the drugs who are giving them I think and I think it’s only engage them find out the concerns that needs then we can address this problem damn in our interventions will be effective then the sugar will be controlled this private GPS a and when you tell them your diabetes has come to a stage where you need injections they will say that this helps and so on they want to try the hub’s first so for that we put that options in as you can imagine the struggle i had when i try to put this into the guide we have a lot of resistance from the clinicians and see how can you put complementary and alternative medicine as an options for the patients to choose we don’t believe it is done there’s not evidence based medicine but that’s an option for the patient if you truly are thinking about patient this is an option for the patient so why can’t we put this in and then discuss it at our normal consultation if you don’t put it in

patients will not tell you that taking it if you put it in that patients say oh you actually realize this is an option then I’ll tell you the actually this is an option then we can have a discussions about it the next one is family involvement I think we know that Asian culture family is very important when I said that to my Western colleagues I think they they are usually they said no family members also very important to us but maybe to a different degree that’s how much we are going to help a sort of involved in the care for family members this is very interesting explorations of not just family involvement but also patients values look at the first level okay these patients believe that incidence is expensive yeah I feel I want to save money my internet is expensive I don’t want to take it just want to take one flew it one tablet okay patience is 55 year old female that’s already 66 year old female and when you pop a little bit more about their life goals and philosophies I’m mostly thinking about work la my son-in-law children how much money can they give my daughter has her own family my son also has his own family so his priority is his children his family not his health and we look even at a broader circle about backgroun patient had to support family of the loss of husband’s job I suffer a lot one well slang my husband retire at 55 because the doctor asked him to stop working that time he has heart problem that’s why every cent i earned give it to my son and daughter to study that’s why every cent is so important to him to her and that’s why he fused that is very difficult for the children to earn money so he doesn’t want to disturb them that’s why he fused that insolence expensive do she can afford it but he just doesn’t want to spend the money it is not to ask for money from the children so when we talk about this you know if we want to discuss insulin this lady you cannot just tackle herself you have to involve the family as well maybe talk to the children find out more about it get them to talk about it otherwise we can’t solve the problem and for that we put this into the decision aight what’s important to you and then that my family may not agree with me starting in saline or at least this is a thing that they talk about about the family so we want them to tell us about it the last point is is insulin how long this came up in our interview as well whereby the purity of insulin injections were some of the concerns for the Muslims Hindus this is particularly in the model rural setting because we interview patients from the rural setting Israel there were also constants about injections during the fasting month for Muslim how can you inject ourselves during fasting month because that would mean that you are not fasting if you cannot fast you pay fine that’s his perceptions I think they were thinking about insulin is from non halal products ok so these are some of the constants we have that we have when we develop patience Center tools we have to take all these into considerations and for that we actually put in this check box there for them to take whether insulin is how long or not so that’s just the insulin patient decision aids that’s just one of the options we can use to help us to implement shared decision-making putting patients in the center of care there are other decision it’s instant have been developed julia is here our prof Julia just develop one fantastic tool on bladder Explorer which helps patients with spinal cord injury who are making decisions about the bladder drainage methods which one to use should they use indwelling catheter should they have operations you know to have a inside to catheter should they just go on diapers without having any catheters these are the options and these are those who struggle to use soldiers develop the ipad version of the decision aight help them and of course I sure is not here prof I sháá together we have sort of built this decision aid to help women 20 with early breast cancer to make decisions about whether to choose mastectomy or lumpectomy plus radiotherapy so what are the options available and this has also been developed into a mobile phone app and last but not least is a prostate cancer decision aids which honor developing it together with prof leaping in from you p.m. and the team and trying to develop we have the already developed this for patients with men with prostate cancer helping them to make decisions as you know early prostate cancer there are lots of options available so all these are fine but can it be implemented otherwise it’s just on the shelves of the researchers okay very nice to show but not being used how do we implement it we are still in the process of trying to find ways of do that and in fact as

Dmitry is trying to do that but one way of doing it is to actually update our decision aids you saw the first versions actually we ran out of it because we print over 100,000 over is right now so we have to print the next one and drink the second versions we update the information change the layout based on the patient’s a feedback and we also develop a website for those who have no access to the book they can at least go to this interactive website and then to actually do this some of the patients family actually wanted to look at decision it so if they didn’t come with the patients if you don’t have decision is at least they can go to the website and find out and there’s also an iPad applications they can use if they want to and we also develop online health care professional training modules which was parked under your MMC website I think now there’s some restructuring so I think we need to put it back again to guide the healthcare professionals on how to start to use the patient decision aids we also have a booklet form all these are available freely online at the website yeah so with that actually then we actually try to use it and at the moment in the local clinic in a few of the clinic acceptance people are using it and now we are trying to do a study to find out whether it’s sustainable what kind of strategies work best to how to implement it so that people will use it not just short-term during the research period but long-term and incorporate it into the routine care so that’s the story about the decision aids and shared decision-making and one way one of the many ways to put patients in the center of our care next the vault the next ten minutes or so I would just like to share a little bit of my other interest which is on himself okay some of you might know me as more like a men’s health person rather than shared decision-making person because recently we’ve conducted the most actual main campaign in ummc with a strong support from the ummc management so this is the men’s health initiative was touch I actually grew moose touch for a month actually well somebody said it didn’t notice the difference actually so haha so well I’ll try again this year so we had disposed to exhibitions and all that the reason why I bring this up why is this what does they have to do a patient-centered care really all because I feel that the next level besides at the clinical level is actually reaching out to the community the people have upped in the community would maybe do not even come to the hospital of the clinic and if we really put people in the center of care then we should reach out to them we should go to where they are and this is where I find other opportunity to work with sylviane happening in the project in hospice Malaysia where by day the patients are almost of the apt in the community is when you go there and visit them then you realize the issues that they have that we truly can occupy that blank space of 364 days and 23 hours because that’s that that’s where they’re living even then we only see a snapshot view of that my involvement with the Sioux chief foundations also helped me to do some home visits to see people out the community which also got me to think that yes truly if you really want to understand them the best way is to just go through them and this is what we did is the posters well designed by chin high and the team and take a most touch and pass it on so things like that and during that campaign we screen about 200 / people men then and we diagnosed we screamed and then found that many of them actually have depression that has never been diagnosed and we used the score to sort of assess it and we found that they are all many of them a severe depression and they could not just hold back and just tell us about your problems and we are so glad I mean those people who are there the doctors were there i think they find very grateful because they find that we really make a difference because these are people who are on the verge of really collapse in terms of the mental health so i think is something I find that is something we should do more the campaign and open up to people and telling them where to seek help and this is a photo I was trying to look for photos for my other I found that I had very few photos but this is one of the things why I put this up is because I think the thing next thing we should move to sort of push patient-centered care the next level in

this case men’s health is that we need to involve different stakeholders in this case we have dr. kamalia who is from the mixture of hell she’s a deputy panera of the family health division well I met yesterday because we are now going on to try to develop policy for men’s now and we have external speakers or expo fastens menzel from Leeds from ellen white of course we have ducked off with a champion of men’s health in Malaysia with from NGOs from a private sector we have profit a who is from with an economy of demographer we are precise full from us and prof long from out for Serena my boss Tong for UK m and Zach Yvonne you Elmo age and profiting from SPM health economist oh I’m showing you this is because i think for things to work you need a whole team and you need to involve many people from different disciplines different institutions and what’s missing here is actually a patient okay but while we have many men here and a subset of lives we are all patients okay and question highs the PhD student with working on this project so is through this no we have different stakeholders that we come together and try to champion a particular calls in this case men’s health and of course there’s a website some advertisements there we also produce Asian men shall report which is now what is circulated is a first in Asia and of the honor of doing it together with profit on as well as chris hole from UK m and shin hye as well and we went on to publish this which have received a lot of feedback about status of men’s health in asia and we also did a Delphie survey where we surveyed the key stakeholders across the world about the views about how we should move men’s health forward so currently we are trying to develop a mess of index which is trying to measure the men’s health status in each so that policymakers then can assess the men’s health status in each country and compared with another country so that they can gauge where they are as through this that policy perhaps can be shaped and changed and men’s health in this case can be improved over time so this last bit of my lecture actually is more about trying to move things perhaps at higher level perhaps in the next ten years of my life I will try to move a little bit more in shared decision-making and try to push this across but I know Ministry of Health is already thinking about that and shot a patient-centered cash and decision-making so I hope I could join in and provide more evidence and do more interventions to try to put patients back in the cut of care and this back to Madame time again I didn’t no matter whether you are medical students whether you’re an ernst a pharmacist a doctor professor a hospital administrator a policymaker I think we need to really listen to Madame tongue and what she has to say what her needs are responds to her needs address the constants knows about her knows about her life knows about the 364 days and in three hours that she lived with besides health only then can we put patients back to the heart of care with that I thank you I like to call a car professor dr. Eddie Baca mosimann to conclude the lecture which has been delivered by professor dr. entertain a moment ago thank you children you didn’t disappoint us taking the first inaugural lecture 4 2016 and I think everyone in the audience I’m sure would agree with me that you’ve made us proud in the sense that you’re the constant doctor consummate researcher and also you know that you it came through very clearly that whatever you do that the patient is at the center of of your of your concern and that you have beautifully married your academic progress to answer the very very many barriers and in questions that that that we all face but instead of just throwing up your hands as i do when i do ward rounds and I see someone’s sugars is not

optimum but you have really beautifully systematically tried to understand what goes on at the bottom of this but not only have you done it in you know in a research-oriented manner in trying to understand the complexities particularly of our patients here in Malaysia where you know religion and family and everything else comes into play you didn’t stop there but you’ve also utilized your your research and analytical background to then try and solve these problems through your through the decision patient what is it called the aids the vision aids and and finally you know in terms of your contribution to men’s health as you said you’re taking it to the level it is not just you know for most people you would think primary care physicians concern about that one on one patient interaction that you all are very good at but you’ve now taken it to the next level in terms of the preventive and and the public health aspects of health care and with that I think it only leaves me to congratulate you and we’re very pleased that you decided to return to Malaysia and made such a huge contribution now your next task is to try and convince those who are still in Singapore to come back and and show that you know we can be as good as them and we can contribute to not just relation health care but but to regional and global health care as well so congratulations and thank you thank you very much professor everyone for sharing this lecture I would like to take this opportunity to thank the management of the Faculty of Medicine international corporate relations office citizens of university of malaya as well as all the guests who came here for your time with this I we have reached the end of the lecture on behalf of the University of Malaya I would like to apologize if there has been any witnesses from our site in organizing this lecture also as a token of appreciation I would like to invite professor dr. Nick shereena hanafi which is out the head of department for primary care medicine to give professor earn a bouquet a flower as a token of appreciation and a congratulation note i will also like to invite mr. Anita who represent professor Ames students to also give him another bouquet of flowers is a token of appreciation thank you very much everyone may I invite you all to a light refreshments that will be served just above this auditorium at level four I would greatly like to see you there ladies and gentlemen I once again thank you and have a pleasant evening thank you very much