the relationship between medical students' attitudes towards communication skills learning and...

The relationship between medical students’ attitudes towardscommunication skills learning and their demographic andeducation-related characteristics

Charlotte Rees1 & Charlotte Sheard2

Introduction The General Medical Council (GMC) has

stressed the importance of medical students’ attitudes

towards learning. However, few studies have explored

medical students’ attitudes towards communication

skills learning. This study explores the relationship

between the attitudes of medical students at two dif-

ferent schools and their demographic and education-

related characteristics.

Methods A total of 490 medical students from the

Universities of Nottingham (Years 1 and 2) and

Leicester (Year 1) completed the 26-item Communi-

cation Skills Attitude Scale (CSAS) and a personal

details questionnaire satisfactorily. The relationships

between students’ attitudes and their demographic and

education-related characteristics were analysed sepa-

rately for Nottingham and Leicester students using

both univariate and multivariate statistics.

Results The attitudes of Nottingham and Leicester

medical students towards communication skills learn-

ing were significantly associated with a number of

demographic and education-related characteristics.

Both Nottingham and Leicester students with more

positive attitudes towards communication skills learn-

ing tended to be female, tended to think their commu-

nication skills needed improving and tended not to have

parents who were doctors. Both Nottingham and

Leicester students with more negative attitudes towards

communication skills learning tended to think their

communication skills did not need improving.

Discussion The results indicate that medical students’

attitudes towards communication skills learning are

associated with their demographic and education-

related characteristics. These findings have a number

of implications for educational practice and further

research and these are discussed in this paper.

Keywords education, medical, undergraduate ⁄*standards; *communication; *learning; attitude of

health personnel; interpersonal relations; question-

naires; England.

Medical Education 2002;36:1017–1027

Introduction

Communication skills learning became an integral part

of undergraduate medical education with the publica-

tion of Tomorrow’s Doctors.1 In this report, the General

Medical Council (GMC) stated that by the end of their

training, students should have acquired and demon-

strated a proficiency in communication. The GMC

concluded that doctors should be good listeners and

should be able to provide advice and explanations that

are comprehensible to patients and their relatives. The

GMC also made recommendations regarding medical

students’ attitudes, suggesting that students should

have acquired and demonstrated attitudes consistent

with effective medical practice by the end of their

training. Included in a diverse list of 12 attitudinal

objectives were four that related to attitudes towards

learning (e.g. having an awareness of personal limita-

tions and willingness to seek help where necessary).

The research literature on medical students’ attitudes

towards communication skills learning2–4 has produced

mixed results. One of the first attempts to assess

medical students’ attitudes towards communication

skills learning was a study conducted by Walker et al.2

These authors assessed the attitudes of final year

medical students qualifying in 1978 ⁄79 towards the

content, teaching and assessment of their medical

training at the University of Aberdeen. Of the 101 final

1Institute of Clinical Education, Peninsula Medical School, Plymouth,

UK2Behavioural Sciences Section, Division of Psychiatry, University of

Nottingham, UK

Correspondence: Charlotte Rees, Peninsula Medical School, ITTC

Building, Tamar Science Park, Davy Road, Plymouth PL6 8BX, UK.

Tel.: 00 44 1752 238009; Fax: 00 44 1752 238001; E-mail:

[email protected]

Clinical and communication skills

� Blackwell Science Ltd MEDICAL EDUCATION 2002;36:1017–1027 1017

year students who were sent a 44-item anonymous

postal questionnaire, 75 responded, giving a response

rate of 74Æ3%. In terms of their attitudes towards

communication skills learning, the authors found that

only 45% of the students thought they had been given

sufficient instruction in doctor–patient relationships,

only 59% thought they had received sufficient instruc-

tion in interviewing techniques and 66% believed that

the scientific aspects of the course had been overem-

phasised. These findings suggested that communica-

tion skills learning was valued and that many students

wanted more. However, this study was conducted over

20 years ago and cannot be taken as representative of

final year students qualifying in the year 2002.

More recently, Rosenthal & Ogden3 conducted a

questionnaire survey in June 1994 to elicit the attitudes

of all undergraduate medical students (Years 1–5) at

the Royal Free Hospital School of Medicine concerning

the GMC’s1 recommendations for changing the un-

dergraduate curriculum. Of the 508 medical students

invited to participate, 383 responded satisfactorily,

giving an overall response rate of 75Æ4%. Of these

students, 64Æ8% agreed with the statement: �Greater

emphasis should be placed on communication skills�,suggesting that the majority of students valued com-

munication skills learning. However, response rates

varied according to the year of training. For example,

first, second and fourth year students had higher

response rates (89Æ3%, 78Æ6% and 88Æ8%, respectively)

than third and fifth year students (65Æ4% and 54Æ2%,

respectively). This suggests that the findings may not

be generalisable to a wider population of third and

fifth year students.

Finally, Rees & Garrud4 conducted a qualitative pilot

study in May 2000 with five medical students from the

University of Nottingham to establish their attitudes

towards communication skills learning. This study

found that some medical students held positive

attitudes towards communication skills learning. For

example, some students thought that in order to

become a �good� doctor, they had to possess good

communication skills. They also thought that commu-

nication skills were lifelong skills and helped them to

work in teams. One student suggested that communi-

cation skills learning was fun, interesting, useful and

applicable to medicine. However, some students had

negative attitudes towards communication skills learn-

ing. Negative attitudes included communication skills

learning not being viewed as a valuable part of the

undergraduate curriculum and being viewed as too

easy. In addition, some students felt unable to vocalise

their personal limitations in this area, a finding that is

inconsistent with the attitudinal objectives of the

GMC.1 Finally, some of the participants suggested

that medical students’ attitudes were related to other

factors like their previous educational experiences, their

age and their communicative abilities. However, given

the small sample size of this study, it is impossible to

extrapolate its findings to a wider population of medical

students.

Although studies have started to explore medical

students’ attitudes towards communication skills learn-

ing, it is difficult to draw any firm conclusions about

medical students’ attitudes because of the limitations

associated with these studies. For example, none of

these studies has used a reliable scale to measure

attitudes. To combat these limitations and to address

gaps in the research literature, the current study aims

to identify the attitudes of medical students at two

different schools using a reliable attitude scale, and to

consider their relationships with medical students’

demographic and education-related characteristics.

The Nottingham and Leicester Schools were chosen

for this study because they offer different communica-

tion skills courses. Although the content of the courses

at Nottingham and Leicester are similar (e.g. both the

Nottingham and Leicester Year 1 courses focus on

information gathering in the medical interview), the

teaching methods differ, as has been found with

other universities.5 The Nottingham courses use more

instructional teaching methods compared to the

Leicester course (e.g. the Nottingham Year 1 course

includes four lectures compared to one lecture at

Leicester). In addition, the Leicester course uses more

experiential methods of learning, such as observed

interviews with simulated patients and feedback,

Key learning points

Both Nottingham and Leicester medical students’

attitudes are associated with their demographic

characteristics (e.g. gender and whether they have

doctor parents).

Both Nottingham and Leicester medical students’

attitudes are associated with their education-

related characteristics (e.g. whether they think

their communication skills need improving).

Further research is needed to establish which

aspects of communication skills courses are asso-

ciated with attitudes.

Further research is necessary to determine whether

medical students’ attitudes change as a result of

communication skills learning.

Attitudes towards communication skills learning • C Rees & C Sheard1018

� Blackwell Science Ltd MEDICAL EDUCATION 2002;36:1017–1027

compared to the Nottingham Year 1 course (e.g. three

2-hour workshops at Leicester compared to one 2-hour

workshop in the Nottingham Year 1 course). In

addition, the Leicester course is more fully integrated

with clinical examination skills and family placement

sessions than are the Nottingham courses, which are

more stand-alone in structure with some integration

with early clinical skills sessions. The use of two

different schools not only enabled us to explore

students’ attitudes towards different communication

skills courses but also allowed us to explore the

differences between the demographic and education-

related characteristics of the undergraduate populations

of Nottingham and Leicester.

Methods

Recruitment procedures

After receiving approval from the Medical School

Ethics Committee at the University of Nottingham,

all Year 1 and 2 medical students at the University of

Nottingham and all Year 1 medical students at the

University of Leicester were invited to participate in

this study. Year 1 students from Nottingham and

Leicester were invited to take part during small group

seminar teaching in November and December 2000.

The authors distributed the study materials to the

seminar facilitators, who handed them out and collec-

ted them during the seminars. The facilitators then

returned the completed questionnaires to the authors in

freepost envelopes provided. Year 2 medical students at

Nottingham were initially recruited by internal mail and

email in October 2000. However, this led to a poor

response (n ¼ 43, 21Æ8%) within a 2-week period.

Therefore, additional Year 2 students (n ¼ 87, 44Æ2%)

were recruited during a 50-minute lecture 2 weeks after

being invited by internal mail and email. The study

materials were distributed during the lecture and

completed questionnaires were collected at the end of

the lecture.

Materials

Communication Skills Attitude Scale

The first author (CR) designed the Communication

Skills Attitude Scale (CSAS) using the findings of an

earlier qualitative pilot study that explored medical

students’ attitudes towards communication skills learn-

ing.4 The scale consists of 26 items with two subscales,

each with 13 items. The first subscale (items 4, 5, 7, 9,

10, 12, 14, 16, 18, 21, 22, 23 and 25) represents


ing, such as: �Developing my communication skills is

just as important as developing my knowledge of

medicine� (item 4). In a previous study6 this subscale

was found to possess satisfactory internal consistency

with 490 medical students (a ¼ 0Æ873) and satisfactory

test-retest reliability with 39 medical students (intra-

class correlation ¼ 0Æ646, P < 0Æ001). The second

subscale (items 1, 2, 3, 6, 8, 11, 13, 15, 17, 19, 20,

24 and 26) represents negative attitudes towards

communication skills learning, such as: �I can�t be

bothered to turn up to sessions on communication

skills’ (item 8). This subscale has also been found

to possess satisfactory internal consistency (a ¼ 0Æ805)

and test-retest reliability (intraclass correlation ¼0Æ771, P < 0Æ001).6

All the 26 items are accompanied by 5-point Likert

scales ranging from 1 (strongly disagree) to 5 (strongly

agree). Two scores can be determined from the CSAS:

the total positive attitude scale (PAS) score and the

total negative attitude scale (NAS) score. After

reversing the scores of items 1 and 22, both the PAS

and NAS scores are established by summing the

scores for the 13 items of each subscale. Both scores

range from 13 to 65, with higher scores indicating

stronger attitudes.

Personal details questionnaire

The personal details questionnaire contained six

demographic items and four education-related items.

Demographic items included age, gender, ethnicity,

first language and the employment history of respond-

ents’ fathers and mothers (to calculate socio-economic

status). Education-related items included what sub-

jects respondents studied before studying medicine,

whether respondents thought their communication

skills needed improving and the mark (out of 20) that

respondents received for their last communication

skills Objective Structured Clinical Examination

(OSCE). Participants were also asked to rate their com-

munication skills on a 5-point scale where 1 ¼ poor

and 5 ¼ excellent.

Data analysis

Data were analysed using SPSS version 10Æ0. Explor-

atory data analysis was conducted first to establish the

distribution of continuous variables. Non-parametric

statistics were used for continuous variables that were

non-normally distributed and parametric statistics were

used for continuous variables that were normally

distributed.

Attitudes towards communication skills learning • C Rees & C Sheard 1019


Descriptive statistics (e.g. frequencies, percentages,

etc.) were used to identify the demographic and

education-related details of the total sample and then

the Nottingham and Leicester students separately.

Univariate statistics (e.g. Mann–Whitney Z statistics

or chi-squared statistics) were used to establish whether

the Nottingham and Leicester samples differed signifi-

cantly in terms of their demographic and education-

related characteristics. Univariate statistics were also

used to establish the relationship between the depend-

ent variables (DVs) (i.e. scores on the PAS and NAS)

and individual independent variables (IVs) (i.e. demo-

graphic and education-related characteristics of partic-

ipants) for Nottingham and Leicester students

separately.

Multivariate statistics (i.e. stepwise multiple regres-

sion) were used to establish the best linear combination

of IVs to predict the DVs for Nottingham and Leicester

students separately. However, some of the DVs

were transformed before running the stepwise multiple

regression procedures. The PAS score for Nottingham

students was negatively skewed and was therefore

transformed using a reflect procedure and a square root

transformation.7 The NAS score for Nottingham and

Leicester students was positively skewed and was there-

fore transformed using a square root transformation.7

Results

Participants’ demographic and education-related

characteristics

Of the 585 medical students invited to participate

in this study, 490 completed the CSAS satisfactorily,

giving a response rate of 83Æ8%. Overall, the sample

ranged in age from 17 to 35 years (median ¼ 19,

interquartile range ¼ 18–19). The majority were

female (n ¼ 281, 57Æ3%), white (n ¼ 352, 72Æ1%) and

came from non-manual socio-economic backgrounds

(n ¼ 473, 96Æ9%). Most of the students spoke English

as their first language (n ¼ 411, 83Æ9%), did not have

parents who were doctors (n ¼ 400, 82Æ0%) and had

studied only pure science subjects before studying

medicine (n ¼ 251, 54Æ3%). Students’ ratings of their

own communication skills ranged from 1 (poor) to 5

(excellent) (median ¼ 3, interquartile range ¼ 3–4)

and nearly all of them thought that their communica-

tion skills needed improving (n ¼ 471, 96Æ3%). Finally,

the majority were studying medicine at the University

of Nottingham (n ¼ 326, 66Æ5%). As students were

recruited from two different schools, their demographic

and education-related characteristics are presented

separately in Table 1.

Relationships between students’ positive attitudes and

their demographic and education-related characteristics

Nottingham students

Scores for the positive attitude subscale (PAS) for

Nottingham students ranged from 14 to 65

(median ¼ 48Æ5, interquartile range ¼ 44–53). Of the

relationships explored between the dependent variable

(PAS score) and the 10 independent variables, three

(30%) were found to be statistically significant at the

P < 0Æ05 level and one (10%) showed a trend towards

significance (Table 2).

The four variables with a significant or a trend

towards a significant relationship with the dependent

variable (PAS score) were entered into a stepwise

multiple regression model. Of these four variables, all

except the OSCE assessment mark were found to be

significantly associated with scores on the PAS. Whe-

ther students had parents who were not doctors seemed

to be the biggest predictor of positive attitudes towards

communication skills learning for Nottingham students

(Table 3).

Leicester students

PAS scores for Leicester students ranged from 34 to 64

(mean ¼ 52Æ38, SD ¼ 6Æ53). Of the relationships

explored between the dependent variable (PAS score)

and the nine independent variables, two (22Æ2%) were

found to be statistically significant at the P < 0Æ05 level

and two (22Æ2%) showed a trend towards significance

(Table 2).

The four variables with a significant or a trend

towards a significant relationship with the dependent

variable (PAS score) were entered into a stepwise

multiple regression model. Of these four variables, all

except whether students thought their communication

skills needed improving were found to be significantly

associated with scores on the PAS. The age of students

(i.e. the younger they were) seemed to be the biggest

predictor of positive attitudes towards communication

skills learning for Leicester students (Table 3).

Relationships between students’ negative attitudes

and their demographic and education-related

characteristics

Nottingham students

Scores for the negative attitude subscale (NAS) for

Nottingham students ranged from 14 to 51

(median ¼ 27, interquartile range ¼ 24–31). Of the

relationships explored between the dependent variable

(NAS score) and the 10 independent variables, one

(10%) was found to be statistically significant at the



P < 0Æ05 level and two (20%) showed a trend towards

significance (Table 4).

The three variableswith a significant or a trend towards

a significant relationship with the dependent variable

(NAS score) were entered into a stepwise multiple

regression model. Of these three variables, all except

ethnicity were found to be significantly associated with

scores on the NAS. Students reporting that their com-

munication skills did not need improving seemed to be

the biggest predictor of negative attitudes towards

communication skills learning for Nottingham students

(Table 5).

Leicester students

Scores for the negative attitude subscale (NAS) for

Leicester students ranged from 13 to 40 (median ¼ 24,

interquartile range ¼ 21–27). Of the relationships

explored between the dependent variable (NAS score)

Table 1 Demographic and education-related characteristics of the sample by school

Frequency (valid percentage)*

Variables Nottingham Leicester Test statistic, P-value**

Age

Median (interquartile range) 19 (18–20) 19 (18–19)

Range 17–35 18–33 Z ¼ ) 2Æ131, P ¼ 0Æ033

Gender

Male 129 (39Æ6%) 80 (48Æ8%)

Female 197 (60Æ4%) 84 (51Æ2%) v2 ¼ 3Æ417, d.f. ¼ 1, P ¼ 0Æ065

Ethnicity�White 245 (75Æ4%) 107 (65Æ6%)

Non-white 80 (24Æ6%) 56 (34Æ4%) v2 ¼ 4Æ650, d.f. ¼ 1, P ¼ 0Æ031

Socio-economic status�Non-manual occupations (I, II, IIIN) 321 (98Æ8%) 150 (92Æ0%)

Manual occupations (IIIM, IV, V) 4 (1Æ2%) 13 (8Æ0%) v2 ¼ 12Æ75, d.f. ¼ 1, P < 0Æ001

Do students have doctor parent(s)?�Yes 57 (17Æ5%) 31 (19Æ0%)

No 268 (82Æ5%) 132 (81Æ0%) v2 ¼ 0Æ076, d.f. ¼ 1, P ¼ 0Æ782

First language

English 288 (88Æ3%) 123 (75Æ0%)

Non-English 38 (11Æ7%) 41 (25Æ0%) v2 ¼ 13Æ396, d.f. ¼ 1, P < 0Æ001

Subjects studied prior to medicine�Pure science subjects only 173 (55Æ8%) 78 (51Æ3%)

Non-pure science subject(s) 137 (44Æ2%) 74 (48Æ7%) v2 ¼ 0Æ658, d.f. ¼ 1, P ¼ 0Æ417

Students ratings of their own

communication skills

Median (interquartile range) 3 (3–4) 3 (3–3Æ75)

Range 1–5 2–5 Z ¼ ) 3Æ218, P ¼ 0Æ001

Do students think their

communication skills need improving?��Yes 313 (96Æ0%) 158 (96Æ9%)

No 13 (4Æ0%) 5 (3Æ1%) v2 ¼ 0Æ065, d.f. ¼ 1, P ¼ 0Æ799

Communication skills OSCE mark

(Nottingham Year 2 students only)

Median (interquartile range) 17 (16–18)

Range 12–20

Positive attitude subscale (PAS) score

Central tendency (distribution) 48Æ5 (44–53)§ 52Æ38 (6Æ53)§§

Range 14–65 34–64 Z ¼ ) 6Æ386, P < 0Æ001

Negative attitude subscale (NAS) score

Median (interquartile range) 27 (24–31)§ 24 (21–27)§

Range 14–51 13–40 Z ¼ ) 6Æ705, P < 0Æ001

*Except age, students’ ratings of their communication skills, communication skills OSCE mark, PAS and NAS scores.

**Non-parametric statistics were used, i.e. Mann–Whitney Z statistics and Chi-squared statistics.

�2 missing cases; � 28 missing cases; �� 1 missing case; § median (interquartile range); §§mean (standard deviation).



Ta

ble

2U

niv

ari

ate

rela

tion

ship

sbet

wee

nsc

ore

son

the

posi

tive

att

itu

de

subsc

ale

(PA

S)

an

dd

emogra

phic

an

ded

uca

tion

-rel

ate

dch

aract

eris

tics

by

school

Dem

ogra

ph

ican

d

edu

cati

on

-rel

ate

dch

ara

cter

isti

cs

Nott

ingham

Lei

cest

er

Med

ian

PA

Ssc

ore

(in

terq

uart

ile

ran

ge)

Tes

tst

ati

stic

P-v

alu

e*

Mea

nP

AS

score

(SD

)

Tes

tst

ati

stic

,P

-valu

e�

Age

–r¼

)0Æ0

79,

P¼

0Æ1

55

–r¼

)0Æ2

15,

P¼

0Æ0

06

Gen

der

Male

47

(42–51Æ5

)51Æ2

6(6Æ9

8)

Fem

ale

49

(45–54)

Z¼

)2Æ3

30,

P¼

0Æ0

20

53Æ4

5(5Æ9

2)

T¼

)2Æ1

71,

d.f

.¼

162,

P¼

0Æ0

31

Eth

nic

ity

Wh

ite

48

(43–53)

52Æ1

4(6Æ4

7)

Non

-whit

e49

(45–53)

Z¼

)0Æ8

01,

P¼

0Æ4

23

52Æ8

8(6Æ7

4)

T¼

)0Æ6

79,

d.f

.¼

161,

P¼

0Æ4

98

Soci

o-e

con

om

icst

atu

s

Non

-man

ual

48

(44–53)

52Æ4

3(6Æ3

9)

Man

ual

occ

up

ati

on

s50

(47Æ5

–54Æ7

5)

Z¼

)0Æ8

77,

P¼

0Æ3

81

52Æ3

8(8Æ3

3)

T¼

0Æ0

22,

d.f

.¼

161,

P¼

0Æ9

82

Fir

stla

ngu

age

En

glish

48

(43–53)

52Æ0

5(6Æ2

5)

Non

-En

glish

49Æ5

(46Æ7

5–52Æ2

5)

Z¼

)1Æ3

19,

P¼

0Æ1

87

53Æ3

9(7Æ3

0)

T¼

)1Æ1

40,

d.f

.¼

162,

P¼

0Æ2

56

Do

stu

den

tshave

doct

or

pare

nts

(on

eor

both

)?

Yes

47

(40Æ5

–52Æ5

)50Æ5

5(7Æ4

7)

No

49

(45–53)

Z¼

)1Æ7

59,

P¼

0Æ0

79

52Æ8

6(6Æ2

4)

T¼

)1Æ7

88,

d.f

.¼

161,

P¼

0Æ0

76

Su

bje

cts

stu

die

dpri

or

tom

edic

ine

Pu

resc

ien

ces

on

ly48

(43–52)

52Æ9

7(6Æ3

9)

Non

-sci

ence

subje

ct(s

)49

(44Æ5

–53Æ5

)Z

¼)

0Æ6

78,

P¼

0Æ4

98

51Æ3

5(6Æ8

0)

T¼

)1Æ5

17,

d.f

.¼

150,

P¼

0Æ1

31

Stu

den

ts’

rati

ngs

of

thei

r

ow

nco

mm

un

icati

on

skills

–r¼

0Æ0

46,

P¼

0Æ4

12

–r¼

0Æ0

26,

P¼

0Æ7

36

Do

stu

den

tsth

ink

thei

rco

mm

un

icati

on

skills

nee

dim

pro

vin

g?

Yes

49

(44–53)

52Æ5

4(6Æ4

0)

No

45

(33–48)

Z¼

)2Æ4

43,

P¼

0Æ0

15

47Æ2

0(9Æ7

8)

T¼

1Æ8

09,

d.f

.¼

161,

P¼

0Æ0

72

OS

CE

mark

(Nott

ingh

am

Yea

r2

stu

den

tson

ly)

–r¼

)0Æ2

18,

P¼

0Æ0

23

––

*N

on

-para

met

ric

stati

stic

sw

ere

use

d,

i.e.

Man

n–W

hit

ney

Zst

ati

stic

sor

Spea

rman

’sr

stati

stic

s.

�Para

met

ric

stati

stic

sw

ere

use

d,

i.e.

Ind

epen

den

tT

-tes

tsor

Pea

rson

’sr

stati

stic

s.



and the nine independent variables, four (44Æ4%) were

found to be statistically significant at the P < 0Æ05 level

(Table 4).

The four variables with a significant relationship with

the dependent variable (NAS score) were entered into a

stepwise multiple regression model. Of these four

variables, two were found to be significantly associated

with scores on the NAS: ethnicity and whether students

thought their communication skills needed improving.

Students’ non-white ethnicity seemed to be the biggest

predictor of negative attitudes towards communication

skills learning for Leicester students (Table 5).

Discussion

As can been seen from Table 1, Nottingham and

Leicester students differed significantly in terms of their

age, ethnicity, socio-economic status, first language,

how they rated their communication skills and their

positive and negative attitudes towards communication

skills learning. There was also a trend towards a signi-

ficant difference between Nottingham and Leicester

students in terms of their gender.

A number of demographic and education-related

variables were found to have significant relationships

with scores on the positive (PAS) and negative atti-

tude subscales (NAS) for Nottingham and Leicester

students.

The relationship between attitudes and demographic

variables

Age was found to have a significant univariate and

multivariate relationship with PAS scores for Leicester

students. As age increased, PAS scores decreased,

suggesting that younger students had more positive

attitudes towards communication skills learning than

older students. A possible explanation for this finding is

that older students at Leicester University may have

utilised their communication skills in a wide variety of

settings outside their academic education, e.g. in

previous employment. As a result, they may not value

the opportunities afforded by a communication skills

course to the same degree as younger students, who

may have less experience communicating with people

they do not know. However, this finding is inconsistent

with previous research,4 which suggested that mature

students were more positive towards learning commu-

nication skills than younger students. This inconsistent

finding may have resulted from the Rees & Garrud4

study, only optimising a small sample size which is

unlikely to be representative of a wider population of

medical students. In addition, all participants in the

Rees & Garrud4 study were students at the University

of Nottingham, so may have had a different demo-

graphic profile to the Leicester students in the current

study. The relationship between age and students’

attitudes needs further exploration in a longitudinal

study.

Gender was found to have statistically significant

univariate and multivariate relationships with PAS

scores for both Nottingham and Leicester students. In

addition, gender was found to have a statistically

significant multivariate relationship with NAS score

for Nottingham students. Female students had higher

PAS scores and lower NAS scores compared to male

students, suggesting that women had more positive

attitudes towards communication skills learning. This

finding is consistent with earlier research,8 which has

found that female students scored the same or higher

Table 3 Multiple regression: dependent variable positive attitude subscale (PAS) score by school

Variable Coefficient B SE (B) Beta t Significance

Nottingham

Constant 5Æ599 0Æ420 13Æ335 0Æ000

DOCPARENT ) 0Æ663* 0Æ220 ) 0Æ277* ) 3Æ014* 0Æ003*

CSIMPROVE 0Æ701* 0Æ334 0Æ194* 2Æ099* 0Æ038*

GENDER 0Æ375* 0Æ184 0Æ187* 2Æ037* 0Æ044*

Leicester

Constant 62Æ523 4Æ829 12Æ948 0Æ000

AGE ) 0Æ685 0Æ237 ) 0Æ218 ) 2Æ884 0Æ004

GENDER 2Æ317 0Æ986 0Æ177 2Æ349 0Æ020

DOCPARENT ) 2Æ535 1Æ270 ) 0Æ151 ) 1Æ997 0Æ048

*Because the DV has been reflected and square root transformed for the Nottingham sample, the direction of the output has been reversed7

DOCPARENT: whether students have doctor parents (one or both); CSIMPROVE: whether students think their communication skills

need improving; GENDER: whether students are female; AGE: students’ ages.



Ta

ble

4U

niv

ari

ate

rela

tion

ship

sbet

wee

nsc

ore

son

the

neg

ati

ve

att

itu

de

subsc

ale

(NA

S)

an

dd

emogra

phic

an

ded

uca

tion

-rel

ate

dch

ara

cter

isti

csby

school

Nott

ingham

Lei

cest

er

Dem

ogra

ph

ican

d

edu

cati

on

-rel

ate

dch

aract

eris

tics

Med

ian

PA

Ssc

ore

(in

terq

uart

ile

ran

ge)

Tes

tst

ati

stic

P-v

alu

e*

Mea

nP

AS

score

(SD

)

Tes

tst

ati

stic

,P

-valu

e*

Age

–r¼

0Æ0

67,

P¼

0Æ2

30

–r¼

0Æ0

99,

P¼

0Æ2

06

Gen

der

Male

27

(25–32)

24

(21–28)

Fem

ale

27

(23–30)

Z¼

)1Æ7

41,

P¼

0Æ0

82

23

(20Æ2

5–26)

Z¼

)1Æ5

68,

P¼

0Æ1

17

Eth

nic

ity

Wh

ite

27

(24–31)

23

(20–26)

Non

-wh

ite

28

(25–31)

Z¼

)1Æ7

06,

P¼

0Æ0

88

26

(22–28)

Z¼

)3Æ3

52,

P¼

0Æ0

01

Soci

o-e

con

om

icst

atu

s

Non

-man

ual

27

(24–31)

24

(21–27)

Man

ual

occ

upati

on

s23

(20Æ2

5–29Æ5

)Z

¼)

1Æ3

20,

P¼

0Æ1

87

23

(21Æ5

–30)

Z¼

)0Æ2

00,

P¼

0Æ8

42

Fir

stla

ngu

age

En

glish

27

(24–31)

23

(20–26)

Non

-En

glish

29

(26–31Æ5

)Z

¼)

1Æ4

85,

P¼

0Æ1

38

26

(22–28)

Z¼

)2Æ7

07,

P¼

0Æ0

07

Do

stu

den

tshave

doct

or

pare

nts

(on

eor

both

)?

Yes

28

(24–32Æ5

)27

(22–31)

No

27

(24–31)

Z¼

)0Æ9

91,

P¼

0Æ3

21

23

(20Æ2

5–26)

Z¼

)2Æ4

08,

P¼

0Æ0

16

Su

bje

cts

stu

die

dpri

or

tom

edic

ine

Pu

resc

ien

ces

on

ly27

(24–31)

23Æ5

(20Æ7

5–27)

Non

-sci

ence

subje

ct(s

)27

(24–31)

Z¼

)0Æ7

87,

P¼

0Æ4

31

24

(21–27)

Z¼

)0Æ2

05,

P¼

0Æ8

37

Stu

den

ts’

rati

ngs

of

thei

row

n

com

mu

nic

ati

on

skills

–r¼

)0Æ0

20,

P¼

0Æ7

24

–r¼

)0Æ0

02,

P¼

0Æ9

76

Do

stu

den

tsth

ink

thei

r

com

mu

nic

ati

on

skills

nee

dim

pro

vin

g?

Yes

27

(24–31)

24

(21–27)

No

30

(27Æ5

–36)

Z¼

)2Æ6

36,

P¼

0Æ0

08

31

(27–32Æ5

)Z

¼)

2Æ7

40,

P¼

0Æ0

06

OS

CE

mark

(Nott

ingh

am

yea

r

2st

ud

ents

on

ly)

–r¼

0Æ0

57,

P¼

0Æ5

58

––

*N

on

-para

met

ric

stati

stic

sw

ere

use

d,

i.e.

Man

n–W

hit

ney

Zst

ati

stic

sor

Sp

earm

an

’sr

stati

stic

s.



than male students in a study to measure professional

attitudes before and after a communication skills

course. Additionally, in his review of the literature

surrounding communication skills learning in medi-

cine, Aspegren9 cited four studies,10–13 all of which

found that male students were slower at learning

communication skills than female students. This may

account for the less positive attitudes held by male

students in this study.

Although PAS and NAS scores were not found to be

significantly associated with socio-economic status, a

significant multivariate relationship was found for both

Nottingham and Leicester students between PAS

scores and whether students had parents (one or both)

who were doctors. Students with doctor parents had

lower scores on the PAS and higher scores on the NAS,

suggesting that they had less positive attitudes towards

communication skills learning than students who did

not have doctor parents. One possible explanation for

this finding is that doctor parents have poor attitudes

towards communication skills learning, possibly

because communication skills were not taught when

they were undergraduates, and that their children

are socialised into adopting these negative attitudes.

Indeed, several researchers14,15 have suggested that

poor attitudes are transferred from practising and

experienced health care professionals to students and

other less experienced workers.

First language was found to have a statistically

significant univariate relationship with NAS score for

Leicester students. Students whose first language was

not English had significantly higher NAS scores,

suggesting that their attitudes towards communication

skills learning were poorer. A possible explanation for

this finding was that non-English speaking students

(n ¼ 13, 31Æ7%) were significantly more likely to have

parents who were doctors (and thus poorer attitudes)

compared with students who were English-speakers

(n ¼ 18, 14Æ8%) (v2 ¼ 4Æ679, d.f. ¼ 1, P ¼ 0Æ031).

Indeed, when controlling for whether students had

parents who were doctors or not, no significant

relationship remained between first language and

NAS score for students who had doctor parents

(Z ¼ ) 1Æ428, P ¼ 0Æ153) or those who did not

(Z ¼ ) 1Æ741, P ¼ 0Æ082). This finding suggested that

the �doctor parent� variable was acting as a confounding

variable.

Ethnicity was found to have a statistically significant

univariate and multivariate relationship with NAS

scores for Leicester students. Students whose ethnicity

was non-white had significantly higher scores on the

NAS, suggesting that their attitudes towards commu-

nication skills learning were poorer. A possible explan-

ation for this finding was that non-white students

(n ¼ 17, 30Æ4%) were significantly more likely to have

parents who were doctors compared to students who

were white (n ¼ 14, 13Æ2%) (v2 ¼ 5Æ900, d.f. ¼ 1,

P ¼ 0Æ015). However, when controlling for whether

students had doctor parents or not, a significant

relationship still remained between ethnicity and

NAS score for students without doctor parents

(Z ¼ ) 2Æ478, P ¼ 0Æ013).

One reason for this finding may be that non-white

students at Leicester have different cultural beliefs

about the importance of communication skills within

medical practice. For example, a greater proportion

of non-white students at Leicester (compared to

Nottingham) may be international students who have

been socialised into a paternalistic model of medical

practice, which does not value the doctor–patient

relationship to the same extent as scientific knowledge.

In addition, Leicester students may not feel that their

specific communication needs are being catered for

appropriately in their communication skills course.

Although they have a module on cultural diversity,

unlike Nottingham students, they do not have sessions

Table 5 Multiple regression: dependent variable negative attitude subscale (NAS) score by school

Variable Coefficient B SE (B) Beta t Significance

Nottingham

Constant 5Æ838 0Æ178 32Æ853 0Æ000

CSIMPROVE ) 0Æ381 0Æ156 ) 0Æ134 ) 2Æ447 0Æ015

GENDER ) 0Æ137 0Æ063 ) 0Æ120 ) 2Æ196 0Æ029

Leicester

Constant 5Æ085 0Æ249 20Æ433 0Æ000

ETHNIC 0Æ277 0Æ082 0Æ254 3Æ373 0Æ001

CSIMPROVE ) 0Æ572 0Æ224 ) 0Æ192 ) 2Æ552 0Æ012

CSIMPROVE: whether students think their communication skills need improving; GENDER: whether students are female; ETHNIC,

whether students are non-white.



within the communication skills course that explicitly

cover communication issues with people of different

ethnic origins and with different first languages. This is

a particularly important issue given that over a third of

Year 1 students at Leicester are of non-white ethnic

origin.

The relationship between attitudes and education-

related variables

The variable �school� (i.e. communication skills courses

attended) had a statistically significant association with

both PAS and NAS scores. Leicester students had

higher scores on the PAS and lower scores on the NAS

than Nottingham students, suggesting that their atti-

tudes were better than Nottingham students. There are

two possible explanations for these findings. Firstly, the

differences between students’ attitudes may have resul-

ted from the different courses offered at each medical

school. As already mentioned, the teaching methods at

each school differ, with Nottingham using more didac-

tic teaching than Leicester. Interestingly, other research-

ers9,16 have suggested that lecture-based teaching is less

effective in terms of communication skills learning than

more practically oriented and problem-based learning.

Secondly, the differences between students’ attitudes

may have resulted from their different levels of experi-

ence regarding communication skills learning at the

time of survey completion. For example, Year 1

students at Leicester were surveyed at the start of their

communication skills course, Nottingham Year 1 stu-

dents were surveyed at the end of their first year course

and Nottingham Year 2 students were halfway through

their second year course. This suggests that students

may be developing more negative attitudes towards

communication skills learning as a result of attending a

communication skills course. Indeed, several research-

ers14,15 suggest that students’ attitudes can become

more negative as a result of teaching. However, this

data is cross-sectional and would need further explo-

ration in a longitudinal study.

Responses to the question �Do your communication

skills need improving?� were shown to have statistically

significant univariate and multivariate relationships

with PAS scores for Nottingham students and NAS

scores for Nottingham and Leicester students. Students

who felt their communication skills needed improving

had more positive and less negative attitudes towards

communication skills learning. A significant relation-

ship was also found between OSCE marks and PAS

scores for Nottingham Year 2 students. As OSCE

marks decreased, positive attitudes towards communi-

cation skills learning increased. Both these findings

suggest that students who felt their communication

skills were lacking (or who received poorer OSCE

marks) valued the opportunities afforded by commu-

nication skills learning more than students who felt

their communication skills did not need improving (or

who received good OSCE marks). These findings

contradict previous research4 that suggested that stu-

dents with better communication skills have more


ing than students with poorer communication skills. In

addition, a recent study by Cronholm et al.17 found

that biochemistry students who scored highly in their

written examination possessed significantly better atti-

tudes towards their biochemistry course than students

who did less well in their examinations. These incon-

sistent findings need investigating in further research.

This study possesses a number of methodological

limitations that must be taken into consideration when

interpreting the results. Firstly, the response rates for

Year 2 students at Nottingham University (66Æ0%) were

lower than those for Year 1 students at both Nottingham

(92Æ0%) and Leicester (93Æ7%). This poorer response

rate may have biased the results for Nottingham Year 2

students, with responders possibly having better or

poorer attitudes towards communication skills learning

than non-responders. Secondly, some of the variables

(e.g. language) are confounded with other variables (e.g.

whether students had parents who were doctors),

making some of the findings difficult to interpret.

Despite the methodological limitations of this study,

a number of findings have implications for educational

practice and further research. In terms of educational

practice, the findings suggest that positive attitudes

may be associated with more problem-based and self-

directed methods of learning in comparison with the

didactic teaching of communication skills. This sug-

gests that co-ordinators should reduce the level of

lecture-based teaching in their communication skills

courses. However, these conclusions can only be

tentative at this stage, and more research needs to be

conducted to determine which aspects of communica-

tion skills courses, e.g. content, teaching methods or

methods of assessment, are associated with students’

attitudes. This data can then be used to help

co-ordinators develop more successful communication

skills courses. The findings also suggest that commu-

nication skills courses should be designed with the

demographic and education-related profiles of the

medical students attending the course in mind. This

is particularly important for courses that have a high

proportion of students from ethnic minority groups.

In terms of further research, this study has suggested

that medical students’ attitudes towards communication



skills learning may change (i.e. get worse) over time,

perhaps as a result of studying communication skills.

However, this data is cross-sectional and may be due

to cohort effects, so we are currently conducting a

longitudinal study to assess medical students’ attitudes

before and after a communication skills intervention.

Contributors

Both authors contributed to the writing of the prelim-

inary and revised versions of this paper. CR designed

the study. Both authors participated in data collection,

data entry and data analysis.

Acknowledgements

Firstly, we would like to thank the students who

participated in this study. Secondly, we would like to

thank Susan Davies, a Year 4 medical student at the

University of Nottingham, for her help in entering study

data onto SPSS and conducting preliminary analyses.

Thirdly, we would like to thank Dr Paul Lazarus from

the University of Leicester for his help in organizing data

collection at Leicester and also for the information he

gave us about the Leicester communication skills

course. Finally, we would like to thank our colleagues

at the Universities of Nottingham and Leicester who

helped us collect data for this study. From the Univer-

sity of Nottingham Division of Psychiatry we would like

to thank (in alphabetical order) Drs Kim Cornish and

Paul Garrud and Amy McPherson. From the University

of Leicester Department of General Practice and

Primary Health Care we would like to thank (in

alphabetical order) Drs Aram, Cole, Coleman, de

Caestecker, Hastings, Hay, Heap, Professor Lindsey,

Dr McKinley, Professor Petersen, Drs Preston-Whyte,

Robinsen, Scarborough, Stokes, Sutton and Turner.

Funding

This study was funded by the Division of Psychiatry at

the University of Nottingham.

References

1 General Medical Council. Tomorrow’s Doctors. Recommenda-

tions on Undergraduate Medical Education. London: General

Medical Council; 1993.

2 Walker LG, Haldane JD, Alexander DA. A medical curricu-

lum: evaluation by final-year students. Med Educ

1981;15:377–82.

3 Rosenthal J, Ogden J. Changes in medical education: the

beliefs of medical students. Med Educ 1998;32:127–32.

4 Rees CE, Garrud P. Identifying undergraduate medical stu-

dents’ attitudes towards communication skills learning: a pilot

study. Med Teacher 2001;23:400–6.

5 Hargie O, Dickson D, Boohan M, Hughes K. A survey of

communication skills training in UK schools of medicine:

present practices and prospective proposals. Med Educ

1998;32:25–34.

6 Rees C, Sheard C, Davies S. The development of a scale to

measure medical students’ attitudes towards communication

skills learning: the Communication Skills Attitude Scale

(CSAS). Med Educ; 2002;36:141–7.

7 Tabachnik BG, Fidell LS. Using Multivariate Statistics. New

York: HarperCollins College Publishers; 1996.

8 Batenburg V, Smal JA. Does a communication skills course

influence medical students’ attitudes? Med Teacher

1997;19:263–9.

9 Aspegren K. Teaching and learning communication skills in

medicine: a review with quality grading of articles. Med Tea-

cher 1999;21:563–70.

10 Holm U. The Affect Reading Scale: a method of measuring

the prerequisites for empathy. Scand J Educational Res

1996;40:239–53.

11 Holm U, Aspegren K. Pedagogical methods and affect toler-

ance in medical students. Med Educ 1999;33:14–8.

12 Marteau TM, Humphrey C, Matoon G, Kidd J, Lloyd M,

Horde J. Factors influencing the communication skills of first-

year clinical medical students. Med Educ 1991;25:127–34.

13 Smith RC, Lyles JS, Mettler JA, Marshall AA, Van Egren LF,

Stoffelmayr BE, Osborn GG, Shebroe V. A strategy for

improving patient satisfaction by the intensive training of

residents in psychosocial medicine: a controlled, randomized

study. Acad Med 1995;70:729–32.

14 Kassebaum DG, Cutler ER. On the culture of student abuse

in medical school. Acad Med 1998;73:1149–58.

15 Rezler AG. Attitude change during medical school: a review of

the literature. J Med Education 1974;49:1023–30.

16 Rutter DR, Maguire P. History-taking for medical students.

II. Evaluation of a training programme. Lancet

1976;2:558–60.

17 Cronholm T, Hoog JO, Martenson D. Student attitudes

towards laboratory exercises in medical biochemistry. Med

Teacher 2000;22:30–4.

Received 24 July 2001; editorial comments to authors 22 October

2001; accepted for publication 13 May 2002



the relationship between medical students' attitudes towards communication skills learning and...

Documents