research paper on communication skills

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research paper on communication skills

This paper is in the following e-collection/theme issue:

Published on 27.8.2019 in Vol 21 , No 8 (2019) :August

Effectiveness of Digital Education on Communication Skills Among Medical Students: Systematic Review and Meta-Analysis by the Digital Health Education Collaboration

Authors of this article:

1 Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore

2 Norfolk & Norwich University Hospital, Colney Lane, Norwich, United Kingdom

3 Health Workforce Department, World Health Organization, Geneva, Switzerland

4 Family Medicine and Primary Care, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore

5 Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, United Kingdom

Corresponding Author:

Lorainne Tudor Car, MSc, MD, PhD

Family Medicine and Primary Care

Lee Kong Chian School of Medicine

Nanyang Technological University

11 Mandalay Road

Phone: 65 69041258

Email: [email protected]

Background: Effective communication skills are essential in diagnosis and treatment processes and in building the doctor-patient relationship.

Objective: Our aim was to evaluate the effectiveness of digital education in medical students for communication skills development. Broadly, we assessed whether digital education could improve the quality of future doctors’ communication skills.

Methods: We performed a systematic review and searched seven electronic databases and two trial registries for randomized controlled trials (RCTs) and cluster RCTs (cRCTs) published between January 1990 and September 2018. Two reviewers independently screened the citations, extracted data from the included studies, and assessed the risk of bias. We also assessed the quality of evidence using the Grading of Recommendations, Assessment, Development, and Evaluations assessment (GRADE).

Results: We included 12 studies with 2101 medical students, of which 10 were RCTs and two were cRCTs. The digital education included online modules, virtual patient simulations, and video-assisted oral feedback. The control groups included didactic lectures, oral feedback, standard curriculum, role play, and no intervention as well as less interactive forms of digital education. The overall risk of bias was high, and the quality of evidence ranged from moderate to very low. For skills outcome, meta-analysis of three studies comparing digital education to traditional learning showed no statistically significant difference in postintervention skills scores between the groups (standardized mean difference [SMD]=–0.19; 95% CI –0.9 to 0.52; I 2 =86%, N=3 studies [304 students]; small effect size; low-quality evidence). Similarly, a meta-analysis of four studies comparing the effectiveness of blended digital education (ie, online or offline digital education plus traditional learning) and traditional learning showed no statistically significant difference in postintervention skills between the groups (SMD=0.15; 95% CI –0.26 to 0.56; I 2 =86%; N=4 studies [762 students]; small effect size; low-quality evidence). The additional meta-analysis of four studies comparing more interactive and less interactive forms of digital education also showed little or no difference in postintervention skills scores between the two groups (SMD=0.12; 95% CI: –0.09 to 0.33; I 2 =40%; N=4 studies [893 students]; small effect size; moderate-quality evidence). For knowledge outcome, two studies comparing the effectiveness of blended online digital education and traditional learning reported no difference in postintervention knowledge scores between the groups (SMD=0.18; 95% CI: –0.2 to 0.55; I 2 =61%; N=2 studies [292 students]; small effect size; low-quality evidence). The findings on attitudes, satisfaction, and patient-related outcomes were limited or mixed. None of the included studies reported adverse outcomes or economic evaluation of the interventions.

Conclusions: We found low-quality evidence showing that digital education is as effective as traditional learning in medical students’ communication skills training. Blended digital education seems to be at least as effective as and potentially more effective than traditional learning for communication skills and knowledge. We also found no difference in postintervention skills between more and less interactive forms of digital education. There is a need for further research to evaluate the effectiveness of other forms of digital education such as virtual reality, serious gaming, and mobile learning on medical students’ attitude, satisfaction, and patient-related outcomes as well as the adverse effects and cost-effectiveness of digital education.

Introduction

Both qualitative and quantitative researchers have intensely studied the importance of communication between patients and doctors since the 1970s. Within health care, where an individual explores the unknown environment of one’s own health and disease, effective communication skills can positively affect a number of health outcomes including better emotional and physical health, higher symptom resolution, improved pain control, greater treatment compliance, and enhanced patient satisfaction [ 1 ]. Furthermore, studies have reported reductions in emotional distress, levels of discomfort, concerns, fear, hopelessness, grief, depression, or health services utilization as a result of effective communication [ 2 , 3 ]. Communication involves respecting the persons’ dignity, integrity, and autonomy [ 4 , 5 ] as well as an ability to explore and discuss their expectations or wishes in a warm, nonjudgmental, and friendly manner. Effective communication (verbal and nonverbal) includes traits such as empathy, understanding, active listening, and the ability to meet patients’ needs and emotionally charged information [ 6 ]. In clinical practice, effective communication also requires features needed for effective symptom control such as honesty, open disclosure, an ability to gain trust [ 7 ], and influence over patient behavior [ 8 ]. These communication skills are essential in building the doctor-patient relationship or “therapeutic alliance.” Finally, physicians have legal, ethical, and moral obligations to demonstrate a variety of communication skills including the ability to gather information, formulate an accurate diagnosis, provide therapeutic instructions and medical advice, communicate risk, and deliver health-related news to the patients [ 9 , 10 ].

Communication skills training is recognized as an important component of the curricula in undergraduate and postgraduate medical education and is endorsed, for example, by the UK General Medical Council, which states that students should be able to “communicate clearly, sensitively and effectively with patients, their relatives and colleagues” [ 11 ]. The optimal method of teaching and learning communication skills is considered a direct observation of the student’s performance, followed by feedback from an experienced tutor [ 12 , 13 ]. This form of small-group teaching requires intensive planning and resources including simulated patients and experienced tutors. The lack of standardization within these patients and tutors can result in unequal learning outcomes.

Digital education encompasses a broad spectrum of didactic interventions characterized by their technological content, learning objectives/outcomes, measurement tools, learning approaches, and delivery settings. Digital education includes online digital education, offline digital education, massive open online courses, learning management systems, mobile digital education (mobile learning or m-learning), serious games and gamification, augmented reality, virtual reality, or virtual patient (VP) [ 14 - 17 ].

For medical students learning communication skills, digital education offers self-directed, flexible, and interactive learning (didactic); novel instructional methods; and the ability to simulate and rehearse different clinical scenarios (experiential learning) [ 18 ]. For instance, online digital education could be a potential method of delivering the theoretical concepts that underpin communication skills. Virtual patient simulations may also be useful in clinical scenarios that are difficult to replicate with standardized patients, such as communication with patients who have rare conditions, speech disorders, and neurological diseases. Digital education can be utilized flexibly and for an unlimited number of times alongside traditional methods such as role play with standardized patients, allowing students to practice their skills “interchangeably.” For educators, digital education offers the potential to free up time, save manpower and space resources, automate evaluation and documentation of students’ progress, and receive feedback from the students [ 19 ].

Given the shortage of trained and experienced health care educators to deliver communication skills training, digital education may be a novel, cost-effective modality. To the best of our knowledge, there is no similar systematic review assessing the effectiveness of digital education for medical students’ communication skills training. The aim of this research was to evaluate the effectiveness of digital education compared with various controls in improving knowledge, skills, attitudes, and satisfaction of medical students learning communication skills. In doing so, we aim to fill an important gap in the literature.

For this systematic review, we adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Guidelines and the Cochrane Handbook for Systematic Reviews of Interventions [ 20 ]. For a detailed description of the methodology, please refer to the study by Car et al [ 21 ].

Eligibility Criteria

We considered studies eligible for inclusion if they were randomized controlled trials (RCTs) of any design and of any type of digital education including blended education (combination of digital education and traditional learning) for medical students (ie, preregistration); measuring any of the primary outcomes, ie, knowledge, skills, attitudes, satisfaction; or measuring secondary outcomes, ie, patient-related outcomes, adverse effects, or costs (economic evaluations). We included studies if the studies compared: digital education versus traditional learning, digital education versus other forms of digital education, digital education versus no intervention, blended digital education versus traditional learning, and blended digital education versus no intervention.

We did not exclude participants based on age, gender, or any other sociodemographic factor. If data within a study included both preregistration (undergraduate level) and postregistration (postgraduate level) students, the study was included if these data were presented separately. We did not impose any language restrictions. Nonrandomized studies or trials of postgraduates including continuous professional development; continuous medical education; and students of traditional, alternative, and complementary medicine were excluded.

Search Strategy and Data Sources

We searched the following databases from January 1, 1990, to September 20, 2018, for all relevant digital education trials: Cochrane Central Register of Controlled Trials (Wiley), Educational Resource Information Centre (Ovid), Embase (Elsevier), Cumulative Index to Nursing and Allied Health Literature (Ebsco), MEDLINE (Ovid), PsychINFO (Ovid), and Web of Science Core Collection. We also searched the two trials registers—International Clinical Trials Registry Platform and metaRegister of Controlled Trials—to identify unpublished trials. We selected 1990 as the starting year for our search because the use of computers was limited to very basic tasks prior to this year. There were no language restrictions. We searched reference lists of all the studies that we deemed eligible for inclusion in our review and relevant systematic reviews. For a detailed search strategy for MEDLINE, please see Multimedia Appendix 1 .

Data Selection, Extraction, and Management

We merged the search results from the databases using EndNote software [computer software] (Version X.7.8. Philadelphia, PA: Clarivate Analytics) and removed duplicates of the same record. Three reviewers (PP, SP, and BK) independently screened titles and abstracts to identify potentially eligible articles. They then read the full-text versions of these studies and assessed them independently against the inclusion and exclusion criteria. Any disagreements about whether a study meets the eligibility criteria were resolved through discussion among the two review authors. A third review author’s opinion was sought to resolve any disagreements between two review authors. If a study had more than one intervention group, for comparison, we chose the relevant digital education group (ie, more interactive intervention) against the least interactive controls. “Interactivity” referred to “the degree of control or adaptiveness a user might have with a system, without necessarily having to give a response” [ 22 ], and we applied this definition of “interactivity” throughout the review. For each of the included studies, two reviewers independently extracted data related to the characteristics of population, intervention, comparators, outcome measures, and study design, and any discrepant opinions were resolved by discussion.

Assessment of Risk of Bias

Three review authors (PP, SP, and BK) independently assessed the risk of bias of the included studies using the Cochrane Risk of Bias Tool [ 20 ]. Disagreements between the reviewers were resolved by discussion. We appraised the following domains: random sequence generation, allocation concealment, blinding (participants, personnel and outcome assessors), completeness of outcome data, selective outcome reporting, and other biases. Each item was judged as having high, low, or unclear risk of bias based on the definitions provided by Higgins and Green [ 20 ]. For cluster RCTs, the risk of bias assessment also focused on recruitment bias, baselines imbalance, loss of clusters, incorrect analysis, and comparability with individually randomized controlled trials [ 23 ]. We incorporated the results of the risk of bias assessment into the review using a graph and a narrative summary.

Data Synthesis and Analysis

For continuous outcomes, we reported postintervention mean scores and SD along with the number of participants in each intervention group. We reported postintervention mean outcome data to ensure consistency across the included studies, as most of the included studies (92%) reported postintervention data. We presented outcomes using postintervention standardized mean difference (SMD) and interpreted the effect size based on the Cohen rule of thumb (ie, with 0.2 representing a small effect, 0.5 representing a moderate effect, and 0.8 representing a large effect) [ 20 , 24 ]. If studies had multiple arms, we compared the most interactive intervention arm to the least interactive control arm and assessed the difference in postintervention outcomes.

For dichotomous outcomes, we summarized relative risks and associated 95% CIs across studies. Subgroup analyses were not feasible due to the limited number of studies within respective comparisons and outcomes. We used a random-effects model for meta-analysis. We used the I 2 statistic to evaluate heterogeneity, with I 2 <25%, 25%–75%, and >75% representing low, moderate, and high degree of inconsistency, respectively. The meta-analysis was performed using Review Manager 5.3 [ 25 ]. We reported the findings in line with the PRISMA reporting standards [ 26 ].

The three authors (SP, PP, and BK) independently assessed the overall quality of the evidence in accordance with the Grading of Recommendations, Assessment, Development and Evaluations criteria [ 27 ]. The following criteria were considered: limitations of studies (risk of bias), inconsistency, indirectness, imprecision and publication bias, and downgrading the quality where appropriate. We did this for all primary and secondary outcomes reported in the review. We rated the quality of evidence for each outcome as “high,” “moderate,” and “low.” We prepared “Summary of findings” tables for each comparison to present the findings and rated the quality of the evidence for each outcome ( Multimedia Appendices 2 - 4 ). We were unable to pool the data statistically using meta-analysis for some outcomes (eg, attitude and satisfaction) due to high heterogeneity in the types of participants, interventions, comparisons, outcomes, outcome measures, and outcomes measurement instruments. We presented those findings in the form of a narrative synthesis. We used the standard method recommended by Higgins et al [ 20 ] to synthesize and represent the results.

We identified 44,054 records overall from electronic database searches. We excluded 43,287 references after screening titles and abstracts and retrieved 28 studies for full-text evaluation, of which 12 studies met the inclusion criteria [ 28 - 39 ] and were included in the review ( Figure 1 ). The total number of students was 2101.

We present details of the included trials in Table 1 . The included studies were published between 2000 and 2018; of these, nine were RCTs, two were cluster RCTs [ 31 , 38 ], and one was a factorial-design RCT [ 30 ]. The studies originated from Australia [ 28 ], China [ 39 ], Germany [ 30 , 37 ], and the United States [ 29 , 31 - 36 , 38 ]. The sample sizes in the included studies ranged from 67 to 421 medical students, and they were in their first, second, third, and fourth year of studies. The included studies focused on different modalities of digital education. For instance, five studies (41.7%) [ 28 , 33 , 35 , 36 , 38 ] used VP, whereas the remaining seven studies (58.3%) used online modules; in addition, five studies (41.7%) used traditional learning in addition to digital education, that is, blended digital education [ 30 , 31 , 34 , 37 , 39 ]. Two studies (22.2%) had more than one intervention arm [ 29 , 30 ]. The content of those interventions also differed from history-taking and basic communication skills [ 28 , 30 , 33 , 36 , 37 ], cross-cultural communication [ 32 ], ethical reasoning [ 34 ], suicide risk management [ 35 ], interprofessional communication [ 38 ], ophthalmology-related communication skills training [ 39 ], and substance abuse–related communication [ 31 ] to end-of-life support [ 29 ]. Comparison groups ranged from other digital education such as virtual patient [ 28 ], online learning [ 38 ], traditional learning (written curriculum, didactic lecture, oral feedback, and standardized patient) [ 29 , 31 - 34 , 36 , 37 , 39 ], video group [ 35 ], or no intervention [ 30 ]. Outcomes were measured using a range of tools including scales, surveys, checklists, Likert scales, and Objective Structured Clinical Examination (OSCE), questionnaires; seven studies (58.3%) reported some type of validity evidence (ie, validity, reliability, and responsiveness for those measurement tools) [ 28 , 30 , 31 , 33 - 35 , 39 ].

research paper on communication skills

a SMD: standardized mean difference.

b RCT: randomized controlled trial.

c IG: intervention group.

d CG: control group.

e VP: virtual patient.

f SP: standardized patient.

g OSCE: Objective Structured Clinical Examination.

h MCQ: multiple-choice questionnaire.

i PACT: Problem Affect Concern Treatment.

j Rating of the technology module overall.

In general, the risk of performance, detection, and attrition was predominantly low, and it was unclear or high for sequence generation bias, allocation concealment, and other bias. Reporting bias was judged as high in two (16.7%) of the studies. For two cRCTs, the overall risk of bias was low or unclear. Four of the 12 included studies (33.3%) were judged to have a high risk of bias in at least one domain ( Figure 2 ). The quality of evidence ranged from moderate to very low due to study limitations, inconsistency, and imprecision across the studies.

research paper on communication skills

Effect of the Interventions

Digital education versus traditional learning.

Four studies [ 29 , 30 , 33 , 36 ] compared the effectiveness of digital education and traditional learning and reported on postintervention skills, attitudes, and satisfaction outcomes. For skills, there was no statistically significant difference between the digital education group (ie, online modules, tutorials, and virtual patient simulation) and the traditional learning group at postintervention (SMD=–0.19; 95% CI –0.9 to 0.52; 3 studies (304 students); I 2 =86%; low-quality evidence; Figure 3 ). However, this finding had high imprecision with wide CIs, which also included a large effect size in favor of traditional learning as well as a moderate effect size in favor of digital education. The high observed heterogeneity was largely driven by a study comparing the effectiveness of VP simulation to simulated patient training [ 33 ]. The remaining two studies compared the effectiveness of online modules or VP simulation with more passive forms of traditional learning such as written materials or usual curriculum [ 29 , 36 ]. Findings from one study [ 30 ] favoring online digital education over no intervention could not be pooled with the other studies due to the lack of comparable numerical data.

None of the studies reported on knowledge, attitudes, satisfaction, adverse effects, patient outcomes, or cost outcomes.

research paper on communication skills

Blended Digital Education Versus Traditional Learning

Six studies [ 30 - 32 , 34 , 37 , 39 ] compared the effectiveness of blended digital education (ie, blended online or offline [video-based] digital education) and traditional learning and assessed students’ postintervention knowledge, skills, attitude, and patient-related outcomes (ie, patients’ satisfaction). For skills, there was no statistically significant difference between the groups at postintervention (SMD=0.15; 95% CI –0.26 to 0.56; I 2 =86%; 4 studies (762 students); small effect size; low-quality evidence; Figure 4 ). The reported findings were imprecise due to wide CIs including moderate effect sizes in favor of blended digital education. Three studies included in the meta-analysis compared a blend of online modules and a small group discussion or standard curriculum with standard curriculum or small group discussions only [ 31 , 32 , 34 ]. The high observed heterogeneity was largely driven by a study comparing role play and video-assisted oral feedback to role play with oral feedback only, favoring blended digital education [ 37 ]. Findings from one study favoring a blend of online tutorials and role play could not be included in the meta-analysis due to the lack of comparable outcome data [ 30 ].

For knowledge, two studies compared the effectiveness between blended online digital education and traditional learning and reported no statistically significant difference between the groups at postintervention (SMD=0.18; 95% CI –0.2 to 0.55; I 2 =61%; 292 students; low-quality evidence; Figure 5 ). Wide CIs around the pooled estimate also included moderate effect size in favor of blended online digital education.

Two studies [ 31 , 39 ] assessed students’ attitude toward the outcome (skills acquisition) at postintervention and reported no difference between the groups [ 31 ] or favored blended online education over traditional learning with didactic lectures ( P =.04) [ 39 ].

One study also assessed students’ satisfaction with the intervention at postintervention and reported no difference between the groups ( P =.61) [ 39 ]. One study [ 34 ] reported patient-related outcomes (ie, patients’ satisfaction) and compared a blend of online modules and small group discussions (ie, blended online digital education) with a control group of small group discussions only. The study reported slightly higher patients’ satisfaction scores in the control group than in the blended online digital education (SMD=–0.43; 95% CI –0.73 to –0.13). None of the studies reported on the adverse effects or cost outcomes.

research paper on communication skills

Digital Education (More Interactive) Versus Digital Education (Less Interactive)

Four studies [ 28 , 29 , 35 , 38 ] compared the effectiveness of more and less interactive digital education and assessed postintervention skills, attitudes, and satisfaction. More interactive forms of digital education (ie, problem solving, VP simulation, and online multimedia modules) reported similar effectiveness or no difference in postintervention skills compared to less interactive forms of digital education (ie, narrative virtual patient simulation, online video-based learning, and classic online modules) (SMD=0.12, 95% CI –0.09 to 0.33, I 2 =40%, 4 studies [893 students], moderate-quality evidence; Figure 6 ).

One study [ 38 ] assessed students’ attitude towards the intervention and reported moderate beneficial effect on postintervention attitude scores in the VP group compared to the online module group (SMD=0.71; 95% CI: 0.51-0.91). One study [ 35 ] assessed students’ satisfaction and reported that students were more satisfied with VP simulation than the online-based video module ( P =.007). None of the studies reported on knowledge, adverse effects, patient outcomes, or cost outcomes.

research paper on communication skills

Principal Findings

This systematic review assessed the effectiveness of digital education on medical students’ communication skills compared to traditional learning or other forms of digital education. We summarized and critically evaluated evidence for the effectiveness of digital education for medical students’ communication skills training. Twelve studies with 2101 medical students met the eligibility criteria. We found low-quality evidence with wide CIs and high heterogeneity, showing no statistically significant difference between digital education and traditional learning in terms of communication skills. Blended digital education seems to be at least as effective as and potentially more effective than traditional learning for communication skills and knowledge. We also found no difference in postintervention skills between more and less interactive forms of digital education. Data on attitudes and satisfaction were limited and mixed. No study reported adverse or unintended effects of digital education nor conducted an economic evaluation. The majority of the studies (N=9, 75%) had a high risk of bias. The quality of evidence ranged from moderate to very low due to the study limitations, inconsistency, and indirectness ( Multimedia Appendices 2 - 4 ).

The included studies differed considerably in terms of intervention, comparators, and outcome measures used, showing a wide scope of potential for the use of digital education in communication skills training for medical students. However, limited primary studies consisting of data with high heterogeneity prevent us from drawing strong conclusions on the topic. Furthermore, seven (58.3%) of the included studies failed to provide details of sample size or power calculations [ 28 , 29 , 32 , 35 - 37 , 39 ]. The included studies may have therefore been underpowered and unable to detect change in learning outcomes. Finally, the effect sizes were typically small. Other limitations pertained to the risk of bias. Overall, four of the 12 included studies (33.3%) were judged to have a high risk of bias in at least one domain.

The included evidence has some limitations. First, most of the studies were conducted in high-income countries (except one study that was conducted in China), which might further limit the transferability or applicability of the evaluated evidence in low- and middle-income countries. Second, the included studies focused only on specific forms of digital education such as online or offline digital education and VP simulation, and there is a need to explore the effectiveness of other forms of digital education such as virtual reality, serious gaming, mobile learning, and massive open online courses on the topic. Third, all included studies assessed short-term effectiveness of the interventions (ie, assessed effectiveness immediately after the intervention), and there is a need to assess long-term effectiveness of interventions through aspects such as knowledge retention and skills retention at 3-month or 6-month follow-ups. Lastly, the included studies mostly evaluated skills outcome, and there is limited evidence for other outcomes such as knowledge, attitude, satisfaction, adverse or untoward effects of the intervention, and patient and cost-related outcomes.

Implications for Future Research

We identified the need for further, more methodologically sound research that may lead to more conclusive findings. Studies identified in this review have many significant methodological weaknesses, from inadequate power to unclear theoretical underpinnings; insufficient description of educational interventions (complexity, duration and intensity); uncertainty of what constitutes a change (compared with baseline); little, if any, description of technical features; skills retention (follow-up); and comparability of the content delivered digitally or traditionally. The use of validated and reliable measurement tools is paramount to advancing the field [ 40 ], as its transparent description on the level of trialists’ involvement in instructions, outcome(s) in the background, usability testing, and data protection policies could affect the results of the outcomes. Other important factors that need further research include the availability of infrastructure, financial incentives for learners, previous experience in digital education, barriers or facilitators, cost evaluation, fidelity, adverse effects, and access to power supply. Finally, incorporation of evidence from low- and middle-income countries should increase generalizability and applicability in those settings.

Strengths and Limitations of the Review

Strengths of this study include comprehensive searches with no language limitations and robust screening, data extraction, risk of bias assessments, and a critical appraisal of the evidence. Nevertheless, some limitations must be acknowledged while interpreting the results of this systematic review. There was a considerable degree of methodological and clinical heterogeneity in pooled analyses, and the applicability of evaluated evidence might be limited due to high heterogeneity. Additionally, most of the included studies (92%) reported postintervention data, and we could not calculate pre-post intervention change scores. We also assumed that baseline characteristics including measure scores were adjusted before randomization. Finally, we were unable to obtain additional information from the study authors in six studies that reported mixed participants and mixed results.

Conclusions

The findings from this review suggest that digital education (standalone or blended with traditional learning) could be as effective as traditional learning (ie, didactic lectures, groups discussions, role play, or oral feedback) in improving postintervention communication skills for medical students. Similarly, more interactive forms of digital education have similar effectiveness or skills outcome compared to less interactive forms of digital education in terms of participant’ skills. The overall risk of bias was high, and the quality of evidence ranged from moderate to very low for the reported outcomes. There is a need for further research assessing long-term effectiveness including knowledge or skills retention, other outcomes such as patient-related outcomes, and cost-effectiveness as well as other forms of digital education for medical students’ communication skills training.

Acknowledgments

This review is conducted in collaboration with the Health Workforce Department, World Health Organization. We would also like to thank Mr Carl Gornitzki, Ms GunBrit Knutssön, and Mr Klas Moberg from the University Library, Karolinska Institutet, Sweden, for developing the search strategy and the peer reviewers for their comments. We gratefully acknowledge funding from Nanyang Technological University Singapore, Singapore, for e-learning for health professionals education grant. We would like to thank Associate Professor Josip Car and Dr James Campbell for providing valuable inputs on the manuscript.

Authors' Contributions

LC, JoC, and PP conceived the idea for the review. SP, PP and BMK wrote the review. LC provided methodological guidance and critically revised the review. JoC and JaC provided insightful comments on the review.

Conflicts of Interest

Medline (Ovid) Search Strategy.

Summary of the findings table for the effects of digital health education on communication skills.

Summary of findings table for the effects of blended digital health education on communication skills.

Summary of findings table for the effects of digital education (more interactive) compared to digital education (less interactive) on communication skills.

Abbreviations

Edited by A Marusic; submitted 21.12.18; peer-reviewed by M Gartmeier, V Dogas, M Vidak, C Bedard, A Giordano; comments to author 17.01.19; revised version received 30.01.19; accepted 10.07.19; published 27.08.19

©Bhone Myint Kyaw, Pawel Posadzki, Sophie Paddock, Josip Car, James Campbell, Lorainne Tudor Car. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 27.08.2019.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.

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Key communication skills and how to acquire them

Good doctors communicate effectively with patients—they identify patients' problems more accurately, and patients are more satisfied with the care they receive. But what are the necessary communication skills and how can doctors acquire them?

When doctors use communication skills effectively, both they and their patients benefit. Firstly, doctors identify their patients' problems more accurately. 1 Secondly, their patients are more satisfied with their care and can better understand their problems, investigations, and treatment options. Thirdly, patients are more likely to adhere to treatment and to follow advice on behaviour change. 2 Fourthly, patients' distress and their vulnerability to anxiety and depression are lessened. Finally, doctors' own wellbeing is improved. 3 – 5 We present evidence that doctors do not communicate with their patients as well as they should, and we consider possible reasons for this. We also describe the skills essential for effective communication and discuss how doctors can acquire these skills.

Summary points

Sources and selection criteria

We used original research studies into doctor-patient communication, particularly those examining the relation between key consultation skills and how well certain tasks (such as explaining treatment options) were achieved. We used key words (“communication skills,” “consultation skills,” and “interviewing skills” whether associated with “training” or not) to search Embase, PsycINFO, and Medline over the past 10 years. We also searched the Cochrane database of abstracts of reviews of effectiveness (DARE).

Deficiencies in communication

Box BoxB1 B1 shows the key tasks in communicating with patients that good doctors should be able to perform. Unfortunately, doctors often fail in these tasks. Only half of the complaints and concerns of patients are likely to be elicited. 2 Often doctors obtain little information about patients' perceptions of their problems or about the physical, emotional, and social impact of the problems. 6 When doctors provide information they do so in an inflexible way and tend to ignore what individual patients wish to know. They pay little attention to checking how well patients have understood what they have been told. 2 Less than half of psychological morbidity in patients is recognised. 7 Often patients do not adhere to the treatment and advice that the doctor offers, and levels of patient satisfaction are variable. 2 , 8

Key tasks in communication with patients

Reasons for deficiencies

Until recently, undergraduate or postgraduate training paid little attention to ensuring that doctors acquire the skills necessary to communicate well with patients. Doctors have therefore been reluctant to depart from a strictly medical model, deal with psychosocial issues, and adopt a more negotiating and partnership style. 2 , 6 They have been loath to inquire about the social and emotional impact of patients' problems on the patient and family lest this unleashes distress that they cannot handle. They fear it will increase patients' distress, take up too much time, and threaten their own emotional survival. Consequently, they respond to emotional cues with strategies that block further disclosure (box (boxB2 B2 ). 9

Blocking behaviour

Even if doctors have the appropriate skills, they may not use them because they are worried that their colleagues will not give sufficient practical and emotional support if needed. 10 Doctors may also not realise how often patients withhold important information from them or the reasons for this (box (boxB3 B3 ). 9

Reasons for patients not disclosing problems

Skills needed to perform key tasks

Eliciting patients' problems and concerns.

Establish eye contact at the beginning of the consultation and maintain it at reasonable intervals to show interest. 11 Encourage patients to be exact about the sequence in which their problems occurred; ask for dates of key events and about patients' perceptions and feelings. This helps patients to recall their experiences, feel understood, 12 and cope with their problem.

Use “active listening” to clarify what patients are concerned about 9 —that is, respond to cues about problems and distress by clarifying and exploring them. 11 But avoid interrupting before patients have completed important statements. 13

Summarise information to show patients they have been heard, and give them an opportunity to correct any misunderstandings. 9 Inquire about the social and psychological impact of important illnesses or problems on the patient and family 14 ; this shows the patient that you are interested in his or her psychosocial wellbeing, and that of the family.

Giving information

Check what patients consider might be wrong and how those beliefs have affected them. 15 Ask patients what information they would like, and prioritise their information needs so that important needs can be dealt with first if time is short. 9 Present information by category—for example, “you said you would like to know the nature of your illness.” Check that the patient has understood before moving on. 16

With complex illnesses or treatments, check if the patient would like additional information—written or on audiotape. However, if you have to give the patient a poor prognosis, providing an audiotape may hinder psychological adjustment.

Discussing treatment options

Properly inform patients of treatment options, and check if they want to be involved in decisions. Patients who take part in decision making are more likely to adhere to treatment plans. 2 Determine the patient's perspective before discussing lifestyle changes—for example, giving up smoking. 2

Being supportive

Use empathy to show that you have some sense of how the patient is feeling (“the experiences you describe during your mother's illness sound devastating”). Use educated guesses too. Feed back to patients your intuitions about how they are feeling (“you say you are coping well, but I get the impression you are struggling with this treatment”). Even if the guess is incorrect it shows patients that you are trying to further your understanding of their problem.

How to acquire the skills

Effective training methods.

Box BoxB4 B4 lists the teaching methods for helping doctors to acquire relevant communication skills and stop using blocking behaviour. 1 , 17 These methods have been used in undergraduate and postgraduate teaching. 18 , 19 A “good” doctor, wanting to audit and improve his or her skills, should ensure that any course or workshop they attend includes three components of learning: cognitive input, modelling, and practice of key skills.

Effective teaching methods

Cognitive input

Courses should provide detailed handouts or short lectures, or both, that provide evidence of current deficiencies in communication with patients, reasons for these deficiencies, and the adverse consequences for patients and clinicians. Participants should be told about the communication skills and changes in attitude that remedy deficiencies and be given evidence of their usefulness in clinical practice.

Trainers should demonstrate key skills in action—with audiotapes or videotapes of real consultations. The participants should discuss the impact of these skills on the patient and doctor.

Alternatively, an “interactive demonstration” can be used. A facilitator conducts a consultation as he or she does in real life but using a simulated patient. The interviewer asks the group to suggest strategies that he or she should use to begin the consultation. Competing strategies are tried out for a few minutes then the interviewer asks for people's views and feelings about the strategies used. They are asked to predict the impact on the patient. Unlike audiotaped or videotaped feedback of real consultations, the “patient” can also give feedback. This confirms or refutes the group's suggestions. This process is repeated to work through a consultation so that the group learns about the utility of key skills.

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Practising key skills

If doctors are to acquire skills and relinquish blocking behaviour, they must have an opportunity to practise and to receive feedback about performance. However, the risk of distressing and deskilling the doctor must be minimised.

Practising with simulated patients or actors has the advantage that the nature and complexity of the task can be controlled. “Time out” can be called when the interviewer gets stuck. The group can then suggest how the interviewer might best proceed. This helps to minimise deskilling. In contrast, asking the doctor to perform a complete interview may cause the doctor to lose confidence because “errors” are repeated.

Asking doctors to simulate patients they have known well and portray their predicament makes the simulation realistic. It gives doctors insights into how patients are affected by different communication strategies.

For a simulation exercise to be effective, doctors must be given feedback objectively by audiotape or videotape. 19 To minimise deskilling, clear ground rules should be followed:

Context of learning

Some doctors feel safer learning within their own discipline. 20 Others welcome the challenge of learning with those from other disciplines, such as nursing 21 ; multidisciplinary groups enable doctors to understand and improve communication between disciplines. The relative merits of these two different environments has still to be determined.

Doctors are more likely to attend workshops or courses in communication skills if they know that substantial time will be devoted to their own agenda. Thus, they should be asked to identify the communication tasks they want help with. These will commonly include the tasks discussed already plus more difficult situations, such as breaking bad news, handling anger, and responding to difficult questions.

Limiting the size of the group to four to six participants creates the sense of personal safety required for participants to disclose and explore relevant attitudes and feelings. It also allows more opportunity to practise key communication tasks. 22

Facilitators who have had similar feedback training are more effective in promoting learning than those who have not. 23 Residential workshops lasting three days are as effective as day workshops lasting five days. 21 Whether longer courses are more effective than workshops plus follow up workshops needs to be determined.

Access to training

Sources of information

Well established courses

Using new skills in practice

Practising communication skills with simulated patients leads to the acquisition of skills and the relinquishing of blocking behaviour. However, doctors do not transfer these learned skills to clinical practice as comprehensively as they should. 24 Offering doctors feedback on real consultations should ensure more effective transfer of skills.

Current evidence suggests that the good doctor who attends short residential workshops or courses to improve his or her skills and then has an opportunity to receive feedback about how he or she communicates in real consultations will learn most. Doctors will find that both they and their patients benefit. Patients will disclose more concerns, perceptions, and feelings about their predicament, will feel less distressed, and be more satisfied. Doctors will feel more confident about how they are communicating and obtain more validation from patients.

Good doctors will wish to continue their learning over time by self assessment (recording their own interviews and reflecting on them) or attending further courses or workshops.

Acknowledgments

PM is also professor of psychiatric oncology at the University of Manchester.

Competing interests: None declared.

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This article is investigating verbal communication research in teaching the English language, its importance, and necessity in daily human life. The article shows how the teacher should help students to improve and develop their verbal communication skills. For this point, there are given some useful and effective techniques with methods in teaching the English language, which we have to use for developing students’ verbal communication skills and speech etiquette. The chosen topic is relevant to the fact that verbal communication and speech etiquette have a key place in a person’s successful life; therefore many researchers and article readers are interested in this topic. Speech etiquette is a component in the linguistic cultural picture of the world, as well as possessions and understanding of speech etiquette depends on the people behavior. Speech etiquette plays a special role in the foreign language study.

English Language , Verbal Communication , Skills , Language Teaching , Speech Etiquette , Learning , Ethics

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1. Introduction

The relationship between language and its meaning is not straight forward (Søren- sen et al., 2019) , one reason for this is the complicated limitlessness of modern language semantics, including English (Wali et al., 2017) . Language is productive in the sense that there is an infinite number of words and phrases. There is no limit to a language’s vocabulary, as new words are introducing daily. Words are not the only things we need to communicate, although they are closely related to verbal and nonverbal (Parikh et al., 2014) symbols in terms of how we make the meaning of language. Every symbol represents some meaning related to a certain activity (Zhirenov et al., 2016) . Symbols can be used for communication verbally, for example, when spelling the word “winter”, in writing it is necessary to put the letters W-I-N-T-E-R together. Communication development is an effective teaching method in improving students technical communication skills as well as empathy (Vogel et al., 2018) .

Verbal communication helps express various needs, and in asking questions, that provide us with specific information. Verbal communication is also used in describing things, events, occasions, people, and ideas, by helping people to inform, persuade, and to take into consideration. In other words, verbal expressions help us to communicate with others in explaining our observations, thoughts, feelings, and needs.

Good communication skills are a self-confidence source, enabling a person to exert more control in their life by obtaining knowledge, research effectively, conceptualize, organize, and present ideas and arguments (Emanuel, 2011) . Verbal communication skills are a necessary tool for prospering in any subject; even learning these skills will take time, better practices can help students to learn quickly and apply knowledge in work. In addition, with improved communication skills, students will have the confidence and knowledge to not only get a good job but to perform well in interviews (Reith-Hall & Montgomery, 2019) . Communication skills are considered as an ability used to give and receive different kinds of information, similarly, in the development of personality throughout human being existence. During this period, communication becomes essential for personal growth, through which communicating people will find themselves, develop self-confidence, and define the relationship with the surrounding environment. The failure in building good communication skills will happen when people do not want to understand other’s opinions, thoughts, ideas, and feelings.

Particularly, there given methods to help students in improving their verbal communication skills and speech etiquette, by the following elements: how to choose words and vocabulary for this or that conversation topic, using key phrases through different dialogues; by watching movies students will be able to understand the language, eye contact, accents; and how to paraphrase and summarize the spoken language, and respond to different types of questions. This article has an actual place in linguistics because important role of verbal communication and speech etiquette in language learning and teaching process. The topic closely connected with methodology, owing to essential methods in teaching verbal com- munication skills and speech etiquette.

2. Communication Skills Importance

For teachers, it is highly important to have enough skills to communicate effectively, because they considered as one of the necessary determinants in teaching and learning success. In addition to transferring knowledge, the word “educate” is supposed to train learners verbal skills to develop themselves, the impact of higher education, the economy and the broader society transformed along time in various ways (Kromydas, 2017) .

In carrying out the learning process, teachers should combine their verbal and nonverbal communication skills; the ability of teachers in applying these types of communication can help improve both, teachers and students impressions in the process of teaching and learning. The teacher is the one who always explains and presents learning material to the class, for this purpose, the teacher should exhibit enough speaking with writing skills. The teacher is required to understand students’ verbal communication and be able to help students improve their verbal communication abilities. Verbal communication skills, either they are oral or written; involve vocabulary, mastering skills in choosing the right words to give meaning to the audience. Verbal abilities also concern with skills to organize the words logically.

More importantly, communication is the manifestation of accurate and open attitudes in information change between learners and students. Communication is closely related to culture (Piller, 2007) . Nevertheless, the culture itself can be a challenge in building interaction that potentially causes misunderstanding. Language problems can be associated with problems of hearing ability and pronunciation, speed, tone, and tune.

3. Developing Students Communication Skills

Participants in this study are teacher and students conducting education process. Students’ and teacher’s good and adequate communication shows their ethical level in the process of learning and teaching the language. Ethics is one of the most important things, which people need daily everywhere. Here we want to emphasize the regulation of ethical communication in foreign language teaching. Ethics is a branch of philosophy and it has been studied for thousands of years by many researchers.

In communication studies, curricula and ethics are often considered as a central place in service-learning courses, community-engaged activity, and communication activism where students come face-to-face with the harsh realities experienced by society. For some students, it may be the first time they witness and interact with people suffering from lack of basic resources, and sufficient educational opportunities, or subject to environmental hazards, to name just a few persistent inequities. These experiences lend themselves to a rich consideration of communication ethics situated at the individual, organizational, and systemic levels to understand how one voice intersects with others to affirm the dignity of all people as well as promoting learning and competence in everyday communication, as well as social changes through a broad and systemic transformation; ethical communication is necessary for social media, also impacting governmental regulation on ethics (Bowen, 2020) .

Competent and skilled communicators are ethical communicators who take responsibility for a message’s creation, impact, and effects in a diverse range of contexts, including mass media, interpersonal, intercultural, professional, and public areas. Stimulating the moral imagination is a key factor that helps students to recognize issues of communication ethics. They learn to weigh their self-interests relative to the self-interest of others, so their communication skills may construct the ethical dimension in the world they live in. In this regard, through the analysis of terminology the term speech etiquette is described in this article. Here we tried to give exact meaning and role of speech etiquette in foreign language learning and teaching.

Speech etiquette is included in the linguistic cultural picture of the world. Possession, understanding and choice of formulas of speech etiquette depends on the people behavior. The choice of speech etiquette formulas is playing a special role in the foreign language study. Without speech etiquette, it is impossible neither to enter the communication, nor to maintain communication, or to complete it. Speech etiquette is a set of requirements to the form, content, order, character and situational relevance of statements adopted in this culture. Speech etiquette, in particular, includes words and expressions used by people to say goodbye, requests, and apologies, accepted in various situations, forms of treatment, intonation features that characterize polite speech, etc. The study of speech etiquette occupies a special position at the junction of linguistics, theory and history of culture, ethnography, country studies, psychology and other humanities (Kereksha, 2019) . On the other hand, speech etiquette can be considered from the point of view of language norm. Thus, the idea of correct, cultural, normalized speech includes certain ideas about the norm in the field of speech etiquette (Ushakov, 2008) .

4. Ways to Obtain Good Communication Skills

There are some characteristics of effective verbal communicators which are very necessary, including active listening, adaptability, adapting one’s communication styles to support the situation, clarity, confidence and assertiveness, constructive feedback to giving and receiving it, emotional intelligence for identifying and managing teacher emotions, as well as students emotions, empathy, interpersonal skills as social skills which are especially useful in building strong arguments, interpretation of language, open-mindedness, patience, simplifying the complex, and storytelling.

The way to obtain a good proficiency in verbal communication is mention attributes concerning both the teacher and learners. Essentially, there are a lot of techniques and tools that teacher can use to improve students’ verbal communication skills ( Figure 1 ).

The useful thing here is to apply technology such as videos and audios, which are playing the most important role nowadays. Additionally, they will be in interesting and effective sense for students and learners.

Figure 1 . Techniques and tools for improving students’ verbal communication skills.

4.1. Watching Films That Model Conversation Skills

The conversation is one of the most basic and essential communication skills. It enables people to share thoughts, opinions, ideas, and receive information. Although it may appear simple on the surface, effective conversations include a give-and-take exchange that consists of elements such as language, eye contact, summarizing, paraphrasing, and responding.

Students can learn the fundamental elements of the conversation by watching films or videos about interactions taking place. The teacher can pause the video and ask questions such as, “What message is the listener sending by crossing his arms? What else can you tell by observing the language expressions in the conversation?”

4.2. Reinforce Active Listening

Communication is not just about speaking, but also about listening. The teacher can help their students to develop listening skills by reading a selection of text, and then having the class discussion and reflect the content by students explanations. Active listening also means listening to understand rather than a reply. Reinforce building good listening skills by encouraging students to practice asking clarifying questions to fully understand the speakers message.

4.3. Offer Group Presentations and Assignments

Team-building exercises can also help students sharpen both oral and written com- munication skills. Not only does it offer students the chance to work in small groups, thereby reducing some of the pressure, but it also allows them to debate their opinions, take turns, and work together towards a common goal.

4.4. Ask Open-Ended Questions

On the occasion where students require more than a one or two-word response, open-ended questions are vital for inspiring discussion and demonstrating that there are multiple ways to perceive and answer a question. A teacher might set a timer for students informal conversations and challenges to use open-ended questions. For example, teacher can show children the difference in how much more information they can obtain by asking, “What did you like best about the song?” rather than simply “Did you like the song?”

4.5. Use Tasks and Activities That Foster Critical Thinking

Another task-based method for improving student communication skills is through critical thinking exercises. These can be done verbally or through written assignments that give students the chance to answer questions creatively using their own words and expressions.

4.6. Offer Reflective Learning Opportunities

Recording students reading selected text or videotaping group presentations is an excellent method for assessing their communication strengths and weaknesses. Students can reflect on their oral performance in small groups. Then, ask each student to analyze the others so that they can get used to receiving constructive criticism. Besides these techniques and methods, there are other activities for improving students verbal communication skills, such as role-playing, which showed effective results from previous experiences.

Effective verbal communication skills include more abilities than just speech. Verbal communication encompasses both how to deliver messages and how to receive. Communication is a necessary skill, which is important to every student, teacher, and person, even to workers, who can convey information clearly and effectively to be highly valued by employers. Employees who can interpret messages and act appropriately on the information they receive have a better chance in their job excellence. Without speech etiquette, it is impossible to join and maintain the communication, or to complete it. Speech etiquette considered as a set of requirements to the certain form, content, order, character and situational relevance of statements adopted in this culture.

Conflicts of Interest

The authors declare no conflicts of interest regarding the publication of this paper.

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