Analyzing Communication Skills Of Medical Students To Patients And Doctor

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ANALYZING COMMUNICATION SKILLS OF MEDICAL STUDENTS WITHIN

DISCOURSE ANALYSIS STUDY

Sukma Sukriana

Faculty of Language and Arts

Padang State University

Abstract

Nowadays, it is hard to find the hospitality communicationin hospital

because communication skill in medical students are barely taught. The practical

and the theory of communication skill do not get along sonc the misunderstanding

of different culture and the discourse analysis issue. Therefore, this study is aimed

at analyzing the communication skill between medical students within discourse

analysis study; showing the difference understanding between students in the first

year and fourth year; showing the lack of understanding culture different among

patients. Data is gained from the theory of Patient - Doctor communication skill

in medical practice. Data is analyzed within discourse analysis study. The

findings of the study revealed that several cases causes lack of communication

skill are culture difference, grade differences and lack of practical. Therefore, the

theory and practical in communication skill has to get along to create the best

hospitality communication among mendical students and patients.

Key words: Medical communication skill, medical student, dicourse analysis

1. Introduction

Being hospitalize is never been fun

fore they should take at least three time a

day and the hospital condition itself. In fact,

the medicine will be nothing if only either

the nurses or the doctor could serve the

patient hospitality. However, it is hard to

find the hospitality communication in the

hospital because communications skills in

medical students barely taught to the

medical students. They only learn about the

disease that their patients have and its

prescription to get them better.

Parker (2006) suggested good

communication skills through training may

improve the physician-patient relationship

and are related to positive health outcomes

for patients, such as improved compliance,

satisfaction with care, and benefits to

physical and psychological health. In

addition, good provider communication

skills have been linked to more efficient

health care organizations and effective

health care delivery, provider and patient

satisfaction, and fewer incidents of

malpractice.

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dr.Suzanne Donnelly (2015) from

UCD Dublin suggested 3 steps before

communicate to the patient. First, ensure

you are obedient with the clinical dress

code, that your name badge is clearly

displayed and wash your hands. Then,

introduce yourself by name and identify

yourself as a Medical Student attached to the

medical team caring for them. The last,

shake their hands unless there is an obvious

reason not to do so – For example painful

hand arthritis. The „3Cs‟ of patient contact

are dominant in all patient encounters

whatever the setting; these are Choice,

Consent and Confidentiality.

The patient must feel at all times that

they are treated with respect. Doctors

expectations of their patients should be fair,

unbiased and without judgment. (Haftel et

al, 2008). All patient-doctor interactions are

influenced by the expectations of both

parties. If the doctor has unfair expectations

of the patient, or the interaction is affected

by bias or unfair judgment, then an effective

relationship will never develop. Likewise, if

the patient‟s expectations of the doctor are

not met, the patient will not develop enough

respect or trust for the physician to accept

his/her suggestions.

However, much of the previous work

in this area has inferred these relationships

among variables rather than specifically

testing them. The reviewed literature

suggests that medical student attitudes

toward communication skills training likely

influences perceptions of the importance of

these skills, and they may eventually

influence the learning and adoption of

communication skills in the clinical setting.

In addition, attitudes toward communication

skills training are also likely to be related to

medical student assessments of their ability

to communicate effectively with patients

(Wright et al, 2006).

Although medical students have

legal restrictions on the clinical work they

can do, they must be aware that they are

often acting in the position of a qualified

doctor and that their activities will affect

patients. Patients may see students as

knowledgeable, and may consider them to

have the same responsibilities and duties as

a doctor. Therefore, having a good

communication between doctor and patients

is important to gain the patients belief.

Through discourse analysis, the talk

under analysis can be slowed down to show

the interpretive processes and overall

patterns of an activity. According to Srikant

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and Celia (2006), when discourse analysts

and health professionals are working

together, they can look at problems in new

ways and develop involvements and tools

for a better understanding of communication

in medical life.

The analysis of discourse frequently

defined as “language use above the level of

the sentence” (Stubbs, 1983) provides

students the meaningful production and

interpretation of texts and talk. Indeed, the

study of the structure and texture of texts as

whole units challenges the very concept of

„sentence‟ and, by adding to other

approaches to language study, enriches

students‟ understanding of how language

works.

Such attention to 'structure', 'form',

'organization', 'order', or 'patterns', is

characteristic of virtually all contemporary

approaches to discourse or conversation

analysis. Some of these approaches are very

sophisticated and detailed, and may be very

technical as is the case of much work on the

grammatical structures of sentences and

sequences of sentences in discourse, or

studies of narrative or conversational

organization. Contributions to this journal

should of course be aware of the current

literature about the different types of

structural patterns text or talk may exhibit to

medical communications.

Note that such a "structural" analysis

need not be limited to "fixed" or "abstract"

structures, but may also focus on the more

'dynamic' aspects of discourse organization,

such as the mental, interactional or social

strategies participants engage in. Thus, we

may analyze the abstract structures of a

medical communication, the persuasion to

the patients, impression formation,

derogation, legitimation, and so on. And

each of such more global strategies that may

characterize a discourse as a whole may

again be analyzed in smaller, functional

components, that is, in terms of moves, as

we also know from a game of chess. For

instance, a doctor may locally enhance the

hospitalitty of the communication with

patients by recurring to the semantic moves

of greetings and making some jokes.

And finally, such a process analysis

may very well be combined with an analysis

of structures or strategies. Indeed, processes

involve structures or strategies of mental

representations. Especially in a more

psychological perspective, an analysis may

not only focus on structures or strategies but

also on processes, such as those of

production and comprehension of discourse;

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the activation of knowledge or opinions

during such processing; the way discourse or

its meanings are represented in memory; or

how mental models of events are formed or

activated during production or

comprehension.

The current study is aimed at

discovering the communication skills of

medical students within discourse analysis

view. As guidance the following questions

were proposed: 1) Why is communication

skill is needed for medical students? 2) Why

should patients and doctors gain trust each

other? 3) How does discourse analysis work

in medical communication skills? 4) How

doctors and patients speak communicatively

and persuasively through discourse analysis

view? 5) Why fourth years and second years

students are different in understanding of

communication skill?

2. Methodology

Data of this study were generated

from review of related literature and

interviewing some medical students from

different institutes with different year of

study. To ensure that the data is reliable, it

provides some appendix of the interview

between those students and transcripst of the

communication between doctor and patients

then drawing the analysis of the difference

between students form first and fourth year

of study within communication skill

understanding based on discourse analysis

view. The data were analyzed to show the

different lexicon and the structure is being

used by the students to the patients when

communicate, and to show whether their

way of communication could gain the

patients belief or not. Finally, the

explanations were sought for each type of

the motive. The first stage in analyzing the

data is the repeated listening to or viewing

of these recordings. This leads to identifying

the phases of the interaction that make up

the whole. Distinct phases are identified by

examining the content, the prosodic cues

(including intonation, rhythm, pausing),

non-verbal cues and other markers that

research in the interactional sociolinguistic

tradition has shown people rely on to make

inferences.

The second stage of the analysis

involves transcribing the data (with line or

turn numbers), using transcription

conventions at different levels of fineness

depending on the features of difference

between participants and our own thematic

focus. The next stage is to go back to the

whole interaction, examine its outcomes

and, wherever possible, gain feedback from

participants on their interpretation of the

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events. The final stage of the analysis

involves a process of constant reading and

re-reading of transcripts, informed by

linguistic, sociological and cultural concepts

that include those described below. This

then leads either to case studies of whole

interactions, or comparative analysis of

distinct phases of an interaction across a

larger amount of data.

3. Result and Dicussion

Observing the comfortable feeling of

the patients in hospital is the main problelm

for this study to analyze the causes.

Therefore, the discourse analysis of medical

communication and medical rhetoric -- how

clinicians, such as physicians and

counselors, talk persuasively (or not) to

patients and clients is the main problem of

this issue.

Recent development in linguistic and

related research is served by analysis of

discourse in medical settings: the

comparison of language in its spoken and

written guises. Note that such a "structural"

analysis need not be limited to "fixed" or

"abstract" structures, but may also focus on

the more 'dynamic' aspects of discourse

organization, such as the mental,

interactional or social strategies participants

engage in.

The medical setting, like most

institutional contexts, entails a continual

mediation between spoken and written

modes: preprinted forms structure spoken

interaction, which is condensed into written

records, which are in turn elaborated in oral

conferences and consultations. And each of

such more global strategies that may

characterize a discourse as a whole may

again be analyzed in smaller, functional

components, that is, in terms of moves, as

we also know from a game of chess. For

instance, a doctor may locally enhance the

hospitalitty of the communication with

patients by recurring to the semantic moves

of greetings and making some jokes.

3.1 Why communication skills in

medical students is needed?

In 1998, the American Academy of

Orthopedic Surgeons (AAOS) conducted an

extensive national survey to which 807

patients and 700 orthopedic surgeons

responded. The patients and surgeons were

asked to rate orthopedic surgeons with use

of the same categories. Patients rated

technical skills as important (“high-tech”)

but valued communication skills equally

(“high-touch”). According to this survey,

75% of the orthopedic surgeons believed

that they communicated satisfactorily with

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their patients, but only 21% of the

orthopedic patients reported satisfactory

communication with their physicians (1998).

This gap was most evident in categories

such as listening and caring and time spent

with the patient.

Malpractice suits often are the results

of differences in expectations between the

patient and the physician. Beckman et al.

(2009) reviewed depositions from sixty-

seven malpractice claims and reported both

the preponderance and the types of

communication problems described in these

depositions. Good communications help

physicians understand patient expectations

thereby reducing liability exposure.

Although, asking patients “How are

you today?” is more of a greeting than a

question in the United States, it can put ill or

injured patients in the awkward position of

responding that they are “fine” just before

relating their story and/or medical problem.

With the initial introduction, say “Welcome”

or “Good to see you” while maintaining eye

contact and offering a handshake, when such

a greeting is culturally appropriate. Another

powerful words is “How can I help you

today?” six simple powerful words.

Open-ended questions allow the

patient the opportunity to define the

conversation. The non verbal

communication that might help patients tell

80% their storyy are nodding, reflective

facial expressions, and continued eye

contact all signal your attention to and

concern for the patient.

When the patient says, for example,

“I’m here because my shoulder hurts,” it

shows the ambiguity of the meaning, the

patient might meant to say that “I wouldn’t

be here if my shoulders doesn’t hurt” or it

might mean that the patient was telling the

pain. The doctor should reply the

appropriate respon to make sure the patient

comfortable, for example “Fine, tell me all

about it” with an uplifting, pleasant tone of

voice indicating interest and concern. If the

doctors say, “Tell me about your shoulder

pain,” it may risk conveying the impression

that you are interested only in a body part

and that only that one complaint can be

considered.

Helpful statements might include

“I’m curious about . . .” or “Tell me more

about . . . .” because it shows the respect to

patients and show how important they are.

Besides, it also get rid of the thought that

they are in pain, instead of just being asked.

Humor can be an important method

of presenting a physician‟s style and

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confidence as well as of lightening and

refreshing an otherwise overly serious

conversation. However, humor can cause

misunderstandings and possibly result in

patients judging physician behavior as being

patronizing or arrogant.

Each of us reflects individual

cultural values as well as the culture of

medicine. We need to be aware of our own

culture, belief systems, and values because

they affect our interactions with patients.

Cross-cultural communication is a critical

skill for physicians and other health-care

workers if we are to reduce disparities in

both access and outcomes of medical care.

Good doctor patient communication

is important and has multiple impacts on

various aspects of health outcomes. The

impacts included better health outcomes,

higher compliance to therapeutic regimens

in patients, higher patient and clinician

satisfaction and a decrease in malpractice

risk. Although medical education has started

to emphasize the importance of

communication between doctor and patient

and start to include the teaching of

communication skills in many

undergraduate and postgraduate programs,

research is in its infancy in Hong Kong.

With the alarming rise in malpractice

claims for doctors in Hong Kong, together

with the increase in the volume of

complaints and enquiries received by the

regulatory bodies and a rise in consumerism

in medicine, having more evidence based

information on the determinants of patient

satisfaction and dissatisfaction as it relates to

local context is important. Conducting

research in this area may help clinicians,

educators and health service administrators

to better understand the doctor patient

relationship and doctor patient

communication that is unique in our culture

and social settings.

This will provide a framework and

foundation from which further studies on

effective intervention that aims to improve

doctor patient relationship can be conducted.

This is a particularly important issue for

family physicians. One of the four founding

principles of family medicine adopted by the

College of Family Practice of Canada is that

"the patient-physician is central to the role

of the family physicians" (CFPC, 2000),

family physicians around the world thus

should make an initiative to make

themselves the advocates for improving

doctor patient relationship in medical care.

Extra effort to improve communication and

relationship with patients would help to

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reduce complaints, improve compliance and

reduce unnecessary investigation.

3.2 Why should patients and doctors

gain trust each other?

Both verbal and nonverbal skills play

a crucial role in face-to-face doctor-patient

encounters. They create trust, understanding

and build a successful rapport. In turn, they

increase the willingness of patients to work

with the healthcare team in person or by

telephone or email. Future studies of doctor–

patient communication will demand

effective training designs and should

combine diverse methods to examine the

rapport between doctor's verbal and

nonverbal behaviors, time-consciousness,

patient-doctor satisfaction and health

outcomes.

Accordingly, effective

communication between doctor and patient

will become a central clinical function and

one of the first steps in building a successful

rapport. Most of the core diagnostic

information will arise from the compliance

plan that will positively influence health

outcome. At present, however, most

complaints by patients about healthcare

providers do not deal or point to their

clinical competency or expertise but to

communication problems. Studies have

shown that only a small proportion of visits

with doctors include any patient education

and a surprisingly high number of patients

do not understand or remember what their

doctors tell them about diagnosis and

treatment due to the insufficient

communicative competence and extensive

use of medical jargon.

On the other hand, greater

participation and involvement of patients in

the encounter would also improve

satisfaction, compliance and the outcome of

treatment. Patients need to be encouraged to

participate in making decisions about the

management of their treatment plan,

provided that they are informed properly and

on time. Consequently, informed patients

are likely to be more satisfied and possibly

more compliant with doctor's

recommendations because building a

successful rapport largely depends upon the

effectiveness of communication between

patient and doctor, the validity of the patient

expectations and the ability of the doctor to

fulfill them.

3.3 How does discourse analysis

work in medical communication

skills?

A number of analytic concepts,

drawn primarily from linguistics and

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sociology, provide the theoretical backdrop.

All of them relate to the overarching

preoccupation with how meaning is

negotiated and how the outcomes from these

negotiations feed into assumptions and

knowledge.

Interactive frames and footing

Framing works as a filtering process

or membrane through which general values

and principles of conduct are reworked to

apply to the particular encounter in hand.

These frames trigger inferences by

constructing possible scenarios. For

example, doctors may have different frames

from patients as to what counts as healthy or

not. Related to this is the idea of _footing.

Goffman reworked the general idea of

putting something on a proper footing to

describe the way in which during an

interaction the roles and relationships of

participants can change. He also talks about

participant frameworks in which people

align themselves to others by the way they

manage their talk in the context of a given

activity.

Contextualization

Talk only has meaning in context

and this has to be actively constructed as the

interaction proceeds. Contextualization cues

are the hidden underbelly of this meaning

making. They are the signs that invoke the

context that gives each utterance a specific

meaning. They channel the inference

processes in a particular direction by calling

up the frames and affecting the footing of

each moment of an interaction. These

linguistic and prosodic signs include words

such intonation, stress, pausing and rhythm.

They tend to be used unconsciously and

their function in establishing or reinforcing

social relations and negotiating shared

meaning goes largely unnoticed.

Face and facework

There is a ritual element to

interaction that is concerned with the

fragility of social relations. We spend a lot

of time in talk both our own and that of

others. This is largely done through

politeness strategies which determine how

direct or indirect to be and how far to claim

relative closeness and informality or relative

distance and formality. Disagreeing with

more powerful people or managing

uncertainty, for example, involve politeness

strategies. So, a stark request or attempting

to challenge or disagree are softened, or

mitigated, by phrases such as the use of

auxiliary verbs.

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Social identity

Our social identity includes our

gender, our social standing, regional and

ethnic backgrounds and so on. These

identities are brought into the encounter but

are also brought about in it. For example, we

can make our powerful status or our

ethnicity more or less relevant in the

interaction. This performed social identity

affects how we get along together in an

encounter and how we judge each other.

Shared ways of speaking or finding

something in common can oil the wheels of

the interaction and create a positive

assessment of the other.

Rhetorical devices

Rhetoric is the use of language to

influence or persuade. Although associated

with political speeches (Martin Luther

King‟s is perhaps the most famous modern

example), these patterns of argumentation

are used routinely as part of institutional

encounters. Rhetorical devices include the

organization of talk around contrasts,

repetition of words and grammatical

structures, metaphor, analogy, reported

speech and lists (often of 3 items).

Rhetorical devices and styles are often

crucial in the assessment of speakers and, in

medical settings, of patients and their

conditions.

These cues, that there is a shift in

context are all conventions used

unconsciously to call up assumptions about

informal doctor) patient relationships. The

patient does not appear to pick up on the

contextualization cues, or infer the purpose

of the doctor‟s remark, and she may be

unfamiliar or uncomfortable with the idea of

chatting with the doctor. However, patients

and doctors are more likely to feel

satisfaction and reach shared agreement

about how to proceed if the basic building

blocks of understanding are in place or at

least repaired as soon as trouble is located.

Discourse analysis works at the level

of whole encounters and at the micro level

of detailed features of talk to focus on

analytic themes, some of which are

discussed above. It explores how

interactions are organized thematically and

rhetorically, and how people make sense to

each other moment by moment through

subtle yet taken for granted processes of

framing and cueing in talk. Discourse

analysts have a responsibility to make

descriptions adequately transparent for

health professionals as well as clients and to

present analysis in illuminating ways.

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By slowing down the activity – the

consultation, meeting, oral examination or

the research interview – it is possible to

show how interpretive processes work and

how patterns emerge across the whole

activity. Generally speaking, the type of data

and detailed analysis illustrated in this paper

can be used for training purposes, as the

following examples illustrate. A theme-

oriented approach encourages a free-range

DA, drawing inspiration from many

approaches. In this strand of DA, analytic

and focal themes overlap. The analyst needs

a bi-focal gaze, noticing both the health

content and the means of structuring talk

and sustaining relationships. So, at its heart

DA remains an ethnographically grounded

study of language in action, connected to

broader themes such as health and

inequality.

Silverman recently argued that we

should be collaborators, not warriors, in our

methodological debates. We take this

collaboration a step further by arguing for

joint activity between discourse analysts and

health professionals in the pursuit of better

understanding of communication in medical

life and research based educational

interventions.

3.4 How doctors and patients speak

communicatively and

persuasively through discourse

analysis view?

Doctors see patients from a range of

ethnic, cultural and socio-economic

backgrounds. Social and cultural factors

may determine such matters as why patients

attend, and may influence the patient-doctor

interaction and compliance. Doctors should

strive to ensure good communication

regardless of the social or cultural

background of patients. Communication is

facilitated when the doctor is aware of and

sensitive to the background or cultural needs

of the particular patient.

All of the advice in this document is

relevant but additional measures to reduce

the risk of misunderstanding include:

• asking questions to appreciate the patient‟s

understanding of health and disease; and

• explaining the doctor‟s understanding of

health and disease.

In certain situations, the following

strategies may also be helpful:

• seeking to establish an environment which

welcomes and affirms the different

background of the patient;

• in negotiation with the patient, considering

the use of assistance of agents such as

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patient advocates, family members,

pastoral care workers or spiritual

leaders;

• using local institutional protocols for

cross-cultural health care practice; and

• seeking advice from, and developing a

working relationship with,

community agencies that understand and

advocate for patients.

Summarized below are some of the

basic elements of communication during the

medical interview/interaction with a patient

that lead to a successful rapport building. It

is by no means definite and does not require

a particular style but it actually encourages

the individual doctor to develop his/her own

approach (Mauksch et al., 2008; Nelson,

2008; Haftel, 2007;Stewart, 1995; Williams

et al., 1998; Krupat et al.,2000; Roter et al.,

1992).

Accordingly, the first impression a

doctor and a patient make of one another is

the most important one. In those first few

minutes in the room with the doctor, the

patient will decide if he/she can feel

comfortable sharing information with the

doctor. In order to avoid building any sort of

a barrier in interaction with the patient the

doctor should pay particular attention to the

following steps during the initial doctor-

patient encounter. Moreover, the doctor's job

is to try in every way possible to relax the

patient and make him/her comfortable by

initially inquiring into non-medical areas of

the patient's life, make the patient feel that

he is a person who has come to the doctor's

office to seek for help and, in the end, be

helped.

The doctor only asks such questions

in order to understand the problem. The

doctor should, also, avoid asking questions

that are too broad because the patient may

not be quite sure what information the

doctor is looking for (for example Tell me

about your present occupation). During an

ongoing conversation with the patient, the

doctor should take the opportunity to learn

about thepatient's family and social history

(How many members are there in your

family? What activities do you participate

in? Are there any stressors that may be

contributing to your present condition? Will

you have any support when a treatment plan

is developed?). This will help the doctor

understand the patient better in the context

of his/her illness and will enable him/her to

treat the patient more effectively. It is often

necessary throughout the course of the

interview for a doctor to repeat the

information he/she has received from the

patient.

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Recent literature shows that

nonverbal behavior on the part of primary

healthcare providers is very much related to

patient satisfaction and rapport building

making the most effective health counselors

the ones whose nonverbal messages are

congruent with their verbal messages. Thus,

through this kind of interpersonal

communication (meaning that only two

persons take part in it), involving both

verbal and nonverbal cues, doctors can

create friendly and cooperative atmosphere

with the patients. Interpersonal

communication can help doctors get

information about health problems of the

patient and at the same time enable them to

educate patients about family planning,

contraception, communicable diseases, etc.

From the cultural standpoint, the

doctor, as the primary health care provider,

must put aside his/her own view of things,

beliefs and values and try not to project

them onto the patient. Patient's medical

problem is not about the doctor, but the

patient who is most likely to have his/her

own belief system. The doctor should,

therefore, not judge the patient and try to put

him/herself in the patient's shoes. Every

healthcare provider must be sensitive to the

patient's concerns, belief system, cultural

issues and must explore any and every

reason why the patient would not be

comfortable with a suggested compliance

plan (e.g. What obstacles/factors would

prevent you from being able to comply with

this plan?). Therefore, a doctor may need to

start negotiating with the patient to arrive at

a mutually acceptable course of action for

treatment.

The end of the interview is the point

when both the doctor and the patient need to

understand what has happened during the

course of it and what the plan for treatment

is going to be. Summary of the doctor-

patient encounter is the easiest way to do

this. The doctor has to make sure that all

questions, concerns and patient related needs

have been fully addressed. On the part of

both the doctor and the patient, it is also

important that a rapport has been established

because the patient needs to be able to rely

on the fact that the doctor will be there in

future if they should need him/her.

3.5 Why fourth years and second

years students are different in

understanding of communication

skill?

The finding that fourth-year medical

students had significantly more positive

attitudes toward communication skills

training than first-year students suggests that

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repeated exposure to communication

training over time and actual clinical

experience may influence attitudes toward

communication skills training. Since the

fourth-year medical students in the current

study had participated in more years of the

four-year course emphasizing commu-

nication skills at the institution that was

investigated in the current study, and they

had more clinical experience than first-year

students, it could be that these experiences

positively influenced attitudes toward

communication skills training, especially in

cases where they could see the benefit of

communication skills in the clinical setting.

However, future studies need to

measure changes in attitudes towards

communication skills training in a longi-

tudinal design to assess whether greater

experience truly influences attitudes toward

communication skills training.

Communication skills training will

continue to be an important component of

the medical school curriculum. While the

findings of the current study shed light on

the relationships among attitudes toward

communication skills training and outcomes,

such as confidence when communicating

with patients and knowledge of appropriate

communication skills, clearly more research

needs to examine the how perceptions of

communication skills training influences

provider behavior. Interventions targeting

affective learning of communication skills,

in conjunction with cognitive and behavioral

training, need to be developed to help

medical students understand the importance

of communication and the complexity of

communication issues in health care.

Faculty development received

limited attention at participating schools.

Students may learn the fundamentals of

effective doctor-patient communication in

classroom settings, but if they fail to observe

preceptors and residents demonstrate these

skills, they may conclude that they are not

relevant to patient care. Because of the

variability in the skills, time, and interests of

faculty preceptors, most of the methods

developed by the UME-21 schools focused

on the classroom setting. A challenge for the

future is to train preceptors who are

scattered over wide geographic areas to

model effective communication skills,

observe students‟ interactions with patients,

and provide specific, reliable feedback based

on these observations, thus creating an

environment that demonstrates and

consistently reinforces the importance of

doctor-patient communication and helps

students improve their skills.

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Despite a growing body of literature

regarding the importance of effective

patient-physician communication, more

research is needed to identify the best

teaching and evaluation methods to improve

the skills of medical students, faculty, and

practicing physicians to communicate

optimally with patients, families, and health

team members. This survey demonstrates

that medical schools can enhance third- and

fourth-year students‟ communication skills

through a variety of curricular themes and

teaching methods.

Given the advances in understanding

communication behaviors in the medical

encounter, and the development of many

successful teaching and evaluation methods,

each school is challenged to develop

practical, comprehensive, longitudinal

programs to ensure that all students acquire

effective communication skills for medical

practice. This is a challenge and opportunity

for medical educators working to teach the

art and science of medicine in the 21st

century.

4. Conclusion and Suggestion

Good doctor patient communication

is important and has multiple impacts on

various aspects of health outcomes. The

impacts included better health outcomes,

higher compliance to therapeutic regimens

in patients, higher patient and clinician

satisfaction and a decrease in malpractice

risk. Extra effort to improve communication

and relationship with patients would help to

reduce complaints, improve compliance and

reduce unnecessary investigation.

Consequently, informed patients are

likely to be more satisfied and possibly more

compliant with doctor's recommendations

because building a successful rapport largely

depends upon the effectiveness of

communication between patient and doctor,

the validity of the patient expectations and

the ability of the doctor to fulfill them.

Discourse analysis works at the level

of whole encounters and at the micro level

of detailed features of talk to focus on

analytic themes, some of which are

discussed above. It explores how

interactions are organized thematically and

rhetorically, and how people make sense to

each other moment by moment through

subtle yet taken for granted processes of

framing and cueing in talk. Discourse

analysts have a responsibility to make

descriptions adequately transparent for

health professionals as well as clients and to

present analysis in illuminating ways.

16

Recent literature shows that

nonverbal behavior on the part of primary

healthcare providers is very much related to

patient satisfaction and rapport building

making the most effective health counselors

the ones whose nonverbal messages are

congruent with their verbal messages. Thus,

through this kind of interpersonal

communication (meaning that only two

persons take part in it), involving both

verbal and nonverbal cues, doctors can

create friendly and cooperative atmosphere

with the patients.

The finding that fourth-year medical

students had significantly more positive

attitudes toward communication skills

training than first-year students suggests that

repeated exposure to communication

training over time and actual clinical

experience may influence attitudes toward

communication skills training. Since the

fourth-year medical students in the current

study had participated in more years of the

four-year course emphasizing commu-

nication skills at the institution that was

investigated in the current study, and they

had more clinical experience than first-year

students, it could be that these experiences

positively influenced attitudes toward

communication skills training, especially in

cases where they could see the benefit of

communication skills in the clinical setting.

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