Introduction

Doctor-patient communication serves as a “central function in building a therapeutic doctor-patient relationship, which is the heart and art of medicine” (1: p. 38). Good doctor-patient communication allows for better identification of patients’ needs, perceptions, and expectations and leads to fewer errors and better patient and doctor satisfaction. Deterioration of medical students’ communication skills as they progress through their medical education has been noted as one of the barriers to good doctor-patient communication (1).

Poor communication has also been cited as one of the reasons for increasing violence against doctors in India (2, 3). Under the current circumstances, medical educators have voiced their concerns that communication skills training is a missing link in the medical education curriculum (4, 5). The Medical Council of India (MCI) has thought of integrating ethics, attitudes and professionalism in all phases of learning as a key curricular change to enable the Indian medical graduate to function professionally. (6: p. 20). The module designed for this purpose was called Attitudes and Communication module (ATCOM) and has now been renamed Attitude, Ethics, and Communication module (AETCOM) (7: p. 11). It is imperative to assess the attitudes of medical students towards communication skills training for successful implementation of this module.

This study was undertaken to assess the following in recently admitted first-year MBBS students:

1. perceptions regarding need for and importance of communication skills training,
2. perceptions regarding self-knowledge on communication skills, and
3. attitudes towards communication skills training.

Methods

Ethical approval was taken from the Institutional Ethics Committee, HM Patel Center for Medical Care and Education, Anand [vide letter no. IEC/HMPCMCE/2015/321/15, dated 31/08/15]. Permission from the Dean of Pramukhswami Medical College, Karamsad, Anand, was taken prior to the conduct of an anonymous, cross-sectional survey amongst recently admitted first-year MBBS students. The institute conducts a one-week foundation programme at the beginning of each academic year. During the first year, the focus is on introduction to the programme, the vision and mission of the institute, and introduction to the concept of professionalism (including communication skills). The survey was carried out at the end of one of the sessions during the foundation programme. A session on communication skills was conducted after the survey was administered.

Students were oriented to the purpose of the study and were invited to participate. Out of a class capacity of 100, nineteen students were absent on the day of the survey. No attempts were made to contact students who were absent. All questionnaires were collected after a break between sessions. Among the 81 students present and who received the paper survey questionnaire, there were no non-responders. Five incomplete questionnaires were excluded from the analysis.

The information at the top of the anonymous survey form informed students that they had the right to not attempt the surveys, that their responses may be subjected to analysis and published without disclosing identities, and that non-response would not have any bearing on their academic performance evaluation. The study questionnaire had three questions for assessment of perceptions regarding need for a formal communication skills training curriculum (“I would like to have communication skills training as part of my curriculum”), importance of communication skills training (“Communication skills training would be/is important for undergraduate medical students”), and self-assessment of communication skills (“I think I have required knowledge on communicating with patients”); a modified version of the Communication Skills Attitude Scale (CSAS) with 25 items was administered (8, 9). The questions were rated on a five-point Likert-type scale ranging from strongly disagree [1] to strongly agree [5], with 3 being neutral or undecided.

The modified version of the CSAS used in a study of Sri Lankan undergraduates was used in this study (8). The Sri Lankan researchers had modified the original (9) as their students had English as their second language. They had omitted one item and reworded others for cultural acceptability. The list of changes (8) is shown in Table 1. The authors read both the original and modified versions and unanimously felt that the reworded questions were more appropriate in the Indian context as well.

CSAS has two subscales named “Positive attitude” (item numbers 1, 4, 5, 7, 9, 10, 11, 13, 15, 17, 20, 21, 22, and 24) and “Negative attitude” (item numbers 2, 3, 6, 8, 12, 14, 16, 18, 19, 23, and 25). A higher magnitude of scores on each subscale indicates a stronger related attitude.

Data were analysed using Microsoft Excel 2007. Descriptive statistics were calculated for the various attitudes. Unpaired t-test was used to compare means between groups. The threshold for significance of p value was set as p < 0.05. While reporting the results in text, Strongly disagree and Disagree have been combined and reported as “Disagree”, and Strongly agree and Agree have been combined and reported as “Agree”.

Results

Seventy-six out of 81 first year medical students filled in the complete study questionnaire with a response rate of 93%. The group consisted of 42 females (55.3%) and 34 males (44.7%).

Seventy-two percent students (n=55) considered communication skills training important for undergraduate medical students, and 68.4% (n=52) felt they would like to have communication skills training as part of their curriculum (need for communication skills training). Sixty percent students (n=46) felt that they had the required knowledge needed for communicating with patients (Knowledge of communication skills). Attitudes towards communication skills training as measured by CSAS are shown in Table 2.

Favourable attitudes about importance of communication skills training

Majority of students (97.4%, n=74) agreed on the positively worded question “To be a good doctor he/she must have good communication skills”. This is further validated by majority of students disagreeing on statements like “I don’t see why I should learn communication skills” (82.9%, n=63), “I don’t need good communication skills to be a doctor” (88.1%, n=67), and “Communication skills learning should be left to psychology students, not medical students” (82.9%, n=63).

Unfavourable attitudes about communication skills as a subject

Forty-three percent (n=33) students agreed with “Communication skills teaching would have a better image if it sounded more like a science subject”, with another 30% (n=23) being ambiguous about it. Almost 40% of the students were ambiguous about “Learning communication skills will be fun” (n=30) and “Learning communication skills will be too easy.” (n=30)

Unfavourable attitudes about teaching of communications skills

Thirty-two percent (n=24) students agreed with “I would find it difficult to take communication skills learning seriously”, with an almost equal number (28.9%, n=22) being ambiguous. Forty percent (n=30) of students were ambiguous about and 15.8% (n=12) agreed with “I find it difficult to trust information about communication skills given to me by non-clinical lecturers.” Twenty-five percent (n=19) students were ambiguous about and 10.5% (n=8) agreed with “I haven’t got time to learn communication skills.” Thirty-five percent (n=27) were ambiguous about and 15.8% (n=12) agreed with “It would be too much trouble to attend sessions on communication skills.”

Unfavourable attitudes about assessment of communication skills

Fifty-five percent (n=42) agreed with “Nobody is going to fail their medical degree for having poor communication skills” and 46% (n=35) agreed with “My ability to pass exams will get me through medical school rather than my ability to communicate.”

The mean positive attitude score (PAS) on CSAS was 3.90 (SD = 0.46) and mean negative attitude score (NAS) on CSAS was 2.54 (SD = 0.34). There was no significant difference in PAS scores of males compared to females (p > 0.05). Those who agreed on the importance of and need for communication skills training held significantly higher favourable attitudes (PAS) on CSAS (p = 0.001 and 0.002, respectively). Those who were ambiguous or disagreed on need for communication skills training held significantly higher unfavourable attitudes (NAS) on CSAS (p = 0.011).

Discussion

Two-thirds of the students agreed that communication skills training is important and needed. Almost a third of the students were ambiguous about or disagreed with the importance and need for communication skills training. Consistent with these findings, research on Sri Lankan undergraduates found that while most students acknowledged the importance of communication skills, a significant minority (26–47%) of students had reservations about attending communication skills training sessions (8).

There was no difference in the positive attitudes of females compared to males. This finding was at variance with earlier research that found female medical students had more positive attitudes towards communications skills training (10).

When the above findings are clubbed with other findings like “It would be better if communication skills training sounded like a science subject” (43% agreement and 30% ambiguous), “It would be difficult for them to trust communication skills training provided by non-clinical lecturers” (15.8% agreement and 40% ambiguous), and Knowledge would get them through medical school (55% agreement), it can be concluded that there is significant prevalence of unfavourable attitudes to communications skills as a subject, teaching and assessment of communication skills amongst recently admitted first year students.

To address this situation, communication skills training must begin early in the course of medical studies, from the first year itself, as is recommended by the AETCOM module, because unfavourable attitudes are much more amenable to change in early years. The AETCOM module has done a good job in addressing the underlying scientific/ethical elements of ethics, communication and professionalism (11).

The AETCOM module has made teachers responsible for delivering the content (4, 11). However, the findings of this study raise concerns about whether students would be open to the teaching of AETCOM by pre- and para-clinical teachers, given the current attitudes. The findings of this study reiterate the felt need to have a faculty development programme in communication skills (4, 11).

Almost half of the students believed that knowledge would get them through medical school. Marambe et al. (8) found one quarter of their students feeling likewise, and Widyahening et al. (12) found almost half of their first-year medical students feeling the same. In our context, these beliefs may be explained by the fact that high-stakes exams (Class 12 board exams and entrance exams) faced by the students until they enter medical college are highly biased towards demonstration of knowledge.

Medical educators have raised concerns about the assessment of communication skills in the AETCOM module (11). It is undeniable that assessment drives learning (13). The bias amongst students towards demonstration of knowledge, and concerns about the assessment component of the AETCOM module, call for strengthening of AETCOM by incorporating an assessment of communication skills in formative and summative evaluations. This would also play a key role in changing students’ attitudes towards communication skills.

One of the authors [JV], along with a faculty member at the institute, made initial attempts at addressing attitudes towards communication skills amongst medical undergraduates. These attempts¹ have included reflection on prior experience of ill health; the role of doctor as healer; the patient as a person; suffering of the person vis-à-vis disease in organ systems; doctors’ insensitivity to the person having the illness; the need for a different set of skills (for example, empathic listening) to diagnose and treat suffering (14). This study is one of the few attempts (15) to explore the attitudes of Indian medical students.

Conclusions

The take home messages from this study are: 1) Unfavourable attitudes about communications skills as a subject, teaching and assessment of communication skills amongst recently admitted first year students are of significant prevalence. 2) Course implementers should be mindful to address positive and negative attitudes towards communication skills training while delivering the content of the course. 3) Communication skills training should start early in the course. Future research should focus on how attitudes change with progress through the medical course, by assessing behaviour towards communication skills training and actual communication abilities. Assessment of communication skills needs to be included in formative and summative evaluations, and a faculty development programme in communication skills training is essential.

Limitations of the study are a small sample size from a single centre, and lack of inclusion of the views of students from other years or faculties. Also, the study’s focus on perceptions is based on self-reporting by medical students rather than behaviour towards communication skills training or actual communication abilities.

Conflicts of interest: None of the authors have any financial conflicts to declare
Source of funding: Self-funded

Note

¹ Dr Jagdish Varma and Dr Himanshu Pandya (Prof in Medicine and Associate Dean of Clinical Services) used Cassell’s paper on Diagnosing Suffering (14) to build an hour-long session as part of the foundation course for first-year medical students. Students were asked to reflect on their experiences of ill health and quality of care received, and their own expectations about a “good doctor”. No assessments regarding change in the students’ attitudes were made and no scholarly work has been published by the authors, based on these courses.