physician - patient communication is well recognized as an important component of good quality health care . although much academic attention has been given to physician - patient communication and its improvement in the western world , research on this topic has only recently begun in the arabian gulf countries . there is a growing interest in this part of the world in physician - patient communication , particularly in regards to the breaking of bad news to a patient and family and communicating with patients with diabetes . the modest literature available suggests that physicians in the arabian gulf countries may benefit from some guidance on how best to communicate in a challenging culturally complex clinical environment . we are aware of only two such published communication skills training programs in this region . a 1-day workshop in saudi arabia for physicians , interns , and students received favorable reviews . educators in oman published a 3-day curriculum for communication skills training , but no results were given . salem and salem broadly generalized some of the beliefs and expectations about the delivery of bad news as illustrations of the differences between eastern and western cultures . they categorized these differences as health - care decisions ; patient 's perspective of bad news ; the family 's involvement in decision  making for a patient 's illness . further , they assert that in muslim cultures , there is concern that a patient 's knowledge of his illness will have a psychological impact leading to low self - esteem , in contrast to western belief that patients have the right to be given the news whatever it is to make better decisions about their care . finally , the illness experience is seen as a family event in arabic and muslim cultures , rather than a personal event as viewed in the west . it should be noted that these are broad generalizations that may not apply to all muslim countries . nevertheless , the multicultural makeup of some arabian gulf countries , although enriching , creates challenges in health - care communication . several factors led to the development and implementation of the training course being reported here . hamad medical corporation ( hmc ) in doha , qatar , has been accredited by both the accreditation council for graduate medical education - international and the joint commission international , leading to increased accountability for the quality of care , education , and patient safety . a previous study in qatar found that the perceived quality of communication between doctor and patient was related to patient satisfaction . in addition , published research demonstrates that people with different cultural backgrounds outside the mainstream of society generally have less access to health care and worse health - care outcomes . it has also been shown that poor communication is the root cause of malpractice claims . since march 2014 , practicing hmc physician specialists applying for promotion to consultant positions ( attending faculty ) the title  specialist  as used in our hospital typically refers to physicians who have completed a residency program followed by board certification , but who do not practice as completely independent consultants or attending physicians . the course prepares these physicians to assume important educational roles as faculty , and improve their delivery of healthcare . the restructuring of physicians ' appointments at hmc as part of the recognition into an academic health system led to many such promotions . the objective of this paper is to describe the implementation of and participants ' satisfaction with a large - scale communication skills training program for specialists in qatar . in addition , we posed the following research questions : 
 what percentage of course participants had previously participated in communication skills training?did previous participation in a communication skills training had any impact on the satisfaction with the current course ? what percentage of course participants had previously participated in communication skills training ? did previous participation in a communication skills training had any impact on the satisfaction with the current course ? participants were predominantly specialist physicians at hmc , a nonprofit public health - care system which provides health - care services throughout qatar . hmc manages eight public hospitals and other health - care services and employs more than 23,000 people . physicians are of many different nationalities , speak different languages , and had often attended medical school and/or had residency training outside of qatar . at the time we began the program , there were approximately 1150 physicians who were specialists . we partnered with the communication skills training and research laboratory at memorial sloan - kettering cancer center ( mskcc , new york , usa ) to run a communication skills training program culturally tailored for our institution . the program developed at mskcc , the comskil model , describes a theory - based , hierarchical structure of health - care communication skills . while these are very useful for early learners such as medical students , they appeared too basic for more advanced learners . for the teaching of practicing physicians , we felt it necessary to have a model that was flexible for many types of medical consultations and allowed for a more learner - centered approach , based on the learners ' strengths . in addition , the skills - based comskil model allowed for discipline and cultural adjustments . the program comprised seven modules to be given on two consecutive days : breaking bad news , shared decision - making , responding to patient anger , working with interpreters , discussing prognosis , discussing end of life goals of care , and conducting a family meeting . the methods of teaching followed international best practice and mirrored the approach taken at mskcc . each module began with a didactic presentation that reviewed relevant studies and explained suggested techniques and skills for that particular module , including demonstration trigger videos for a large group discussion . four of the seven modules included facilitator - led small group role - play sessions with trained standardized patients ( sps ) . role - play facilitators were healthcare physicians or other providers who had previously completed the course and had been identified as having an interest in becoming facilitators . those who participated in this study attended a training course . to keep their appointment , facilitators were required to participate twice during each academic year and attend one refresher course . sps are nurses who volunteered to participate in the program and completed a training course in january 2015 . although we kept the core of the mskcc comskil curriculum , in terms of educational approach and the skills - based curriculum , changes were made in the modules to meet local and cultural needs . the names and patient backgrounds in the role - play scenarios were changed to be more consistent with those seen in our country . locally used metaphors and terminology were employed . studies from regional and culturally similar countries and information about hospital policies to the didactic sessions for topics such as breaking bad news and end of life discussion were added . we have also developed new local videos for some modules that show our own doctors meeting with simulated patients . we significantly changed the focus of two of the modules , to be better tailored culturally to our population . the module on  conducting a family meeting  was changed to place emphasis on how to respond to the historically cultural practice of families asking doctors to withhold the disclosure of life - threatening disease to patients and place strong emphasis on the role of the family from the arab and islamic perspectives . the module on  working with interpreters  was also changed to focus on working with untrained interpreters , as there is no department of trained interpreters . finally , a variety of role - play scenarios were developed to meet different needs of the various disciplines : pediatrics , obstetrics and gynecology ( obgyn ) , medicine , critical care , surgery , and cancer . because each small group was interdisciplinary , the facilitators had to guide the selection of a role - play that was available , or developed a new one within the group . a 17-item online survey with qualtrics survey software was sent to the physicians after the training . three reminders were sent in a period of 10 days following the initial survey e - mail . evaluation items included an overall 5-point scale rating of satisfaction ( very dissatisfied - very satisfied ) ; rating of how much the components of the training ( e.g. , presentation , role - play ) helped improve communication skills using a 4-point scale rating of the usefulness of the individual modules again on a 4-point scale . there were also open - ended questions on the strengths and weaknesses of the workshop . in addition , physicians were asked if they had ever participated in a communication skills training workshop that included role - play . question was specifically asked about role - play as an indicator of experiential learning , which is widely accepted as the most critical part of communication skills training . data were transferred from qualtrics software ( provo , ut , usa ) into spss version 22 ( armonk , ny , usa : ibm corp ) for analysis ; frequencies and percentages were calculated , and statistical significance was tested using chi - square test . to examine the role of previous experience on the ratings , dichotomous variables were created for satisfaction ( very satisfied and satisfied vs. other ) , helpfulness of components ( none / little vs. some / a lot ) , and usefulness of individual modules ( completely useless / useless vs. useful / very useful ) . because the number of participants who gave low ratings was small , a second set of dichotomous variables was created to split the highest ratings ( very satisfied , a lot , and very useful ) from the rest . it was attended by 410 physicians , 326 of whom completed the course evaluation yielding an 80% response rate . these physicians came from 26 departments , and the number of participants per course ranged from 21 to 39 ( average = 27.33 ) . overall , participants were satisfied with the 2-day course , with 39.2% of the doctors responding very satisfied and 48.8% of doctors responding satisfied . as shown in table 1 , all modules received a high rating for usefulness . the module of breaking bad news received the highest combined ratings of useful and very useful . participants found the small group role - play the most helpful component of the course for improving their communication skills , with 20% reporting  some  and 77% marking physicians ' ratings of usefulness of modules for their communication with patients physicians ' ratings of helpfulness of components of communication skills workshop for improving communication skills the most frequent response to the open - ended question on what was found the most useful was role - play , ( 27% ) . however , the majority ( 57% ) of respondents answered this question by referring to a module topic , and  breaking bad news  was the most frequently quoted . answers to the question on the improvement of the workshop were diverse , with suggestions on timing , length of course , logistics , role - play scenarios , videos , and having it more tailored to specific disciplines . participants most frequently suggested the following topics for future workshops : communication with other health - care staff , medical errors , adverse events , and requesting consent , as well as topics on specific specialties ( e.g. , communicating with parents of a young child ) . one - third ( 33.3% ) of the physicians reported that they had previous experience of communication skills workshops that included role - play . there were no differences between those with previous experience and those without , on any of the dichotomous ratings of satisfaction , helpfulness of course components , and usefulness of the modules . improving health - care communication is an important undertaking , particularly in arab and muslim countries of the arabian gulf region , where multi - cultural influences are at play . overall , the doctors who participated in our training program reported that they were very satisfied and gave high ratings for the elements and modules of the course . they reported that the experience of role - play was the most useful for improving their own communication skills and that the module on breaking the bad news was the most helpful . participants in a course implemented in saudi arabia also reported that role - play was a major strength of the workshop . approaches to education such as role - play work in non - western countries , our results , as well as those from the saudi arabian study , indicate that experiential role - play could have cross - cultural effectiveness . communication skills training has not historically been part of medical education in this region , and some other regions where our doctors were trained . this is supported by the fact that two - thirds of the doctors who attended our course had never been on an experiential communication skills training course , though it is possible that they had participated in lectures or discussions related to communication in healthcare . it is interesting that previous experience with communication skills training was not associated with satisfaction with the course or evaluations of it . it may be that previous training was so varied in content , format , and had taken place so long ago that it did not impact the evaluations of this course in any systematic way . our experience may serve as a model for utilizing external expertise to initially implement a communication skills training program and subsequently build the capacity to sustain the program using only local resources . however , there are challenges to such a model . transferring a western health - care communication curriculum into a multicultural muslim arab culture is not the easiest thing to do . for instance , the cultural practice in some cases is to disclose the diagnosis of cancer or any life - threatening disease for that matter to the family but not to the patient . despite the hospital policy on patients ' rights to information , the reality is that information is rather disclosed to families and withheld from patients . the module on breaking the bad news that does not take this into account is thus not culturally - sensitive . the rapid demographic changes in qatar , as well as the numerous languages , in excess of 40 , spoken by the patient population , are barriers to such a program . consequently , we adapted the module to suit working with untrained interpreters . to make the program more applicable in qatar , we initially adjusted the role - play scenarios to the local culture by changing the names and background characteristics of the patients . however , the didactic presentations cited western studies and the physicians and patients acting in the exemplary videos were primarily caucasian . in addition , the initial program was focused on cancer only , but since our groups were multidisciplinary we have eventually modified the presentations and created some videos of our own . however , more improvements are required . creating videos with a local flavor seems to be a particularly important part of tailoring the curriculum to fit our cultural milieu . building and retaining a core of dedicated and skilled instructors and facilitators also takes time . this has been the objective of our train - the - trainer courses , monthly e - newsletters , and refresher courses we will continue to put resources into keeping our teaching faculty skilled and enthusiastic as participants , as the program is only good as long as there is continued engagement in teaching and interest as facilitators . teaching new consultants as well as keeping a strong cadre of skilled instructors may also contribute positively to counteracting the  hidden curriculum ,  the implicit learning that happens outside the classroom , usually through the transmission of cultural norms and role modeling . as trainees interact with the faculty who have participated in the workshop , it is our hope that they will increasingly become aware of models of good communication skills and patient - centered care . another consideration when organizing such large scale communication skills training programs is whether to teach the course using a multidisciplinary approach , as we have done , or focus on specific disciplines such as obgyn or cancer . , it may be more feasible to have participants from different departments come on the same day so that patient care is not unduly affected . in addition , participants seemed to genuinely appreciate meeting and learning from each other , although physicians reported that they would like to have more discipline - specific videos and role plays . limitations of this study include the lack of evidence of skills transfer to real encounters with patients . with diverse group of trainees from several hospitals , such since the survey did not sought any demographic information , it is impossible to look for associations with gender , years of experience , etc . a further limitation is our inability to triangulate our data with precourse evaluation data , which was not collected . our future work includes continuing to fine - tune the implementation and curriculum of our program . we also would like to expand our module topics to include some of the challenging scenarios that the participants mentioned in their course evaluations . these include consent , discussion of adverse events , and communication with other health - care providers . finding a feasible and effective way to measure the impact of the course on actual practice is also a priority . the result of the evaluation of this program conducted over a 2-year period shows that the communication skills training course was well accepted and was effective in helping our physicians learn new communication skills . as this program progresses , we hope to make a substantial and sustainable difference in the quality of care through improved communication skills . educators in non - western countries may find that initially using western - developed communication skills training programs with some cultural modifications may be feasible and acceptable . role - play , in particular , seems to be an acceptable valuable teaching strategy .
objective : health - care communication skills training may be particularly needed in the arabian gulf countries because of the variety of cultures within the physician and patient populations . 
 this study describes the implementation and results of a communication skills training program for physicians in qatar that assessed previous training , and effect of previous training on participants ' course evaluations.materials and methods : we conducted a 2-day communication skills training course covering seven culturally adapted modules . 
 educational strategies included large and small group work with the standardized patient , demonstration videos , and lectures . at the end 
 , participants completed a course evaluation survey . 
 data analysis performed with spss ; frequencies and percentages were calculated , and chi - square test applied to evaluate statistical significance.results:a total of 410 physicians in qatar have participated in the course over a period of 2 years . 
 evaluation ratings of the course were high . 
 participants rated the module on breaking bad news as the most useful , and the small group role - play as the most helpful course component . 
 one - third of participants had previously participated in experiential communication skills training . 
 there was no association between previous experience and evaluation of the course.conclusion:physicians in qatar positively evaluated a 2-day communication skills course , though the majority of participants did not have any previous exposure to experiential communication skills training .