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Multi-Opinion Behavior in-Patient with Common Otolaryngological Procedures in Turkey
Our objective with this study is to examine the patient behaviours and attitudes that have emerged following the changes in healthcare practices in Turkey.
This study was carried out in Istanbul. The study was conducted on patients who were operated at the ENT clinics. 413 patients from the Bezmialem Vakıf University, Hospital and 361 patients from the Marmara University Hospital were included in the study.
320 of the patients included in the study were female with an average age of 38.12. The patients presented to 2.85 different hospitals before undergoing surgery, they were examined by 3.02 different ENT specialists before undergoing surgery and it took the patients 218.40 days to decide that they would undergo surgery. The period of time that elapsed before an appointment was scheduled for patients who decided to undergo surgery was 58.43 days.
Considering that it is a necessity to have the opinion from a second physician for the patients to be operated, what should be the approach towards the patients who would like the opinions of a third and a fourth physician? Such patient behaviour is a pattern that has emerged on account of healthcare system changes.
The changes in healthcare policies implemented by the Ministry of Health, Republic of Turkey, since the year 2005 have resulted in important changes in the healthcare perception of the society. Before the year 2005, an office- and physician-oriented system used to be implemented; after the year 2005, the system was transformed into a private hospital- and state hospital-oriented system. It was prohibited that the physicians employed at state and university hospitals open an office. The most important influence of these practices has been on the patient-physician relations. Important changes occurred in the patient and physician behaviours for this reason, as well.
Significant changes take place in the patient-physician relationship and in the attitudes and behaviours of as a result of legislative amendments made with a view to gaining votes by ignoring the employee personal and social rights of physicians.
In this study, we investigated whether the changes made in the healthcare system have changed patient behaviours or not.
This study was conducted in Istanbul, the most populated and crowded city of the Republic of Turkey, between February, 2012 and August, 2013. For this purpose, the study was planned to be held in two different continents in Istanbul, at the BezmialemVakıf University, School of Medicine Hospital, which has the Private Hospital status offering tertiary health care and at the Marmara University Hospital, which is under The Council of Higher Education, yet operated by the Ministry of Health. This study was performed as a prospective, longitudinal clinical study. The study was approved by the Local Clinical Ethics Board and informed consents were obtained from all patients. The study was carried out by physicians on the post-operative day one on the patients who underwent surgery in the ENT clinics of the above-mentioned hospitals. BezmialemVakıf University 413 patients and 361 patients at the Marmara University Hospital were included in the study.
The outpatient clinic patients and patients referred from another center in oral or written fashion as well as patients showing signs of a psychiatric disease (body dysmorphic disorder) were not included in our study.
The patients were asked 4 questions; 1. How many different hospitals did you present to before deciding to undergo surgery? 2. How many ENT physicians were you examined by before deciding to undergo surgery? 3. How long did it take you to decide to undergo surgery? 4. For how many days later was your appointment scheduled?
774 patients were included in the study, the average age was 38.12 (Min 1- Max 87); 454 patients were male and 320 were female. It was identified that the patients presented to 2.85 (1-11) different hospitals and that the patients were examined by 3.02 (1-9) different ENT physicians before undergoing surgery. The time that elapsed before the patients took the decision to undergo surgery was 218.40 (1-850 days) days on average. It was identified that the patients, who decided to undergo surgery, were scheduled for a surgery appointment for 58.43 (1-700 days) days later on average. The name of the surgeries that the patients received and their distribution are provided in Table 1.Table 1. Distribution of the performed operation name and percentage
|Tonsillectomy and/ or Adenoidectomy||73||9,43|
|Neck lymph node excision||31||4,00|
|Head neck cutaneous tumor excision||9||1,16|
|Submandibular gland excision||7||0,90|
|Thyroglossal duct cyst excision||3||0,38|
|Direct laryngoscopy - MLS||81||10,46|
|Tympanoplasty and / or mastoidectomy||110||14,21|
|Functional Endoscopic Sinus Surgery||63||8,13|
There are many benefits of the patient's trust in the physicians; among them are increased satisfaction, full compliance with treatment and ability to complete the treatment. Trust also reduces treatment costs. In cases where trust cannot be assured, the patient presents to different centers, which results in increased overall costs due to transfer costs and re-testing of the patient due to inadequate information provided by him/her.1
The factors that ensure patient trust: thorough assessment of the problem, understanding the symptoms explained by the patient, providing care for the patient, providing appropriate and correct treatment, establishing open and understandable communication, development of a partnership with the patient in treatment and demonstration of honesty and respect2.
The decision of a patient to seek a second opinion is influenced by culture and tradition. A study by Sato et al3 found that a second opinion is regularly requested by 41% of patients in Japan compared with only 19% in the USA. In the UK, patients have access to specialist consultation only by referral through their family doctor. This applies to both the public and private sectors of health care. The impression is that second opinions in the UK are infrequent compared with healthcare systems where patients have direct access to specialists. In the USA, patients may seek a second opinion directly and an industry has developed in providing ‘medical second opinions’ advertised on the Web4.
It is a fundamental principle of patient autonomy that patients have the right to all knowledge and information about themselves to allow them to have proper control over their body and their decisions in relation to their treatment5, 6.
As stated by Atunet al.7 in their article titled “Universal Health Coverage in Turkey”, which describes the healthcare system in Turkey at great length, not everything is run smoothly. Within the last 5 years, there have been serious changes in the practices and behaviours of physicians on account of healthcare policy changes. The practices of physicians on patients have been reduced significantly and there have been considerable losses in the Medical and Specialization educations. The healthcare expenditures that increase daily, the coverage of the expenditures for the social security system (pension, disabled, etc.) as well as healthcare services by the same budget item lead the healthcare system into a stalemate.
Our study is an unprecedented study in this field and it represents a new outlook in that it concentrates on patient behaviours resulting from changes in the healthcare system. The study was conducted in the most developed city and hospitals of Turkey. It is an important medical decision for a patient to undergo surgery. The study includes only patients that underwent surgery.
The ENT branch is a surgical branch of moderate degree of difficulty and it includes patients from every age group and both sexes. In that respect, it is a branch that provides a good reflection of the society.
The study does not encompass all branches. It has not been possible to conduct a study including all branches on account of differences among cities, hospitals, branches, general branches, physical and technological infrastructures. The study was conducted in a single branch since homogenization would be inversely proportional with the number of branches studied.
The reason why outpatient clinic patients were not included is that there are too many variables in that area. The average frequency per person of seeing a doctor at an outpatient clinic in Turkey is 10 times a year since the services is free of charge and the number of examinations is unlimited. Taking into account that there are people who never see a doctor, the number of doctor visits per person is rather high.
The patients who were referred were not included in the study since this group does not include patients referred by physicians and it is the patients' right as well as a requirement to be referred to related departments and centers.
Due to changes in the healthcare system, we have come to face a patient population that goes from one physician and one hospital to the next. As a result of inadequate communication and trust in the patient-physician relationship, the physicians are not able to demonstrate their responsibility to take ownership of the patient's treatment. Accordingly, the patients begin a quest for multiple physicians whereas physicians fall into recessive medical practices.
There have been significant differences in the behaviours of patients and physicians in Turkey as a result of the healthcare policies in the last 7-8 years; we have decided to carry out this study as a result of the exercises we have often encountered and observed in daily practice. We have observed significant differences as compared to the past years with the increase in the number of patients going from one hospital or one physician to the next. We have defined such patients as “Multi-opinion behavior” patients.
If we consider the opinion of a second physician as a fundamental right, how should we assess the opinion of a third, fourth, not to say, a fifth physician? Departing from this point of view, we actualized this study.
While the physicians exhibit a recessive attitude towards patients, the patients demonstrate behaviours of going from one hospital or one physician to the next as a result of healthcare policies. This is a general healthcare problem. In that respect, our article is marked as being the first article in this field.