Dermatology: Practical and Conceptual Original Article | Dermatol Pract Concept. 2023;13(2):e2023120 1 Dermatologists Communication Skills and Performance From Point of View of Patients Nasim Farajtabar Nashli1, Parvaneh Hatami1, Zeinab Aryanian1, 2, Abbas Rahimi Foroushani³, Reza Robati4,5, Azadeh Goodarzi6,7, Masoud Assadi8,9, Narges Ghandi1,10 1 Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran 2 Department of Dermatology, Babol University of Medical Sciences, Babol, Iran 3 Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Science, Tehran, Iran 4 Skin Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran 5 Department of Dermatology, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran 6 Department of Dermatology, Rasool Akram Medical Complex Clinical Research Development Center, School of Medicine, Iran University of Medical Sciences, Tehran, Iran 7 Skin and Stem Cell Research Center, Tehran University of Medical Sciences, Tehran, Iran 8 Health Research Institute, Babol University of Medical Sciences, Babol, Iran 9 Department of Medical Ethics, School of Traditional Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran 10 Department of Dermatology, Razi Hospital, Tehran niversity of Medical Sciences, Tehran, Iran Key words: communication skills, Calgary- Cambridge Observation Guide, CCOG, dermatology, Persian Citation: Farajtabar Nashli N, Hatami P, Aryanian Z, et al. Dermatologists’ communication skills and performance from point of view of patients. Dermatol Pract Concept. 2023;13(2):e2023120. DOI: https://doi.org/10.5826/dpc.1302a120 Accepted: November 16, 2022; Published: April 2023 Copyright: ©2023 Farajtabar Nashli et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding author: Narges Ghandi, MD, Autoimmune Bullous Diseases Research Center,Razi hospital ,Tehran University of Medical Sciences, Tehran, Iran Tel: +98(912)3276640 E-mail: nghandi@tums.ac.ir Introduction: Effective communication is an important issue in patient-doctor interaction which is even more important regarding chronic disorders which need a strong relationship between patient and clinician for better compliance and optimal control disease. Objectives: This study was aimed to develop the best cultural adapted Persian version of the 28-item Calgary- Cambridge Observation Guide (CCOG) questionnaire. Methods: In this descriptive-analytic study, data collected from 400 patients attending the outpatient dermatology clinics of 3 major hospitals in Tehran using the modified Persian version of CCOG ques- tionnaire, both before and after being visited by dermatologists. Results: The difference of CCG scores for all of questions, except for questions number 1,16 and 22, was statistically significant. The highest score, both before and after visiting, attained by question regarding being respectful. The lowest scores for necessary behavior and the adequate amount of ex- ABSTRACT 2 Original Article | Dermatol Pract Concept. 2023;13(2):e2023120 Introduction Effective communication is an important issue in patient-doctor interaction and has been proved to be asso- ciated with positive health-related outcomes [1-4]. Hence, finding the appropriate tools to assess communication skills in medical staffs, seems to be essential and also challeng- ing. Mostly, some checklists for performance comparison and feedback are used [5]. One of the most useful check- lists in this regard is Calgary- Cambridge Observation Guide (CCOG) which is a 28-item questionnaire derived from Cal- gary- Cambridge Process Guides and consists of six blocks/ domains with a 3-point scale (yes/ yes, but and no) and has been previously shown to have adequate psychometric prop- erties [5]. Since many of dermatologic disorders are chronic con- ditions which need a long-lasting patient-doctor interaction, effective communication is essential to provide a better pa- tient’s compliance and adherence to treatment which is an even more important issue for optimal control of chronic disorders. Objectives This study was aimed to develop a Persian version of the 28-item CCOG questionnaire and try to reach the best cross-cultural adapted form of it to assess medical commu- nication skills in dermatology clinics via a validated Persian questionnaire. Methods We conducted this study based on previous recommenda- tions [6] via the following stages: translation, review by a committee of specialists and pretesting for assessing its validity. Initially, two bilingual translators provided two Persian versions of the questionnaire, independently. These forms were sent to an expert committee consisting of five associ- ated professors of dermatology to check its reliability. They checked the contents, provided some changes and sugges- tions and tried to merge two forms into a complete, final version, ready for pre-testing. After reaching a consensus, the final version was applied to 15 patients coming to the Razi dermatology Hospital, af- filiated to Tehran University of Medical Sciences (TUMS). The patients visited a dermatologist at a baseline visit and two weeks later and were asked to fill out the questionnaire. All doubts and concerns regarding the questionnaire were discussed and patients were guided through the process in case they encountered any difficulty. The translated form of questionnaire is available in the appendix. The statistical analysis was performed using SPSS, version 20. We estimated the Cronbach’s alpha coefficient and the spearman correla- tion coefficient to assess the internal consistency of each do- main and the correlation between the domains. After confirming the validity of questionnaire, it was filled out by 400 patients attending the outpatient derma- tology clinics of 3 major hospitals in Tehran (Razi hospital, Rasoul-e-akram hospital and Shohadaye tajrish hospital). For questions regarding necessity of performing a behav- ior by clinician, the answers were scored as follows: Below (1), at (2) or above (3) the expected level. About the adequate amount of implementing that behavior by clinician, the an- swers were again scored as follows: No (0), Somehow (1) and Yes (2). Then, sum of the scores per each question was calculated and final scores for each question was calculated using this formula: sum of scores × 100/800 Inferential statistics were performed using paired t-test, Chi-Square and Mann-Whitney tests, where appropriate. A significant P value was considered less than 0.05. Results Based on Spearman ratio and Cronbach Alfa of 0.838 (95% CI: 0.82 -0.86), the translated questionnaire was proved to be valid (data was not shown). Demographic and socioeconomic characteristics of par- ticipants are shown in Table 1. The participants were mainly female (67% versus 33%) with a mean age of 37.5 ± 5.6 years, ranged from 12 to 73 years. Table 2 shows CCGS before and after a dermatology visit. As shown above, the difference of CCG scores for all of questions, except for questions number 1,16 and 22, was statistically significant. ecution were related to questions number 3 (Introducing self) and 4 (Introducing role), respectively. Age and educational level of patients were significantly correlated with their expectations regarding communication skills of clinician. Conclusions: This study showed the acceptable validity of modified Persian version of CCOG-24 item questionnaire. Our findings also demonstrated that there was a significant difference between what patients expected from a dermatologist and the manner they actually were treated regarding physician communication skills. Original Article | Dermatol Pract Concept. 2023;13(2):e2023120 3 Table 1. Demographic and socioeconomic characteristics of participants. Number % Hospital Razi 300 75 Shohadaye Tajrish 60 15 Rasoule Akram 40 10 Gender Male 132 33 Female 268 67 Education level Under diploma 77 19 Diploma 121 30 Associate 35 9 Bachelor 103 26 Master or above 64 16 Occupation Employee 123 30.8 Self-employed 96 24 Worker 7 1.8 Housewife 115 28.8 Collegian 35 8.8 student 24 6 Residential area Tehran 310 77.5 Other cities 85 21.3 Rural area 5 1.3 Reason of attendance Dermatologic disease 299 74.8 Cosmetic problems 42 10.5 both 59 14.8 Number of attendance First visit 141 35.3 Second visit or more 259 64.7 Table 2. Mean CCG scores before (necessity of execution of behavior) and after (the actual amount of execution of behavior) visiting by dermatologist. N Question Mean necessity of execution Mean actual amount Effect size P value 1 Greeting patient 1.51 1.55 0.094 0.061 2 Asking patient name 1.10 0.97 0.11 0.028 3 Introducing self 1.07 0.63 0.38 <0.001 4 Introducing role 1.29 0.45 0.69 <0.001 5 Behave patient respectfully 1.91 1.59 0.16 0.002 6 Encourage patient to tell the problem 1.86 1.84 0.4 <0.001 7 Does not interrupt or direct patient statements 1.89 1.55 0.33 <0.001 8 Uses understandable questions without any professional vocabulary 1.79 1.67 0.24 <0.001 9 Establishes dates and sequence of events 1.79 1.67 0.13 0.001 10 Exploring patient worries regarding problems discussed 1.60 1.07 0.52 <0.001 11 Encourage patient to express feelings 1.34 0.83 0.45 <0.001 12 Pays enough attention to patient behaviors 1.72 1.37 0.38 <0.001 13 Makes a note of important issues 1.54 1.40 0.13 0.011 14 Appropriate time management of interview 1.74 1.50 0.26 <0.001 15 Appropriate coping with patient 1.57 1.16 0.41 <0.001 Table2 continues 4 Original Article | Dermatol Pract Concept. 2023;13(2):e2023120 Our findings demonstrated that there was a significant difference between what patients expected from a derma- tologist and the manner they actually were treated regard- ing physician communication skills evaluated by the CCG questionnaire. Overall, mean general score for necessitation of commu- nication skills was 81% and the most important issues in this regard were “being respectful” and “presenting complete and adequate data”. Contrary, “introducing self and role” was considered the least important item by patients. These results are in line with Afkham et al study in which the main priority of patients was acquisition of adequate and complete data [8]. Athari et al showed the importance of being respectful in a review published in 2010 which is congruent with our results [9]. From the point of view of our patients, criteria regarding “gathering information” and “initiating the session” were the most and the least important items, respectively. These findings are against the results of previous studies conducted in some Western countries in which initiation of the session and introducing the clinician seems to be very important for patients [3]. This discrepancy in results could be explained by cultural differences. In fact, Iranian patients do not expect the clinician to introduce her/his self or encourage them to express their feelings. Hence, culture building in this regard seems to be necessary among Iranian patients. We found that older patients compared to young ones emphasized more on the necessity of communication skills, especially regarding criteria related to initiating the session and understanding the patient’s perspective. This indicates the significance of implementing these skills of older people. The study also highlighted the relationship between ed- ucational level and some GCG criteria including “under- standing the patient perspective”,” building relationship” and “closing the session”. In fact, patients with higher edu- cational level were more likely to be understood by physician and have a summary at the end of the session. The highest score both before and after a visit was at- tained by question number 5 which was about being respect- ful (92% and 85%, respectively). The lowest scores for necessary behavior and the ade- quate amount of execution were related to questions num- ber 3 (Introducing self) and 4 (Introducing role), respectively (Table 2). Based on our results, questions number 5 and 7 were noted to be more important for patients and items number 6 and 16 were the most executed behavior by dermatologists (Table 2). Several subgroup analyses were performed to peruse the correlation of various characteristics of participants with GCC scores. The results showed that age and educational level of patients were significantly correlated with their ex- pectations regarding communication skills of clinician, as follows: The answers to questions number 1,2,3,4,11,13,15 and 21 were correlated to age of participants (P values: 0.04, 0.032, 0.016, <0.001, 0.001, 0.004, 0.04 and 0.013, respectively). Educational level of subjects affected the response to questions number 7,11,12,14,15,18,19,21 and 22 (P values: 0.045, 0.023, <0.001, 0.006, 0.008, 0.025. 0.037, <0.001 and 0.001, respectively). Regarding adequate execution of skills by clinicians, educational level of patients was the only factor that af- fected their opinions: answers to the questions number 5,8,9,14,16,17 and18 were significantly correlated with educational level of patients (P values: 0.036, 0.010, 0.022, 0.001, 0.009, 0.002 and 0.019, respectively). Conclusions The reliability coefficient of questionnaire was 0.84 in our study which was in the acceptable range of 0.8 to 0.9 [7]. Hence, this study showed the acceptable validity of modified Persian version of CCOG-24 item questionnaire. N Question Mean necessity of execution Mean actual amount Effect size P value 16 Appropriate self-confidence 1.842 1.79 0.08 0.081 17 Present complete and appropriate data 1.91 1.67 0.36 <0.001 18 Repeats medical advice in order to help to a better understanding by patient 1.57 1.067 0.39 <0.001 19 Shares decision making process with patient 1.58 1.24 0.33 <0.001 20 Final check if patient has any question or other items to discuss 1.54 0.93 0.54 <0.001 21 Summarizes patient information at the end of visit 1.51 0.90 0.55 <0.001 22 Scheduling for next visit 1.77 1.56 0.094 0.061 Table 2. Mean CCG scores before (necessity of execution of behavior) and after (the actual amount of execution of behavior) visiting by dermatologist. (continued) Original Article | Dermatol Pract Concept. 2023;13(2):e2023120 5 The mean score for executing the communication skills by clinicians was 65%. The highest and lowest scores in this regard were attained by “being respectful” and “introducing role” (92% and 23%, respectively). The rate of patient satisfaction among whom attending to outpatient dermatology clinic was shown to be 60% in previous studies [10] which is somehow similar to our results regarding communication skills. Finally, we found that our dermatologists were rela- tively weaker on criteria related to initiating the session, coping with patients and caring for their feelings which mandates future changes in their educational curriculum in this regard. However, other potential reasons could be a higher number of patients in clinics of educational hos- pitals and the absence of enough time for visiting patients as well as a relatively higher workload and exhaustion of physicians in this setting. This study had some limitations: firstly, illiterate patients could not participate in the study and secondly, the ques- tionnaire was only about physicians, but other medical staffs might be as important as clinicians and might lead to pa- tient’s dissatisfaction as well. Future studies for evaluating the behavior of other medical staffs are needed to enhance the satisfaction level of patients. References 1. Dwamena F, Holmes-Rovner M, Gaulden CM, et al. Interventions for providers to promote a patient-centred approach in clinical consultations. Cochrane Database Syst Rev. 2012;12:CD003267. DOI: 10.1002/14651858.CD003267.pub2. PMID: 23235595. 2. Smith SM, Soubhi H, Fortin M, Hudon C, O'Dowd T. Interven- tions for improving outcomes in patients with multimorbidity in primary care and community settings. Cochrane Database Syst Rev. 2012;(4):CD006560. DOI: 10.1002/14651858.CD006560. pub2. PMID: 22513941. 3. Poitras ME, Maltais ME, Bestard-Denommé L, Stewart M, For- tin M. 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