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Year : 2008  |  Volume : 21  |  Issue : 2  |  Page : 62

Communication Skills Training: Effects on Attitudes toward Communication Skills and Empathic Tendency

1 Adnan Menderes University, Aydin, Turkey
2 Npistanbul Neuropsychiatry Hospital, Umraniye, Istanbul, Turkey

Date of Submission29-Jun-2007
Date of Acceptance16-May-2008
Date of Web Publication25-Aug-2008

Correspondence Address:
H Harlak
Adnan Menderes University, Aydin
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Source of Support: None, Conflict of Interest: None

PMID: 19039739


Objective: This study explored and compared medical students' attitudes toward communication skills and empathic tendency before and after communication skills training.
Methods: Fifty-nine first-year students voluntarily completed a questionnaire consisting of the Communication Skills Attitudes Scale and the Empathic Tendency Scale before and after training. K-means cluster analysis and Student's t-test were used for statistical analysis.
Results: In the pre-test, 49% of the students had positive attitudes toward communication skills learning and 59% had higher empathic tendencies. In post-test, the mean score in the positive attitude group decreased significantly, whereas there was no change in the negative attitude group. In the high empathy group, empathy scores did not change significantly after training; however, in the low empathy group, empathic tendency significantly increased.
Discussion: As students' low empathic tendency level became higher and positive attitudes toward communication skills learning significantly changed in a negative direction after training, we observed that our training programme seems to have an effect that makes students similar to each other in terms of their empathic tendency and attitudes toward communication skills learning. Women had more positive attitudes toward communication skills and their empathic tendencies were higher than men's.
Conclusions: Our findings suggest that our curriculum is in need of further examination and modification. Future studies with larger samples are needed to investigate the effects of communication skills training on students' attitudes.

Keywords: Medical education, communication skills training, attitudes, empathy, undergraduates

How to cite this article:
Harlak H, Gemalmaz A, Gurel F S, Dereboy C, Ertekin K. Communication Skills Training: Effects on Attitudes toward Communication Skills and Empathic Tendency. Educ Health 2008;21:62

How to cite this URL:
Harlak H, Gemalmaz A, Gurel F S, Dereboy C, Ertekin K. Communication Skills Training: Effects on Attitudes toward Communication Skills and Empathic Tendency. Educ Health [serial online] 2008 [cited 2022 Jan 27];21:62. Available from:


Many medical educators and physicians appreciate the importance of communication skills (CS) for clinical practice (Lloyd & Bor, 1996). Harrison and Glasgow (1996) reported that students’ interview skills improved after training.

The long-term effects of CS training have not been assessed yet; however, studies have shown that students hold positive attitudes toward CS (Rees & Sheard, 2002). To our knowledge, there has been no study assessing attitudes toward CS with standard measuring tools and examining the effects of CS training in Turkey.

Physician’s empathic skills are critical for doctor-patient interaction (Ong et al., 1995). A study by Winefield & Chur-Hansen (2000) showed that 70% of first-year medical school students improved their empathic skills after training.

Previous studies on CS in medical education focused on either empathic tendency or attitudes toward communication. This study investigated and compared medical students’ attitudes toward CS and empathic tendencies before and after CS training.



During the academic year 2004-2005, first-year students (n=70) at the Medical School in Adnan Menderes University were invited to participate in the study, which was presented to and approved by Medical School Administrators and the Lecturer’s Committee for CS.


The questionnaire included the Communication Skills Attitudes Scale (CSAS) (Rees et al., 2002), Empathic Tendency Scale (ETS) (Dökmen, 1988) and questions about age and gender.

Communication Skills Attitudes Scale (CSAS)

The CSAS measures attitudes toward CS learning. It has two subscales (positive and negative), each consisting of 13 items on a 5-point Likert scale. The CSAS was previously translated into Turkish and then back-translated into English by three bilingual experts. The authors compared the two versions of CSAS items and created the final version.

Empathic Tendency Scale (ETS)

ETS is a 20-item self-report scale, using a 5-point Likert scale.


In our curriculum, CS training begins with basic CS (30 hours) in year 1 and continues with clinical CS in the remaining years. CS training in year 1 covers basic topics in communication (concepts, self and social perception, emotions and listening). Teaching methods are interactive presentations, exercises, role-playing, pair-works and group discussions. Family physicians and social and clinical psychologists are involved in the training programme.

In the first lecture, before any CS training, the questionnaire (pre-test) was presented to the students with the following instruction: “We would like to know your opinions about and attitudes toward CS in medical practice.” Participants were not informed about a post-test at the time of the pre-test. The post-test was completed at the end of year 1.

Statistical analysis

Data were analyzed using SPSS 13.0. Internal consistency was calculated for both scales in the pre-test. Pre-test students were grouped using K-means cluster analysis. Student’s t- and Wilcoxon z-tests were used to compare means in the pre- and post-tests.


A total of 59 of 70 students (84%, with 49% female respondents) participated in the study; 11 students were not present at the time of data collection.

Internal consistency of the Scales

Alphas were 0.84 for the Positive Attitudes Subscale (PAS) and 0.61 for the Negative Attitudes Subscale (NAS) of the CSAS. Since alpha was lower than 0.70 for NAS, we reverse-coded the data for negative items and calculated alpha for the total scale score: 0.82 in pre-test; 0.83 in post-test. This alpha justified the use of the scale with the total score. For the ETS, alphas were 0.75 in pre-test and 0.73 in post-test.

Cluster analysis

Students were grouped unintentionally into two groups for attitudes toward communication skills and empathic tendency by using K-means cluster analysis. In the pre-test, 29 (49%) students had positive attitudes toward CS learning and 35 (59%) had higher empathic tendencies (Table 1). These groups were named as positive and negative attitude group (PAG and NAG) and as higher and lower empathic tendency group (HEG and LEG). The mean scores of two CSAS clusters and of two ETS clusters significantly differed in pre-test (t=-0.87, d.f.=57, p<0.001 and t=-8.80, d.f.=57, p<0.001 respectively).

Comparisons of pre- and post-test findings

In PAG, attitudes decreased significantly after training, whereas in NAG they did not change significantly. In HEG, empathy scores did not change significantly however, in LEG empathic tendency significantly increased (Table 1).

Table 1: Pre- and Post-test Comparisons of First-year Medical Students’ Responses to Clinical Skills Training

Gender differences

Women students had higher mean scores than men in both CSAS and ETS and in pre- and post-tests. In the pre-test, CSAS scores and ETS scores were significantly different by gender (t=-3.49, p=0.001, t=-2.23, p=0.03, respectively). In the post-test, this difference was also significant for CSAS (t=-3.94, p=0.001) and ETS (t=-2.16, p=0.03).


At the beginning of CS training, almost half of our students had positive attitudes toward CS, similar to findings from a study by Dereboy et al. (2005). However, our students were not nearly as positive as students in a study by Rosenthal and Ogden (1998), who reported that 89.3% of first-year students agreed on the importance of CS training. This might be related to the fact that we used a scale to measure the attitudes, whereas Rosenthal and Ogden obtained their ratio from the participants’ single response to the statement: “Communication skills should be emphasized more.”

One of the effects observed was that our year 1 programme appeared to reduce the differences in students’ attitudes toward CS and their interpersonal CS. There was also a moderation in attitudes and empathic tendencies by the end of the year. In PAG, attitudes actually shifted to less positive. This change could be interpreted in terms of a “boomerang effect” due to negative perceptions about the source of influence (in this case the tutors). Another reason for this effect might be a phenomenon described as ‘reactance’, i.e. if people think a message is deliberately intended to persuade or manipulate them, then, they may not be easily persuaded (Brehm, 1966). A third reason might be a reaction to changing attitudes. Some students could have felt forced to behave in a specific way - different from what they were used to. Finally, it is possible that our curriculum itself was not effective enough to achieve the goal of changing students’ attitudes toward CS in a desirable direction.

Comparisons of empathic tendencies between pre- and post-tests indicated that in LEG, training increased students’ empathic tendencies whereas in HEG it did not. Hojat et al. (2004) found that empathic tendency decreased from the beginning to the end of the third year, more in line with our HEG participants.

Overall, women’s attitudes were more positive and their empathic tendencies were higher than men’s, which is consistent with findings from other studies (Rees & Sheard, 2002; Hojat et al., 2002). This might suggest the need for additional training for male students.

There are limitations to our study. First, data related to students’ perceptions about tutors were not collected. Gathering students’ feedback about tutors and course content after the classes would be useful in future investigations. Second, the number of students was limited, only 59 participated (though the participation rate was 84%). Third, given the study focus on first-year students, it was not possible to examine multiple and long-term effects on attitudes and empathic tendencies throughout medical school.


In view of our findings, it can be speculated that our curriculum is in need of further examination and modification in order to create positive changes in students’ attitudes toward communication skills. Future research comparing different medical schools and classes on larger samples is likely to enhance our knowledge about the effects of communication skills training on students’ attitudes.


Brehm, J.W. (1966). A Theory of Psychological Reactance. New York: Academic Press.

Dereboy, Ç., Harlak, H., Gürel, F.S., & Gemalmaz, A. (2005). Tıp eğitiminde eşduyumu öğretmek [Teaching empathy in medical education]. Türk Psikiyatri Dergisi [Turkish Journal of Psychiatry], 16: 83-89.

Dökmen, Ü. (1988). Empatinin Bir Modele Dayandırılarak Ölçülmesi ve Psikodrama ile Geliştirilmesi. [Measuring empathy based on a model and improving it by psychodrama] A.Ü. Eğitim Bilimleri Fakültesi Dergisi [Ankara University. Journal of Educational Sciences], 6: 155-190.

Harrison, A., & Glasgow, N. (1996). Communication skills training early in the medical curriculum: UAE experience. Medical Teacher, 18: 35-44.

Hojat, M., Gonnella, J.S., Mangione, S., Nasca, T.J., Veloski, J.J., Erdmann, J.B., et al. (2002). Empathy in medical students as related to academic performance, clinical competence and gender. Medical Education, 36: 522-527.

Hojat, M., Mangione, S., Nasca,. T.J., Rattner, S., Erdmann, J.B., Gonnella, J.S., et al. (2004). An empirical study of decline in empathy in medical school. Medical Education, 38, 934-41.

Lloyd, M.,& Bor, R. (1996). Communication Skills for Medicine. New York: Churchill Livingstone.

Ong, L.M.L., DeHaes, J.C.J.M., Hoos, A.M., & Lammes, F.B. (1995). Doctor-patient communication: A review of the literature. Social Science and Medicine, 40: 903-918.

Rees, C., & Sheard, C. (2002). The relationship between medical students’ attitudes towards communication skills learning and their demographic and education-related characteristics. Medical Education, 36: 1017-1027.

Rees, C., Sheard, C., & Davies, S. (2002). The development of a scale to measure medical students' attitudes towards communication skills learning: The Communication Skills Attitude Scale (CSAS). Medical Education, 36:141-147.

Rosenthal, J., & Ogden, J. (1998). Changes in medical education: The beliefs of medical students. Medical Education, 32: 127-132.

Winefield, H.R., & Chur-Hansen, A. (2000). Evaluating the outcome of communication skill teaching for entry-level medical students: Does knowledge of empathy increase? Medical Education, 34: 90-94.


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