Patient Education and Counseling 98 (2015) 1–2

Editorial

Improving health professionals’ communication skills: A major globalendeavour

Contents lists available at ScienceDirect

Patient Education and Counseling

jo ur n al h o mep ag e: w ww .e lsev ier . co m / loc ate /p ated u co u

1. Growth and the phenomenon of Mainland China

Mainland China is a country where the statistics about humanactivity and volume of services are breathtaking. To give a sense ofthe staggering nature of the size of this rapid economic expandingcountry is to realise the level of hospitals and clinics numbers roseto more than 320,000 with over 1.97 million doctors at the end ofthe last decade. The ratio of 15 doctors per 10,000 personscompares with the USA of 25 per 10,000 [1] http://www.china-today.com/data/data.htm. Changes within Chinese society areremarkable with the ability to communicate among citizensimproving enormously with nearly half a billion cell-phone usersand similar internet reach (2010 figures) and rapidly growing.There has been dramatic change in the organisation of healthservices in mainland China as shown by the strength of purpose toestablish a public health insurance scheme for the large majority ofthe population. The challenges of organising health in this hugecountry is not without precendence of course as there aredisparities between the cities and rural areas in accessibility tohealth care and the changes in treatable infectitious diseases tomore chronic life-style illnesses such as diabetes and obesity.Hospital care in particular has seen some de-coupling from centralpublic funding. Financial survival of these health care services isdependent on medical investigations and treatments. Accusationsof over-treatment have been common threads of media coverage inthe past few years in Chinese newpapers. Doctors and other healthcare workers feel under valued and under pressure from a publicwho have raised expectations. This wide scenario is common withothers in the western world where complaints and litigation haveinexorably risen to unprecedented levels. However the situation inChina is exacerbated by the rapidity of changes within the healthcare system and their wider society. Additional factors are linked toa low base of formal training of communication skills withinChina’s Medical Schools. An example is the fact that thiseducational input focussing on health care interaction with thepatient is often optional for undergraduate students.

An important phenomenon with mainland China are thecultural changes that have occurred within society who haverelied on the traditional speciality of medicine (known asTraditional Chinese Medicine, TCM), with a reliance on earlyidentification of disease and a focused tailoring of interventionupon a detailed assessment. Typically this involves carefulattention to person-centred variables, not least the belief structureof the individual seeking advice and intervention. The TCM

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approach has been advocated for combining with classical westernmedicine to attempt to get the best of both spheres of influence tocooperate towards a unified system. This has proved to be elusive,but the reasons for lack of integration are meaningful whenattempting to explain the lack of attention to doctor patientinteraction in a modern hospital and clinic settings.

2. The patient voice and research on healthcarecommunication

Some recent reports of the strains that have started to appearwithin the health care system within mainland China can be citedfrom the reports appearing in the academic press. Most notable isan editorial in the Lancet quoting some extremes that patients ortheir family members have resorted to physically abusing themedical staff providing health care that resulted in permanentinjury or death. These traumatic events, in some instances makeinternational headlines, and raise close attention to the factorsresponsible for such violent outbursts. Calls to change the systemare naturally voiced and also met with doctors advocating the needfor better training and understanding the factors that areresponsible for sensitive management of patients. Clinical curiosityhas motivated research questions. Research in communicationskills in health care settings in China has indeed responded. Forexample an interesting new study examining the empathic abilityof doctors, as rated by patients, was tested in one major Chinesehospital and showed that face mask wearing by doctors was nothelpful in the communication process between patient andclinician [2]. Over 1000 patients were recruited to this random-ised-controlled study demonstrating that the ability of Chineseinvestigators to collect sizeable numbers of patients for theirresearch is laudable. It is a remarkable feature of a great deal ofclinical research with mainland China is the sheer capacity ofcollecting large sample sizes. This dedication and persistence toanswer a research question definitively is to be lauded.

3. A milestone review for Chinese healthcare communicationresearch

Within this issue of Patient Education and Counseling thereappears an important review of the status of clinical communica-tion skills training in mainland China [3]. The authors were drivento enquire about three main issues, namely: (i) the trainingprogrammes being used within the medical educational system (ii)

Editorial / Patient Education and Counseling 98 (2015) 1–22

the accompanying assessment instruments, and thereby (iii) themonitoring of effectiveness of these programmes. Finally, a set offuture research goals were outlined to assist a programme ofstructured activity to improve the quality of care provided. Thearticle has highlighted a vital set of issues for reflection and action.

A carefully conducted systematic review, adopting many of thefeatures that help confirm that the work had been rigorous and fair,found 20 studies worthy of detailed description following theselection process which was dependent on quality. The studiesreported showed the importance of use simulated patients androle-play. Some findings reflected the situation found elsewhere onthe globe that staff value the training, and that it has highacceptability within the medical workforce on follow-up evalua-tion. However the authors note that some of the assessmentsystems have been modified from US frameworks or simply fromnon-validated self-prepared measures of limited validity. Theauthors call for more extensive validated procedures to confirmgains in staff performance and also patient satisfaction.

The reader will recognise the scholarly approach of thissystematic review applied to a comparatively new educationalmethodology of experiential learning in the development of vitalclinical skills. The importance of these skills will become ever morecentral to the everyday practice of the medical care personnel aspatients seek advice and attend clinics more frequently. Theincrease in attendance to seek medical care will be predicated byan increased probability of life-style ailments including respiratoryand circulatory disease entities. These chronic illnesses, resulting,for example, from smoking tobacco or consuming large quantitiesof high-fat foods, have the capacity to increase health care costsand stretch existing resources. It is hoped that this first review ofits kind in this key world region will act as a stimulus to theChinese health care system to develop their training models for

clinical communication skills. Researchers in communication andhealthcare may respond enthusiastically by recognising thechanges in the pattern of illness, the industriousness of itsworkforce and the national commitment to community develop-ment and planned expansion of economic activity to promote newtraining initiatives and resource to assist the professional healthcare provider to become more responsive to patient requirements.

To show that developments are progressing, beyond simply theacademic, the senior author of the review paper, included in thisissue of the journal, has been elected at the national representativeof the EACH Steering Group Committee. This appointment is madewhen sufficient members from a country become members ofEACH. Hence, recent interest in communication skills research andteaching has expanded in a tangible way with links with a keyresearch and teaching network established.

References

[1] China Information and Sources: China Statistics. http://www.chinatoday.com/data/data.htm.

[2] Wong CK, Yip BH, Mercer S, Griffiths S, Kung K, Wong MC, et al. Effect offacemasks on empathy and relational continuity: a randomised controlled trialin primary care. BMC Fam Pract 2013;14:200.

[3] Liu X, Rohrer W, Luo A, Fang Z, He T, Xie W. Doctor–patient communicationskills training in mainland China: a systematic review of the literature. PatientEduc Couns 2014;98:3–14.

Gerry Humphris*

Medical School, North Haugh, University of St Andrews, Fife, UK

*Tel.: +44 1334463565; fax: +44 1334467470E-mail address: gmh4@st-and.ac.uk (G. Humphris).