OBJECTIVES

This study attempts to explore:
1. Current practices of communication skills of primary health care physicians in health care centers in National Guard Health Affairs in Riyadh.
2. Main barriers that can affect doctor-patient communications.
3. Primary health care physicians' knowledge about effective doctor-patient communications.

METHODOLOGY

Study Design: This is a cross-sectional study.
Setting: Held in National Guard Primary Health Care Centers in Riyadh.
Duration of Study: This study was held during the period from November 2009 till July 2010.
Sample Size: Seventy primary health care physicians participated.
Sampling Technique: Survey questionnaire was distributed to willing participants.
Sample Selection: All primary health care physicians of different levels and qualifications.
Data Collection Procedure: Data for this study were collected by questionnaire which was distributed during Sunday morning professional education activity of the department of Family Medicine and Primary Healthcare in each center for physicians and Half Day Release Course in Monday morning activity for residents.
Data Collection Instrument: Questionnaire consisted of four sections. The first section asked for physicians' demographic data, educational items and to rate their communication skills with patients. The second section asked about common barriers which can affect communication skills. The third section asked about the current practice, and the fourth asked about the physician's knowledge about communication skills by giving them a sentence and asked about what kind of skills that sentence indicates.
Ethical Consideration: Anonymity was maintained throughout. The subjects received the self-administered questionnaire with a cover letter explaining the project and the subject's rights. The choice of the items in the questionnaire was based on the level of communication skills a General Practitioner needs.
Data Analysis Procedure: Once the data collection was completed, it was checked and entered into the computer using the Statistical Package for Social Sciences (SPSS), version 15. Descriptive analysis of mean, median mode, frequencies and percentages were carried out on most of the variables, including, age, gender, self-rating of skills, years of experience, levels of experience, training history, communication skill practices and knowledge scores. In addition, relationships were explored using chi-square, linear regression, Kruskal Wallis and Mann Whitney where needed.

RESULTS

A total of 70 primary health care physicians participated in the study. Table 1 shows, 30 (42.9%) were male and 40 (57.1%) were female. Maximum age was 58 years old and minimum age 26 years. Fifty-one (72.9%) were Saudi, 19 (27.1%) were non-Saudi. The physicians position were 25(35.7%) residents, 17(24.3%) MBBS/MD and 28(40%) specialists. The maximum years of experience were 25 years and minimum was 2 years.

Table 1: Demographic data of participants


Table 2 shows that 14.3% of the physicians did not receive formal training about communication skills during medical consultations, while 85.7% did receive formal training. Over two-thirds of the primary care physicians consciously applied specific communication skills frequently in their daily practice. On a self rating scale of communication skills (1-4 scale) over 75% of the physicians rated their communication skills as good or excellent.

Table 2: Communication skills: training and attitude


Barriers of effective communication skills were divided into three categories: physician, patient and system barriers [Table 3]. The two most significant physician barriers were lack of formal training (68.5%) and natural limitations e.g. quiet or shy personality (41.4%). The two most significant patient barriers to communication skills reported by physicians, were cultural norms or gender different from physicians (51.4%) and personality trait of patient, i.e. too aggressive or shy (44.2%). The two most significant system barriers as perceived by physicians were lack of consultation time (82.8%) and lack of continuity of care with patients, i.e. patient seen by different doctor each time (62.8%).

Table 3: Barriers to effective communication skills in medical consultation

Click here for Table 4: Communication of skill practice pattern and PHC physicians

Table 4 Shows that nearly 69% of physicians rarely or sometimes involved the patient in decision making; another 70% rarely or sometimes discussed goals of consultation with their patients or used 'pause or silence' in communicating with their patients. Around 2/3rds of physicians rarely or sometimes inquire about the person accompanying the patient. For female patients there were 73.2% of female physicians who rarely or sometimes felt the need to ask their female patients to remove their face-cover in daily practice to assess their facial expressions better.

Table 5: Communication skills knowledge score percentages of physicians


In Table 5 the majority of empathy, empowerment and negotiating knowledge were answered incorrectly while the majority of listening, explaining and building rapport knowledge were answered correctly.

Figure 1: Distribution of practice scores among physicians

The total maximum score of practice questions was 60. Figure 1 shows mean of practice score 37.2, SD +/- 7.093, maximum score 49 and minimum score 20. Questions # 13 & 17 were excluded from the total score (See Table 4). For each question the value ranged from 1-4. Total score for each physician was added and all scores are presented in Figure 1.

Figure 2: Distribution of knowledge scores among physicians


The total score of the knowledge questions was 6. If a physician answered a question correctly one score was awarded. Thirty-one (44.3%) physicians scored 3 out of 6.

Figure 3: Relationship between knowledge and practice scores


Figure 3 shows no relationship between score of knowledge and practice of communication skills based on linear regression.

Figure 4: Relation between Age and Practice


Figure 5: Relation between Years of Experience and practice


Figures 4 & 5 show that age of physician and years of experience are positively correlated to practice scores. Linear regression of age and years of experience with practice scores yielded an R Square 0.143, F statistic 5.602 and P value 0.006.

Table 6: Relationship of practice scores & communication skill values


The score of practicing communication skills was found to be not significantly different based on gender of physicians. Using Kruskal-Wallis Test it showed that communication skills practice scores were significantly different between resident, MBBS/MD and specialists [Table 6].

Table 7: Relationship of knowledge scores & specific variables


The score of knowledge of communication skills was significantly different based on whether the physicians received training or not [Table 7], however there was no statistically significant difference between the knowledge scores on the basis of current position, self-confidence of practicing skills or application of communication skills consciously.

Multiple comparisons was done using Post Hoc Tukey test between practice scores and current position of participants. It showed there is a real difference between communication skills practice score of residents with that of MBBS/MD or specialized physicians but there was no difference between MBBS/MD practice score and specialized physicians.

Applying communication skills consciously was influenced by the current position of physicians; most residents in a sample (25) applied their communication skills rarely or infrequently whereas 23 of the 28 specialized physicians applied their skills quite frequently, Chi-square 15.505 and P value 0.004.

The residents were less confident of their communication skills, while MBBS/MD physicians and specialized physicians rated their communication skills as good and excellent, chi-square 13.754 and P value 0.008.

DISCUSSION

This study provides information not previously available from National Guard primary health care physicians on the knowledge, attitude, practice and barriers of effective communication skills during medical consultation. The distribution of population was almost equal between male (42.9%) and female (57.1%), the majority of them were Saudis (72.9%), between residents (35.7%), specialized (40%) and staff physicians (24.3%). Average years of experience in primary care ranged between 2-25 years. Most of the physicians did receive formal training of communication skills in our study (Table 2). Communication skills training has been embedded in the curriculum of graduate medical and post-graduate trainings for over 15 years in some parts of the world [5]. Over forty percent of physicians applied communication skills frequently and 51.4% rated themselves as good communicators (Table 2).

Most of the physicians thought that lack of training (68.5%), cultural norms or gender difference between patient and doctors (51.4%), and lack of time (82.8%) are the main barriers to apply effective communication skills with patients. In our study, one of the main patient related barriers, as perceived by the physicians, was different cultural norms or gender from that of the physician. There is one study that showed the majority of patient's preferred Saudi doctors, suggesting that doctor-patient communication is much easier when both patient and doctor come from the same culture [29].
In the same study most patients expected GPs to spend some time explaining the nature of their illnesses and the results of tests done [29]. This is consistent with the findings of other studies [30] and this study, as most physicians answered correctly the knowledge question about explaining to the patient in detail, as an important communication skill (Table 5).

A study conducted to assess the impact of two communication skills training programs on the evolution of patients' anxiety following a medical consultation found no significant difference was observed. Results of that study confirm results of other studies that have shown that some reassurance may produce anxiety and have suggested that communication skills are probably efficient if physicians discuss their patients' concerns in depth by using some basic communication screening questions [31].

In this study using non-verbal cues to communicate with patients were obviously rarely and sometimes used (Table 4). In other studies they found that patients offer clues that present opportunities for physicians to express empathy and understand patients' lives. In both primary care and surgery, physicians tend to bypass these clues, missing potential opportunities to strengthen the patient-physician relationship. Research on teaching communication skills demonstrates that physicians can learn to modify their communication style [32-34].

Despite widespread interest in the effects of physician gender on the care process, the literature describing these effects is small [35], and in this study there were no differences between male and female physicians in practicing communication skills.

It was observed in this study that there was no correlation between knowledge and practice of communication skills (Figure 3) suggesting a gap between knowledge and practice. It was also noted that the physicians who consciously applied the communication skills in their practice, scored better in daily practice of these skills with their patients. The physician may have knowledge but if he did not make a deliberate effort to apply that knowledge in his practice, it did not show in his actual practice.

Most residents received training of communication skills during their program but they seemed to apply these skills in their daily practice to a lesser degree than the MBBS/MD and specialized physicians (Table 6). Communication skill training is very important to have knowledge of skills but having a good knowledge did not affect the practice if the physician did not have the attitude of applying that knowledge in the practice (Table 7).

Specialized and MBBS/MD physicians were more confident in their self rating of communication skills, while the majority of residents evaluated their communication skills with lesser self-confidence. This translated into better practice scores.

Figure 4 and 5 show there is a strong relation between age and years of experience in the medical field with practicing of communication skills. Years of practice was found to be a larger predictor of practicing communication skills when compared to age, however both factors had significant overlap, suggesting that with increasing age and experience in work, physicians practiced their communication skills more.

A study showed that the level of communication skills and the content of the consultation with regard to psychosocial issues, patient concerns and the informing and planning of procedures (with a representative patient in a general practice setting) among graduate medical students are significantly correlated; that means having the knowledge of communication skills is important [36], however in this study, age and years of experience were more important than having good knowledge only.

It means that training is important but having self confidence and a genuine desire to apply that knowledge are valuable in practicing communication skills, which certainly improves with age and experience.

LIMITATIONS

There are four limitations of this study which deserve emphasis:
1. Small sample size.
2. Study was done among primary health care physicians in National Guard which cannot be generalized to PHC physicians in Saudi Arabia.
3. Majority of the sample was Saudi and 35.7% were residents.
4. Only six categories evaluated the knowledge of physicians.

CONCLUSION

This study suggests that knowledge base in communication skills can improve with training however having the knowledge of good communication with patients does not influence the practice of communication skills unless the physician is self-confident and has the right attitude of consciously applying that knowledge in his/her practice. Lastly, communication skills improve with age and experience.

RECOMMENDATIONS

1. Younger physicians need to put more emphasis on the use of communication skills; having the knowledge is not sufficient.
2. Involve the less expert physician in a teaching clinic or increase the number of simulated clinics during the training of communication skills program and improving the continuity of care between physicians and their patients will show good outcomes in improving the application of those skills.
3. How can doctors best continue to develop their skills, apply them within their daily work, survive emotionally, and feel more satisfied? How can persistent behavioral, perceptual, and personal changes be produced? Self learning and self monitored feedback, distance learning, and serial workshops seem to be promising approaches for qualified doctors.
4. Finally, it is my hope that the findings will help in planning a strategy for improving services, making effective communication skills attitude more acceptable and believable in the PHC sitting in our community to improve patient care in all aspects.

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