Introduction

The importance of effective communication skills (CS) between health care professionals and their patients is well documented.1,2,3 Although much of this evidence relates to doctors and patients, there is some evidence that dentists and patients also benefit from effective CS.4,5 The patient-centred interview (PCI) focuses on the patient's needs and whenever possible encourages the patient to play an active role in his/her care.3 Briefly, the key concepts in a PCI are that the interviewer: provides an opportunity for the patient to express his/her main concerns; identifies any specific requests; explores the patient's understanding of his/her illness; encourages the patient in the expression of his/her feelings; provides the patient with information; and, involves the patient in developing a treatment plan.3 Evidence supporting the PCI is largely from research in Western settings.

Patient-centred care is widely promoted in medical schools. Similarly, there is a trend towards patient-centred care in dentistry evidenced by the inclusion of behavioural sciences teaching in undergraduate education and clear statements from professional associations emphasising the importance of understanding a patient's dental condition in relation to his/her psychosocial status.6,7,8 However, the extent to which patient-centred care crosses professional and cultural boundaries is unclear. This paper describes the evaluation of a half-day CS workshop based on the PCI for dentists.

Methods

The CS workshop was offered by the Department of Community Medicine, University of HK in conjunction with the Department of Health to dentists working in government clinics throughout HK in 1996. The workshop was conducted by three tutors with experience in teaching CS to medical students and doctors. The sessions included a range of learning experiences such as: role-play exercises in pairs with feedback from tutors; fish bowl exercises where a role-play would be conducted in front of a group with tutors and participants providing feedback; and, two pre-recorded instructional videotapes demonstrating the PCI and information giving skills. Participants also reviewed a manual providing a theoretical background on these and other CS topics. English was the language of instruction while Cantonese translations were provided when requested by any participant. There were also opportunities for role-play and small group discussions to be conducted in Cantonese.

The principal goal of this research was to determine the effect of the workshop on the participants' knowledge, attitudes and reported skills in relation to the PCI. Given their Western foundations, the structure and the process of the workshop were evaluated focusing on the cultural and clinical relevance of the teaching materials and educational techniques. The research methods were selected to reflect the characteristics of the half-day workshop. Time constraints prevented direct evaluation of interviewing skills. Objective and subjective measures were obtained by self-administered questionnaires. Figure 1 illustrates the research design in which participants were pre-tested and then post-tested both immediately and eight weeks after the workshop. Knowledge was evaluated by multiple choice and true/false questions based on the contents of the manual while attitude was measured using semantic differentials. Skills were evaluated by self-report responses to open-ended questions.

Figure 1
figure 1

Research Design

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Paired t-tests were used to compare means while chi-square tests were used to analyse demographic and personal characteristics. Qualitative data was analysed by content analysis. Post hoc reliability analysis showed alpha coefficients of 0.7 for both knowledge and attitude forms while face validity was achieved by basing the questions and statements on the concept of the PCI as described in the workshop manual.

Results

Twenty-five dentists (100%) completed the pre-test while 24 (96%) and 23 (92%) dentists returned evaluation forms at the first and second post-tests respectively. Demographic characteristics of the dentists attending the workshop revealed a diverse group in terms of age and sex. Although the majority of the participants were born in HK, their professional experiences varied widely. Twenty dentists had completed their undergraduate education in HK, eight had undertaken post-graduate studies either in HK or abroad and fifteen dentists had studied CS at some stage during their dental education.

Table 1 shows the summary scores for knowledge and attitude over the three tests. Analysis of individual changes in knowledge scores demonstrated a statistically significant difference before and immediately after the workshop (t =-3.30, df = 23, p<01). However, there were no significant differences between the pre-test and second post-test knowledge scores. Average summary scores reflected 72% to 78% of the total knowledge score. Analysis of individual questions showed that the greatest improvement in knowledge related to the topic of empathy.

Table 1 Table 1
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Mean attitude scores remained largely unchanged during the period of the evaluation and represented 76% to 79% of the total score demonstrating positive attitudes throughout the period of study. However, analysis of individual scores revealed statistically significant declines between the pre-test and second post-test (t=2.4, df=22, p<0.01) and between the post-tests (t=2.81, df=22, p<0.01). Demographic variables were not related to either knowledge or attitude scores. However, knowledge and attitude scores were related at the second post-test. That is, dentists with the highest knowledge scores at the second post-test also held the most positive attitudes (p<0.001).

In the subjective evaluations dentists used a three-point scale to rate the degree to which he/she met the specified learning objectives: (1) not at all, (2) partially and (3) completely. Table 2 shows that dentists at least partially met each of the seven learning objectives except for the objective on describing important concepts to consider when breaking bad news. The objective on defining empathy was the most frequently met objective. Using the three-point scale described above, the workshop was supported with ratings of at least partially applicable and practical for the eight aspects about which the respondents were questioned. These aspects included: an instructional videotape on the PCI, role-play and information on thoughts and feelings, empathy, the PCI, breaking bad news, patient education and pain management. The information on empathy was rated the most applicable and practicable.

Table 2 Table 2
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Similarly, dentists rated the educational value of eight aspects of the workshop as at least average. Twenty of the dentists reported that they had partially met their personal objectives after attending the workshop. Twelve of the 23 dentists' returning the second post-test reported improvements in their CS, specifically in gathering information, showing empathy and information giving, especially breaking bad news. Twelve dentists also reported increased job satisfaction at the second post-test. Reasons cited for this increased satisfaction were associated with improvements in the dentist–patient relationship.

Eight weeks after the workshop, twelve dentists wanted to learn more about specific aspects of CS, especially talking about sensitive issues and giving bad news to patients. Twenty-three dentists' recorded their impressions of the workshop. Statements were overwhelmingly positive and included descriptions such as: 'stimulating,' 'educational,' 'interesting' and 'worthwhile.' Specific reference was made to the usefulness of the information on empathy. Most participants gave at least one suggestion on how to improve the workshop. A notable theme was the request for more relevant material both in terms of the local context and dental practice.

Discussion

The evaluation of the CS workshop for dentists provides insight into an under studied area. The literature describes a lack of formal structure for continuing education of practising dentists6 and as a consequence there is little published research in the field of evaluations of graduate dental programmes. No studies could be found on CS teaching in continuing education for dentists. Research in the US has shown that despite the promotion of patient- centred care in undergraduate education, task-oriented models of care are more familiar in practice.6

Dentist-patient communication research

Relatively little research exists on communication in dental consultations, despite considerable evidence that indicates the importance of interpersonal skills in other patient–practitioner relationships. That which does exist supports findings on research relating to communication between doctors and patients. For example, Gale et al. found that patients rated dentists who 'interacted' with them more positively than dentists who did not make this effort.9 The authors also reported that unhelpful behaviours of the patient could be changed by treating the patient with respect.

A study in HK in which dentists in private practice were observed and recorded in 42 consultations revealed interesting patterns of communication.10 Although most of the dentists greeted their patients with warmth, subsequent communication was authoritarian in almost half of the consultations. Only 38% of the consultations revealed communication exchanges compatible with patient-centred care. As the consultations progressed, patient-centred care diminished and dentists assumed increasingly authoritarian roles. The authors highlighted the importance of the dentist obtaining the patients' trust and confidence and that this is best achieved not only by technical competence but also by effective patient-centred communication.10

Features of dentist-patient communication

The nature of dentistry is such that dentists often communicate with patients while the patients' ability to effectively initiate communication or to respond is impaired. This may result in a failure of communication. Although the nature of the information dentists and patients exchange is different to that discussed by doctors and patients, it is apparent that dentists, like doctors also fail to meet the information needs of their patients. There is evidence that patients expect information from dentists, specifically with respect to pain management and how to use their hands as stop signals during dental procedures. The provision of such information has been demonstrated to reduce dental patients' anxiety.4,5

Relevance of the PCI

The PCI addresses many of the problems associated with ineffective and failed communications in dental practice and as such formed the basis for the teaching in this workshop. This was the first time that the PCI has been taught and evaluated in the context of improving communication between dentists and patients in HK. The results of the evaluation demonstrated that the workshop was successful in increasing the knowledge of participants immediately after the workshop although eight weeks later, there was no evidence of maintenance of recently acquired knowledge. The high levels of knowledge in the pre-test reduced the margins for improvement after the workshop while the changes that did occur demonstrated a characteristic pattern of learning. Mean attitude scores remained largely unchanged throughout the period of study however, the analysis of individual scores showed a decline both immediately and eight weeks after the workshop. The high pre-test scores showed that the research instrument may not have been sensitive to changes in knowledge and attitude. Further, attitudes are often firmly established in adults and usually take longer to change than attendance at one half-day workshop, especially when there was no follow-up session.

Given that tests were based entirely on the CS manual, the high levels of knowledge and positive attitudes at the pre-test may indicate a workshop pitched at too basic a level. It can be difficult to identify the correct level for a workshop when participants have varied social and professional backgrounds. However, heterogeneity among learners is a feature of continuing professional education. Future workshops should consider testing participants before the workshop meets in order to accurately identify the needs of the participants.

In this evaluation the subjective data demonstrated the relevance of the PCI and the educational techniques used in the workshop to the practices of these dentists. With respect to content, the information on empathy was cited as especially useful in improving their relationships with patients. Further, dentists reported that these improvements had increased their job satisfaction and that patients' adherence with prescribed dental care had improved. These are clearly very important outcomes. However, the validity of self-reporting as a reliable measure needs further investigation. Future evaluations should consider more objective measures such as ratings from observations of dentists interviewing patients (or simulated patients) and patient satisfaction surveys.

Dentists' ratings of the degree to which they met learning objectives and the educational value and applicability of the workshop content supported the areas in which respondents achieved short-term knowledge gains. Improvements in the dentist–patient relationship were cited and attributed by the respondents to their improved empathic behaviours.

There were limitations on the study resulting from the necessity of teaching the workshop in a half-day session. Too much information was introduced to the participants at the expense of experiential exercises. The short period of time and breadth of materials did not provide the opportunity for using simulated patients and videotape replay with feedback. These methods of teaching CS have been shown to be the most effective in teaching medical students and doctors and so should be considered in future workshops. The range of topics introduced during this half-day workshop are usually taught over several weeks and reinforced with multiple practical exercises because it is well known that the acquisition of skills is most effective when learners have the opportunity to practice and receive feedback on their performance.

Participants' suggestions to improve the workshop focused on more of what was already provided supporting both the content and the teaching methods used during the workshop. Other suggestions for improvement related to increasing the dental and cultural relevance of the content. Although tutors attempted to present knowledge and describe skills that were culturally and professionally relevant, further progress needs to be made in this direction. Dentists were clearly keen to learn more about CS as evidenced by the subjective evaluations requesting more information about wide ranging CS topics.

Conclusion

The objective and subjective results of this study revealed that dentists had high levels of knowledge and positive attitudes about communication skills in dental care. However, the objective measures showed that the workshop did not have statistically significant long-term benefits in relation to individuals' levels of knowledge while attitude scores declined during the period of study. In contrast, the subjective evaluations showed that half of the participants reported improvements in their communication skills eight weeks after the workshop. Such results show the importance of both objective and subjective evaluations. That is, evaluations that rely only on objective measures may lose valuable information about the strengths and weaknesses of a workshop. The patient-centred interview was found to be relevant to the practices of these dentists and the participants valued the educational techniques used in the workshop. Future workshops should consider the use of educational techniques such as videotape replay with feedback and further adaptation of the patient-centred interview to dental and local practices.