10.5826/dpc.1302a120
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 questionnaire, 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 execution 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.
text/xml
2160-9381
2771
en
Narges Ghandi
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
Persian
Dermatologists Communication Skills and Performance From Point of View of Patients
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Original Article
2023-04-29
2022-08-19
2023-04-29
2023-06-05
e2023120
Dermatol Pract Concept
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 questionnaire, 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 execution 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.
Narges Ghandi
2023/04/29
10.5826/dpc.1302a120
e2023120
Department of Dermatology, Razi Hospital, Tehran  University  of Medical  Sciences, Tehran,  Iran
2160-9381
Persian
en
e2023120
Renzi C, Abeni D, Picardi A, et al. Factors associated with patient satisfaction with care among dermatological outpatients. Br J Dermatol. 2001;145(4):617-623. DOI: 10.1046/j.1365-2133.2001.04445.x. PMID: 11703289.
Dermatologists Communication Skills and Performance From Point of View of Patients
https://dpcj.org/index.php/dpc/article/download/2771/2063
            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




  ABSTRACT             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-




Original Article | Dermatol Pract Concept. 2023;13(2):e2023120                                                                           1
                      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.



Introduction                                                         After reaching a consensus, the final version was applied
                                                                 to 15 patients coming to the Razi dermatology Hospital, af-
Effective     communication   is   an   important   issue   in   filiated to Tehran University of Medical Sciences (TUMS).
patient-doctor interaction and has been proved to be asso-       The patients visited a dermatologist at a baseline visit and
ciated with positive health-related outcomes [1-4]. Hence,       two weeks later and were asked to fill out the questionnaire.
finding the appropriate tools to assess communication skills     All doubts and concerns regarding the questionnaire were
in medical staffs, seems to be essential and also challeng-      discussed and patients were guided through the process in
ing. Mostly, some checklists for performance comparison          case they encountered any difficulty. The translated form
and feedback are used [5]. One of the most useful check-         of questionnaire is available in the appendix. The statistical
lists in this regard is Calgary- Cambridge Observation Guide     analysis was performed using SPSS, version 20. We estimated
(CCOG) which is a 28-item questionnaire derived from Cal-        the Cronbach’s alpha coefficient and the spearman correla-
gary- Cambridge Process Guides and consists of six blocks/       tion coefficient to assess the internal consistency of each do-
domains with a 3-point scale (yes/ yes, but and no) and has      main and the correlation between the domains.
been previously shown to have adequate psychometric prop-            After confirming the validity of questionnaire, it was
erties [5].                                                      filled out by 400 patients attending the outpatient derma-
    Since many of dermatologic disorders are chronic con-        tology clinics of 3 major hospitals in Tehran (Razi hospital,
ditions which need a long-lasting patient-doctor interaction,    Rasoul-e-akram hospital and Shohadaye tajrish hospital).
effective communication is essential to provide a better pa-         For questions regarding necessity of performing a behav-
tient’s compliance and adherence to treatment which is an        ior by clinician, the answers were scored as follows: Below
even more important issue for optimal control of chronic         (1), at (2) or above (3) the expected level. About the adequate
disorders.                                                       amount of implementing that behavior by clinician, the an-
                                                                 swers were again scored as follows: No (0), Somehow (1)

Objectives                                                       and Yes (2). Then, sum of the scores per each question was
                                                                 calculated and final scores for each question was calculated
This study was aimed to develop a Persian version of the         using this formula: sum of scores × 100/800
28-item CCOG questionnaire and try to reach the best                 Inferential statistics were performed using paired t-test,
cross-cultural adapted form of it to assess medical commu-       Chi-Square and Mann-Whitney tests, where appropriate. A
nication skills in dermatology clinics via a validated Persian   significant P value was considered less than 0.05.
questionnaire.

                                                                 Results
Methods
                                                                 Based on Spearman ratio and Cronbach Alfa of 0.838 (95%
We conducted this study based on previous recommenda-            CI: 0.82 -0.86), the translated questionnaire was proved to
tions [6] via the following stages: translation, review by a     be valid (data was not shown).
committee of specialists and pretesting for assessing its            Demographic and socioeconomic characteristics of par-
validity.                                                        ticipants are shown in Table 1.
    Initially, two bilingual translators provided two Persian        The participants were mainly female (67% versus 33%)
versions of the questionnaire, independently. These forms        with a mean age of 37.5 ± 5.6 years, ranged from 12 to
were sent to an expert committee consisting of five associ-      73 years.
ated professors of dermatology to check its reliability. They        Table 2 shows CCGS before and after a dermatology visit.
checked the contents, provided some changes and sugges-              As shown above, the difference of CCG scores for all
tions and tried to merge two forms into a complete, final        of questions, except for questions number 1,16 and 22, was
version, ready for pre-testing.                                  statistically significant.



2                                                                     Original Article | Dermatol Pract Concept. 2023;13(2):e2023120
                    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.
                                                                        Mean necessity        Mean actual   Effect
  N                              Question                                of execution          amount        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                1.79                1.67       0.24         <0.001
       vocabulary
 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



Original Article | Dermatol Pract Concept. 2023;13(2):e2023120                                                                     3
 Table 2. Mean CCG scores before (necessity of execution of behavior) and after (the actual amount
                 of execution of behavior) visiting by dermatologist. (continued)
                                                                      Mean necessity        Mean actual         Effect
    N                          Question                                of execution          amount              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                 1.57                1.067            0.39      <0.001
        understanding by patient
 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           1.54                 0.93            0.54      <0.001
        discuss
 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



    The highest score both before and after a visit was at-            Our findings demonstrated that there was a significant
tained by question number 5 which was about being respect-          difference between what patients expected from a derma-
ful (92% and 85%, respectively).                                    tologist and the manner they actually were treated regard-
    The lowest scores for necessary behavior and the ade-           ing physician communication skills evaluated by the CCG
quate amount of execution were related to questions num-            questionnaire.
ber 3 (Introducing self) and 4 (Introducing role), respectively        Overall, mean general score for necessitation of commu-
(Table 2).                                                          nication skills was 81% and the most important issues in
    Based on our results, questions number 5 and 7 were             this regard were “being respectful” and “presenting complete
noted to be more important for patients and items number 6          and adequate data”. Contrary, “introducing self and role”
and 16 were the most executed behavior by dermatologists            was considered the least important item by patients.
(Table 2).                                                             These results are in line with Afkham et al study in which
    Several subgroup analyses were performed to peruse the          the main priority of patients was acquisition of adequate
correlation of various characteristics of participants with         and complete data [8]. Athari et al showed the importance
GCC scores. The results showed that age and educational             of being respectful in a review published in 2010 which is
level of patients were significantly correlated with their ex-      congruent with our results [9].
pectations regarding communication skills of clinician, as             From the point of view of our patients, criteria regarding
follows:                                                            “gathering information” and “initiating the session” were
    The answers to questions number 1,2,3,4,11,13,15 and 21         the most and the least important items, respectively. These
were correlated to age of participants (P values: 0.04, 0.032,      findings are against the results of previous studies conducted
0.016, <0.001, 0.001, 0.004, 0.04 and 0.013, respectively).         in some Western countries in which initiation of the session
    Educational level of subjects affected the response to          and introducing the clinician seems to be very important for
questions number 7,11,12,14,15,18,19,21 and 22 (P values:           patients [3]. This discrepancy in results could be explained
0.045, 0.023, <0.001, 0.006, 0.008, 0.025. 0.037, <0.001            by cultural differences. In fact, Iranian patients do not expect
and 0.001, respectively).                                           the clinician to introduce her/his self or encourage them to
    Regarding adequate execution of skills by clinicians,           express their feelings. Hence, culture building in this regard
educational level of patients was the only factor that af-          seems to be necessary among Iranian patients.
fected their opinions: answers to the questions number                 We found that older patients compared to young ones
5,8,9,14,16,17 and18 were significantly correlated with             emphasized more on the necessity of communication skills,
educational level of patients (P values: 0.036, 0.010, 0.022,       especially regarding criteria related to initiating the session
0.001, 0.009, 0.002 and 0.019, respectively).                       and understanding the patient’s perspective. This indicates
                                                                    the significance of implementing these skills of older people.

Conclusions                                                            The study also highlighted the relationship between ed-
                                                                    ucational level and some GCG criteria including “under-
The reliability coefficient of questionnaire was 0.84 in our        standing the patient perspective”,” building relationship”
study which was in the acceptable range of 0.8 to 0.9 [7].          and “closing the session”. In fact, patients with higher edu-
Hence, this study showed the acceptable validity of modified        cational level were more likely to be understood by physician
Persian version of CCOG-24 item questionnaire.                      and have a summary at the end of the session.



4                                                                       Original Article | Dermatol Pract Concept. 2023;13(2):e2023120
    The mean score for executing the communication skills              2. Smith SM, Soubhi H, Fortin M, Hudon C, O'Dowd T. Interven-
by clinicians was 65%. The highest and lowest scores in this                tions for improving outcomes in patients with multimorbidity in
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Original Article | Dermatol Pract Concept. 2023;13(2):e2023120                                                                            5
