it is necessary for taking a history , explaining the diagnosis , giving instructions regarding medicines or obtaining consent for diagnostic and therapeutic procedures . empathy indicates one person 's appreciation , understanding and acceptance to someone else 's emotions . have explored medical students understanding of empathy , emphasising its importance in modern patient - centered care . lack of empathy is associated with suboptimal patient care behaviours and more recently as important clinical outcomes such as blood glucose and lipid control in diabetic patients . smith and mishra stated that in any doctor - patient encounter , fact - finding and information gathering is the agenda of a doctor , whereas exploring hopes and fears rather than precisely giving information about symptoms is seen on the part of the patient . communication should not be a mere exchange of words ; in anaesthesia teams , it should be directed towards co - ordinated and safe progress of the patient into anaesthesia . communications by the anaesthetist can elicit subconscious patient responses in mood resulting in anxiolysis and analgesia . for example , calling the sensation of a local anaesthetic injection  a numbing sensation rather than  a sting may result in quite different perceptions . pain being an unpleasant sensory and emotional experience associated with actual or potential tissue damage ; therefore a nocebo or negative suggestion will elicit a subconscious change that might be expected to adversely affect the post - operative experience . senior faculty members were involved in training and teaching as follows : lectures were taken to create a background that patients are fearful about anaesthesia . students were informed about their involvement in patient interaction and the need for effective communication . students were explained the pathophysiology of pain and the need to adopt the practice of sympathetic listening to alleviate patients anxiety about anaesthesia and surgery . need for attitudinal change to impart the understanding about behavioural modification in future practice was taught . students were informed about the questionnaires [ annexures 1 and 2 ] that they will be required to ask to the patients . students were not aware as to which teacher is evaluating his / her performance at the time of giving spinal anaesthesia . the teachers were blinded about the type of questionnaire that the student will receive post - operatively . pre - operatively all students informed the patients about the proposed conduct of spinal anaesthesia in a sympathetic manner . post - operatively they were randomly given the questionnaires to allocate them into group p or group c [ annexures 1 and 2 ] . the interview questions in group p ( pain ) mainly focused the attention of patients on the surgical pain and those of group c ( comfort ) mainly diverted their attention from the pain . the effect of students communication skill of alleviating patients anxiety about pain was to be tested . students performed spinal anaesthesia under direct observation of procedural skills ( dops ) and their performance was assessed [ annexure 3 ] . the extent of patient cooperation and skill of communication acquired was judged using smith and kendall behaviourally anchored scale ( skbs ) . data was analyzed using chi - square test to find association between group p and group c with respect to questions-1 , 2 , pain on movement , pain at rest and botheration due to wound . whitney test was used to find significant differences between groups p and c with median vas and median vnrs . two independent sample t - test was used to find the significant difference between the study groups for mean dops and skbs scores . communication skills and professional attitudes , as well as procedural skills , were taught to these students before they were subjected to this evaluation . the responses to the questionnaires that were given to the students for a patient interview in the post - operative period were collected . the checklists that the teachers were given to judge the students performance were also collected . patients undergoing elective lower segment caesarean section ( lscs ) were included . those with complications like pregnancy induced hypertension , coagulation disorders , placenta previa , heart disease and multiple pregnancies were excluded . totally 100 patients were studied with the indications for lscs being : previous lscs-24 , previous 2 lscs-11 , oligohydramnios-10 , post - dated pregnancy-7 , cephalo - pelvic disproportion-18 , intrauterine growth restriction-17 , failure of induction-5 and breech presentation-8 . the questions that were asked to patients in each group were comparable as shown in table 1 . comparison of number of patients responding to question 1 showed that , out of 50 patients in group p , 33 ( 66% ) did not complain of pain while 17 ( 34% ) had pain . in group c , 47 ( 94% ) patients felt that they were recovering and 3 ( 6% ) felt they were not . for comparison of question 2 in group p 27 ( 54% ) said yes , 23 ( 46% ) said no ; and in group c 40 out of 50 patients ( 80% ) said yes , 10 ( 20% ) said no . this shows that number of patients not having pain is more in c - group than in p - group . comparison of questions in both groups comparison of questions with results in both groups median visual analogue scale ( vas ) in group p was 3 , and in group c it was 8 . whitney test was used ; ( p < 0.01 ) significant difference in groups p and c was noted . lower vas score in group p means lesser pain scores in the group and higher vas score in group c means more comfort . comparison of number of patients responding to question 3 , when pain on movement was asked showed that in group p , 29 ( 58% ) had pain and 21 ( 42% ) had no pain . in group c , 24 ( 48% ) had pain , 26 ( 52% ) had no pain . p = 0.423 indicates , more patients complained of pain in group p ; in group c , number of patients not having the pain was more but not statistically significantly higher . comparison of number of patients responding to question 4 , when pain at rest was asked showed that in group p , 11 out of 50 patients ( 22% ) had pain and 39 ( 78% ) did not have pain . in group c , 6 ( 12% ) had pain , 44 ( 88% ) did not have pain . comparison of number of patients responding to question 5 showed that in group p , 20 ( 40% ) patients complained of wound pain and 30 ( 60% ) did not complain of pain . in group c , 14 out of 50 patients ( 28% ) complained of pain and 36 ( 72% ) did not complain of pain . verbal numerical rating scale ( vnrs ) median in group p was 2.5 and that in group c it was 7 . lower vnrs score in group p means lesser pain scores in the group and higher vnrs score in group c means more comfort . student evaluation by teachers mean value of dops score obtained by 11 students in p - group was 3.98 ( standard deviation [ sd ] = 0.62 ) out of total 5 points and that obtained by 9 students in c - group was 4.13 ( sd = 0.56 ) . this indicates no significant variation in procedural skills of students allocated randomly into two groups . thus , students allocated to p - group have performed spinal anaesthesia equally effectively as those allocated to c - group . mean value of skbs obtained by 11 students in p - group was 7.23 ( sd = 1.27 ) out of 10 points and that obtained by 9 students in c - group was 7.31 ( sd = 0.95 ) . this indicates no significant variation in behavioural skills of students allocated randomly into two groups . comparison of number of analgesic doses required in post - operative period in both groups showed that , in group p , 10 , 17 , 13 , 5 and 5 patients required 0 , 1 , 2 , 3 , and 4 analgesic doses respectively , post - operatively and in group c , 13 , 13 , 19 , 5 and 0 patients required 0 , 1 , 2 , 3 and 4 analgesic doses respectively post - operatively . frenk et al . state that professional health education has not kept pace with the advances in the health systems worldwide in 21 century . largely fragmented and static curricula are likely to produce ill - equipped graduates if complete redesigning is not undertaken . the core of the system is the encounter between people who need services and those who have been entrusted to deliver them . the charter of medical professionalism states that , to focus on  primacy of patient welfare , doctor self - care is necessary for the doctors to meet the professional obligations expected of them . empathy can be threatened by doctor 's distress , which is seen at all levels of medical training . clinical teaching brings together the learning triad of patient , student and clinician / teacher in a particular clinical environment . direct contact with patients is important for the development of clinical reasoning , communication skills , professional attitudes and empathy [ annexure diagram 1 ] . it is generally observed that patients do not know about anaesthesia - related procedures and are anxious about surgery resulting in an overall excessively painful post - operative experience . pain , modulate the neurobiology towards more excruciating post - operative pain . overall goal of our study was to teach the learning anaesthesiologists to communicate effectively with the patients . the aim was to teach them to build a rapport with patients , so as to assure them a smooth intra and less painful post - operative course . the teaching was expected to be effective enough to obtain a calm and cooperative patient for spinal anaesthesia on table . the positive modulation of the neurobiology of patients was tested post - operatively by asking them both positively as well as negatively valenced questions . the questionnaires were either oriented towards pain ( pain group ) or towards comfort ( comfort group ) . the questions in both groups were serially comparable , and the responses obtained were statistically correlated [ tables 1 and 2 ] . the professionalism and attitudinal skills of the students were tested by different teachers on different occasions . mean value of dops score obtained by 11 students in p - group was found to be 3.98 ( 0.62 ) on a 5-point scale ; that of 9 students in c - group was 4.13 ( 0.56 ) . p value of two independent sample t - test was 0.567 ( p > 0.05 = not significant ) . this indicated that students allocated to p - group performed spinal anaesthesia equally effectively as those allocated to c - group . thus , the professional skills were comparable in two groups . comparing the attitudinal and behavioural skills using skbs score , p - 0.867 ( p > 0.05 = not significant ) . mean value of skbs score on a 10 point scale , of 11 students of p - group was 7.23 ( 1.27 ) and that of 9 students of c - group was 7.31 ( 0.95 ) . this indicated that there was no significant difference between behavioural skills of students allocated to two groups [ table 3 ] . in a similar study , patients were interviewed using standard questionnaires by two midwives before evaluation by doctors , post - anaesthesia . the midwives were aware about the group to which a patient was allocated , but the patients had no idea of any such intervention . written informed patient consent to take part in the study was obtained after the questioning was completed . post - operative pain management was given to all patients as per usual protocol . according to authors , though different questionnaires were employed both ultimately focused patients attention towards pain . they expressed a need of phrasing post - operative questions more accurately and improving internal validity in terms of randomisation and allocation concealment to minimise bias . they reported that 75.7% of patients in pain group had pain and 79.4% patients in comfort group were comfortable . in our study , 54% patients in group p had pain and 80% patients in group c were comfortable . 60% patients in group p had no botheration due to wound compared to 72% in group c. however , this number was not statistically significantly higher in group c compared to group p. thus , in our study 28% patients in group c and 40% patients in group p were bothered because of wound , whereas chooi et al . thus , as a result of communication skill training given to students , they could improve the intra and post - operative patient satisfaction significantly . the pre - operative visit helped to improve patients psychology to undergo anaesthesia procedures and surgery as has been judged by dops and skbs tool by teachers while assessing the students . effective communication between doctor and patient has been stated the core of clinical requirement for the medical profession . multi - disciplinary assessment of students clinical performance using amsterdam attitude and communication scale ( aacs ) has been made precise by de haes et al . the goal of their study was to enhance students awareness about the relevance of learning behavioural skills in the earlier stages of their medical training . four hundred and forty - two 5 year clinical students were judged 6 times in two settings by doctors and nurses and video - taped interviews judged by psychologists and doctors . overall mean of the clinical performance was 3.96  0.55 ; judgments of behaviour in the clinic were more precise standard error ranging from 0.11 to 0.16 . in conclusion , the authors have recommended the use of aacs and the like instruments in other medical schools also for their summative assessments to be more feasible and useful . comparison of the analgesic requirement in our study shows group c patients more comfortable than group p. dauphinee described the outcome of current education policies in health professions . he referred to the need of a common framework to find out the impact of education programs at advance levels of training . he suggested studying patient outcomes like improved survival , fewer complications and fewer side - effects from the hospital records and patient feedbacks about the quality of life reported after the treatment from patient records . though post - operative questions were oriented towards either pain or comfort , number of patients without pain was found to be more in c - group than in p - group . pain at rest and botheration due to wound was found to be comparable with less requirement of analgesics in c - group . we , therefore , conclude that the pain mechanism was effectively modulated pre - operatively with the soothing pre - operative dialogue .
background and aims : pre - operative negative valence communications adversely affect intra and post - operative pain experience . 
 this study was conducted to evaluate the teaching of communication skills by teachers in anaesthesia department and whether the post - operative pain is effectively modified due to the skill of communication acquired by students.methods:all students and teachers in the department participated in the study . 
 patients with uncomplicated pregnancy posted for elective lower segment caesarean section were involved . 
 students were taught to explain the anaesthesia plan pre - operatively to the patients in a positive manner . 
 they were taught the practice of giving positive suggestions before any potentially painful stimulus . pre 
 - operatively all students informed the patients about the conduct of spinal anaesthesia . 
 the teachers evaluated the students performing spinal block . 
 the performance was rated for procedural and interpersonal skills ( direct observation of procedural skills [ dops ] and smith and kendall behavioural scale [ skbs ] respectively ) . 
 the extent of cooperation and the ease with which spinal block could be administered correctly by the student was judged by the teacher . 
 post - operatively students were randomly provided questionnaires to elicit answers from patients.results : 
 p value dops and skbs ( 0.567 , 0.867 ) show no significant statistical variation . 
 p > 0.05 = not significant , indicates no significant variation in procedural and behavioural skills of students in two groups.conclusion:teaching of communication skills to students showed a demonstrable effect on their pre - operative dialogue with patients . 
 pain mechanism was effectively modulated by improving patients psychology to undergo anaesthesia .