Clinicians’ Voices on a Disciplinary Approach to Teaching Clinical Communication in the Chinese Context: Priorities, Challenges, and Scope

Background: In the absence of a well-rounded syllabus to teach clinical communication, emphasising both interpersonal and medical dimensions, medical students in the early stages of their career may nd it challenging to effectively communicate with patients, especially those from different cultural backgrounds. Aims: To explore the priorities, challenges and scope of teaching clinical communication in a Chinese context using a disciplinary approach, and to investigate how medical educators and clinicians teach clinical communication in their respective clinical disciplines. Design: Interpretative phenomenological analysis. Data sources: Nine medical educators, all experienced frontline clinicians from 7 clinical disciplines, were recruited from 7 Hong Kong hospitals and 2 medical schools. They were interviewed to seek their views on teaching clinical communication in the Chinese context, specically its priorities, challenges, and scope. Results: The interview data revealed 5 themes related to the priorities, challenges, and scope of teaching clinical communication across a wide range of clinical disciplines in the Chinese context, namely (1) showing empathy with patients; (2) using technology as a modern teaching approach to combine medical and interpersonal dimensions; (3) shared decision-making, reecting the inuence of Chinese collectivism and cultural attitudes towards death on communication with patients and their families; (4) interdisciplinary communication between medical departments; and (5) the role of language in clinician– patient communication. Conclusions: Taking a disciplinary perspective, the clinicians in this study approached the complex nature of teaching clinical communication in the Chinese context in different ways. The ndings illustrated the need to teach clinical communication using a disciplinary approach in addition to teaching it generically across specialties. This is particularly important in the Intensive Care Unit (ICU), where clinicians frequently cooperate with physicians from other departments. This study also highlighted how non-verbal social cues, communication strategies, and the understanding of clinical communication in the Chinese context operate differently from those in the West, because of socio-cultural factors such as family dynamics and hierarchical social structures. We recommend a dynamic teaching approach using roleplaying tasks, scenario-based examples, and similar activities to help medical students to establish well-rounded clinical communication experiences in preparation to overcome challenges in their future real-life clinical practice.


Introduction
The teaching of clinical communication has been extensively explored in the eld of medical education in the West, including curriculum, assessment, learning outcomes and educator training [1][2][3][4][5]. The expansion of this area has been re ected in the increased emphasis on communication skills in many medical education programmes worldwide. However, the teaching of clinical communication itself remains peripheral; training in communication skills is often not routinely implemented in healthcare professional programmes [6]. Despite theoretical exploration of the teaching of communication skills, relatively few studies have explored the effectiveness of speci c communication training programmes.
Noting this research gap, researchers have begun to conduct empirical studies to test the feasibility of different teaching models. For example, Brown and Dearnaley [7] investigated the effectiveness of an integrated clinical communication programme involving a medical school and a hospital. The study concluded that such an integrated approach to teaching clinical communication can motivate students to re ect on the model of patient-centred care, its usefulness in collecting clinical histories, and its role in building rapport with patients. The study thus demonstrated that an integrated approach can help medical students bridge the gap between learned theory and practice with real patients in terms of delivering a holistic approach to clinical communication. In addition, a quasi-experimental study conducted by Rashwan et al. [8] further proved the effectiveness of holistic training designed for medical students through evaluating the outcomes of the Scenario-Based Clinical Simulation (SBCS) experience and the students' anxiety level. According to the ndings, all the participating students (100%) in the intervention group achieved satisfactory total percent scores of skills after two weeks of SBCS sessions while only 20% of those in the control group performed well (p <0.001). To be speci c, it was found out that the two groups of students exhibited psychomotor, cognitive and interpersonal skills simultaneously in one particular clinical scenario during a simulation session. Training sessions such as this allow medical students to collaborate and re ect on each other's performance [9], thus preparing them to work as teams in highly complex medical settings.
According to an ethnographic case study conducted by Quilligan [10], it is important to ensure that medical students participate in ward rounds, as this ensures that the teaching of clinical communication can be woven into authentic real-time communicative routines on the ward. The ndings also showed that the students who participated in the project respected the senior doctors as role models and integrated their knowledge of theories from their classes into their emerging medical practices and future professional identities. Quilligan [10] found that medical students can maximise their experiential learning in busy wards by practising their communication skills across a wide range of scenarios. The ndings also revealed medical students' ability to adapt their communication based on the needs of an environment made complicated by the diversity of patient groups and their different health literacy levels, the nature of observed interactions, their own actions, and input from role models. Experiential learning is thus another approach to teaching clinical communication that help connect theories to real practice.
Experiential learning and holistic and integrated approaches to teaching clinician communication can thus help medical students gain practical and real-life experience of encountering patients. However, these methods might not be su cient to help students learn how to deal with certain rare but critical clinical situations. This is one of the reasons why, as Shorey et al. [11] noted, medical educators use technological tools such as virtual reality platforms for modern pedagogical purposes. Their study, which [15]. However, there has been a dearth of studies exploring this topic in the Chinese context, and the lack of attentiveness in these settings to the diversity of patients' cultural contexts has meant that local curricula have not considered cultural competence to be a core element of medical professionalism [24].
A number of studies highlighting the particularities of East Asian clinical contexts have demonstrated the importance of lling this gap and moving beyond a preference for merely Western models of communication practices in clinical settings. For instance, as elaborated by Pun et al. [25] in a review article regarding health professional-patient communication practices in East Asia, patients from different Asian countries have been found to have different attitudes towards death and terminal illnesses. Taiwanese patients' families are often reluctant to discuss end-of-life issues. Upon receiving bad news, both Taiwanese and Korean patients' families leave decision-making to the oldest family member. Japanese patients' families tend to bring patients home for end-of-life care. By highlighting the role of families in decision-making on treatments, Pun et al. [25] demonstrated the complexity and heterogeneity of clinician-patient communication in East Asia. These ndings indicate the necessity of developing culturally appropriate approaches that are relevant to speci c cultural contexts, when incorporating the teaching of cultural competence in local medical education systems.
To teach clinical communication in a culturally appropriate way to medical students in a Chinese context, it is important to rst break down the cultural homogeneity inherent in the existing medical education system. In Hong Kong, for example, there are two o cial languages, namely Chinese (both written Chinese and its spoken varieties, including Cantonese and Putonghua) and English [26], which leads to di culties speci c to medical practice in the region. In a study examining clinical handover in a bilingual setting, Pun [27] found that bilingual staff in Hong Kong usually had little to no familiarity with Chinese medical terminology and thus read and recorded almost all of the medical information in written English during their everyday routine work, while using Cantonese verbally to converse with their patients. Pun [28] thus noted the potential communication gap faced by medical students who study medical curricula in English but speak to patients in Cantonese. As for clinician-to-clinician communication, Pun [27] observed that most of the staff in this bilingual context code-switched or engaged in translanguaging between spoken Cantonese and English-language medical terminologies. These ndings con rmed the problem of miscommunication that may arise because of the difference in the language used for medical terms and everyday conversation, as indicated in Pun et al.'s [29] earlier study, which observed that medical information was altered when staff switched between spoken Cantonese explanations and spoken English terms. The ndings of these studies indicate that among medical students, the homogenous use of English in the teaching of clinical communication leads to gaps in communication training for real-life scenarios, potentially leading to miscommunication with Cantonese-speaking local patients in real-life practice. Such observations highlight the importance for a more inclusive approach to communicating with patients. There is a need to conduct communication training in native languages to prepare medical students to develop rapport with their patients and accurately and clearly deliver medical information in the patients' native languages. disciplinary training, only a few empirical studies have gathered data from across disciplines to investigate doctor-patient encounters in hospitals, as noted by Jensen et al. [38]. One was their own study conducted in Norway, in which Jensen et al. [38] found that the 'four habits' training model (invest at the beginning; elicit the patient's perspective; demonstrate empathy; and invest at the end), was a suitable generic postgraduate teaching tool for clinical communication across different clinical settings (except psychiatry): anaesthesiology, paediatrics, surgery, internal medicine, gynaecology/obstetrics, neurology, orthopaedics, and ear-nose-throat medicine. They also found that a 20-hour intervention derived from the Four Habits model was able to improve doctors' communication skills and lead to the implementation of a more patient-centred model when treating patients. As the outcomes of that study showed, discipline-focused research can inform the development of medical communication training programmes that are applicable across many clinical settings; such programmes can more effectively teach clinical communication, particularly for scenarios such as the Intensive Care Unit (ICU), where physicians from different departments frequently cooperate with each other.
Extensive discipline-focused research on clinical communication has been conducted using interdisciplinary approaches in the US and European countries (e.g., Jensen et al, 2011 [38]; Tahir et al., 2018 [37]). However, such studies are lacking in Asian contexts, and in Chinese settings in particular. The importance of context-speci c research that assesses the suitability of particular teaching approaches to clinical communication is illustrated by the study conducted by Bellier et al. [39]. Their cross-cultural study sought to explore the feasibility of implementing the 'four habits' coding scheme in France.
According to the ndings, the French version demonstrated satisfactory internal consistency, but the real effects were moderate, and 2 raters were needed to effectively assess the clinical communication skills acquired by medical students. Therefore, considering the speci c cultural contexts of different Asian and Chinese-speaking regions and the need to develop culturally appropriate approaches to teaching clinical communication across disciplines, it is necessary to conduct discipline-focused research on the topic across various specialties, to gain a comprehensive overview of this area of medical education.

Research design
A cross-sectional, qualitative research design was used for this study. Speci cally, the research team analysed interview data using interpretative phenomenological analysis (IPA), an approach originating in the eld of psychology, which focuses on the examination of personal lived experiences. According to Smith and Osborn [40], IPA is founded on individuals' personal experiences and how they make sense of these experiences. Researchers who use IPA assume that individuals engage actively and continuously with their environments and then re ect on and integrate their personal experiences [40]. Therefore, using IPA to examine data on participants' personal experiences is fundamentally a type of allegorical analysis conducted by both the participants and the researchers involved. To understand how participants understand their surrounding world, a dual interpretation process, called the 'double hermeneutic', is carried out, involving both the participants and the researchers. During the process, the researchers actively seek to determine how the participants engage in and make sense of their surrounding world [40]. In light of the diverse experiences of teaching cultural competence in the area of medical education, this analytical approach was chosen for this study because of its seminal nature and its capacity to examine participants' complex real-life lived experiences.
In addition, a disciplinary approach to the studying of clinical communication was taken to draw out a wide range of views and ideas on this speci c research topic and demonstrate the contributions made by each discipline to patient care in terms of clinical communication in light of the speci c purpose that the teaching of this topic has in their discipline [41]. To arrive at this more comprehensive overview of the current state of teaching clinical communication, the study analysed the teaching approaches used by experts from different disciplines, including surgery, geriatrics, neurology, ICU medicine, nursing, oncology, and palliative care. To contribute to the development of discipline-focused and interdisciplinary teaching programmes for medical schools, the researchers identi ed different teaching strategies currently used and the communication skills considered to be important in each discipline.

Data collection
The research team conducted one-on-one, face-to-face semi-structured interviews with the participating clinicians. In this study, all of the participating clinicians were pro cient in speaking Cantonese, had been working for 6 years or more at a local hospital, and had earned a postgraduate degree in their specialty.
Each interview lasted about 30-60 minutes, during which the team explored the interviewed clinician's lived experiences, particularly in terms of the communication challenges they encountered when interacting with their colleagues across disciplines, patients, and patients' families, and their teaching of clinical communication. Table 1 illustrates the participants' demographic details. The participating clinicians' (n = 9) clinical specialties spanned 7 disciplines, namely surgery, geriatrics, neurology, critical care medicine in the ICU, nursing, oncology, palliative care, and obstetrics and gynaecology. Of the 9 participants, 5 were male and 4 were female. The interviewed clinicians had been working in clinical settings (either territory hospitals or teaching hospitals) for between 9 and 13 years.

Analysis
Using IPA, an idiographic approach, allowed the researchers to analyse a tightly de ned group of participants who drew from their lived experiences to express their opinions on the focal area of research. The research team comprised multidisciplinary experts (M = 3, F = 2), including two linguists (PhD) who had extensive research experience in health communication, one physician (MD) from the accident and emergency department, one professor (PhD) in nursing, and one nursing manager (PhD). The team adopted the suggestion proposed by Smith et al. (1996) of analysing the interview transcripts in stages. Following the IPA model, the team rst analysed the transcripts on an individual and descriptive level. Based on these analyses, the data were then interpreted to suggest new teaching approaches to different medical disciplines. The researchers read through the transcripts carefully line by line and noted down exploratory comments based on their interpretations of the participating clinicians' use of language and teaching strategies. As noted by Smith et al. [42], such an approach, consisting of the techniques of subsumption and abstraction, is helpful in constructing thematic analyses.

Patient and public involvement
No patients were involved.

Ethics
This study was approved by the ethics committee of the City University of Hong Kong. All methods were performed in accordance with the Declaration of Helsinki. Written consent was obtained from all 9 eligible clinician participants.

Results
Five themes emerged from the thematic analysis. These were (1) showing empathy with patients; (2) using technology as a modern teaching approach for combining medical and interpersonal aspects; (3) shared decision-making, re ecting the in uence of Chinese collectivism and cultural attitudes towards death on communication with patients and their families; (4) interdisciplinary communication between medical departments; and (5) the role of language in clinician-patient communication.

Showing empathy with patients
Empathising with patients is the core element of patient-centred care. As discussed by Quince et al. [43], clinicians who express empathy help their patients feel more satis ed, comfortable, and con dent in them, and thus reassured. This may result in better diagnoses and smoother processes of shared decision-making because of the caring attitudes established by both parties, which is extremely important during the phases of diagnosis and treatment in Hong Kong [44]. In the Chinese context, showing empathy is particularly important and is treated as one of the core communication skills in any medical education programme.
However, a recent study indicated that medical students trained in Asia showed less empathy than those in North America and Europe, due to Asian medical schools' science-oriented selection systems [43]. In addition, in the Chinese context, male doctors are perceived by patients to have more trustworthy clinical skills than female doctors, a perception that is mostly due to traditional beliefs about gender roles in Chinese social culture [45]. These underscore the need for Asian and speci cally Chinese medical students to be trained to empathise with patients.
Some aspects of Hong Kong culture are similar to those of other Chinese cultures, but Hong Kong also has distinctive cultural features that have implications for clinical communication education in Hong Kong. In one study, Hong Kong patients were found to be keen to appropriate the Western model of patient-centred care [25]. In another, they were found to be open to discussions of advanced malignancy and willing to be directly involved with their end-of-life arrangements [46]. These preferences expressed by patients in Hong Kong can be addressed by helping medical students to develop greater rapport and empathy with patients [47]. At the same time, such a teaching approach can counter the patriarchal elements of Chinese culture present in Hong Kong medical settings.
The following interview quotations reveal how the interviewed clinicians specialising in surgery, oncology, and nursing perceived the communication strategy of showing empathy with patients.

Surgery
Surgeries are very important and sometimes life-saving procedures in the clinical context. Thus, it is important for surgeons to equip themselves with the communication skills of developing rapport and showing empathy when delivering bad news [47], not unlike the discourse strategy used in Chinese medical clinics, which emphasises patients' emotional needs [28]. Interviewee A (surgery) noted: The most important thing is to have empathy. I think it really needs practice and also requires life experience in the outside world. You have to be engaged in the outside world. -Interviewee A (Surgery) Related to this, surgeons tend to show their care by create a space for patients' families to tell their stories, as Interviewee A described: If you are concerned about a patient, ask the patient's family questions and make sure that your communication is not abrupt or brutal. In this way, they will sense that you care. -Interviewee A (surgery) Practice is required to develop the ability to engage in empathetic dialogues. Interviewee H (surgery) noted that he usually assigns two students to act as the patient and the doctor, respectively. The roleplaying task involves the following: . .. one tries to convey the bad news to the patient, and the patient tries to be a di cult patient, so tries to act out, tries to be emotional and sees how they cope with that. Palliative Care Medics from the department of palliative care added that family culture and beliefs regarding death also had to be taken into consideration when negotiating the direction of treatments. Family dynamics play an important role in the process of decision-making, especially in end-of-life situations. As stated by Interviewee G (palliative care): One must be proactive in preparing carers' expectations along the course of the disease. They have to be told what to be expect, such as the gradual deterioration of the patient, and how to act. When, for example, breathing is becoming di cult, they have to call the ambulance. They have to be told what to discuss with the patient, such as their will, last wishes, advanced directives, and the aftermath. All of this has to be done tactfully over time and by developing rapport. Essential family dynamics must also be observed, as well as family culture regarding death and dying and suffering. The above data show that the communication strategy of negotiating shared decision-making on treatments is particularly important to this eld.

Interdisciplinary communication between medical departments
As discussed by Bok et al. [54], effective interprofessional communication between healthcare professionals from various disciplines helps facilitate negotiation and shared decision-making [55]. The strategy of shared decision-making is thus not limited to clinicians' interactions with patients and their families; it is also applicable to interactions between clinicians from different disciplines and between clinicians and external supporting parties. Both the neurology specialist and the intensive care specialist interviewed in this study expressed the belief that medical students should learn how to collaborate with medics from other disciplines.

Neurology
When bad news has been made available to all parties, neurologists are able to provide support for patients and family members by collaborating with nurses, allied health workers, psychologists, social workers. -Interviewee C (neurology)

ICU-based critical care
The nature of the ICU is primarily interdisciplinary, because in critical illness often more than one organ system is involved, so it really takes a lot of time and repeated interviews to try to get the patient to understand what is happening to them and to have a realistic expectation of how things will progress. -Interviewee D (ICU) This involves a lot of communication between various medical disciplines, as patients might have problems simultaneously with their heart, with their lungs, their kidneys, these are major organs that are involved in an acute illness. .. [and they have to] be in close communication with a cardiologist, respirologist [or] surgeon if an operation is planned or if the patient is in the early postoperative stage. And then we also speak with dieticians to try to optimise nutrition. We have to speak to physiotherapists and speech therapists and come up with a plan for management as a whole team. -Interviewee D (ICU)

Language and clinician-patient communication
In the study by Pun et al. [29] of clinicians' perceptions of communication challenges in the trilingual environment of a local emergency department, Hong Kong clinicians felt that they were unable to engage in interpersonal communication with their patients because of the linguistic complexity, long working hours, time constraints, and high patient loads. Although most of the respondents in the study recognised patient-centred care to be optimal, they hardly listened to their patients [29] and prioritised basic duties over developing empathy or rapport with their patients through interpersonal communication [47].
Moreover, as mentioned in the literature review above, Hong Kong clinicians speak in their mother tongue Cantonese but receive their medical school training in English [29]. Because of the high number of immigrants from mainland China, they also speak with some patients in Mandarin [56], making local clinical settings trilingual and thus linguistically complex. Coupled with the high pressure of Hong Kong's clinical environments, language plays an important role when clinicians attempt to intersperse medical talk with interpersonal chat with patients [47], because they have to translate English medical jargon into plain language. Clinicians working in the disciplines of neurology, intensive care, and nursing said that they addressed this challenge by shifting between technical and conversational language to explain medical concepts clearly, repeating key information [47], and communicating through both verbal and non-verbal means.

Neurology
To clearly describe diseases and medical concepts to patients and their families, neurologists at the focal hospital moved between technical and conversational language [47]. Interviewee C noted that it is essential to break down messages in small chunks, into very very simple messages, and then ask the translator to tell them or to back translate. For example, Interviewee C often compared the functioning of the heart to the mechanism of a kitchen tool: It is like your blender in your kitchen. If you press different buttons to change the speed of the blender, 0 1 3 2 4, it will not blend nicely and it will form curves, so on and so on, and if you imagine this is the heart, if it is not beating regularly, then clots can form, but then obviously if these block any blood vessels, then there can be detrimental consequences.

Discussion
As stated in the results section, the 5 themes that emerged from the thematic analysis were as follows:

Showing empathy with patients
The clinicians from the disciplines of surgery, nursing, and oncology all noted the importance of showing empathy. This nding echoed the results of Slade et al. [47] in which surgeons and oncologists in particular stressed the communication strategy of interspersing medical talk with interpersonal chat [47]. . In the current study, the clinicians from these three disciplines all mentioned speci c teaching approaches to encourage students to engage in empathetic conversations with patients. For example, the surgeons said that they trained their students to be empathetic by asking them to connect with the wider social environment and re ect on the similarities between patients' situations and their own life experiences. The oncologists interviewed said they used a similar teaching approach when they encouraged their students to view themselves as both their patients' healthcare providers and their friends. Such approaches indicate that medical students should focus not only on their patients' physical needs but also their emotional ones, and that they should converse empathetically with their patients. This is supported by the nding of Slade et al. [47] that incorporating medical talk into interpersonal conversations improves patients' evaluations of the quality of care they have received and increases patients' involvement in decision-making on their treatments [47]. This thus indicates that the strategy can facilitate the effective implementation of patient-centred care; it also indicates the importance of including this strategy when teaching clinical communication. The data from the current study also suggested that it is important for medical students to be strategic in their use of this approach, engaging in interpersonal conversations but preventing such conversations from encroaching on the time allocated for treatments. This need is especially important in cases in which patients have disabilities such as deafness, which makes linguistic barriers especially di cult to surmount. To guarantee equal access to healthcare information and services for such patients, it is important to help nursing students gain the experiential learning experience of communicating with them.
The ndings of these abovementioned studies highlight the need to review the current approach to nurse-patient relationships. Our interviewee from the discipline of nursing focused especially on the concerns of patients with special needs. Interviewee E explained that senior nurses in Hong Kong clinical settings tended to train their students to attend to patients' special needs. This was done, for example, by involving the students in the processes of helping patients with special needs to understand medical information. She cited the speci c instance of creating instructional healthcare videos with her students, in relation to which she emphasised the importance of empathetically bearing in mind the needs of patients with hearing loss. The interviewee also mentioned that, in turn, this process could raise the students' awareness about disabilities and make them more empathetic towards disabled patients.
The ndings in this study indicate that the communication skill of being empathetic is also important in clinicians' encounters with patients' families. The importance of the family in Asian clinical settings was highlighted by Ishikawa and Yamazaki [13], who observed that within Asian cultures, patients are treated not as individual units but as parts of larger social units, particularly in the context of decision-making. Western individualistic models are thus inapplicable to Asian contexts. Rather, in Asia, it is crucial for medical students to acquire the skills needed to communicate with patients' families. The interviewed surgeons highlighted the need for medical students to ask patients' families questions and express care for them, thereby giving them the space to tell their stories. By adopting such a strategy, students can demonstrate empathy with patients' families, thus facilitating shared decision-making processes. These insights underscore that it is important for medical education programmes to include the teaching of shown that video instruction helps ensure performance outcomes and boost students' con dence, because students nd videos particularly useful for revision and preparation for medical practices [67].
As a result, students prefer instructional videos to conventional face-to-face instruction [67][68][69]. Videos are also easily accessible because of the ubiquity of portable video-playing devices such as smartphones [70].
Most of these studies, however, have been conducted in English-speaking countries and have not focused on the teaching of clinical communication. The researchers in the current study noted this research gap and sought feedback on the suitability of using videos for teaching communication in the speci c setting of Hong Kong. The interviewee from the discipline of surgery con rmed that instructional videos showcasing scenarios in Hong Kong clinical settings could help surgical students prepare to adopt the strategy of interspersing medical talk with interpersonal chat [47].
Interviewee E (nursing) described a different approach to using video technology in teaching clinical communication. She mentioned that seniors involve students in the process of creating healthcare- for medical students to understand their patients' goals, in light of the incurability of many illnesses. The interviewee thus found it particularly important for clinicians, patients, and their families to come to a consensus regarding the bene ts and limitations of certain treatments and which choices best aligned with the patients' interests through the strategy of negotiating shared decision-making about treatment [47].
Clinicians working in the ICU and the department of palliative care also reported negotiating shared decision-making about treatment [47]. For instance, clinicians from the ICU said that they discussed their patients' conditions with those from other departments to negotiate and arrive at the best treatment plan. Apart from involving different parties of medical experts in the decision-making process, the interviewed ICU clinician also noted that they took an inclusive approach, even with patients who could not speak.
The interviewee believed that in many cases these patients -such as those who were intubated -were actually conscious and desired to actively participate in medical discussions, as the study by Leung et al. [72] showed. Therefore, it was important to conduct interviews in front of these patients.
Moreover, given the collectivist attitude of Chinese culture, as mentioned above [13], clinicians usually advise their students to involve patients' families when negotiating shared decision-making on treatment [47]. In this study, this theme was mentioned by interviewed ICU clinicians and palliative care specialists.
In many East Asian cultures, there is a three-way clinician-patient-family dynamic [73,74] and decisionmaking is family-centred [75]. As the interviewed ICU clinician stated, it is important to ensure that patients' families understand different treatment options and agree with the potential decisions; this can be facilitated by the strategy of repeating key information [47]. Information was often repeated in both verbal and written forms such as interviews and lea ets. The interviewed palliative care specialist further discussed the importance of observing family dynamics when engaging in end-of-life communication, in which clinicians have to manage the expectations of the patients' families, such as those pertaining to patients' deterioration, measures to take in emergencies, and patients' last wishes. The interviewee emphasised that it is important for students working on such cases to learn about the family's dynamics and attitudes towards death; in such cases, clinical communication is highly dependent on the context, especially in light of Chinese cultural taboos regarding the discussion of death [25]. Therefore, in end-oflife scenarios, medical educators in Chinese contexts should teach students not to engage in explicit conversation about death but rather be attuned to the high-context nature of such scenarios and develop strategies of using indirect expressions or non-verbal communication [76].

Interdisciplinary communication between medical departments
The importance of acquiring the skill of negotiating shared decision-making inter-professionally is mainly due to the interdisciplinary nature of most medical procedures; for example, the interviewed neurologist described the need in their discipline to offer emotional and physical support to patients and their families by working with nurses, allied health workers, psychologists, and social workers. An ICU clinician also stated that it was often necessary to work in an interdisciplinary manner with other clinicians, such as surgeons and cardiologists, because patients tended to have more than one damaged organ.
Clinicians are only able to design the best treatment plans and give appropriate support to patients and their families through inter-departmental collaborations. However, in study conducted by Ng et al. [77] on the speak-up culture at a local ICU, many interviewees found that the culture of speaking up was not welldeveloped when it came to intradepartmental communication, because of hierarchies between clinical departments.
Although some existing programmes aim to help medical students develop the skills for implementing effective interdisciplinary communication, most programme designs lack a longitudinal perspective and effective means to appraise competency [54]. Therefore, it is important for medical educators to consider recent studies and cultural contexts when designing interprofessional communication training programmes aimed at helping students identify the interwoven nature of cognitive and procedural knowledge across different clinical settings [54]. This should make the process of shared decisionmaking smoother across disciplines and allow for better cohesion and interdisciplinary communication.
The role of language in clinician-patient communication The nal theme that emerged from this study was the role that language plays in clinician-patient communication. Interviewee C, a neurologist, for example, described the way that he encourages students to adopt the communication strategy of explaining medical concepts clearly by shifting between technical and plain language [47]. Interviewee C said that to do so, it is important for translators to rst break down medical information 'into small chunks' to convey 'simple messages' without excessively using English 'medical jargon and complex terminology'. In addition to providing medical information in clear and simple ways, Interviewee C gave additional examples of interspersing medical talk with interpersonal chat [47]. One strategy he mentioned was to 'convey complex problems' to patients using everyday examples, such as comparing the mechanism of the heart to the motion of a blender. Such a strategy demonstrates empathy because the clinician shows the patient that he or she values ensuring that the patient understands the medical information. By shifting between technical and plain language and interspersing medical talk with interpersonal talk, clinicians are able to rst communicate medical knowledge to patients and then develop good clinician-patient relationships [47].
To make sure that clinicians clearly convey medical knowledge to patients and sometimes patients' families, this study also found that some clinicians use the strategy of repeating key information [47], as mentioned above. For instance, Interviewee D, an ICU-based critical care physician, noted that it was sometimes important to repeat 'similar information' to patients' family members until they complied with treatment plans. This particular strategy, along with the delivery of additional information in written form, was identi ed as being able to help patients' families understand the different treatment options and their respective bene ts and drawbacks. Moreover, by couching this information in plain language, patients' families could easily digest the medical information before making shared decisions.
The varieties of languages used in clinical communication are not limited to verbal languages, because some patients have disabilities such as hearing loss. Many deaf patients experience medicine-related mistreatment because of ineffective communication and a lack of access to information [78]. Such cases fall short of the standards described in the United Nations' Disability Rights Agreement, which advocates equal access to healthcare services for the disabled [79]. To implement patient-centred care, it is necessary to take patients with special needs into consideration. Interviewee E, who is a nurse, noted this issue and described how nursing students were involved in the process of creating media content that had sign language subtitles. Such an inclusive approach to treating deaf patients runs counter to the Chinese cultural norm whereby a functional approach is adopted to meet patients' medical and emotional needs [64,80]. The example raised by Interviewee E indicates the need for medical students to consider ways of communicating medical knowledge with patients with disabilities, such as by asking medically experienced sign language interpreters for help.

Conclusion
Over the decades, medical education programmes in the West have developed in important ways. While programmes in Western countries have bene ted from research, testing, and innovative reforms [30], those in Asian countries and regions have lagged behind. To implement patient-centred care in Asian cultural contexts, it is necessary for medical educators to train medical students to be culturally competent. This study re ected on clinicians' observations, opinions, teaching approaches, and experiences across disciplines and drew on the collected qualitative data to suggest possible teaching approaches to clinical communication based on speci c cultural values. These suggestions encourage future medical education programmes to focus on developing medical students' communication skills and cultural competency by implementing their local adaptations of patient-centred models.
This study is signi cant for comprehensively conducting research across 7 disciplines in Hong Kong hospitals, and for advocating the teaching of interdisciplinary communication to more effectively achieve the goal of shared decision-making. The ndings of this study indicate the value of conducting nationwide quantitative and interdisciplinary research on clinical communication, which may guide future researchers based in Asia.