The teaching of clinical communication has been extensively explored in the field of medical education in the West, including with regard to curricula, assessment, learning outcomes, and educator training [
1‐
7]. The recent expansion of this research area has been reflected in the increased emphasis on communication skills in many medical education programmes worldwide. Moreover, regardless of this emphasis in current teaching, clinicians and medical practitioners have to interact with patients from different milieus and with varied experiences. Therefore, knowing how to adapt to address patients’ concerns and communicative needs is of substantial importance for medical students [
8].
Researchers have begun to conduct empirical studies to test the effectiveness of different teaching models. For example, Brown and Dearnaley investigated the effectiveness of an integrated clinical communication programme involving a medical school and a hospital [
9]. They concluded that such an integrated approach could motivate students to reflect on the model of patient-centred care, its usefulness for collecting clinical histories, and its role in building rapport with patients. The study thus demonstrated that an integrated approach could help medical students bridge the gap between learned theory and practice by teaching them to approach clinical communication holistically. A quasi-experimental study conducted by Rashwan et al. further demonstrated the effectiveness of holistic medical training by evaluating the effects of scenario-based clinical simulation (SBCS) sessions on students, including their anxiety levels [
10]. According to the findings, all of the students in the intervention group achieved satisfactory total percent scores when tested on their clinical communication skills after two weeks of SBCS sessions, while only 20% of the control group performed well (
p < 0.001). It was also found that the first group of students were able to train their psychomotor, cognitive, and interpersonal skills simultaneously in one clinical scenario during a simulation session. The findings suggest that training such as SBCS sessions enables medical students to collaborate and reflect on each other’s performance, thus preparing them to work as teams in highly complex medical settings [
11].
Experiential learning is another approach to clinical communication learning that helps students connect theories to real practice. Quilligan found that medical students could maximise their experiential learning in busy wards by practising their communication skills in a wide range of scenarios [
12]. The findings also revealed medical students’ ability to adapt their communication based on the needs of an environment made complicated by the diversity of patient groups and their different health literacy levels, the nature of observed interactions, the students’ own actions, and input from role models. Experiential learning and holistic and integrated approaches to clinical communication teaching can thus help medical students gain practical and real-life experience in encountering patients. However, these methods might not be sufficient to help students learn how to deal with rare but critical clinical situations. As Shorey et al. noted, this is partly why medical educators use technological tools such as virtual reality platforms in modern pedagogy [
13]. Using the Virtual Counselling Application using Artificial Intelligence developed by the National University of Singapore, the researchers found that the use of virtual patient simulations enhanced the students’ sense of preparedness and confidence, thus helping them become more effective communicators.
As most studies on clinical communication training have been conducted in the West, their findings may not apply to the socioculturally different East. In addition, they may have neglected developments in the latter context. Consequently, the perceptions of clinical communication and its training by Eastern physicians need to be explored and reported to improve clinical communication and thereby patient-centred care in the East. For instance, Ishikawa and Yamazaki outlined the ways in which studies may not have accounted for how clinical communication may differ across sociocultural contexts [
14]. They based their compositional approach to culture on the idea that culture is a manifestation of all aspects of social life and is a layered structure of rituals, practices, hidden beliefs, and assumptions. They noted some core cultural differences between the East and the West that affect physician–patient relationships: (1) individualism vs collectivism and (2) high-context vs low-context communication. For example, as members of a high-context culture, Chinese people in general are evasive about death; some even believe that mentioning the word ‘death’ can lead to actual deaths [
15]. This evasive attitude leads many patients’ families to misguidedly believe that modern medicine is always able to prevent deaths, and that death is due to the doctors’ failure to properly treat patients [
15]. In this way, end-of-life communication in the Chinese context is very different from that in the West. Achieving effective patient-centred care requires research into the lived experiences of medical educators to explore the teaching of clinical communication in culturally specific contexts. This research would facilitate the development of local and culturally appropriate teaching models and cultural competence among students.
Clinical communication in the East Asian and Hong Kong contexts
As noted by Lu et al., globalisation has made it necessary for medical educators to respond to increased cultural diversity [
16]. Cultural competence, an attribute that has been stressed by the US Association of American Medical Colleges [
17] and the UK General Medical Council [
18], is important for medical professionals because it helps to prevent miscommunication and establish culturally appropriate expectations of healthcare [
19]. The role that medical educators play in helping medical students prepare for effective communication with their future patients, regardless of the patients’ social or cultural backgrounds, has thus become widely recognised [
20‐
22].
While clinical communication teaching as a whole has been investigated widely in recent years [
20], the aforementioned recognition has in the past few decades led to a specific increased focus on cultural competence within this research. Within the international medical community, the capacity to communicate effectively with patients from specific cultural backgrounds has become commonly recognised as a desirable attribute of a graduate [
23‐
26], and a comprehensive system for evaluating cultural competence in medical education has been developed [
16]. However, there is a dearth of studies exploring this topic in the Chinese context. The lack of attention in this context to the diversity of patients’ cultural backgrounds also means that local curricula have not considered cultural competence to be a core element of medical professionalism [
27].
A number of studies highlighting the particularities of East Asian clinical contexts have demonstrated the importance of filling this research gap and moving beyond strictly Western models of communication practices in clinical settings. For instance, in a review article on health professional–patient communication practices in East Asia, Pun et al. noted that patients from different East Asian countries have different attitudes towards death and terminal illnesses [
28]. Specifically, Taiwanese patients’ families are often reluctant to discuss end-of-life issues. Upon receiving bad news, both Taiwanese and Korean patients’ families leave decision-making to the oldest family member. Japanese patients’ families tend to bring patients home for end-of-life care. By highlighting the role of families in decision-making on treatment, Pun et al. demonstrated the complexity and heterogeneity of clinician–patient communication in East Asia [
28]. These findings indicate that when incorporating the teaching of cultural competence into medical education systems, it is necessary to develop culturally appropriate communication approaches for specific cultural contexts within Asia.
To teach clinical communication with cultural appropriateness in a specific Asian context, it is important to first break down the cultural homogeneity inherent in the existing medical education system. In Hong Kong, for example, there are two official languages, namely Chinese (both written Chinese and its spoken varieties, including Cantonese and Putonghua) and English, which leads to difficulties specific to medical practice in the region [
29]. In a study examining clinical handover in a bilingual setting in Hong Kong, Pun found that the bilingual staff usually had little to no familiarity with Chinese medical terminology and thus read and recorded almost all of the medical information in written English [
30]. Pun also observed that most of the staff in this bilingual context code-switched or engaged in translanguaging between spoken Cantonese and English medical terminologies [
31]. These findings relate to the problem of miscommunication that may arise due to differences in the language used for medical terms and everyday conversation, as indicated in Pun et al.’s earlier study, which observed that medical information was altered when staff switched between spoken Cantonese and spoken English [
32]. The findings of these studies indicate that for medical students, the homogenous use of English in the teaching of clinical communication leads to gaps in their training, potentially leading to miscommunication with local Cantonese-speaking patients in real-life practice.
Beyond linguistic concerns, research has found that doctors in Chinese-speaking Asian contexts rely on their own experiences rather than formal medical education to learn about and adapt to different cultural contexts [
16]. In a study conducted in Taiwan, Lu et al. found that the lack of teaching materials on cultural competence in clinical communication had led to culturally essentialist beliefs, such that Taiwanese doctors tended to stereotype and oversimplify certain cultures that they encountered instead of trying to understand their complexity [
16]. Because medical schools in Asia had few communication training programmes that focused on the Chinese-speaking context, students were prepared only to communicate medical information, not to address patients’ emotional needs [
33].
The unique linguistic and sociocultural features of the Chinese-speaking context make Western teaching models inapplicable to such settings. This indicates the need for a new, culturally appropriate approach to clinical communication teaching in the Chinese-speaking context that is grounded on an understanding of the specific clinical needs of each field of medicine. Addressing this research gap can help build an effective system for teaching clinical communication in Chinese-speaking settings. Therefore, this study explored the perspectives of clinicians from different disciplines in Hong Kong to inform medical educators about current trends in teaching approaches, issues, and topics relevant to local clinical communication, with the aim of improving clinician–patient relationships.
While Hong Kong culture is similar to other Chinese cultures in some respects, Hong Kong also has distinctive cultural features that have implications for local clinical communication education. In one study, Hong Kong patients were found to be keen to appropriate the Western model of patient-centred care [
28]. In another study, they were found to be open to discussions of advanced malignancy and willing to have direct involvement with their end-of-life arrangements [
34]. Medical educators can address these patient preferences by helping students develop greater rapport and empathy with patients [
35]. At the same time, such a teaching approach may counter the patriarchal elements of Chinese culture present in Hong Kong medical settings.
Teaching clinical communication with a multidisciplinary approach
As confirmed by Tahir et al. in their investigation of interprofessional relationships and medical school teaching in primary social care settings [
36‐
39], it is important to train clinicians in the early stages of their careers in clinical communication via approaches that integrate care strategies from different disciplines. Despite the established benefits of cross-disciplinary training, only a few empirical studies have gathered data from multiple disciplines to investigate doctor–patient encounters in hospitals, as noted by Jensen et al. in their own such study in Norway [
40]. They found that the Four Habits training model (invest at the beginning, elicit the patient’s perspective, demonstrate empathy, and invest at the end), originally developed by Krupat et al. [
41], was a suitable generic tool for teaching clinical communication to postgraduates across the following clinical settings (excluding psychiatry): anaesthesiology, paediatrics, surgery, internal medicine, gynaecology/obstetrics, neurology, orthopaedics, and ear–nose–throat medicine. They also found that a 20-hour intervention course derived from the Four Habits model was able to improve doctors’ communication skills and lead them to implement a more patient-centred model when treating patients. Their results show that through investigating the perspectives of clinicians from different disciplines, researchers may inform the development of medical communication training programmes that are applicable across many clinical settings. Such programmes may more effectively teach clinical communication, particularly in settings such as the intensive care unit (ICU) where physicians from different departments frequently cooperate with each other.
Extensive discipline-focused research on clinical communication teaching using interdisciplinary approaches has been conducted in the US [
41] and European countries [
36,
40]. However, no such studies have been conducted in Asian contexts, and in Chinese-speaking settings in particular. The importance of context-specific research that assesses the suitability of particular teaching approaches to clinical communication was illustrated by Bellier et al. [
42]. Their cross-cultural study sought to explore the suitability of the Four Habits coding scheme for assessing clinical communication skills in France. According to their findings, the French version of the scheme demonstrated satisfactory internal consistency, but the real effects were moderate, and two raters were needed to effectively assess the clinical communication skills acquired by medical students. Therefore, it is necessary to conduct discipline-focused research on clinical communication teaching across specialties in different Asian and Chinese-speaking regions to gain a comprehensive overview of this area of medical education and to develop culturally appropriate, multidisciplinary teaching approaches.
This study focused specifically on the context of Hong Kong, as the city is considered an ‘entrepreneurial city’ in terms of its entrepreneurial discourse, narratives, and self-image [
43]. Many sectors, including the medical sector and academia, adopt an entrepreneurial mindset in their daily operations in response to global trends in the knowledge economy [
43]. Therefore, Hong Kong is a site at which the East converges with the West, and is a global hub for knowledge and cultural exchange. As a result, the city serves as an effective research base for researchers investigating intercultural clinical communication. Researchers may evaluate and compare Western and Chinese medicine in terms of clinicians’ communication strategies, patients’ expectations and satisfaction, and transfers between the two systems. Moreover, owing to the increasingly globalised patient population in Hong Kong, the city’s healthcare system exemplifies the general way in which healthcare is increasingly conducted in culturally and linguistically diverse settings around the world.