Patients of Our Own: Defining "Ownership" of Clinical Care in Graduate Medical Education

Patient care ownership in medical students: a validation study

BACKGROUND

Psychological Ownership is the cognitive-affective state individuals experience when they come to feel they own something. The construct is context-dependent reliant on what is being owned and by whom. In medical education, this feeling translates to what has been described as "Patient Care Ownership," which includes the feelings of responsibility that physicians have for patient care. In this study, we adapted an instrument on Psychological Ownership that was originally developed for business employees for a medical student population. The aim of this study was to collect validity evidence for its fit with this population.

METHODS

A revised version of the Psychological Ownership survey was created and administered to 182 medical students rotating on their clerkships in 2018-2019, along with two other measures, the Teamwork Assessment Scale (TSA) and Maslach Burnout Inventory (MBI) Survey. A confirmatory factor analysis (CFA) was conducted, which indicated a poor fit between the original and revised version. As a result, an exploratory factor analysis (EFA) was conducted and validity evidence was gathered to assess the new instruments' fit with medical students.

RESULTS

The results show that the initial subscales proposed by Avey et al. (i.e. Territoriality, Accountability, Belongingness, Self-efficacy, and Self-identification) did not account for item responses in the revised instrument when administered to medical students. Instead, four subscales (Team Inclusion, Accountability, Territoriality, and Self-Confidence) better described patient care ownership for medical students, and the internal reliability of these subscales was found to be good. Using Cronbach's alpha, the internal consistency among items for each subscale, includes: Team Inclusion (0.91), Accountability (0.78), Territoriality (0.78), and Self-Confidence (0.82). The subscales of Territoriality, Team Inclusion, and Self-Confidence were negatively correlated with the 1-item Burnout measure (P = 0.01). The Team Inclusion subscale strongly correlated with the Teamwork Assessment Scale (TSA), while the subscales of Accountability correlated weakly, and Self-Confidence and Territoriality correlated moderately.

CONCLUSION

Our study provides preliminary validity evidence for an adapted version of Avey et al.'s Psychological Ownership survey, specifically designed to measure patient care ownership in a medical student population. We expect this revised instrument to be a valuable tool to medical educators evaluating and monitoring students as they learn how to engage in patient care ownership.

Association between patient care ownership and personal or environmental factors among medical trainees: a multicenter cross-sectional study

BACKGROUND

Patient care ownership (PCO) is crucial to enhancing accountability, clinical skills, and medical care quality among medical trainees. Despite its relevance, there is limited information on the association of personal or environmental factors with PCO, and thus, authors aimed to explore this association.

METHODS

In 2021, the authors conducted a multicentered cross-sectional study in 25 hospitals across Japan. PCO was assessed by using the Japanese version of the PCO Scale (J-PCOS). To examine the association between personal (level of training, gender, and department) or environmental factors (hospital size, hospital type, medical care system, number of team members, number of patients receiving care, mean working hours per week, number of off-hour calls per month, and perceived level of the workplace as a learning environment) and PCO after adjusting for clustering within hospitals, the authors employed a linear mixed-effects model.

RESULTS

The analysis included 401 trainees. After adjusting for clustering within hospitals, it was confirmed that the senior residents had significantly better J-PCOS total scores (adjusted mean difference: 8.64, 95% confidence interval [CI]: 6.18-11.09) than the junior residents and the perceived level of the workplace as a learning environment had a positive association with J-PCOS total scores (adjusted mean difference per point on a global rating of 0-10 points: 1.39, 95% CI: 0.88-1.90). Trainees who received calls after duty hours had significantly higher J-PCOS total scores than those who did not (adjusted mean difference: 2.51, 95% CI: 0.17-4.85). There was no clear trend in the association between working hours and PCO.

CONCLUSIONS

Seniority and the perceived level of the workplace as a learning environment are associated with PCO. An approach that establishes a supportive learning environment and offers trainees a reasonable amount of autonomy may be beneficial in fostering PCO among trainees. The study findings will serve as a useful reference for designing an effective postgraduate clinical training program for PCO development.

Linking Patient Care Ownership and Professional Identity Formation through Simulation

The link between ownership of patient care and professional identity formation (PIF) has not been formally established, yet PIF researchers frequently cite clinical experiences as powerful contributions to PIF. Hypothesis: Using clinical simulation, this study aimed to explore the relationship between patient care ownership and the cognitive processes involved in the creation of a professional identity. Methods: In 2018-2019, 189 third-year students participated in a simulation in which they were placed in the role of a physician treating a patient in respiratory distress. Data were collected from 12 focus groups (n = 84; 44% of the third-year class), each lasting 15-25 minute. Students were asked four questions designed to identify moments when they felt like a physician and experienced feelings of ownership. Each focus group was transcribed and analyzed for the presence of known elements that contribute to feelings of psychological ownership, and then inductively for how students related their feelings of ownership to their professional identity. Results: When students were asked to take ownership of their patient's care, they underwent a three-step process: (1) experiencing disorientation, (2) reconceptualizing roles and responsibilities, and (3) reorientation to professional goals. Patient care ownership was disorienting because it marked a departure from the clinical roles the students had previously experienced. While disoriented, students engaged in a process of reflection during which they asked themselves who they were, who they were becoming, and who they needed to become to effectively serve in the role of a physician. This process prompted students to realize the limitations of their clinical reasoning abilities and that the role of a physician requires new ways of thinking. Conclusions: This study advances a conceptual model of PIF that identifies patient care ownership as a catalyst in developing a professional identity. Assuming responsibility for patients places students into an unfamiliar role, which opens a channel for students to access new perspectives in their development as physicians.

"It is you, me on the team together, and my child": Attending, resident, and patient family perspectives on patient ownership

INTRODUCTION

Patient ownership is an important element of physicians' professional responsibility, but important gaps remain in our understanding of this concept. We sought to develop a theory of patient ownership by studying it in continuity clinics from the perspective of residents, attending physicians, and patients.

METHODS

Using constructivist grounded theory, we conducted 27 semi-structured interviews of attending physicians, residents, and patient families within two pediatric continuity clinics to examine definitions, expectations, and experiences of patient ownership from March-August 2019. We constructed themes using constant comparative analysis and developed a theory describing patient ownership that takes into account a diversity of perspectives.

RESULTS

Patient ownership was described as a bi-directional, relational commitment between patient/family and physician that includes affective and behavioral components. The experience of patient ownership was promoted by continuity of care and constrained by logistical and other systems-based factors. The physician was seen as part of a medical care team that included clinic staff and patient families. Physicians adjusted expectations surrounding patient ownership for residents based on scheduling limitations.

DISCUSSION

Our theory of patient ownership portrays the patient/family as an active participant in the patient-physician relationship, rather than a passive recipient of care. While specific expectations and tasks will vary based on the practice setting, our findings reframe the way in which patient ownership can be viewed and studied in the future by attending to a diversity of perspectives.

'Whispers and shadows': A critical review of the professional identity literature with respect to minority physicians

OBJECTIVES

Professional identity formation (PIF) is a growing area of research in medical education. However, it is unclear whether the present research base is suitable for understanding PIF in physicians considered to be under-represented in medicine (URM). This meta-ethnography examined the qualitative PIF literature from 2012 to 2019 to assess its capacity to shine light on the experiences of minoritised physicians.

METHODS

Data were gathered using a search of six well-known medical education journals for the term 'professional identit*' in titles, keywords, abstracts and subheadings, delineated with the date range of 2012-2019. All non-relevant abstracts were removed and papers were then further reduced to those that focused only on learners' experiences. This left 67 articles in the final dataset, which were analysed using a collaborative approach among a team of researchers. The team members used their professional expertise as qualitative researchers and personal experiences as minoritised individuals to synthesise and interpret the PIF literature.

RESULTS

Four conceptual categories were identified as impacting PIF: Individual versus Sociocultural Influences; the Formal versus the Hidden Curriculum; Institutional versus Societal Values; and Negotiation of Identity versus Dissonance in Identity. However, a major gap was identified; only one study explored experiences of PIF in URM physicians and there was an almost complete absence of critical stances used to study PIF. Combined, these findings suggest that PIF research is building on existing theories without questioning their validity with reference to minoritised physicians.

CONCLUSIONS

From a post-colonial perspective, the fact that race and ethnicity have been largely absent, invisible or considered irrelevant within PIF research is problematic. A new line of inquiry is needed, one that uses alternative frameworks, such as critical theory, to account for the ways in which power and domination influence PIF for URM physicians in order to foreground how larger sociohistorical issues influence and shape the identities of minoritised physicians.

Problems No One Looked For: Philosophical Expeditions into Medical Education

Issue: Medical education has "muddy zones of practice," areas of complexity and uncertainty that frustrate the achievement of our intended educational outcomes. Slowing down to consider context and reflect on practice are now seen as essential to medical education as we are called upon to examine carefully what we are doing to care for learners and improve their performance, professionalism, and well-being. Philosophy can be seen as the fundamental approach to pausing at times of complexity and uncertainty to ask basic questions about seemingly obvious practices so that we can see (and do) things in new ways. Evidence: Philosophy and medical education have long been related; many of our basic concepts can be traced to philosophical ideas. Philosophy is a problem-creation approach, and its method is analysis; it is a constant process of shifting frames and turning into objects of analysis the lenses through which we see the world. However, philosophy is not about constant questioning for the sake of questioning. Progression in medical education practice involves recognizing when to switch from a philosophical to a practical perspective, and when to switch back. Implications: In medical education, a philosophical approach empowers us to "slow down when we should," thereby engaging us more directly with our subjects of study, revealing our assumptions, and helping us address vexing problems from a new angle. Doing philosophy involves thinking like a beginner, getting back to basics, and disrupting frames of reference. Being philosophical is about wonder and intense, childlike curiosity, human qualities we all share. Taking a philosophical approach to medical education need not be an unguided endeavor, but can be a dialog through which medical educators and philosophers learn together.