The very high response rate (95%) of this questionnaire may have reflected general interest, or may have resulted from the advantages of self-assessment which itself may improve performance. The results on the CSKS show that basic knowledge of interns in Iran about communication skills is limited. Researchers have reported similar findings in other countries which reveal a deficit in the knowledge of doctors about communication skills . The importance of communication skills has long been acknowledged in general practice training  and the need to teach communication skills formally, as part of British undergraduate medical education, has also been recognised . In Iran, interns' knowledge deficiency may be attributed to the fact that interns have never been trained to consult in the general practice setting, and their skills are limited to making value judgements, often using the only available criterion, comparison with their own style . This approach to a patient is not cost effective and may lead to negative health outcomes such as patient dissatisfaction, poor adherence to treatment and medical errors . A few students reported their attendance at courses such as EBM, semiology, skills lab or CPR, which have no relation with communication skills training. This indicates that students are not familiar with the tasks of communication skills .
The vast majority of research studies have been conducted on the outcome of communication skills in the practice and training of doctors in western countries. Even here, despite doctors trained in communication skills and the advocacy of the use of a patient-oriented approach, some evidence suggests that there are difficulties in practice [19, 20]. However, research has demonstrated that communication skills training intervention using behavioural, cognitive and affective domains can increase not only potentially beneficial and effective interviewing styles, but also alter attitudes and confer other benefits [9, 21].
The results of the study show that there were significant differences between males and females with regard to their reported knowledge of the main communication skills. Women were less confident of their skills. The deficit may partly be an artefact of an inadvertent prestige bias of the male students. The deficit is particularly notable in sex education. There are three possible explanations for this. Firstly, in general, Iranian female interns are very shy to ask patients about sexual issues. Therefore they may feel that sex education skills have no implications for their practice and hence pay less attention to sex education training. Secondly, it may be a systematic error in female respondents, i.e. they may be shy to discuss their knowledge about sex education skills rather than lack knowledge. Thirdly, in the past, sex education was regarded as a taboo in Iran and was not available in schools, especially for girls . This perhaps acts as an inhibitory factor on the basic knowledge of sex education. Within this context, there is no evidence that shows similar results for gender difference on the knowledge of sex education in the practice and training of doctors.
The results on the CSKS suggest that there are areas of weakness in the communication skills confidence of interns, particularly in breaking bad news. While it is well recognised that delivering bad news is a difficult task that requires skills and sensitivity , both female interns and male interns reported that their confidence in breaking bad news is low, especially the female interns. While the interns commented on the need to improve medical students' communication skills, it seems that guidelines on delivering bad news to patients and patients' family members have not been seriously taken into consideration in the practice and training of doctors in Iran. This could be due to interns possessing deep fears regarding delivering bad news to patients' family members, or because they are unaware of the general guidelines about delivering bad news . Three studies which have attempted to address residents' perception of delivering bad news indicate that residents had experienced discomfort with psychosocial issues related to the conveyance of bad news, such as personal fears and different perceptions of bad news [25–27].
There is a significant difference between the mean score of the interns on breaking bad news. The female interns have reported lower confidence than the male interns. The deficit could be an inadvertent prestige bias of the male students. However, to our knowledge, there is no evidence that underpin such finding. Although Orlander et al's work  demonstrated there were no significant differences between males and females with regard to the type of bad news, residents' knowledge with regard to breaking bad news was not reported by the authors. Therefore, some empirical research is essential.
Given the poor levels of confidence about communication skills, particularly sex education skills, revealed in this study, it is concluded that educational programmes are necessary. In sex education skills training, given the complex interplay of cultural and religious beliefs in Iran, particular attention must be paid to multicultural and religious issues. Therefore, further work is needed on gender education and stereotypes in sex education; learning styles; the 'hidden curriculum'; and how far medical schools make organisational and administrative arrangements on the basis of gender and the implication for female and male interns.
The enthusiastic response to the questionnaires may suggest that medicine is accepting the need for developing communication skills within the medical curriculum. Medical education in Iran must respond to this challenge.
Finally, our findings may be somewhat limited in generalisability because they are derived from only one medical school in Iran. Self-assessment data may suffer from biases such as prestige bias. Despite these caveats, the authors believe the data to be an accurate reflection of current practice in Iran, based on the Iranian authors training experiences, and consistency with previous accounts.