International Journal of Public Health Science (IJPHS)

Vol. 10, No. 2, June 2021, pp. 361~369

ISSN: 2252-8806, DOI: 10.11591/ijphs.v10i2.20612  361

Modification of Calgary Cambridge for Indonesian medical

students: Communication guidelines

Galih Cahya Wijayanti1, Rizma Adlia Syakurah2, Mariatul Fadilah3

1
Medical Profession Students, Medical Faculty, Sriwijaya University, Indonesia
2
Public Health Faculty, Sriwijaya University, Indonesia
3
Indonesian Medical Council, Indonesia

Article Info ABSTRACT

Article history: Effective communication skill applied by doctors in the doctor-patient
consultation process becomes one of important factors that can improve the
Received Aug 8, 2020 consultation outcomes such as patient satisfaction, adherence to treatment
Revised Jan 8, 2021 and recovery process. However, effective doctor-patient communication is
Accepted Mar 12, 2021 rarely applied in practice. Limited consultation time, patient overload, doctor
burnout, and poor communication skills are among the factors that cause
ineffective doctor-patient communication process. This study aimed to
Keywords: develop a new effective communication guideline for doctor-patient
communication in Indonesia by modifying the Calgary Cambridge medical
Calgary Cambridge Guide interview guide. This study uses qualitative approach within four stages:
Doctor patient communication expert panel, student panel and focus group discussion, expert review, and
Modification trials. Informants were chosen purposively. Three points of high category, 24
points of middle category and 44 points of low category are resulted from
expert panel stage which consists of specialist representatives from 12
clinical divisions in Dr. Moehammad Hoesin central public hospital
(RSMH), Palembang, South Sumatera, Indonesia. The high and middle
category were discussed by two groups of internships doctors in RSMH in
student panel and focus group discussion (FGD) session. The results were
validated by a doctor-patient communication expert (expert reviewer) and
then tested by the internship doctors through role play at the trial stage. The
final result yields eight main points and eleven effective tips of the Calgary
Cambridge Guide checklist modification with five to six minutes effective
consultation time. This modified guideline is appropriately applicable for
doctor-patient communication in daily consultation in Indonesian practical,
social and cultural context.
This is an open access article under the CC BY-SA license.

Corresponding Author:
Rizma Adlia Syakurah
Public Health Faculty
Sriwijaya University
Jl. Raya Palembang-Prabumulih KM. 32 Indralaya, Ogan Ilir, Sumatera Selatan, 30662, Indonesia
Email: [email protected]

1. INTRODUCTION
Communication in the medical field which is one of the basic clinical skills included in the
competency area that has been validated by the Indonesian Medical Council is important to be developed in
order to build the clinical competence of a doctor along with the clinical knowledge, problem solving skills,
and physical examination [1]-[3]. Doctor-patient communication skills (the ability to hear, empathize, and

Journal homepage: http://ijphs.iaescore.com

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use open sentences) have been shown to affect medication adherence, increase patient satisfaction, and the
healing process [4], [5].
In terms of clinical expertise, Indonesian doctors are as skilful as the foreign doctors, but not in the
doctor-patient communication aspect where the foreign doctors are better than the Indonesian doctors. Some
patients testify that the medical treatments in Singapore are very satisfying because the consultation process
with the doctor can take an hour. In Indonesia, on the other hand, the doctor-patient communication tends to
be a one-way process and it is quite rare for a patient to get adequate time for consultation, even for fifteen
minutes of time, so the patient's need to communicate their health problems and get a convincing response
from the doctor is not fulfilled. Basic communication, such as asking the patient's name, introducing
themselves, and giving informed consent is quite seldom to be implemented by doctors [6], [7]. Time
limitation, large number of patients, doctor fatigue and poor communication habits are the factors that affect
the process of doctor-patient communication [8], [9].
To improve and practice effective communication skills for both doctors and medical students, the
Calgary Cambridge Guide can be used. The Calgary Cambridge Guide describes and defines the consultation
process into stages in a systematic and comprehensive manner that contains 71 basic clinical skill points.
This guide has been used extensively in various countries as a resource of the main study, assessment, and
research communication skills of doctor-patient [2], [10]. The Calgary Cambridge Guide has a large number
of points, and it is deemed less effective to be applied in the existing conditions, so it is necessary to make a
simpler and more applicable guide adapted to the existing practical conditions, social and culture.

2. RESEARCH METHOD
This research used qualitative approach by describing data from a phenomenon systematically and
presented in explanatory sentences [11]. There were four stages in this study, namely expert panels, student
panels and focus group discussion (FGD), experts review, and trials [12]. Informants were selected by purposive
sampling. The expert panel informants were representatives of specialist doctors from 12 divisions at Dr.
Mohammad Hoesin central public hospital (RSMH), Palembang, Indonesia and asked to choose maximum 20
points out of 71 Calgary Cambridge points that are considered to be the most effective and useful for
communication to be applied. Student panel, FGD, and trial informants were internship doctors at RSMH.
The total of recommendation points from the expert panel was compared to doctor-patient checklist
from the previous research and Universitas Padjajaran (UNPAD) checklist. Then, the data obtained from the
expert panel stage was categorized based on a scoring system. Score of 0-5 is presented as low category, 6-10
as middle category, and 11-14 as high category. High and middle points were discussed in the student panel
and FGD stage by two groups of internship doctors in RSMH while the low category points were not
included in the next stage.

3. RESULTS AND DISCUSSION

The expert panel stage was carried out by informants who were representatives of specialist doctors
from 12 divisions of RSMH. Researchers asked informants to choose as many as 10-20 points from 71 points
in the checklist of Calgary Cambridge which are believed to be the most important and effective points to be
implemented. After the data was collected, a scoring was carried out and resulted in three points for the high
category, 24 points for the middle category, and 44 points for the low category. Student panel and FGD
discussed the 24 middle category points. Seventeen points were chosen and agreed by the two FGD groups,
five points were chosen by one group, and two points were not chosen at all by both two groups. The Points
agreed by both of groups based on FGD presented in Table 1. The points agreed by one group based on FGD
presented in Table 2. The points of disagreement by both groups based on FGD presented in Table 3.

Table 1. Points agreed by both of groups based on FGD

No. Content
Demonstrate respect and interest, prioritize physical comfort.
3 FGD 1: “It's necessary, so they feel comfortable and being respected by the doctor”
FGD 2: “It is important during the meeting with the patient, especially at the beginning to build patient’s trust.”
Prepare safety nets, explain possible unexpected outcomes, what to do if the plan does not work, when and how to seek help.
54 FGD 1: "Agree, it is necessary to explain."
FGD 2: "Patients must be provided with CIE (Communication, Information and Education)”
Inform the name of the action or treatment offered, steps involved, how it works, the benefits and advantages, and the possible
side effects.
62
FGD 1: "Must be explained."
FGD 2:

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No. Content
2F: “(What is) usually explained is the name of the drug, how it works and side effects.”
2G: "It can be applied, usually at polyclinic where there is rejection and approval checklist.”
Provide clear information on procedures.
69
FGD 2: "(It) can be applied, a must. Just combine it with points to provide information on action or treatment. "
Encourage the patient to tell the story of the problem(s) from when it first started to the present in their own words.
FGD 2:
2B: "Yes ... you can."
8 2D: "But this point is similar to the patient's listening point without interruption."
2G: "It's different from the point of listening without interruption, but the two points can be combined."
MD: "So what about this point? Can you use it? "
All Information: "Yes, you can, but if the story starts to deviate politely interrupt the patient."
Involve the patient:
During physical examination, explains process, asks permission
FGD 1: "Explain the process as well as the informed consent before physical examination.
32 FGD 2:
2C: "Must seek approval."
2D: "Explain the process in an outline, for example, the stomach will be examined later on, ma’am, some pressure will be put
on it."
Involve patient:
- To suggest and make options rather than being directive.
- To contribute their ideas and suggestions.
Student Panel: “If the patient takes so long (decision), is confused and hesitates for an urgent and emergency decision, a doctor's
direction is more needed than advice and options.”
FGD 1
1D: "Just give the patient directions, because the patient is usually confused."
48 1F: "But the patient has right to choose, so first explain what the options are."
1A: "Agree, according to the points, the doctor gives advice and options, the doctor explains which option is the most
appropriate but the choice remains with the patient if the directions seem to force the patient to follow the doctor's advice."
FGD 2
2E: "Can be applied to cases that require consent."
2A: "For example in the selection of birth control pills, anaesthetics, surgery."
2B: "For important decisions, emergencies, or when the patient is unsure or confused about choices, directions tend to be more
required and needed than advice.”
Use concise, easily understood questions and comments, avoid using medical language.
FGD 1:
1D: "When asking, you should be brief. If you explain too much it will be hard for the patient to understand."
15 1B: "But if you explain too much it will take time, at least when it comes to risks then it will be explained."
1H: "So it's good when asking questions in layman's language and just briefly, but when explaining it can use medical language
as long as it is explained again using the patient's language."
FGD 2: "Avoid medical language, the patient will be confused."
Use concise, easily understood language and sentences and comments, avoid using medical language.
40 FGD 1 and FGD 2: "This point has the same meaning as point 15, so you can use only one of the points or the two points are
combined into one point."
Do a final check to ensure that patient agrees and is comfortable with the plan, and ask whether there are any corrections,
questions or other items to discuss.
FGD 1: "It must be done, ask again if there is anything that is still unclear or what the patient will convey and schedule the next
56
consultation."
FGD 2: "Yes, it should be. If necessary, review the plans to be carried out and other important things so that the patient doesn't
forget. "
Use open and closed questioning techniques, it is more appropriate to start with the open questions then move to the closed ones.
FGD 1: "It needs open questions so that the interview is not rigid, if there are too many closed questions as if the patient is not
9 given the opportunity to tell and express his opinion, the patient cannot be open and doctors will only receive limited information
to diagnose.”
FGD 2: "Yes, it should be."
Use verbal and non–verbal cues (body language, speech, facial expression, affect) appropriately.
FGD 1
1G: "It can be done while the patient is talking and afterward, the doctor watches the patient speak and says" err is that so
12
ma'am "after the patient finishes telling the story, so the doctor looks enthusiastic and pays attention to the patient."
1H: "When the patient talks, the doctor can show a response such as nodding his head."
FGD 2: "It could be applied."
Demonstrate appropriate non-verbal behaviour.
- eye contact, facial expression
- posture, position & movement
- vocal cues e.g. rate, volume, tone
23 Student Panel: “Agree, but if you're tired, sometimes (you) forget to do these points. Doctors are not robots who have to keep
smiling all the time.”
FGD 1 and FGD 2: "Agreed, but combined with similar points."
1A: "Is it similar to point 12?"
1D: "Why not only use one (of the points) or combine it?"
Use empathy to communicate understanding and appreciation of the patient’s condition.
FGD 1: “Agree, combine with other similar points.”
27
1D: "Empathy through understanding and facial expressions."
FGD 2:

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No. Content
2A: "You can show empathy but not pity."
Involve patients:
Involve patient by explaining answers or rational reasons to the patient's questions or as part of a physical examination.
Student Panel: “During the physical examination, it is preferable to be uninterrupted, explain the results after completing the
31 physical examination only.”
FGD1: "Agree, it is better for the doctor to provide an explanation before or after the physical examination.”
FGD 2: "Before the physical examination, the doctor explains the physical examination process that will be carried out and asks
the patient's consent (join point 32)"
Discuss options e.g., whether or not some action, investigation, medication or surgery, non-drug treatments will be carried out
(physiotherapy, walking aides, fluids, counselling, preventive measures).
FGD 1: "It's the same as negotiating a plan. It must be done so that the patient knows more clearly about the actions and
61
management that will be given."
FGD 2: "Agree, it needs to be discussed and explained even though there is no action."

Provide opportunities and encourage for patient to contribute: to ask questions, seek clarification or express doubts.
FGD 1 and 2: "Agree"
44
"Only done at the end of the explanation or when the patient looks confused, by asking" Are you clear yet? Is there anything you
want to ask or not? "

Table 2. Points agreed by one group based on FGD

No. Content
Actively determine and appropriately explore:
• patient’s ideas
• patient’s concerns (i.e. worries) regarding each problem
• patient’s expectations
• how each problem affects the patient’s life
FGD 1: “Agree’”
1E: "It's necessary, as long as it's concise and doesn't waste time."
17
FGD 2: “Disagree.”
2E: "This means you have to capture the patient's concern, huh?"
2H: "For example, I understand your concern."
All informants: “I can't do this, it takes too long. It's also rarely done, but if this point can be sufficiently described in simple way
like 'I understand how you feel', then it is okay to do it "
An example of this point statement according to FGD2: "I understand what you mean………."
"I know you are worried ..............."
Discuss possible undesirable results of treatment plans and follow-up actions, explain it whenever possible.
71
FGD 1: "Just combined it with an explanation of side effects."
When reading, writing notes or using the computer, do it in a way that does not interfere with the conversation or rapport.
Student Panel
“Reading, taking notes or using a computer is better done after the conversation, if it is done during the conversation, it looks
disrespectful to the patient, unprofessional, and makes the patient feel uncomfortable, and difficult to do because of divided
attention / focus."
“Good communication should be reciprocal and involve both parties, doctor and patient. You need to focus on your patient first
24 without doing other activities such as taking notes or using a computer.”
FGD 1: “Disagree.”
1F: "At RSMH, I never take anamnesis while using a computer, but I often take notes (while doing the anamnesis)"
1A: "(I) listen first until it's finished then take notes, I'm afraid not to concentrate and ask the patient the same thing"
1C: "Yes, it seems that you don't pay attention to the patient if you take notes (while doing the anamnesis)"
FGD 2: "It can be as long as it's not in an emergency condition, (I’m) afraid to forget if (I) don't take notes, but ask the patient's
permission first."
Accept legitimacy of patient’s views and feelings; is not judgmental.
Student Panel
“Not all views and opinions of patients are correct. It needs to be corrected so that perceptions are the same.”
“Patients with certain characteristics (stubborn) must be educated with a little judgment / affirmation so as not to repeat
mistakes.”
FGD 1: “Disagree, we need to improve the wording.”
1A: "Don't judge, it means not to blame, huh?"
1F: "But usually at RSMH if a patient is wayward, he has to be judged."
26
1A: "Maybe he or she needs to be educated, without blaming and judgment."
All informants: "Not all views and opinions of patients can be accepted, so listen to what his opinion is, if the patient's opinion
is wrongly justified and then explain carefully."
FGD 2
2C: "You can't just judge, just give advice and education."
2A: "But Indonesian patients must be judged in order to comply, just add the judgment for patients who do not comply."
2H: "The patient's wrong views, for example certain traditions or habits, should not be accepted, listen to it first and then
correct it."
Describe the benefits, values and objectives associated with procedure plan treatment.
Student Panel
70
“This point is important to apply because sometimes the patients forget the things which have been told if they are not
explained more deeply and repeatedly.”

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Table 3. Points of disagreement by both groups based on FGD

No. Content
Structures interview in logical sequence
Student Panel: “Getting the interview conclusion should not ask sequential history, but what is remembered first."
FGD 1
All informants: "No need"
1C: "For history, it doesn't have to be sequential, just what the patient remembers at the first place."
1D: "Sometimes amidst the consultation, patient suddenly comes up with a complaint that has not been stated before."
21 1H: "It doesn't matter if it's not in order, the important thing is to ask all of them and at the end we summarize ourselves."
1C: "But if the structure of the interview from the beginning to the closing must be sequential."
FGD 2
2C: "Too formal if you have to ask the history in order."
2F: "Just according to the situation and conditions, which one is remembered first, but for the sequence from introducing names,
asking complaints, physical examination to the end of the review, the good ones are in order so that it is more focused."

Listen attentively to the patient’s opening statement, without interrupting or directing patient’s response
Student Panel
“Time does not allow the doctor to listen to all the patient's complaints without interruption, sometimes patient says something
out of context, therefore, permission to interrupt is needed so that the contents of the interview do not deviate.”
FGD 1
1A: "Don’t use it, it will take too long if you don't interrupt."
5 1B: “If there are a lot of patients, it's not effective to listen to the complaints without interruption. Even in the polyclinic, we
haven't asked yet but the patient has already told a long story. "
1C: "It is necessary to keep the timing, so it needs to interrupt and direct (the patient)."
FGD 2
2C: "No, you can't, the patient will pour his heart out too long."
2F: "If you have deviated anywhere, it must be interrupted."
2A: "If the anamnesis takes so long, it will be scolded by the resident doctors."

Besides discussing the middle category points, the two groups also discussed high category points
because two points in the high category were not carried out and not approved by informants in previous
studies [4]. The high category points as shown in Table 4.

Table 4. High category points

No. Content
1 Greet patient and ask patient's name.
2 Introduce yourself and clarify the role, and nature of the interview, ask approval.
Identify the patient's problem, the main reason for visiting, and the expectations that you want to get from the consultation with
4
open-ended questions.

From the results of FGD by the two groups, it was found that the effective time estimated for
implementing doctor-patient communication is about 5-15 minutes with 15-20 effective points. According
to the informants, the allocated time could be conditioned if there were no obstacles such as differences in
language and misunderstanding.
The results gained from the high and middle point’s discussion, the estimated time and number of
effective points, were then consulted with doctor-patient communication expert to validate and approve the
modification of the Calgary Cambridge checklist. The expert approved 27 points proposed consisting of
three points for the high category and 24 points for the middle category. Several points that have the same
meaning were combined or used only one of them and finally they were separated into two parts, eight main
points and eleven tips. These points were arranged in order of the interview structure from the beginning to
the end of the doctor-patient communication process. The main points and tips of Calgary Cambridge Guide
modification a shown in Tables 5 and 6.

Table 5. Calgary Cambridge Guide modification (main points)

No. Content
1 Greets patient, obtains patient's name, introduces self, role and nature interview
2 Identifies the patient's problem or the issues that the patient wishes to address with appropriate opening question
3 Encourages patient to tell story of the problem(s) from when first started to the present in own words
4 Involves the patient during physical examination, explain process, asks permission
Discusses option e.g., no action, investigation, medication or surgery, non-drug treatments (physiotherapy, walking aides,
5
fluids, counseling), preventive measures
Provides information on action or treatment offered: name steps involved, how it works, benefits and advantages, possible side
6
effects
7 Safety nets, explaining possible unexpected outcomes. What to do if plan is not working, when and how to seek help
8 Final check that patient agrees and is comfortable with plan and asks if any corrections, question or other issues

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Table 6. Calgary Cambridge Guide modification (tips)

No. Content
1 Demonstrates respect, interest, and attends to patient’s physical comfort
2 Listens attentively to the patient’s opening statement, without interrupting or directing patient’s response
3 Uses open and close questioning techniques, appropriately moves from open to closed
Actively determines and appropriately explores: patient’s ideas, patient’s concerns, patient’s expectations; structures interview in
4
logical sequence
5 Picks up verbal and non- verbal cues (body language, speech, facial expression, affect)
6 Structures interview in logical sequence
7 If reads, writes notes or uses computer does in a manner that does not interfere with dialogue or rapport
8 Uses empathy to communicate understanding and appreciation of the patient’s feelings or predicament
9 Explains rationale for questions or parts of physical examination
10 Provides opportunities and encourages patient to contribute: to ask questions, seek clarification or express doubts
Involves patient: offers suggestions and choices rather than directives, encourages patient to contribute their own ideas,
11
suggestions

After being confirmed by the expert that the modification of the checklist of Calgary Cambridge
Guide was valid, the modified checklist was then being trialled through a role play by three internships
doctors and it was found that the consultation time without physical examination is five to six minutes.

3.1. Starting the interview (Initiating the session)

The patient's first impression is important for the effectiveness of the doctor-patient communication
process. Some doctor's behaviours that can give the first impression as expected by the patient are asking and
mentioning the patient's name, introducing himself, telling what will be done during the consultation and
showing appropriate expressions, eye contact, and gestures [13]. From the FGD results, it was found that
greeting and asking the patient's name can avoid mistakes of patient identification and status build rapport
and comfort. It is important for doctors to introduce themselves to patients because they can build initial
relationships and good communication with patients, besides that the Joint Commission International (JCI)
assessment at RSMH requires patients to know the name of the doctor who treats them.
This result contrasts with the previous research that assessed the doctor-patient communication in
2014 conducted to the residents of internal medicine polyclinic at RSMH Palembang using a checklist
concise Calgary Cambridge Guide. The observations conducted to the internal medicine residents indicated
that the patient's name was not asked because of stated patient's status. Self-introducing and explaining the
purpose of anamnesis were not applied because it was not important and the atmosphere was too stiff [8].

3.2. Gathering information

In doctor patient communication, there are two important sessions, namely the information
gathering session which contains the history taking process and the delivery of information. Through a
complete history, about 78.6% can support the diagnosis [14]. For typical and frequently encountered
complaints, doctors can give specific and narrow questions to make them more focused and save time [15].
According to the FGD group, a complete history involving patients to tell stories about the complaint itself is
important, but if the patient talks in length and is not directed, the doctor may interrupt and direct the focus of
the conversation politely and subtly.
The FGD informant argued that the use of open-ended questions first then closed questions must be
done and the users need to pay attention, because if they use too often closed question, it can give impression
to the patient that it is difficult for him to tell and put forward his opinion, so the information obtained is
limited and patients are less open. Listening skills, empathy, and the use of open-ended questions are some
examples of communication skills that can affect patient satisfaction and improve health care outcomes [16].

3.3. Physical examination

In the consultation process, physical examination contributes 8.2% in determining the diagnosis of
the patient's disease. According to the FGD informant, before the physical examination, it is important for the
doctor to outline the process and ask for informed consent. Providing consent is carried out to a conscious
patient by explaining the patient's current condition, the physical examination to be carried out, the benefits
and risks and given in understandable language. If the information provided by the doctor is not fully
understood by the patient, the informed consent basically cannot be confirmed [17]-[19].

3.4. Explanation and planning

The explanation and planning stage aim to provide accurate and comprehensive information. It is
important to explain and discuss options and procedures (whether there is action or not), provide information
and explain the course of action, treatment, goals, side effects, and benefits of therapy offered. If the patient

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does not agree to the therapy or action offered, the patient may refuse by filling in the refusal sheet provided
at the health facility (polyclinic at RSMH).
A complete doctor's explanation and good communication regarding the diagnosis, treatment
options, and prognosis can influence the patient in determining the treatment options given and improve
patient adherence [4], [20]. It is also important to provide safety net against unexpected things, and explain
the possibility of unexpected results, what should be done if the plan does not go smoothly according to the
FGD discussion. This point is the same as communication, information, education (CIE) and important to
give to patients. The importance of providing information about the unexpected things has led to the creation
of policies and programs in America regarding transparency of communication with patients. The patient
expects earlier information about the possibility of something unexpected. It was hoped that the ability to
deliver communication, provide information and education in the form of preventive, promotive, curative and
rehabilitative forms is needed since the primary health care level [21]-[23].

3.5. Closing the interview

At the closing stage of the interview, final checking to ensure that the patient understands, agrees
and is comfortable with the plan and asks if there are corrections, questions or other things that are not clear
and reminds the schedule of consultation (if needed) is important to do so that the patient does not forget
important things that have been described. At the end of the interview, it is important for the doctor to build
the understanding of the patient about his condition, what is happening and what plans are going to be done.

3.6. Building the relationship

Effective doctor-patient communication is characterized by the interaction that provides reciprocal
information between doctors and patients, both verbal and nonverbal and can build good relationships with
patients [3]. The FGD discussion stated that showing respect, attention, empathy, and prioritizing patient
comfort are some examples of important points to make to build patient’s confidence in the treating doctor,
besides that the patient will feel comfortable and appreciated by the doctor.
Empathy to understand communication and appreciate the patient's feelings or condition according
to FGD information is important as long as the doctor does not get carried away to cry (sympathy), empathy
is shown by appropriate facial expressions and words that show that the doctor understands the patient's
condition. The empathy shown by the doctor to the patient will foster a patient's sense of trust in his doctor
which will influence satisfaction and patient adherence to treatment [24].
Two-way communication and focus on the patient without doing other activities such as using a
computer or taking notes is important, but if necessary, it is better to ask the patient's permission first. Give
complete attention to the patient, do not concern himself with other things and if deemed necessary to record
information about the patient, tell the patient first [25].
During the consultation process, it is important for doctors to give patients the opportunity to ask
questions, clarify, express doubts or his by saying at the beginning of the meeting to the patient to ask and
reveal his opinion during or at the end of consultation process. The doctor can also ask the patients to ensure
their understanding toward what is being explained when the patient shows non-verbal sign of confusion. A
study in Korea concludes that patients will have a negative view of doctors who have a dominant
communication style towards patients and do not provide opportunities for patients to express their views
[24]. The doctor-patient communication paternalistic pattern is commonly applied in Southeast Asia due to
time constraints, the number of patients, and the low level of education [26].

3.7. Structuring the interview

The ability to structure interviews aims to ensure that the consultation process can take place with a
definite purpose. According to the two FGD groups, the logical sequence of the interview structure is needed
if it is intended as a sequence from opening the interview to the closing session; but it does not need to be
sequential in terms of asking various histories related to the patient's complaints as long as the doctor can
summarize and conclude the patient's condition at the end of the consultation. A sequential and structured
interview that does not jump from topic to topic can make patient understand the purpose of the questions
asked by the doctor and make the doctor easier to diagnose and summarize the entire consultation process.
Based on the results of this study, in interview structure the summary making at the end of every
question session and confirming to the patient before moving on to the next session which is commonly
known as content reflection were not included. According to expert panel informants, these points indicate
that doctors do not pay enough attention nor listen to patients so there is no need to do so. Meanwhile,
according to the student panel, these points were only carried out and summarized at the end of the
consultation, because if at the end of each session confirmation carried out, the patient tends to get bored and
the patient will doubt the doctor's ability. Effective communication can be characterized by reciprocity, a
good listener, the use of open questions, reflection, and summarizing the patient's condition [27].
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3.8. Consultation time

The results of the FGD discussion stated that the effective consultation time at RSMH ranged from
5-15 minutes. After being tested with the role play method using Calgary Cambridge Guideline
modifications, it was found that the consultation time was between 5-6 minutes without physical
examination. In line with this, a research conducted at Makassar Hospital, Indonesia regarding patient
satisfaction in implementing effective patient doctor communication found that most respondents spent 6-10
minutes for consultation and treatment because the number of patients was relatively large with only one
doctor serving in each clinic. In addition, doctors who serve often come late, thereby reducing the availability
of time to serve patients [28]. Based on research in Japan regarding consultation time and its influence
variables, the overall average consultation time was six minutes 12 seconds, 11% of the samples obtained an
average time of three minutes or less [29].
Most general practitioners in London think that the ideal consultation time is around 10 minutes, but
10 minutes is not enough for chronic cases, complex conditions, geriatric patients and health promotion
targets. Dr. Burnett said that the quality of the consultation is more important than the quantity of time
spent [30].

4. CONCLUSION
The modification of Calgary Cambridge Guide checklist developed in this research consists of eight
main points and eleven effective tips. This modification guideline is suitable to be used in daily doctor-
patient consultation and communication in Indonesia concerning its practical condition and socio-cultural
context.

REFERENCES
[1] Herqutanto et al., “Determinant of Doctor Patient Knowledge and Communication Skills,” Journal of The
Indonesian Medical Association, vol. 61, no. 5, pp. 196-199, 2011.
[2] Kurtz, S.M et al., “Marrying Content and Process in Clinical Method Teaching and Enhancing the Calgary
Cambridge Guides,” Academic Medicine, vol. 78, no. 8, pp. 802-808, 2003.
[3] Ali. M.M et al., “Effective Doctor Patient Communication. Jakarta: Indonesian Medical Council; 2006.
[4] Fong Ha. J, Hons, and Longnecker, N., “Doctor-Patient Communication: A Review,” The Ochsner Journal,
vol. 10, no. 1, pp. 38-42, 2010.
[5] Thorne et al., “Cancer care communication: the power to harm and the power to heal?,” Patient Educ Couns, vol.
71, no. 1, pp. 34-40, 2008.
[6] Herqutanto, “O Doctor, Please Communicate,” Majelis Kedokteran Indonesia, vol. 59, no. 2, pp. 35-37, 2009.
[7] Mochtar, “Doctors Are Human Too,” Jakarta: PT Gramedia Pustaka Utama, 2009.
[8] Awinda, D., Syakurah, R., and Fadilah, M., “Assessment of Doctor-Patient Communication Among Residents in
Internal Medicine Polyclinic at RSUP Dr. Mohammad Hoesin Palembang 2014 Using Simplified Checklist of
Calgary Cambridge Guide,” Medicinus, vol. 7, no. 6, pp. 184-194, 2020.
[9] Wilson, A., and Childs, S., “The relationship between consultation length, process and outcomes in general
practice: a systematic review,” British Journal of General Practice, vol. 52, no. 485, pp. 1012-1020, 2002.
[10] Simmenroth et al., “Physchometric properties of the Calgary Cambridge guides to assess communication skills
of undergraduate medical students,” International Journal of Medical Education, vol. 5, pp. 212-218, 2014.
[11] Cresswell, J.W., “Research Design; Qualitative, Quantitative, and Mixed Methods Approaches,” Sage
Publications, Los Angeles, 2009.
[12] Irwanto, “Focused Group Discussion (FGD) A Practical Introduction,” Jakarta: Yayasan Obor Indonesia, 2006.
[13] Haftel, L., “Patient-doctor communication: The fundamental skill of medical practice,” Medical School
University of Michigan, 2008.
[14] Roshan, R. and Rao, AP., “A study of relative contributions of the history, Physical examination and
investigations in making medical diagnosis,” Journal Association Physicians India, vol. 48, no. 8, p. 771, 2000.
[15] Hillen, H.C.B., “The IT anamnesis? Diagnosing software requiremnets,” Thesis, Radboud University Nijmegen,
2012.
[16] Arora, N.K., “Interacting with cancer patients: the significance of physicians’ communication behaviour,” Social
Science & Medicine, vol. 57, no. 5, pp. 791-806, 2003.
[17] Consumer Health Forum of Australia. Informed consent in healthcare: An Issues Paper, 1-14, 2013.
[18] The Minister of Health Republic Indonesia. Regulation of The Minister of Health Republic Indonesia No.
290/Menkes/Per III/2008 pasal 9 concerning Approval of Medical Action. Jakarta, 2008.
[19] Guwandi, “Medical Error and Medical Law,” Jakarta, Publisher Center for the Faculty of Medicine, University of
Indonesia, 2006.
[20] Baile et al., “SPIKES-a six step protocol for delivering bad news: application to the patient with cancer,” The
Oncologist, vol. 5, no. 4, pp. 302-311, 2000.
[21] National Quality Forum. Safe Practices for better healthcare. Washington, DC: National Quality Forum; 2007.

Int. J. Public Health Sci., Vol. 10, No. 2, June 2021: 361 – 369
Int. J. Public Health Sci. ISSN: 2252-8806  369

[22] Mazor, KM et al., “Health plan members' views about disclosure of medical errors,” Annals of Internal Medicine,
vol. 140, no. 6, pp. 409-18, 2004, doi: 10.7326/0003-4819-140-6-200403160-00006.
[23] Beaglehole et al., “Improving the revention and management of chronic disease in low-income and middle income
countries: a priority for primary healthcare,” Lancet, vol. 372, no. 9642, pp. 940-949, 2008.
[24] Kim and Park, “Patient-perceived communication styles of physicians in rehabilitation: The effect on patient
satisfaction and compliance in Korea,” American Journal of Physical Medicine & Rehabilitation, vol. 87, no. 12,
pp. 998-1005, 2008.
[25] Pamungkasari et al., “Communication Skills 1 Connect Sense,” Department of Public Health, Biochemical, and
Nutritionts Science Faculty of Medicine Universitas Sebelas Maret, Surakarta, 2012.
[26] Claramita et al., “Doctor-patient communication in a Southeast Asian setting: the conflict between ideal and
reality,” Advances in Health Sciences Education, vol. 16, pp. 69-80, 2012.
[27] Klaber B., “Effective feedback: an essential skill,” Postgraduate Medical Journal, vol. 88, no. 1038, pp. 187-
188, 2012, doi: 10.1136/postgradmedj-2012-130921.
[28] Asdawati, Sidin, A.I, and Kapalawi I., “Description of Patient Satisfaction in Implementing Effective
Communication of Doctors at Regional Public Hospital Makassar,” Department of Hospital Management,
Faculty of Public Health, Hasanuddin University, pp. 1-10, 2014.
[29] Wooldridge, A.N et al., “Truth or fallacy? Three hour wait for three minutes with the doctor: Findings from a
private clinic in rural japan,” Asia Pacific Family Medicine, vol. 9, no. 1, pp. 1-11, 2010.
[30] Oxtoby, “Consultation times. BMJ Careers; 2010. [Online]. Available: http://careers.bmj.co,/careers/advice/view-
article/html?id=20001044

Modification of Calgary Cambridge for Indonesian medical students… (Galih Cahya Wijayanti)