they help to achieve an accurate diagnosis , build trust with patients , and improve compliance to treatment , overall patient satisfaction , therapeutic outcome , and avoid litigation .
the initial and most important step in communication with patients is the establishment of rapport .
this may take time , but will definitely decrease the patient 's tension and fear and improve doctor  patient relationship , which in turn creates a strong base for further management .
rapport is established through a series of verbal and nonverbal means of communication such as smiling , introducing oneself , calling the patient by the preferred name , making eye contact and assuming a welcoming posture , and showing empathy .
when communication improves , the risk of malpractice may decrease , but compliance , patient satisfaction , and outcomes improve .
moreover , physicians who use their rapport - building skills often experience less stress in their work and are more satisfied . building rapport , as an essential part of physician 
patient communication and relationship , needs training that emphasises on using the local language and being aware of the cultural attributes of patients .
for example , in the ksa , many patients prefer to be called by a nickname that includes their oldest son 's name , but shaking hands with the opposite sex is unacceptable .
communication skills have not been part of some of the study curricula in pregraduate medical schools in saudi arabia .
furthermore , foreign doctors , even those who are trained in communication skills have difficulty in applying their skills due to language problem and cultural barriers .
the objective of this study was to assess the establishment of rapport with patients by physicians working in the primary health care center ( phcc ) , dammam city , ksa and assess patients ' satisfaction with that relationship .
a cross - sectional study was carried out at the phcc in dammam , ksa .
all physicians and patients at the phcc , dammam , who were more than 15 years of age and were mentally and physically able to communicate in simple arabic about their medical care were included .
patients who were < 15 years of age and unable to communicate verbally ( e.g. , speech disorder and hearing impairment ) were excluded .
using the automated sample size calculator , the sample size of attendees was estimated at 374 subjects from the phcc with a total population of 9000 patients per month , with a confidence interval of 5% .
the sample size of the physicians was a comprehensive sample of all 30 physicians , 27 ( 90.0% ) of whom participated in the study .
the patient sample of attendees was selected using a systemic sampling procedure , whereby every seventh patient visiting the phcc , dammam , on two days per week , over a period of 3 weeks was selected .
the days were divided into morning and afternoon clinics . on day 1 , the females were taken in the morning , and the males in the afternoon and the converse was done on the 2 day of that week .
data were collected using a self - administered structured questionnaire completed by the selected physicians and attendees visiting the phcc , dammam , under direct supervision .
each positive and negative response was assigned a mark of  1  or  0  , respectively .
a rapport score was computed as the sum of all positive answers of the rapport questions .
score values equal or greater than the median were considered as  good  , and those below as  poor . 
the rapport score was treated as the dependent variable and the independent variables included age ( categorized as young , middle or elderly ) , gender , years of experience ( categorized as short , average , and long ) , job title ( general practitioner , resident , specialist , and consultant ) , whether speaks arabic or not , and whether the primary language is arabic or not arabic .
in addition , physicians were categorized into those whose specialty was of a surgical nature , i.e. , whether the management of their patients involved surgical procedures or not .
each positive and negative response was assigned a mark of  1  or  zero ,  respectively .
the score for satisfaction with rapport was computed as the sum of all positive answers on the rapport questions .
score values equal or greater than the median were considered as  good  , and those bellow it as  poor .  satisfaction with the rapport score was similarly treated as the dependent variable for which the independent variables included age , gender , level of education , residence , with or without a chronic disease , with or without an appointment , visit type , physicians ' specialty , and language .
age was recorded to the nearest year and subjects were categorized as young ( < 30 years ) , middle - aged ( 3054 years ) , or elderly ( 55 years and over ) ; level of education was defined as low ( illiterate and primary school ) , intermediate ( intermediate and high school ) , or high(university graduates or postgraduate ) ; has or does not has chronic disease , e.g. diabetes mellitus , hypertension , bronchial asthma , and sickle cell anemia ; with or without an appointment ; visit type defined as new or follow - up ; physicians ' specialty categorized as surgical or nonsurgical involving surgical means of patient management ; physicians ' professional status recorded as consultant , specialist or other ; and physicians ' language defined as arabic or non - arabic . physicians ' experience was categorized as short ( < 5 years ) , intermediate ( 59 years ) , and long ( 10 years and over ) .
data were entered into the computer and analyzed using the statistical package for social sciences ( spss ) , version 20.0 .
the questionnaires ' reliability , as tested by spss , using the split half guttman method , was 67.1% and 79.3% for patients ' and physicians ' questionnaires , respectively .
the study proposal was approved by the research committee of the national guard health authority , eastern region , as well as by the local supervisory training committee for family medicine , in the eastern province , ksa . a pilot study involving 20 subjects
was carried out to test the logistics of the study , but the data were not included in the main study .
a total of 374 attendees participated in the study with a response rate of approximately 92% and 27 physicians participated with a response rate of 90.0% .
the attendees ' mean age was 37.12  11.2 years ( mean  standard deviation [ sd ] ) , with a range of 1675 years .
attendees in the young , middle - aged , and elderly groups were 46.8% , 44.4% , and 8.8% , respectively .
females and males in the sample were 55.9% and 44.1% , respectively [ table 1 ] .
attendees residing in dammam made up 75.7% of the total , 19.8% resided in al - khobar and 4.5% in other areas .
the majority ( 59.1% ) had average education , and very few were highly educated [ table 2 ] .
sociodemographic characteristics of study sample in relation to rapport score at primary health care center , dammam , kingdom of saudi arabia , 2013 relation of the study sample attendees satisfaction with sociodemographic and disease - related variables at the primary health care center , dammam , kingdom of saudi arabia , 2013 almost 40.0% of the attendees had chronic illnesses .
those who had appointments were 48.1% , while those attending as walk - in were 51.9% .
about 75% were seen by physicians with a nonsurgical specialty , and 25.4% were seen by physicians whose specialty was surgical in nature .
fourteen percent physicians were consultants , 31.0% were specialists , and 54.5% were of junior status [ table 3 ] .
physicians characteristics in relation to attendees satisfaction score with the physicians at primary health care center , dammam , kingdom of saudi arabia , 2013 the attendees seen by male and female physicians were 44.9% and 55.1% , respectively .
ninety four percent were seen by arabic - speaking physicians and 6.0% were seen by non - arabic speaking physicians . for 23.0% , it was the first visit to the physician , while for 77% , it was a follow - up visit .
the physicians ' mean age was 41  9.9 years ( mean  sd ) with a range of 2558 years .
young physicians constituted 37.0% , middle - aged physicians 48.1% , and older physicians were 14.8% of the sample .
the mother tongue of 88.9% of the physicians was arabic and for 11.1% it was not arabic .
the mean years of experience was 14.9  8.4 years ( mean  sd ) .
physicians with short experience ( working years for 16 years ) came to 40.7% , 22.2% of the physicians had average experience ( 712 years ) , while 37.0% had long experience ( more than 12 ) .
physicians with booked clinics were 55.6% while those with walk - in clinics were 44.4% .
the percentage of physicians with good rapport practice score was 51.9% with a mean rapport score of 71.8%  11 ( mean  sd ) , and a range of 47.491.2% .
regarding the relation of sociodemographic and clinical characteristics of the study sample physicians with rapport practice score , there were significantly more older physicians than younger ones who had a good rapport score ( p < 0.016 ) .
significantly more physicians with long experience than those with shorter experience had a good rapport score ( p < 0.031 , and p < 0.031 , respectively ) .
furthermore , significantly more consultant physicians than the rest had a good rapport score ( p < 0.043 ) [ table 1 ] .
attendees who were satisfied with their physician 's rapport with them amounted to 50.5% while 49.5% were dissatisfied .
the mean satisfaction score was 77.7%  16.9 ( mean  sd ) with a range of 20.6100% .
significantly more elderly attendees , those with a lower level of education , those with chronic illnesses , and those with fixed appointments were satisfied with physicians ' rapport than other groups ( p < 0.0001 ) [ table 2 ] . regarding physicians ' characteristics , significantly more consultant physicians and those with nonsurgical specialties affected attendees ' satisfaction ( p < 0.0001 ) [ table 3 ] . logistic regression analysis of the relation of significant factors predicting rapport practice score among study sample physicians showed that the age of the physician was a significant predictor of a good rapport score ( p < 0.042 ) [ table 4 ] .
logistic regression analysis of variables predicting rapport practice score among study sample physicians at primary health care center , dammam , kingdom of saudi arabia , 2013 moreover , logistic regression analysis of the relation of significant factors predicting satisfaction score among study sample attendees showed that attendees with chronic diseases , those with a prefixed appointments and those seen by consultant physicians , as well as those seen by nonsurgical physicians were significantly satisfied with the attention received ( p < 0.001 , p < 0.004 , p < 0.005 , and p < 0.000 , respectively)[table 5 ] . logistic regression analysis of variables predicting satisfaction score among study sample attendees at primary health care center , dammam , kingdom of saudi arabia , 2013
in this study , the sample of attendees comprised mainly the young and middle - aged , providing a wide spectrum of ages .
the percentages of females and males were almost the same , is roughly representative of the population of saudi arabia .
the education of the majority of the study sample attendees average which is similar to the population of saudi arabia as published by the central department of statistics and information , saudi arabia , 2013 .
the percentage of satisfied attendees was 50.5% , and in a phcc setting , which is considered the main venue for health care provision , and continuous care , this percentage is mediocre , especially since the range of ages sampled is very wide , covering almost all age groups .
research has shown good communication skill to be the key to better patient outcomes , and better patient satisfaction .
also , patients ' satisfaction appears to be a strong motivation for compliance to treatment and its success .
for instance , physicians who are warm , friendly , and understanding demonstrate better rapport with their patients than those who are not .
the study revealed that most attendees were seen by physicians who were not consultants , and who displayed little rapport with their patients thus failing to stimulate much attendee satisfaction .
the lack of skills for building rapport in saudi arabian hospitals may be explained by the fact that though physicians are of diverse nationalities , religions and cultures , and speak different languages , they all have to deal with the cultural norms , religion , and language of the saudi population . moreover , since these factors influence rapport building the lack of training on communication skills is made all the more obvious .
it appears that the ideal circumstances for optimal communication in health care are for both physicians , especially primary care physicians , and patients to speak the same language . besides
, the physician is required to identify with and respect different values , beliefs , cultural norms , especially those related to gender and social circumstance .
unfortunately , there does not seem to be many programs that train physicians on communication skills , nor are there studies to address this problem in saudi arabia in general and in phccs in particular .
elderly attendees and those with little education indicated greater satisfaction than younger and more educated attendees .
in addition , those with chronic illnesses and those who had appointments were also better satisfied than others .
research has shown that satisfaction was related to patients ' age , psychological morbidity , and most significantly satisfaction with the length of waiting time at the clinic , which was less for patients who had appointments .
in addition , patients ' confidence and trust in their physicians increased with the patient 's age .
another possible explanation is that patients with chronic illness usually had constant health care at booked clinics , where a good relationship with their caregiver had already been built .
this shows the importance of continuity of health care and the fact that sustained continuity of care is associated with improved patient satisfaction , especially in patients with chronic conditions .
furthermore , it was found that continuity of care was associated with a lower rate of visits to the emergency department and hospitalization .
in addition , continuity of care improves the quality of the patient  physician communication and relationship , management of patients with chronic conditions , and patients ' quality of life .
this may also explain the dissatisfaction of walk - in attendees or low rapport scores because walk - in patients tend to impose an unusual burden on the physician .
a system should , therefore , be developed to deal effectively with the attendance of walk - in patients .
visiting a physician with a high professional status was also observed to be positively related to satisfaction with physicians ' empathy , while the gender of the physician and the language had no such effect .
it was found that surgeons ' expression of empathy with patients was infrequent , and any social conversation was brief .
it has been documented that the specialty physician had an effect on patterns of communication and on patient satisfaction , for the satisfaction of the patients of family physicians was more closely linked to rapport building , psychosocial exchange , and patient - centeredness than they were for other specialties .
similar to the satisfaction score , physicians ' practice score for rapport was moderate , only 51.9% .
it was found that the older the physician , the better he / she was in establishing rapport . also , more consultants and highly experienced physicians had better rapport scores than others .
the reason for this is that the development of a good relationship with patients comes with time and certain skills .
this improved communication can only be developed through mutual trust , and respect which promotes the development of a therapeutic relationship .
however , rapport and good communication with patients are not skills that are easily acquired .
nonetheless , practitioners who are clinically competent , consistent , honest , and committed to their patients are able to further the building of patient trust and improve communication , rapport , and outcomes .
though the establishment of rapport is important when dealing with patients , it is not given much attention .
it is the responsibility of the health care providers to give more training to improve their skills and practice to create better physician 
moreover , the study showed that attendees ' satisfaction with physicians ' empathy was not high .
 background : establishing rapport is an important step in physician  
 patient communication resulting in a positive effect on patient satisfaction and overall clinical outcomes . 
 however , there is a dearth of studies on the condition of doctor  
 patient relations in saudi arabia . this study was performed to estimate the proportion of physicians who have a good rapport with patients in their practice and the proportion of satisfied attendees.materials and methods : a cross - sectional study was conducted at a primary health care center , dammam , ksa . 
 the data were collected through a structured self - administered questionnaire given to samples of attendees and physicians to estimate patient satisfaction and the practice of rapport by physicians.results:a total of 374 attendees and 27 physicians participated in the study . 
 the percentage of physicians who had good rapport was 51.9% . 
 factors that showed significant relationship with rapport practice were : physician 's age ( p = 0.016 ) , physician 's experience ( p = 0.043 ) , and professional status ( p = 0.031 ) . 
 the attendees satisfied with their physician 's rapport with them were 50.5% . 
 factors that showed significant relationship with satisfaction were : attendee 's age ( p < 0.0001 ) , educational level ( p < 0.0001 ) , having a chronic illness ( p < 0.0001 ) , having appointment ( p < 0.0001 ) , physicians ' professional status ( p < 0.0001 ) , and a nonsurgical specialty ( p < 0.0001).conclusion and recommendation : physicians ' rapport with patients and patients ' satisfaction with physicians ' empathy is not high . 
 training is required to optimize physician  
 patient communication . 
INTRODUCTION
MATERIALS AND METHODS
RESULTS
DISCUSSION
CONCLUSION AND RECOMMENDATION
Financial support and sponsorship
Conflicts of interest