Medical professionalism from a socio-cultural perspective: Evaluating medical residents communicative attitudes during the medical encounter in MalaysiaK Ganasegeran1, SAR Al-Dubai2
1 International Medical School, Management and Science University, Shah Alam, Selangor, Malaysia
2 Department of Community Medicine, International Medical University, Kuala Lumpur, Malaysia
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0022-3859.128799 Clinical trial registration NMRR-11-1128-9716
Source of Support: None, Conflict of Interest: None
Clinical trial registration NMRR-11-1128-9716
Context: The practice of medicine requires good communication skills to foster excellent rapport in doctor patient relationship. Reports on communication skills learning attitude among medical professionals are key essentials toward improving patient safety and quality of care. Aims: We aimed to determine factors affecting communication skills learning attitudes among medical residents in Malaysia. Settings and Design: Cross-sectional survey, in a Malaysian public health hospital. Materials and Methods: A total of 191 medical residents across medical and surgical based rotations were included. We assessed the validated communication skills attitude scale among medical residents from different rotations. Statistical Analysis: Statistical Package of Social Sciences (SPSS®) (version 16.0, IBM, Armonk, NY) was used. Cronbach's alpha was used to test the internal consistency of the scale. Descriptive analysis was conducted for all variables. Bivariate analysis was employed across the socio-demographic variables. Results: Majority of the residents believed that communication skills training should be made compulsory in Malaysia (78.5%). Medical residents agreed that acquiring good communication skills is essential to be a good doctor. However, the majority cited time pressures for not being able to learn communication skills. Significant differences in communication skills learning attitude scores were found between Malays and Chinese. Conclusion: The majority of medical residents had a positive attitude toward communication skills learning. Socio-demographic factors influenced communication skills learning attitude among medical residents. Incorporating communicative skills modules during hospital Continuous Medical Education for medical residents is essential to cultivate communicative skills attitudes for effective doctor-patient relationship during the routine medical encounters.
Keywords: Communicative attitudes, medical encounter, medical residents, patient care, professionalism
"Professionalism is defined as those skills, attitudes and behaviors which we have come to expect from individuals during the practice of their profession and includes concepts such as maintenance of competence, ethical behavior, integrity, honesty, altruism, service to others, adherence to professional codes, justice, respect for others, self-regulation, etc."  Of all complaints against physicians, challenges in communication has been cited as the greatest; with arrogance and discourtesy reflecting negatively on a profession whose primary purpose is patient care.  The fundamentals of establishing an effective doctor-patient relationship is accuisition of good communication skills and attitudes.  Effective communication provides optimum information and psychological support to patients.  It facilitates accurate diagnoses and ensures better adherence , promotes effective use of health resources, improves patient satisfaction and reduces malpractice. ,,,, The importance of patient centeredness has been known to to improve the quality of care and promote patient satisfaction. ,, The transformation of modern medical practice has put greater onus on clinicians to enhance doctor-patient communication. , Amendments in citizenship and immigration laws have led to diversification with socio-cultural and linguistic differences posing significant barriers toward effective doctor-patient communication. ,
Previous studies have postulated that communication skills can be taught to and learned by medical students, residents and general practitioners. , As medical residents are primary liners in providing patient care from various public health facilities within Malaysia, it was desirable to determine their perceptions toward doctor patient communication in empowering patient-centered care. This study was aimed to explore the factors affecting attitudes of medical residents toward enhancing communication skills in Malaysia.
General design and ethics
This cross-sectional study recruited all available medical residents from six major departments at the Tengku Ampuan Rahimah Hospital (HTAR) Selangor, Malaysia, the country's second busiest public health facility. They were approached by one of researchers with the companion of chief residents during hospital Continuous Medical Education (CME) sessions and after working hours.
This research protocol was approved by the Ethics Committee of the National Institutes of Health, Ministry of Health Malaysia (government approval number: NMRR-11-1128-9716) and written, informed consent was obtained from all participants.
A self-administered questionnaire consisting of two parts was used in this study. The first part included questions on gender, age and race, university of graduation, graduate qualification, residency training level and current rotation. The second part was the
Communication skills attitude scale (CSAS), a validated
26-item instrument originally developed to assess communication skills learning attitudes among medical students.  It is comprised of two 13-item subscales, namely the positive attitude scale (PAS) and the negative attitude scale (NAS), focusing on both positive and negative communication skills learning attitudes. We adapted 20-items from the CSAS (12 from PAS and 8 from NAS) that we felt were relevant to the study population. The items deleted from the original questionnaire were applicable to medical students, but not to medical residents. All 20 items had a response option with a five-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). 
The Statistical Package of Social Sciences version 16.0 was used to analyze data. Both the PAS and NAS scores were calculated by summing the response values of the items in each subscale. Possible range of scores for PAS varied from 18 to 60 and for NAS ranged from 10 to 32, with higher scores indicating stronger attitudes.  Test of normality of the total score for both PAS and NAS was conducted using the Kolmogorov Smirnov test. Cronbach's alpha was used to test the internal consistency of PAS and NAS. Student t-test and analysis of variance (ANOVA) test were used to compare means of attitudes across variables. The accepted level of significance was set below below 5%.
Socio-demographic characteristics of respondents
The mean (±standard deviation [SD]) age of the respondents was 26.5 (±1.6) years and the majority were aged 25-27 years (65.4%). The bulk of respondents were women, (55.5%), and Chinese (35.6%) and had graduated from local public universities (41.4%) with a "pass" (71.7%). Of all respondents, 61.8% were senior residents, currently undergoing rotations. (57.6%) [Table 1]. Cronbach's alpha coefficient for PAS sub-scale was 0.91, indicative of high internal consistency and Cronbach's alpha coefficient for NAS sub-scale was 0.68, showing an acceptable internal consistency for these items.
The majority of the residents believed that communication skills training should be made compulsory in Malaysia (78.5%). The mean (±SD) for PAS was 45.7 (±6.1) and the scores ranged from 18 to 60. Item means for PAS ranged between 3.6 and 4.5 [Table 2]. The mean (±SD) for NAS was 22.2 (±3.7) and the scores ranged from 10 to 32. Item means for NAS ranged between 2.0 and 3.1 [Table 3].
Association between communication skills attitude and socio-demographic characteristics
There was a significant difference in negative learning attitude score between the different races (P = 0.03). A post hoc test revealed that Chinese (21.5 ± 3.5) exhibited lower negative attitudes when compared to Malays (23.2 ± 3.3) (P = 0.03). There were also significant differences in both positive and negative learning attitude scores between the universities of graduation (P = 0.03, P = 0.04 respectively). However, post hoc test failed to determine where the difference was [Table 4].
This study has explored factors affecting communication skills and learning attitude among medical residents from the Malaysian perspective. The majority of the residents believed that communication skills training should be made compulsory in Malaysia. Medical residents agreed that good communication skills build an essential foundation to be a good doctor. The majority of medical residents cited communication skills learning enhanced their team-working skills
This study found that Cronbach's alpha for PAS was 0.91; indicative of high internal consistency, while for NAS was 0.68, showing an acceptable internal consistency. These values are similar to previous studies; Cronbach's alpha for PAS ranged from 0.87 to 0.90 and for NAS ranged from 0.65 to 0.80. ,,
Medical residents in this study generally portrayed higher positive attitudes (45.7 ± 6.1) as compared to negative attitudes (22.2 ± 3.7) toward communication skills learning. Studies from different countries reflected similar findings among medical students. , They also believed that learning communication skills would prompt clinicians to respect patients during consultations. Respecting patients' autonomy, rights, informed consent, confidentiality and privacy during medical examinations is crucial regardless of the culture we live in.
With respect to negative attitudes, majority of medical residents claimed that insufficient time during clinical practice hindered efforts to enhance communication skills. Medical residents are primary liners at major public health facilities within Malaysia with demands of a significant workload and responsibilities for critical decisions. care. 
This study found a significant difference in the communication skills attitude between races. Malaysia is a multicultural country comprising of three ethnic groups; Malay, Indians and Chinese, with Malay, Tamil, Hindi, Punjabi and Chinese as native languages. This diversity of language and culture would be factors that result in some barriers during the doctor-patient communication, prompting attending doctors to choose appropriate words, tones and facial expressions to result in an effective medical encounter.  We found a significant association between ethnicity and communication skills learning attitude among medical residents in this study. Chinese residents possessed a significantly lower negative attitude when compared to their Indian or Malay counterparts. The apprehension of Chinese speaking patients to preferably converse and comprehend in local Chinese language when seeking medical services have likely prompted these medical residents to value communication skills during clinical practice in Malaysia. Currently, 65% of medical institutions have included communication skills module in the medical curriculum to cultivate effective communication skills among the future doctors for an effective patient encounter session.  With the increase in cultural diversity and efforts to improve and assessing communication skills among medical professionals simultaneously are timely to overcome barriers for effective communication during medical practice. 
This study found significant differences in both positive and the negative learning attitude scores between the universities of graduation. Curriculum drafted at certain institutions of higher learning, both locally and internationally to facilitate communication skills learning module during medical training may have prompted medical residents to cultivate positive learning attitudes towards communicative skills during the clinical practice. We believe, an ideal doctor who listens, communicate effectively, empathize patients, being culture sensitive and provides emotional support to patients are vitals toward enhancing patient care, as mused Osler (1952) in his epitaph, "…the good physician treats the disease; the great physician treats the patient who has the disease!".  In contrast, routines of modern medical workplace with intense drama, time pressures and deadlines to meet and increased workload would have triggered negative interests among medical residents in clinical practice toward cultivating communicative skills learning attitude. 
The cross-sectional design of this study limits our ability to make generalizations. However we believe that , the situation is almost similar in all public health hospitals in Malaysia, particularly in regards to medical residents.
Negative attitudes that hindered communication skills learning should be addressed and dealt appropriately in future research. Incorporating communicative skills modules during hospital CMEs for medical residents is essential to cultivate communicative skills attitudes for effective doctor-patient relationship during medical encounters.
The authors would like to thank the hospital management and all heads of departments in HTAR for their approval and support to conduct this study. We thank all chief residents for their assistance in data collection and medical residents who volunteered consent to participate in this study.
[Table 1], [Table 2], [Table 3], [Table 4]