Table 3 Select GPs Quotations for each theme explaining the reasons for the ranking results

Impact on diabetes patients

Patients understanding of condition

“It is best for patients to understand their condition, such as the severity. When they do not understand, we will give a simple example, so that they can understand the disease, the treatment and progress. They also can better cooperate with our treatment.” (GP 12, Group 2, item 4)

Long-term cooperation with doctors

“There was a patient who came in with breast cancer and diabetes. She was very secretive. She did not want to people know she had breast cancer. But when I started talking to her, she told me that she did. And then her tears came out. She said no one cared about her. She had seen diabetes for so many years that no one cared about her comorbidities and complications. Then I saw how sad she was, and I held her hand. And then there was a silence, she said a lot of her worries. I just listened and did not give a lot of guidance, because after all, I was not very good at breast cancer treatment. From then on, this patient only came to see me once a month. She did not go to clinics when I'm resting or when I’m out of the clinic. Therefore, I think this skill is very important, because the patient will understand your caring, patient will be in close contact with you, and will be more compliant to your opinions.” (GP 20, Group 3, item 4)

Patients' experience improvement

“I tell my patients a lot of things to encourage them. Life is a state of mind. Even the same disease, same symptoms, maybe this person thinks it's okay and he's going to have a very fulfilling life. But for some people, it is like the sky is falling in. So, I think communication is very important, it can explore patient's attitude towards life, as well as improve his experience with diabetes. I want my patients to be optimistic. No matter what kind of diseases or difficulties they face, I will teach them such a positive thought by using communication skills.” (GP 11, Group 2, item 8)

GPs attitudes towards communication skills

Seldom using communication skills

"In practice, we really ignored them. We did not do enough." (GP 1, Group 1, item 5 and 16)

Essential competencies

“Active listening, expressing empathy, sharing bad news, using examples, are skills that went on almost every day in our daily work, and I think it should be basic competencies for every doctor.” (GP 20, Group 3, item 1, 2, 3 and 4)

Mutual understanding

"If good communication skills used during consultation, it will be easy to build a common understanding with diabetes patients. They can feel that you are caring. " (GP 18, Group 3, item 8)

Patients’ factors influence on application of communication skills

Personality

“Different levels of patients have different ideas, concerns, and expectations. We need to observe and understand the patient's background to know how to communicate with them.” (GP 26, Group 4, item 5)

Health literacy

“Many patients have different levels of awareness of diabetes, especially in the urban and rural areas, and most of them are not well educated. Sometimes, when explaining his condition to him, such as medication, the patient thought that his blood sugar was well controlled, he would stop the medication on his own, and would not follow the doctor's advice. It will take a long time for doctors to work in and communicate with him before things get better.” (GP 5, Group 1, item 13)

Aging population

“Most of the patients I care for are the elderly, and their desire to talk is very strong. Even some old people come to me, they neither want to prescribe medicine or cope with symptoms. They just want to talk to me. So, I think it's important to listen to patients.” (GP 28, Group 4, item 1)

Local context factors influence on application of communication skills

Insufficient time

“I feel it is quite difficult. In our general practice, one doctor sees dozens of patients in the morning. And if each patient wants to say everything, there is definitely not enough time.” (GP 16, Group 2, item 9)

Regional differences

“The electronic medical record system is far from perfect. Only in our own clinic patients’ records can be traced. But here we have a higher population floating (migrant population), for example, patients who do not always live in this area, they may have gone to another village or community. It would take a long time to retrieve the patient's records from other medical institutions. Sometimes even more than half an hour spent, there is no guarantee of a result. Even if we could retrieve the patient's records, things in our hands were not what we doctors wanted.” (GP 16, Group 2, item 19)

Healthcare resource, policy and guidelines

“Even if we are trained to recognize anxiety, depression, and other mental health issues, we don't have the capacity to help them. At best, we just comfort him with words, right? To talk to him about life matters, only to this level. When it comes to medication, there are not enough medicines in our community health care service. Doctors have no experience in using drugs and are afraid to give them to patients. If I find that the patient has mental problems that need to be referred, I find that I don't know how to answer this question, and I don't have a good way to help him. That is to say, how do I help patients to refer patients to which hospital, which department, which doctor? Basically, there is no system of referral.” (GP 27, Group 4, item 14, 15)

Factors involved in communication skills training program implementation

Previous training experience

“It is difficult to master this skill aimed at improving patient adherence, and there is no previous training in this aspect.” (GP 5, Group 1, item 9,13)

Trainees' gender difference

“In my opinion, it may be better for female doctors to show empathy. Sometimes, male doctors may not easily show their feelings or emotions as well as speak out. Female GPs trained have advantages in using those skills.” (GP 4, Group 1, item 2,6)