Comparative Study of Attitudes towards Communication Skills Learning between Medical and Dental Students in Saudi Arabia

Background: Communication skills (CS) learning is a core skill in medical and dental education. The comparison of attitudes towards CS between dental and medical students based on the taught curriculum (problem-based learning vs. traditional teaching) in Saudi Arabia awaits investigation. Aims: (1) To assess the attitudes of both undergraduate dental and medical students towards communication skills (CS) learning and (2) to compare the attitudes towards CS between Medical and Dental students in relation to sociodemographic and education-related characteristics. Methods and Materials: A cross-sectional study, using an online survey, invited 260 conveniently sampled Taibah university medical and dental undergraduate students. The survey collected data on sociodemographic characteristics, education-related factors, and CS using Communication Skills Attitude Scale (CSAS) that assess positive and negative attitudes (PAS, NAS). Data analysis included descriptive statistics and the Mann–Whitney U test. Results: Of the distributed questionnaire 91% responded (145 dental and 91 medical students). There were, overall, non-significant scores’ differences between medical and dental students on PAS (Medicine Median 51 vs. Dentistry Median 50, p = 0.059) and NAS (Medicine Median 32 vs. Dentistry Median 32, p = 0.596). Older medical students, those at clinical levels and those who reported they need to improve their communication skills and student whose parents were not doctors, tended to score statistically significantly (p = 0.032, 0.017, 0.034, and 0.004, respectively) on PAS compared with dental students; on the other hand, medical students with doctor parents scored significantly high in NAS compared to dental students (p = 0.015). Conclusion: Demographic and education-related characteristics underpinned medical student positive attitude towards CS compared to dental students. Although medical and dental students showed no differences in self-rating their attitudes towards (CS). Different factors influence medical and dental students’ attitudes towards CS learning.


Introduction
Communication by health care professionals is a key process in a patient-clinician relationship [1]. Communication skills (CS) learning is an integral component of medical and dental education, these core skills positively contribute to various aspects of the healthcare process, including conducting a meticulous examination, reaching a correct diagnosis, formulating a comprehensive plan, and providing adequate treatment [2,3]. Recent initiatives from authoritative medical educational bodies, licensing examination formats, and accreditation procedures are probing these essential core skills. Notably, medical educational authorities recommend that medical and dental graduates should have certain levels of mastery of CS for interactions with patients, colleagues, and team In the health sciences education literature in general, several studies have compared communication skills among traditional and problem-based curricula. A cross-sectional survey on four different universities showed that students at traditional curriculum scored the lowest at knowledge acquisition in communication skills when compared to students of two PBL schools and students of one integrated medical school [22]. In another nationwide study in Norway, a clear difference was observed on how communication skills were reported between the traditional curriculum students and those among integrated curricula students [21].
Current literature suggests that there is a paucity of research in SA, comparing medical and dental (or traditional and integrated) students' attitudes toward CS learning and training. At Taibah University in Madinah, SA, the College of Medicine (COM) has adopted a reformed problem-based learning (PBL) undergraduate curriculum, that integrates all levels of the program. The College of Dentistry (COD), on the other hand, still utilizes a traditional approach that arguably lacks CS as a main component in the curriculum. Comparing the two colleges in terms of student attitudes towards CS learning and training would provide a unique opportunity to study the influence of both learning approaches i.e., traditional vs. integrated curricula, and identify possible determining or contributory factors. Thus, the aims of this study were [1] to assess the attitudes of both undergraduate dental and medical students at Taibah University towards communication skills learning and [2] to compare the attitudes towards communication skills between medical and dental students in relation to sociodemographic and education-related characteristics.

Study Design, Setting and Sampling
This analytical cross-sectional study recruited a convenience sample of undergraduate students attending colleges of Medicine and Dentistry at Taibah university in Madinah, Saudi Arabia, during the academic year 2019-2020. Students enrolled in the common preparatory year, internship program and postgraduate residency training were excluded. The inclusion of undergraduate medical and dental students was on the basis that by the end of the undergraduate program students should have acquired and demonstrated proficiency in communication skills (CS) and are able to provide advice and explanation to patients and their families and relatives [11].
A cluster sampling was undertaken from the total number of medical and dental students. Each student representative in every academic level distributed the questionnaire to his or her group, and responses from the first 20 participants were deemed adequate. In this study the strategy of sample size calculation was based on the statistical validation of the Communication Skills Attitude Scale (CSAS), i.e., item-subject ratio and was within the range of 1:20, as the literature suggests [29]. Accordingly, the required sample size calculated was 236 and increased to 260 to compensate for non-respondents.

Measurements, Data Collection and Ethical Approval
An English self-administered questionnaire (Supplementary Material) was used to assess students' attitudes towards communication skills. This questionnaire is composed of two sections: section one asked questions about age, gender, college, academic year, self-reported socioeconomic status, job of parents (medical doctors or other), self-rating of communication skill, and whether students thought their communication skills needed improving, the latter three questions were adapted from relevant literature [13,14].
Section two focused on communication skills using the Communication Skills Attitude Scale (CSAS) [17,18]. The CSAS is a validated, well-established instrument used for assessing CS [18]. The CSAS was transculturally adapted into different languages, i.e., German, Korean, and Norwegian, and was used as a probing tool for students' attitudes towards CS learning [10,30,31]. The selection of the CSAS scale allows comparison of findings of the present study with other relevant studies using the same scale. This scale consists of 26 items: 13 positive (CSAS-PAS) and 13 negative statements (CSAS-NAS) [10]. The items are anchored to a five-point Likert-scale responses, ranging from 1 (strongly disagree) to 5 (strongly agree) and these items were presented randomly in the scale [10].
The questionnaire was preceded with cover page that stated the aims of the study, anonymity and confidentiality of the responses and the voluntarism of the participation. In addition, the ethical committee that approved the study and the contact details of one the team investigators for any queries was made available. It took approximately ten minutes to fill and was sent electronically via a WhatsApp message that linked to a Google form. The responding students were instructed on completion filling the form, to submit the web form to the web server. This latter inserted the collected data into Excel spread sheet that stored the data for retrieval and analysis. The Taibah University College of Dentistry Research Ethics Committee reviewed and approved the study (Ref: TUCDREC/20200322/AANourein). The study adhered to the World Medical Association guidelines set at the Declaration of Helsinki. The questionnaire responses were anonymous and were coded during data analysis. The participants' informed consent was waived as the research ethics committee approved the study and deemed it as self-administered questionnaire with voluntary and anonymous participation. In addition, no personal information would be obtained. However, the submission of the questionnaire was considered as a proxy of consent to participate in the study.

Statistical Analysis
The Statistical Package for Social Sciences 16 (SPSS, version 16, Inc., Chicago, IL, USA) was used for data analysis. Previous relevant studies guided the statistical analysis plan for the present study [10,32]. Descriptive analysis was performed to summarize sample characteristics and were presented as median and interquartile range (IQR), as all the continuous data did not adhere to normality distribution (Kolmogorov-Smirnov ≤ 0.05), and frequencies with percentages (F%) for categorical data. The overall internal consistency of the CSAS was tested alongside the subscales CSAS-PAS and CSAS-NAS, for medical and dental students, using Cronbach's alpha coefficient (α). The statistically significant differences for the CSAS-PAS and CSAS-NAS between the medical and dental students in relationship to sociodemographic and education-related characteristics was determined using the Mann-Whitney U test. The number of variables in Table 1, result section was recategorized. The socio-economic status (SES) was recategorized to 'Other levels [low and middle]' and 'High level' due to small number [33] of students with low SES. In addition, the self-reported communication skill was recategorized into 'Excellent', 'Very good', 'Fair' and 'Poor' and Very poor' to have meaningful analysis. The age of students was categorized according to training level. The significance level was set at p-value ≤ 0.05.  Table 1 shows the whole set of sample characteristics, and attendance at the according college (Medical and Dental). The median (IQR) age of the whole participating students was 22.0 [3] years, 91 (36.6%), and 145 (61.4) of the responding students were from medical and dentistry college. The majority (70%) of the responding students were at clinical levels. The overall internal consistency (α) of the CSAS and for the subscales (PAS and NAS) was 0.70, 0.88, and 0.63, respectively. As for the medical students, internal consistency (α) of the CSAS and for the subscales (PAS and NAS) was 0.56, 0.85, and 0.55, respectively; meanwhile the α of the CSAS among dental students was 0.75 and for the subscales (PAS and NAS) 0.90 and 0.67, respectively.

Comparisons of Attitudes towards CS Skills between Medical and Dental Students
There was over all non-significant scores' differences between medical and dental students on PAS (Medicine Median 51 vs. Dentistry Median 50, p = 0.059) and NAS (Medicine Median 32 vs. Dentistry Median 32, p = 0.596). However, as shown in Table 2, older medical students, those at clinical levels, those who self-reported that they need to improved their communication skills and that their parents were not doctors, tended to score statistically significantly (p = 0.032, 0.017, 0.034, 0.004, respectively) on PAS compared with dental students. Surprisingly, medical students who reported their parents' job as doctors scored statistically significantly on NAS compared to counterparts' dental students (p = 0.015). Table 2. Comparisons of medical and dental students' attitudes towards CS skills (n = 236). tors showed negative attitudes towards communication skills learning. Nevertheless, the literature also reported that students' self-rating and self-efficacy in communication skills encouraged medical educators to provide more engaging student-centered instructional methods [6]. Interestingly, neither medical college nor dental college showed significant differences in attitudes towards (CS) were observed between males and females, a finding inconsistent with the mainstream of the literature [10,12,41,43]. However, similar findings were obtained from a study in Sri Lanka [44]. The present study did not find a significant relationship between the self-reported socioeconomic status of medical students and their attitudes towards communication skills learning. Similarly, the self-reported socioeconomic status of dental students was non-significant in relation to their attitudes towards communication skills learning. No study showed a correlation between the self-perceived socioeconomic status of dental students with regards to their attitudes towards communication skills learning. In the literature, some studies defined socioeconomic status as whether the students had any working experience in health services [10,45]. While in the current study, socioeconomic status referred to the self-perception of such status by the students. As Taibah University is a governmental university, all students are granted free education, consequently aiding their dedication to learning.

PAS M(IQR) p-Value NAS M(IQR) p-Value
The current study also showed that NAS among medical students towards CS learning were associated with parents of medical backgrounds, i.e., physicians. This finding is similar to other studies [11,45] that hypothesized that there was a possible transformation of poor attitudes from experienced practicing health care professionals, i.e., 'doctor parent', to immature 'student siblings', since communication skills at the time of the parents' education were not taught as of today's teaching [11].
One limitation that should be acknowledged is that this study was a cross-sectional in nature, thus causality is precluded. Second, the findings were reported from one institute in Saudi Arabia. Therefore, generalizability of the findings to dental and medical institutes within the context of SA is not possible. Moreover, the self-selection of the students within the institute to participate in the study could have biased the results. One should consider that this study was conducted during the pandemic of COVID-19, i.e., students were under urgent re-arrangement of their environment of education, which might have made them deprioritize the participation in the survey. Finally, the self-reporting of CSAS could have invoked social desirability, therefore, self-reporting of CSAS would have been enhanced and validated if objective measures were utilized.

Conclusions
Within the limitations of this study, it can be concluded that positive (PAS) and negative (NAS) attitudes of medical and dental students towards communication skills (CS) learning were generally similar. Medical students' (PAS) towards communication skills learning were related to older age, clinical level training students, non-medical family background and low self-rated students' views on communication skills. The (PAS) of dental students, on the other hand, were more related to high self-rating in communication. Parents with medical backgrounds were associated with NAS towards CS learning more among medical students than in dental students. Further studies are needed to provide educational leaders with evidence-based feedback for improvement of communication skills learning courses, to probe for feedback weaknesses, and for maximizing students' potential towards more professional and patient-centered care.
Supplementary Materials: The Survey questionnaire is available online at https://www.mdpi.com/ 1660-4601/18/1/128/s1. Author Contributions: A.A.E.N. conceptualized and designed the study, acquired data, reviewed the literature, analyzed the data, and critically commented and wrote the original draft and manuscript. R.F.S. contributed to the study literature review, interpreted the results and wrote the manuscript. M.A.A. contributed to the study literature review, interpreted the results, wrote the manuscript. S.S.A.-H. managed data collection, contributed to the study literature review, interpreted the results, wrote the manuscript and contributed to manuscript writing. H.T.F. contributed to study discussion, critically commented and wrote the manuscript. S.K. contributed to the design of the study, contributed literature review, methods, analyzed the data, interpreted the results, contributed in writing the original draft critically commented and wrote the manuscript. All authors have read and approved the final manuscript.
Funding: This research received no external funding.