Communication Skills of Resident Physicians in Aseer Region, Saudi Arabia


 Background: Effective communication improves patient-physician relationship and the overall quality of care. Objectives: The aim of this study was to evaluate communication skills of resident physicians at different health care facilities in Abha, Saudi Arabia.Methods: A cross-sectional, questionnaire-based study on a total of 210 resident doctors.Results: The communication skills scores were nearly normally distributed with a mean score of 113.30 ± 32.25.In comparing the skills by various socio-demographic factors, it was noted that gender and age played a significant role in specific communication skills. There was significant difference in mean scores of younger and older physicians in domains of interpretation and clarification (p < 0.001), asking (p < 0.001), feedback (p < 0.01), punishment and reward skills (p < 0.001). In asking skills, there was significant difference in mean scores of male and females (p < 0.001). Residents in the specialty of Internal Medicine had significantly higher scores than other specialties (CI 95% = 107.74–127.07; p < 0.001). Fifth-year residents had significantly higher scores than those of other levels (CI 95% =123.94-142.05; p < 0.001). Residents with more than one year of experience after the basic degree had significantly higher scores than residents with lesser experience (CI 95% = 123.76–137.68; p < 0.001). Residents who had taken training in communication skills had higher scores than those who had no prior training (CI 95% = 112.78-124.48; p = 0.07). Conclusion:The resident physicians are lacking in communication skills. Results of this study point towards a lingering need to focus on training of physicians in effective communication and efforts should be made to include it as a core competency in medical curriculum.

Specialties such as Family Medicine consider communication and consultation skills part of the training program, but the training approaches in most of these programs are primarily theoretical (14). To the best of our knowledge, no study has been conducted that focuses on the communication skills of resident physicians across specialties of the Saudi Board of Health Specialties in the Aseer region. This study was conducted to assess communication skills among resident physicians at health care facilities in the Aseer region, and to identify the socio-demographic and job factors that could affect those skills.

Methods:
This cross-sectional study took place between January and July 2018 in Abha City, which is the capital of the Aseer Region in Kingdom of Saudi Arabia (KSA). All residents in the specialty programs were invited to participate. A total of 210 resident physicians from the specialties of Family Medicine, Internal Medicine, Pediatrics, Obstetrics/Gynecology, and General Surgery took part in the study. The questionnaire was distributed to respondents at their place of training, namely, the outpatient clinics of Aseer Central Hospital, Abha Maternity and Children's Hospital, and primary health care centers accredited for Family Medicine training. All participants were briefed by the researcher about the objectives of the study and assured about the voluntary nature of their participation,anonymity and full con dentiality of their responses through an information sheet attached with the questionnaire.The study instrument was based on a self-administered pre-validated questionnaire from a previous studyin Iran (15) for assessing the communication skills. It also included questions on personal characteristics, namely, age, gender, program of residency (specialty), level of residency (i.e., year of residency), years of experience (prior to joining the residency program), and formal training in communication skills. The second part comprised questions related to interpersonal communication skills and barriers of communication (not included in this paper). The alpha Cronbach coe cient (α = 0.89) of the questionnaire was reported in the source study. The interpersonal communication skills section included 36 items grouped into seven domains of communication skills, i.e., general communication (6 items), speaking (5 items), listening (5 items), interpretation and clari cation (5 items), asking (5 items), feedback (5 items), and reward and punishment (5 items). For each statement, there were 5 Likert-scale responses (never, rarely, sometimes, mostly, and always). The score for each item ranged from 1 to 5. The total score ranged from 36 to 180. The Statistical Package for Social Sciences version 23.0 (16) was used for data entry and analysis. In the presentation of results, categorical variables are presented as frequency and percentage distribution, and continuous variables as means and standard deviations. To examine the differences in the communication skills scores of physicians according to their socio-demographic and job characteristics, an independent t-test and ANOVA were applied. All tests were two-tailed, and results considered signi cant at 95% CI and a p-value less than 0.05.
Results: Table 1 shows the background characteristics of participants. The total number of physicians included in the study was n = 210 doctors. There were 122 (58.1%) males and 88 (41.9%) females among the participating residents. In terms of age, the mean age was 28.5 years (SD ± 1.78 years), with a range of 25-33 years. The median age was 29 years. The majority (n = 66, 31.4%) were Internal Medicine trainees, followed by 57 (27.1%) who were Family Medicine trainees, 35 (16.7%) who were Pediatrics trainees, 31 (14.8%) who were Obstetrics and Gynecology trainees, and 21 (10%) who were Surgery trainees. The majority (n = 63, 30%) were second year resident (R2) trainees, followed by 60 (28.6%) R3 trainees, 45 (21.4%) R1 trainees, 36 (17.1%) R4 trainees, and only 6 (2.9%) R5 trainees. Only 73 (34.8%) had preresidency clinical experience, compared to 137 (65.2%) who did not. This pre-residency clinical experience was less than one year for 55 (26.2%) trainees, and more than a year for 26 (12.4%) trainees. Previous training on communication skills was reported by 74 participants (35%), of which, 16.7 % had received continuing medical education (CME) and 18.7% had received other training methods. In comparing the skills by various socio-demographic factors, it was noted that gender and age played a signi cant role in speci c communication skills. There was signi cant difference in mean scores of younger and older physicians in interpretation and clari cation skills (p < 0.001), asking skills (p < 0.001), feedback skills (p < 0.01), and punishment and reward skills (p < 0.001). In asking skills, there was signi cant difference in mean scores of male and females (p < 0.001). Other socio-demographic factors did not show an effect on the communication skills of the participants. This information is presented in Table 3.
The differences between groups based on specialty, residency level, years of experience, training in communication skills, and type of training were studied for the total communication skills scores. Post hoc analysis was used to con rm the differences. Residents in the specialty of Internal Medicine had signi cantly higher scores than other specialties (CI 95% = 88.6488-102.3688; p < 0.001). Fifth-year residents had signi cantly higher scores than those of other levels (CI 95% = 81.3998-99.9335; p < 0.001). Residents with more than one year of experience after the basic degree had signi cantly higher scores than residents with lesser experience (CI 95% = 123.7650-137.6870; p < 0.001). Residents who had taken training in CME in communication skills had signi cantly higher scores than those who had no prior training or had attended other methods of training (CI 95% = 121.4108-135.3320; p < 0.05). Table 4 presents the above ndings.The correlation between the total years of experience and communication skills mean score was signi cant at the 0.01 level, r = 0.443(not shown).

Discussion:
It is well-known that communication skills are a pillar of clinical practice (1). To be an effective doctor, in addition to knowledge and technical skills, communication skills are also essential. These skills are not limited to talking, but include listening and nonverbal communication (17). The ndings of the current study indicate that the level of communication skills of local resident trainees was not satisfactory and are similar to communication skill levels reported in regional studies (8,9,11,12,18).
Our study uncovered several important factors that could help understand communication issues among resident physicians. One of the ndings of our investigation was that female gender is associated with better asking skills, whereas, in other components, there were no differences between female and male residents. This is contrary to past studies where Saudi patients rated male trainees higher than females (11). We also con rmed that older residents have higher scores in communication skills.
Pre-residence clinical experience also stood out as a factor for better communication skills. Work experience is an established factor in improving and re ning communication skills for doctors and medical students (19). Interaction with patients leads to better understanding of their needs, better recognition of verbal and non-verbal cues, and better communication with both patients and their signi cant others (17,19). In this study, we found that the number of years of clinical experience had a strong association with better communication skills. This could be expected and is consistent with past research (20). In addition, local research has con rmed that experienced senior physicians are more competent in terms of communication skills than their younger colleagues (12).
In our study, the speci c specialty did not affect communication skills, with the exception of Internal Medicine. Although Family Medicine necessitates particular communication skills, as it deals at the primary care level with patients of all ages and social backgrounds, and their families, their mean scores were lower than their counterparts in Internal Medicine, Surgery, and Obstetrics and Gynecology. Other studies have reported Family Medicine trainees are more skilled than Surgical trainees in providing information (18). It should also be noted that patients' perceptions of the communication skills of Family Medicine trainees in Saudi Arabia were shown to be relatively favorable in previous studies, however, this nding could not be replicated in the current study (11).This is an important nding that points towards gaps in specialty training in Family Medicine in the region and warrants further exploration. For pediatric trainees, there is inherent complexity around effective communication with patients and families (21). Communication skills' training for medical students has gained more focus recently (22), particularly in surgical specialties such as Obstetrics and Gynecology (23) and General Surgery (24), which may have some role in our study ndings.
An important nding of our investigation is that communication skills were affected by the level of residency and attendance at training through CME events. In terms of the structure of the current training system for communication skills development, this is a positive nding. This clearly complements international literature that emphasizes improvement in communication skills with progression in training for residents across specialties (25). Training in communication skills has become a core competency in modern medical education (26) given its established positive effect on various clinical outcomes (27).
Effective training and teaching has been shown globally to enhance communication skills among postgraduate medical residents (28).Superior communication skills equip doctors with con dence in dealing with di cult situations and improve patient satisfaction (29,30). Communication thus deserves greater focus during doctors' training.
Any interpretation of the results of this study should be mindful of one important limitation. The crosssectional design does not imply causation of poor levels of communication skills by the signi cant factors studied. However, it is clear that the communication skills of residents are lacking. Previous research has reported differences between self and patient perceptions of physicians' communication skills (31). This comparison is lacking in the current work and is one of its limitations. The authors contributed equally to the concept and design of the study,manuscript writing,editing and manuscript review. Author 1 collected the data and author 2 analysed the data.

Conclusions
-Acknowledgements:The authors acknowledge the support of the chairman,department of family and community medicine, King Khalid university and all study participants.