Application of doctor-patient communication skills in clinical teaching of postgraduates of tumour radiotherapy

Background: To cultivate the doctor-patient communication ability of medical students as the core and explore the new model of clinical communication ability training and evaluation for graduate students majoring in tumour radiotherapy and its application value. Methods: From January 2018 to June 2019, 60 postgraduates who were interned in the Department of Tumour Radiotherapy in our hospital were selected as the subjects, who were randomly divided into the experimental group (30) and control group (30). The experimental group adopted the Case Based Learning(CBL) teaching mode of introducing doctor-patient communication skills training, and the control group adopted the traditional CBL teaching method. After the teaching, the two groups of students were evaluated, measured and gave feedback on the effect of the teaching through the combination of examination and patient satisfaction questionnaire. The data were statistically analysed by SPSS19.0 software. Results: The doctor-patient communication skills assessment scale score of the experimental group was better than that of the control group, and the difference was statistically signicant (P<0.05). Patients' satisfaction in the experimental group was higher than that in the control group (P<0.05). Conclusion: The CBL teaching mode of introducing doctor-patient communication skills training for postgraduates of tumour radiotherapy can increase doctor-patient communication ability and improve patient satisfaction.

department in our hospital were selected as the subjects, which were randomly divided into the experimental group and the control group. Among them, 30 students (13 males and 17 females) were in the experimental group, with an average age of 23.00 ± 0.36 years, and 30 students (12 males and 18 females) were in the control group, with an average age of 22.50 ± 1.20 years. Students normal grades in the experimental group and control groups were 88.2 ± 5.5 and 89.0 ± 3.7, respectively. They were all majors in clinical medicine. All students in this study participated voluntarily. Before the study, all students participated in the questionnaire survey of clinical doctor-patient communication and participated in the whole course of the study. There was no exit halfway. There was no signi cant difference in general data between the two groups(P>0.05),as shown in Table1. The two groups of postgraduates were taught by one tumour radiation therapy teacher.

Control group (CBL teaching model)
The speci c steps of the CBL teaching mode are as follows: 1) Choose a relatively simple and common case of cancer radiotherapy, which is sent to students one month before the course; 2) Before the course, make a brief presentation of the case and ask questions, including the concepts of disease, epidemiology, diagnostic points, radiotherapy methods, etc.; 3) Postgraduate students will ask questions and think based on the questions prepared in advance, and the professional teachers will give appropriate guidance; and 4) 3 days after class, summarize and answer the questions for the case. The professional teacher will ask questions and correct their mistakes. The control group only taught clinical expertise according to the traditional CBL teaching model and did not involve doctor-patient communication training.
Experimental group (The CBL teaching mode of introducing doctor-patient communication skills training) Based on the CBL teaching mode, the experimental group conducted special training and teaching of doctor-patient communication-1) Teaching of Classroom Theory from Clinical Practical Cases; 2) Training communication methods. Teachers should inform students of common communication skills and explain and demonstrate from real cases of medical disputes and hospital emergencies to fully motivate students to actively communicate; 3) Under the guidance of the teacher, students will repeat the scenario simulation with the standardized patient(SP) and practice doctor-patient communication after the diagnosis of a malignant tumour and before radiotherapy and provide one-on-one guidance at the bedside on the ward. The teaching content is based on the SEGUE Framework scale(SEGUE ), which includes 5 stages: from the doctor's preparation stage for consultation to the communication with the patient, that is, information collection, information giving and understanding of the patient, and then to the end of the consultation. The teaching focus of the experimental group was to let the students learn to understand the patient's changes in condition and basic demands, then give feedback to the patient's demands, and nally develop mutual trust with patients.

Teacher Grading
Clinical examinations were divided into theoretical examinations and operational examinations.
Examinations were conducted one week after the graduate student had completed teaching. All questions were randomly selected by computer and scoring of operational exams by the same clinician. The evaluation of doctor-patient communication skills was to randomly match 60 students by computer, to videotape the communication between medical students and patients, and obtain evaluation from by the same tumour radiotherapy physician, according to the SEGUE scale. The scale includes 5 dimensions: communication initiation, information collection, information giving, understanding of patients, and end of communication. The total score of the scale is 25 points. Scoring criteria: communication content items (items 1-4, 6-11, 16-18, 20, 21, 24 and 25 of the scale)-points were given as soon as they appear once and communication skills items (items 5, 12-15, 19, 22 and 23 of the scale)-no points were awarded as long as they were not done once. The higher the score was, the better the student's communication skills.

Student Self-evaluation
One week after the course, a questionnaire survey was conducted for each group of students. The content of the questionnaire includes ve items, which including the improvement of self-communication ability, the improvement of analytical ability, the solution of the doctor-patient relationship problem, the satisfaction with the teaching mode and the increased con dence in working in the medical( including 20 small items, with a total of 50 points).

Patient score
After the training, satisfaction questionnaires were conducted on the patients who were interviewed by the two groups of students. Patient satisfaction (0-10 points): 3-5 points are dissatis ed, 6-8 points are more satis ed and 9-10 points are satis ed.

Statistical Methods
Statistical analysis was performed using SPSS 19.0 software, measurement data were expressed as (x±s), t test was used, and P <0.05 was considered statistically signi cant.

Results
Comparison of Doctor-Patient Relationship Evaluation before and after the Research Before and after the research, the degree of evaluation of the doctor-patient relationship between the postgraduates in the experimental group and the control group was not statistically signi cant (P>0.05), as shown in Table 2, Figure1-2.

Postgraduates Consider the Factors that Cause Tension in the Doctor-Patient Relationship
Before the research, the two groups of postgraduates believed that there was no statistically signi cant difference in the proportion of various factors that caused tension between doctors and patients (P>0.05). After the research, the experimental group thought that the proportion of medical and nursing factors affecting doctor-patient relationship was signi cantly higher than that before the same group (P <0.05), and the rest had no statistical signi cance (P>0.05), as shown in Table 3,Figure3-4.

Theory Exam and Operation Exam
In the two groups of clinical assessments, the theoretical test scores of the experimental group were higher than the control group, but the difference was not statistically signi cant (P>0.05). The operational test scores of the experimental group were lower than the control group, and the difference was also not statistically signi cant, as shown in Table 4.

Evaluation of Doctor-Patient Communication Skills
There was no signi cant difference in the total score of the SEGUE scale score between the two groups before the research. The score of the control group was slightly improved before and after teaching, but the difference was not statistically signi cant (P>0.05). The total score of the experimental group increased after teaching, compared with the control group, the difference was statistically signi cant (P <0.001), as shown in Table 5.
In the experimental group, communication start; information collection; understanding of the patient and communication ends, the individual scores of the four dimensions were improved after training, and the differences were statistically signi cant (P <0.05). There was no signi cant difference in the scores of information giving, as shown in Table 6.

Student Self-Assessment Survey
The student self-assessment survey includes self-communication ability,solving doctor-patient relationship problem and the degree of satisfaction with the teaching mode, the scores in the experimental group were higher than that in the control group, but the difference was not statistically signi cant, as shown in Table 7.

Patient satisfaction score
The patient satisfaction survey of the two groups of postgraduates was shown in Figure 5, which can be seen that the satisfaction of the experimental group is higher than that of the control group, and the dissatisfaction of the control group is higher than that of the experimental group.

Discussion
In recent years, with the obvious increase in the incidence and mortality of tumours, malignant tumours have become a major disease that seriously threatens human health. Cancer patients and their families often endure the torture of the disease, pain of treatment, and high cost of medical treatment. However, they must face heavy blows, such as tumour recurrence, metastasis, and disease progression, which often cause great psychological pressure [5]. On the one hand, due to the lack of understanding of malignant tumours, patients have a strong psychological dependence on doctors. On the other hand, because the therapeutic effect of radiotherapy often fails to meet their psychological expectations, they also have a distrust of doctors. Effective communication can signi cantly reduce the occurrence of doctor-patient contradictions, and because of the particularity of its disease, the tumour radiotherapy department has different characteristics in communication from other departments. Effective doctorpatient communication should include two aspects: communication with the patient and communication with families of patients [6]. Existing research has proved that psychological support, surgery, chemotherapy and other treatment methods have equal importance in the clinical treatment and rehabilitation of cancer [7]. Therefore, it is very important to strengthen the communication between doctors and patients for the diagnosis-and treatment-related issues that patients are most concerned about and fully inform patients and their families about changes in disease and prognosis. Giving proper psychological support is essential to the doctor-patient relationship and to ensure that examinations and treatments run smoothly.
Many medical students who have just begun clinical practice cannot change their roles as clinicians when facing patients and their families. It is often di cult to fully understand, analyse, and judge the disease during the process of diagnosis and treatment for patients, and even the knowledge of hard textbooks, thus affecting the diagnosis and treatment of patients. In clinical work, the front-line medical workers are often young resident doctors, so the cultivation of their doctor-patient communication skills during the postgraduate internship period is very important. Good doctor-patient communication can help to establish su cient trust between doctors and patients, especially in patients with oncology radiotherapy. Anxiety is manifested in all stages of the patient's disease. If the treatment is only symptomatic and ignores the patient's psychological needs, it may aggravate the condition and seriously opportunity to discuss and give feedback. Through the doctor-patient communication scenario simulation and using the SEGUE scale as evaluation, medical students will continuously accumulate practical experience in doctor-patient communication, which is more conducive to improving communication skills.
Due to the complexity and speci city of malignant tumour disease itself, tumour radiotherapy often has mild or severe adverse reactions. Postgraduate students of tumour radiotherapy must make correct judgements and treatments and truthfully inform patients and family members about the treatment programmes and what will happen after the disease develops to ensure that cancer patients fully understand the diagnosis and treatment plan. Postgraduate students need to accurately, timely and effectively inform about the disease, provide necessary psychological counselling for patients and their families, which can effectively alleviate the patient's panic and make them trust doctors more, and promote healthy development of the doctor-patient relationship. Studies have evaluated anxiety and depression in women with breast cancer one year after diagnosis, and those who were satis ed with the initial disease noti cation were signi cantly less anxious and depressed than those who were dissatis ed [13]. Therefore, in the clinical teaching process, the timing and skills of informing are particularly important for medical students who have just entered the hospital to work. The Fukuoka Declaration states: "Such as medical technology, the doctor-patient communication ability of a doctor is also a doctor-level performance. Doctor-patient communication skills are an important indicator of a doctor's success." Good communication skills are essential clinical skills for an excellent clinician [14]. Therefore, in clinical teaching, it is necessary to step out of the traditional concept of education, strengthen the training of doctor-patient communication and communication skills, and strengthen the cultivation of language arts for medical students, which is an inevitable requirement in the new era and new environment [15][16].
Doctors should emphasize the importance of humane care in medical practice and fully understand the psychological needs of patients, give guidance when patients are confused, give attention when patients are helpless, encourage them when discouraged, and give comfort when they are anxious [17]. Through communication and exchanges to conduct psychological interaction, nally achieve mutual understanding and cooperation between doctors and patients [18]. Starting from the patient's psychological needs. The respect and care for patients is the core of the clinical communication education between doctors and patients and the guarantee of building a harmonious doctor-patient relationship [19].

Conclusion
In summary, for postgraduates in the tumour radiotherapy department, strengthening the specialized training of doctor-patient communication is an important link in today's medical education. This will de nitely help the postgraduates of tumour radiotherapy to cope with future medical work more easily, create a harmonious doctor-patient relationship, and establish a good image for the hospital.

Declarations
Ethics approval and consent to participate This article was approved by Ethics Committee of Harbin Medical University Cancer Hospital.Written informed consent was obtained from all participants and the study was conducted according to the bylaws of the institution. We abide by all ethical considerations and keep the patients' personal information con dential.

Consent to publication
Not applicable Availability of data and material All data and materials are fully available without restriction.

Competing interests
Author Guohui Liu declares that she has no con ict of interest. Author Feng Liu declares that he has no con ict of interest.Author Chunbo Wang declares that he has no con ict of interest. Author Tian Lan declares that she has no con ict of interest. Author Mingyan E declares that she has no con ict of interest. The fund project was applied by the rst author, so the role the funder in our study is the rst author.
Authors' contributions GH L participated in drafted and nalized the manuscript.
F L substantial contributions to the conception and design of the work.
CB W acquisition, analysis, and interpretation of data for the work.
T L responsible for the language modi cation of the paper MY E responsible for the guidance and proofreading of the paper All authors have contributed signi cantly, and that all authors read and approved the nal manuscript. Grade First Grade 18 16 Second Grade 10 8 Third grade 2 6 Usual score 88.2±5.5 89.0±3.7      The degree of satisfaction with the teaching mode 7.83±0.54 7.68±0.51 Figure 1 Comparison of Doctor-patient Relationship Evaluation before and after Research in the Experimental Group.

Figure 2
Comparison of Doctor-patient Relationship Evaluation before and after Research in the Control Group. The Patient Satisfaction Survey of the two Groups