Patients' Perceptions of Communication and Clinical Skills of Primary Healthcare Physicians in Oman.

OBJECTIVES: As a large proportion of patients are seen in primary healthcare (PHC) centres, it is important to explore patients' perceptions of communication and clinical skills of PHC physicians. In Oman, PHC is provided by both trained family physicians (FPs) and general practitioners (GPs).
METHODS: This cross-sectional study was conducted at 12 PHC centres in Muscat Governorate, Oman between November 2014 and August 2015. Adult Omani patients' perceptions of Omani and other Arabic-speaking doctors were examined using an Arabic translation of a validated self-administered questionnaire.
RESULTS: A total of 626 patients completed the questionnaire (response rate: 100%). The patients' responses were significantly more positive towards FPs compared to GPs on whether the doctor provided reassurance (P = 0.03), took a complete medical history (P = 0.03) and gave the patient the opportunity of a follow-up with the same doctor (P = 0.01).
CONCLUSION: Certain skills in communication and clinical aspects of FPs were favourably viewed by patients compared to GPs.

Primary healthcare (PHC) plays a fundamental role in establishing strong healthcare systems.1 In addition, studies have confirmed the value of PHC in making healthcare systems more cost-effective.2 Patients’ perceptions are widely used as an indicator for assessing the performance of healthcare systems and has been frequently utilised by policymakers for corrective measures to improve healthcare services.3,4

Various studies have addressed patients’ opinions, perceptions or satisfaction about quality in PHC and in general, demonstrated positive perceptions and satisfaction towards PHC physicians.3–6 In Arab countries, several studies have focused on major aspects of PHC such as accessibility to care, communication skills and technical competencies; they found an overall good level of patient satisfaction.7–10

Albalushi et al.’s study was conducted in Muscat, Oman, in 2009 and focused on the major domains of care such as “accessibility to service, continuity of care, humaneness of staff, and effectiveness of services” and indicated an overall good level of satisfaction with PHC services.11 However, they reported dissatisfaction with the level of continuity of care.11 An earlier study in the rural Al Dhahira Governorate showed a positive association between patients’ perceived health status and satisfaction with quality of care.12 Another study conducted by Al-Mandhary et al. in Al Batinah region showed an adequate level of acceptance to Omani doctors.13 Their study assessed participants’ acceptance of the communication skills of their Omani doctor, care to the patient, absence of a language barrier, competence level, preference to be seen by a doctor of the same gender, embarrassment from seeing an Omani doctor, qualifications, experience, knowledge and skills of the Omani doctor and trust in the Omani doctor.13

In Oman, PHC is provided by two types of practitioners: 1) trained family physicians (FPs) who have undergone a structured four-year residency training in family medicine; and 2) general practitioners (GPs) who did not undergo any structured postgraduate training or have higher qualifications in other disciplines of medicine except family medicine. The majority of practitioners who work in PHC in Oman are GPs.

This study aimed to explore the perceptions of patients on the communication and clinical skills of Arabic-speaking PHC physicians and to identify any differences in the perceptions towards FPs and GPs.

Methods

This cross-sectional study was carried out between November 2014 and August 2015 at 12 PHC centres located in Al Seeb (n = 8) and Bowsher (n = 4) Wilayats in Muscat Governorate, Oman. There are 27 PHC centres in Muscat Governorate distributed in six Wilayats. Al Seeb and Bowsher Wilayats were selected because they have the largest population and highest number of total daily visits compared to other Wilayats in Muscat Governorate. The total number of visits to these two Wilayats represented approximately 57% of the total daily visits in Muscat Governorate.14

A sample size of 610 patients was calculated using nMaster, Version 2.0 (Department of Biostatistics, Christian Medical College, India) assuming a 70% positive perception, 80% power and 95% confidence level. The sample size was equally divided among the 12 studied PHC centres.

All Omani patients who were ≥18 years of age were included in this study. Patients who were illiterate or had impaired cognitive abilities were excluded. Data were collected through a self-administered questionnaire which consisted of two parts. The first part included socio-demographic information of the patients (age, gender and educational level), information about the visit (time and day of the week [workday or weekend]), first visit or follow-up, frequency of visits with the same treating doctor and their self-perceived health status (‘good’ or ‘not good’). The second part consisted of an Arabic translation of a validated 22-item scale created by Haddad et al.15 The scale was translated from English to Arabic following the standard procedure of forward-and-backward translation. This validated scale covers three main domains; doctor’s communication skills, clinical skills and result or outcome of care. The Cronbach’s alpha coefficients of the Arabic version ranged from 0.86–0.92 for the three domains. During the pilot study, patients were requested to complete questions under the domain of ‘outcome of care’ 1–3 weeks after the day of consultation. Despite several reminders, none of the participants responded. Hence, the researchers decided to omit the ‘outcome of care’ part of the questionnaire in the current study and to include only the first two domains.

The questionnaire was distributed by the main investigators with the help of healthcare assistants/ medical orderlies working in the participating PHC centres. Questionnaires were distributed to eligible patients who were seen by doctors who spoke Arabic. Questionnaires were given to patients after the consultation and upon completion were collected on the same day. The name of the physician was recorded by the healthcare assistant after the completion of the questionnaire and the details of the physician (gender, nationality, FP or GP and total years of experience) were later separately collected from the medical officer in charge of the PHC centre. Data collection were done during different times of the day and on both workdays and weekends.

A five-point Likert scale was used to classify responses as ‘strongly agree’, ‘agree’, ‘neutral’, ‘disagree’ or ‘strongly disagree’. The responses were then recategorised as ‘agree’, ‘neutral’ and ‘disagree’ for the purpose of analysis.

The characteristics of the respondents along with the gender and nationality of their treating physicians were expressed as proportions. The patient responses to the communication skills and clinical skills of their treating doctors were tested individually for any statistical association within the sub-groups of the specialty of their treating PHC physician using a Chi-square test. Statistical Package for the Social Sciences (SPSS), Version 20 (IBM Corp., Armonk, New York, USA) was used for data entry and analysis. A P value of <0.05 was considered statistically significant.

A written informed consent was obtained from all the participants and enrolment in the study was voluntary. The ethical approval for the study was obtained from the Research and Ethics Committee of the Ministry of Health, Oman (MH/DGHS/DPT/877/2014).

Results

A total of 626 participants completed the questionnaire (response rate: 100%). The majority of participants were ≤40 years of age (91.7%), had at least a secondary level education (93.5%), were female (74.8%) and reported their perceived health status to be good (85.9%) [Table 1]. A total of 125 PHC physicians working in the included centres were evaluated in this study. The majority of physicians were GPs (72.8%), had Omani nationality (88%) and were female (86.4%). The female-to-male ratio among GPs was 6:1 while among FPs it was 7.5:1 [Table 2].

Table 1

Characteristics of patients who completed the questionnaire on primary healthcare (PHC) physicians’ communication and clinical skills in 12 PHC centres in Muscat Governorate, Oman (N = 626)

Characteristic	n (%)
Gender
Male	158 (25.2)
Female	468 (74.8)
Age group in years
18–30	403 (64.4)
31–40	171 (27.3)
41–50	46 (7.3)
51–60	6 (1)
Education level
Elementary	13 (2.1)
Preparatory	28 (4.5)
Secondary	268 (42.8)
College/higher	317 (50.6)
Perceived health status
*Good	538 (86.5)
Not good	84 (13.5)

A total of 622 responded to this item.

Table 2

Characteristics of the primary healthcare physicians treating patients who were evaluated in the study (N = 125)

Characteristic	n (%)
	Male		Female		Total
Nationality	GP	FP	GP	FP
Omani	9 (69.2)	4 (100)	67 (85.9)	30 (100)	110 (88)
Non-Omani	4 (30.8)	0 (0)	11 (14.1)	0 (0)	15 (12)
Total	13 (10.4)	4 (3.2)	78 (62.4)	30 (24)	125 (100)

GP = general practitioner; FP = family physician.

Overall, patient responses were positive for most of the items regardless of whether the patient had seen a GP or a FP. However, FPs received better responses for almost all items but without reaching a level of statistical significance. Patients gave the lowest responses for the “time spent waiting to obtain test results was appropriate” and “the tests and exams prescribed by the doctor were appropriate in my opinion” items.

The patients’ responses towards FPs were significantly more positive compared to GPs on whether the doctor had reassured the patient (P = 0.03), had taken the complete medical history (P = 0.03) and whether the doctor permitted the patient to follow-up with them (P = 0.01) [Table 3].

Table 3

Percentage of ‘agree’ responses by patients regarding communication and clinical skills items comparing general practitioners versus family physicians at primary healthcare centres in Muscat Governorate, Oman (N = 616)

Item number	Questionnaire domains and items	Percentage of ‘agree’ responses*		P value†
		GP	FP
Communication skills of doctors
1	The doctor received me in a good manner (polite, kind and set me at ease).	91.7	96.7	>0.05
2	The doctor showed me respect regardless of my age, I expect to be treated as a person and not as a number.	92.3	95.8	>0.05
3	The doctor reassured me.	87.7	95.8	0.03
4	The doctor respected my privacy during the physical examination.	93.1	95.0	>0.05
5	The doctor listened to me and encouraged me to express my problems.	89.5	91.7	>0.05
Clinical skills of doctors
1	The doctor took my complete medical history (previous illnesses, personal problems and family history).	72.4	82.5	0.03
2	The doctor was skilled in making the physical examination more comfortable.	84.1	85.0	>0.05
3	The doctor explained my health problem clearly and completely (cause, seriousness and progress).	79.2	80.8	>0.05
4	The doctor involved me in decisions concerning tests and treatments.	74.0	78.3	>0.05
5	The doctor explained the tests and radiological findings clearly and completely (the process, and the test results).	80.2	85.8	>0.05
6	The time spent waiting to obtain test results was appropriate.	66.5	69.2	>0.05
7	The tests and examinations prescribed by the doctor were appropriate.	56.3	60.0	>0.05
8	I think the doctor made the correct diagnosis.	77.8	82.5	>0.05
9	The doctor explained the chosen treatment clearly and completely (process, effects and complications).	78.8	87.5	>0.05
10	The time spent in consultation with the doctor was appropriate.	82.7	88.3	>0.05
11	The doctors have given me the chance to see them for follow-up.	73.0	85.8	0.01
12	In general, the doctor’s care was good.	88.5	88.3	>0.05

GP = general practitioner; FP = family physician.

A total of 496 patients responded for general practitioners and 120 patients for family physicians.

Using Chi-square test.

Discussion

The current study has shown an overall good level of patient satisfaction with the performance of PHC physicians working in Muscat Governorate. These results are consistent with previous studies in terms of high levels of satisfaction with similar data.3,5,6 Patients’ perceived certain communication and clinical skills as significantly more positive in the FPs sub-group compared to the GPs; this may be attributed to better training as FPs in Oman undergo a four-year structured residency training program prior to receiving their qualification, unlike GPs who usually have no post-graduate training. A study from Thailand found similar higher patient satisfaction with FPs compared to GPs in the dimension of communication skills.16 Effective doctor-patient communication is one of the most important aspects of medical care and has been associated with a better doctor-patient relationship and positive health outcomes.17 Reassurance and relief of anxiety from illness plays a major role in physical and psychological well-being of the patient and should be considered as one of the initial management goals of PHC physicians.18

However, the current study has some limitations. No other study using the same scale utilised in the present study could be identified. Thus, it was not possible to compare these findings with other studies. This study was conducted in urban Muscat, which is different from other regions in Oman in terms of setting, patient characteristics and composition of PHC physicians which might affect the generalisability of the findings to other parts of Oman.

Conclusion

The findings of this study should reassure policymakers about the positive levels of patients’ perceptions regarding the communication and clinical skills of PHC physicians in Muscat, Oman. Overall, locally trained FPs possessed some key aspects necessary for the delivery of better healthcare. In addition, completion of training in a family medicine residency programme appears to result in acquiring better communication skills.